The practitioners guide in urinalysis

Preface

The object of the present little work is to enable the practitioner of but little experience in the use of chemicals and the microscope, to ascertain as accurately and rapidly as possible the physical characteristics of the urine, to determine its constituents, normal and abnormal, the contents of sediments, etc., etc., and after the various substances entering into the composition of the fluid have been ascertained by analysis, to teach the clinical significance of the same. With this end in view, the book is divided into two parts : I. Practical, and II. Clinical. In Part I. the methods of analyzing urine have been set forth together with the microscopical appearances of deposits, etc., in the simplest and plainest language possible. At the end of every few pages a « Clinical Summary" is given explaining in condensed and general terms the clinical significance of everything ascertained up to that point by chemical or microscopical means. The clinical hints and aids to diagnosis given in Part I. are more widely touched upon in Part II., and some little attention given to the more recent discoveries in urinary pathology. The order in which the book is written enables the hurried practitioner to find everything of the greatest consequence in routine practice in Part I. ; in doubtful cases where more study and attention must be given it is hoped that Part II. may be of aid. Inasmuch as few works on the urine go into detail in describing chemical apparatus, reagents, etc., an introduction to Part I. has

PREFACE.

been arranged in which even the simplest matters relating to the use of chemicals and the microscope have been explained. In describing chemical tests the physician may here and there find a well-known one omitted, but this has been done only where, in the author's experience as a teacher, he has seen it cause confusion. Moreover in describing tests for important abnormal constituents a simple clinical test has been given first, followed by a more thorough and conclusive one.

Chemical terms, when used, are simplified as far as possible without being actually inaccurate. Among the large number of writers from whose works and articles the author has collected his facts, he is especially indebted to Vogel and Balfe, for aid in studying the clinical significance of urine; to Senator, who in his recent work entitled " Die Albuminuric," has discussed at considerable length the so-called "normal albumin," and to Prof. E. H. Wood, of the Harvard Medical School, for his plea in favor of the "twenty-four hours urine" in cases of

Bright' s disease.

Observations of the author on the daily quantity and specific gravity of normal urine as observed by him during a period of some fifty days, together with such cases in his own analytical practice as have been of especial interest to him, will be found in part Part II. (See also Appendix.)

Chicago, III.,

296 Erie Street,

September /, 1882.

I^TEODUOTIOX.

TEST-TUBES.— Most of the work to be clone in examining a specimen of urine requires some familiarity with the use of test-tubes, Fig. 1 — small glass cylinders closed at one

5 O O QO O O <Q§a

Fig. i.

end and open at the other. Test-tubes holding one-half a fluid ounce are of convenient size in urine analysis ; when filled with any liquid they should be stood in the apertures of a test-tube rack or stand (Fig. 1); when cleaned, a test-tube brush should be used, which is merely two wires twisted together, holding at one end a number of bristles. Test-tubes are so called from the fact that in them "tests" are conveniently made; a specimen of urine is said to be "tested" for any substance it may contain when certain processes, chemical or physical, are gone through with, with a view to ascertain whether or not the

INTRODUCTORY.

m

= substance be present in the urine. Thus, a "test" is said to be made for albumin when the urine, supposed to contain it, is heated, or when nitric acid is added, etc.

After a test has been made the test-tube which has been used should at once be cleaned ; if it be not convenient for any reason to do this the tube may stand in the rack until all work of the kind has been finished, when all the test-tubes which have been used may be cleaned at one time. , It is not advisable to allow urine to remain in the tubes for any length of time especially when to it have been added various reagents.

Never stand a test-tube in a cup, glass or leaker, hit always in the rack.

To clean the tubes pour out the liquid contained in them, if any, rinse out with water, which if possible should be warm, then filling half or two -thirds full of water introduce the test-tube brush and work it to and fro carefully pushing it down to the very end of the tube. After the tubes have been washed they should be inverted over the pegs in the rack to dry.

Never use a dirty test-tube, and never perform more than one test at a time in one tube, unless particularly directed.

If the tubes cannot be thoroughly cleaned with water, try acids, ammonia, alcohol, or ether.

How to heat or boil urine. — To heat urine fill the test-tube half-full and hold over an alcohol-lamp flame gently moving the tube from side to side so as to prevent boiling ; when it is necessary to boil the urine, take a strip

Fig. 2.

IKTRODUCTOKY. 7

'of paper four or five inches long, and say, half an inch wide, fold it around the tube a little above the point coi responding to the surface of the liquid inside, press the two ends of the paper tightly together keeping the tips of the thumb and forefinger against that part of the paper which envelopes the tube, then hold the tube cautiously over the flame until it boils.

It is not desirable to use a gas flame for heating or boiling urine inasmuch as the test-tube becomes covered with soot and if the flame be too strong there is danger of cracking the tube unless it be kept actively in motion.

With an alcohol-lamp flame urine can be boiled for some time without bubbling over, if due care be exercised.

In testing urine always notice whether the directions given in the "Manual" used are to heat or to boil, and if the former is specified, remove the test-tube from the flame before the first sign of ebullition.

If any reagent to be boiled, as Fehling's solution, have a tendency to "bump," i. e., suddenly and without warning to boil over, add a few fragments of an ordinary claypipe which must be clean and new.

TEST-GLASSES. — Next in importance to test-tubes are the glasses in which urinary sediments are collected.

To collect a sediment or deposit, allow the urine to stand at rest in a tall, narrow, cylindrical glass vessel like the one shown in Fig. 2 ; the best are those provided with a lip. After the deposit has settled to the bottom of the test-glass, remove the clear urine by decantation.

To decant urine hold the test-glass very steadily in the right hand ; against the lip hold with the left hand a glass rod, grasping the latter near its upper end.

Next incline the test-glass in such a way as to pour the urine down the rod into any vessel desired. Cease pouring the moment any of the sediment is seen to slip out.

It is well to have one test-glass which is graduated either in centimetres or fluid ounces, large enough to hold four or five of the latter and provided with a foot or base.

PIPETTES. — To examine a sediment with the microscope there is need of the little instrument called a pipette, which is merely a slender glass tube six to twelve inches long with an internal diameter of from -^ to -^ inch and drawn out to a pointed end ; the use of a pipette is to transfer a drop of urine containing sediment to the glass slide used in microscopical work. After the deposit has settled to the bottom of the test-glass place the tip of the forefinger over the upper end of the pipette and dip the lower or pointed end into the sediment. Next remove the finger for an instant, then quickly close the orifice again with it. A portion of the sediment has passed into the pipette and can be held there as long as the finger is tightly pressed against the orifice in the upper end of the pipette, hence can be carried to a glass slide, when on removing the finger, the sediment will flow out.

The best pipette for collecting urinary sediments is (b) a glass tube having a calibre of one inch in diameter and a length of ten or twelve inches ; one extremity is tapered off to a very small orifice and furnished with a glass stop-cock. The sediment having been obtained in a test-glass as before, decant the supernatant urine, then pour the sediment into pipette (b) and allow it to settle. Carefully open the stop-cock and a drop of the densest part of the deposit may be received on a glass slide and examined with the microscope.

INTRODUCTORY.

If is much better to use pipette (b) than the kind mentioned first.

FILTRATION. — Before performing certain tests, as for albumin, sugar, etc., it is advisable that the urine be filtered ; the apparatus essential to filtration is composed of a funnel, filters or filter paper ', a filter ring and stand and a test-glass. Funnels are of glass and of various sizes ; those three or four inches in diameter across the top are of convenient size.

Filter paper is unsized and many varieties of it are in aim-

mi

f actured ; the so-called " Prat- Dumas" French filter paper comes cut in circular form in packs of 100 filters each and is the best for the physician's use.

Filters having a diameter of 7-iinches are of convenient size for the funnel mentioned above.

A filter ring and stand is shown in Fig. 3.

In order to filter, take one paper from the package of cut filters (or cut out from Swedish filter paper a circular piece of 7 or 8 inches in diameter), fold in two, next turn over each edge as you would two opposite leaves in a book, namely one end from right to left and the other from left to right until they just do not meet. A funnel shape is in this manner given to the paper (Fig. 4). Thus folded, place the filter into the funnel, open on the side opposite to where it was last

Fig.

Fig. 4.

folded, and fit it closely down into the funnel. Do not

let the paper project over the rim of the funnel and before pouring the urine into it moisten with distilled water evenly and gently from the lowest part upward. Having fitted the paper to the funnel and moistened as described, next set the funnel into the filtering-ring and place a test-glass or any glass vessel desired beneath the spout of the funnel. Now pour the urine into the funnel after the method of decantation by means of the glass rod, and when about seven-eighths full cease pouring. Observe whether the urine trickling through into the test-glass or beaker beneath the funnel be clear ; if not, pour the urine in the funnel, into the test-glass, take out the filter paper, throw it away and fit a new one. Next take a clean test-glass or beaker, place it beneath the spout of the funnel, and pour the urine now contained in the first test-glass or beaker into the funnel.

Chemical Examination of Sediment. — If it be desired to examine the sediment chemically, w T ait until the urine has completely filtered, remove the filter-paper, place it in a porcelain dish, make a small hole in it and wash the sediment through this hole by means of the ivash-bottle ; the latter is a flask or bottle closed w T ith a twice perforated snugly-fitting stopper through which two glass tubes are passed, each bent above the cork, the one at an acute angle the other at an obtuse. When the bottle is filled with water, blowing through the obtuse-angled tube will force a stream of water with considerable violence through the acute-angled tube, and any precipitate or deposit adhering to the filter paper may be washed off. Ordinarily the physician need not have recourse to this method of obtaining a sediment as decantation of the supernatant urine will answer most purposes, leaving, as it does, the sediment at the bottom of the test-glass.

GLASS JARS. — The physician should own a few half-gallon or gallon glass jars in which to collect the urine of a patient when the whole quantity for twenty-four hours is required ; besides these it is convenient to have a cylindrical jar graduated in cubic centimeters or fluid ounces, capable of containing 1000 cubic centimetres (a little over a quart — two pints two fluid ounces nearly). The patient having collected the urine of twenty-four hours in one of the half-gallon jars the physician can measure the amount by one of the graduated jars.

Miscellaneous. — Besides the instruments mentioned thus far it is desirable to have three pipettes graduated in 5, 10, and 20 cubic centimetres, an alcohol lamp, three or four porcelain dishes of different sizes, a small chemical thermometer for taking the temperature of urine, three or four glass rods, a pair of small brass forceps, litmus paper, both red and blue, readily obtained in little books, and an urinometer and beaker (see Specific Gravity).

CHEMICAL REAGENTS.— Chemicals used in testing the urine are called reagents, the chemical processes being known as reactions.

The following are useful in urinalvsis :

Nitric acid, chemically pure, kept away from light and in glass-stoppered bottle.

Hydrochloric acid, chemically pure, kept away from ammonia in glass-stoppered bottle.

Acetic acid of two kinds, (i.) pure glacial and (ii.) dilute — one part glacial to five parts distilled water, in glass-stoppered bottles.

Sulphuric acid, chemically pure, colorless, in glass-stoppered bottle.

Nitric acid, commercial, containing Nitrous acid, in glass-stoppered bottle.

Trichloracetic acid, pure in crystals, in tightly-stoppered

bottle.

Ammonia, one part strongest to three parts distilled

water.

Potassa, one part solid caustic potash to ten parts distilled water by weight.

Silver nitrate, one part crystals to ten parts distilled water by weight, kept from the light.

Barium chloride, solution of the same proportions as the silver nitrate.

Potassium ferrocyanide, solution of the same proportions as the silver nitrate.

Fehling's solution — described under Sugar.

Chlorinated Soda, IT. S. P. — preferably Squibb's.

Alcohol, 95 per cent.

Spirits Turpentine.

Tincture Guaiac.

Ammonium moiybdate in solution.

Caustic Potash, in sticks, kept in a £or#-stoppered bottle.

Distilled water in a glass-stoppered bottle holding one quart or more.

Condensed yeast, to be bought fresh whenever needed.

CHEMICAL TERMS. — Add nitric acid, add ammonia, etc. When the term "add" is used without specifying the amount, neither too much nor too little of the reagent should be added to the urine ; if the test-tube be half full of urine fifteen to thirty drops of the reagent may be used.

Alkali, Alkaline, Alkalinity. — An alkali is a compound substance very soluble in water, turning red litmus paper blue, and opposed in its properties to the characters of sour or acid substances. The alkali most familiar to every one is ammonia which from its well-known tendency to evaporate is called a volatile alkali. Potash and soda are called on the other hand fixed alkalies. The urine is said to be alkaline when a piece of red litmus paper dipped into it is turned blue ; in such a case an alkali of some sort is present in the urine and we speak of the alkalinity of the latter.

Acid, Acids, Acidity. — The sour substances called acids are of several varieties ; mineral acids are very corrosive, generally liquid in form and have a powerful action on the skin, clothing, etc. Those used in urinary analysis are nitric, hydrochloric and sulphuric. They are corrosive poisons. Stains caused by acids are best removed by ammonia; nitric acid stains, however, must be washed repeatedly with a concentrated solution of potassium permanganate, then with water. Eemove the brown stain of the permanganate by an aqueous solution of sulphurous acid.

Vegetable acids are less corrosive than mineral acids but are frequently poisonous ; the most important acid of this class used in urinary work is acetic acid. An acid substance may be recognized by its power of neutralizing an alkali (either entirely or partly), that is, destroying the characteristic properties of the latter.

Acids turn blue litmus paper red and when the urine has this effect upon such paper it is said to be acid and we speak of its acidity.

In case a strong mineral acid be accidentally taken internally an alkali must be administered as an antidote such as dilute carbonate of soda, magnesia with milk or water, carbonate of lime, mixture of soda; if an alkali be swallowed by mistake the antidote is an acid solution such as vinegar and water equal parts, lemon juice, or the like. The same substances may be used for external injuries from strong acids or alkalies as the case may be, alkalies for acid burns and acids for alkali burns.

Salts. — A salt is a compound substance containing an acid in combination with a base (the latter term being applied to any compound body capable of neutralizing an acid partly or entirely as oxide of zinc, any of the alkalies, etc., etc.) ; a salt may also consist of a metal in combination with chlorine, bromine, iodine, etc. It is not necessary that the practitioner trouble himself greatly about these definitions; in this book when we speak of calcium carbonate we mean a salt of calcium containing carbonic acid in combination, when of potassium nitrite a salt of potassium containing nitrous acid in combination, when of sodium chloride a salt of sodium containing chlonw*.

A solution of ammonia, soda, or potassa is often called solution of ammonium hydrate, sodium hydrate, etc. ; in familiar language these may also be termed solution of caustic potash, solution of caustic soda, etc.

Precipitate. — When a reagent is added to urine and a cloudiness or turbidity ensues some substance which heretofore has been dissolved in the urine appears and causes this cloudiness, the urine on addition of the reagent no longer being able to hold the substance dissolved, or else some new and insoluble substance being formed from a

INTRODUCTOKY. 15

combination of the reagent with some constituent of the urine, a turbidity is seen. Thus if nitric acid be added to urine containing albumin the latter is seen in the form of a cloudiness or turbidity since the acid has rendered the

as

urine incapable of holding the albumin dissolved ; similarly if silver nitrate be added to urine a dense turbidity is at once seen caused by the formation of silver phosphate and silver chloride, both of which salts are insoluble in urine. The technical term for the cloudiness or turbidity thus produced is " precipitate " ; albumin may be said to be precipitated on adding nitric acid to urine, and silver chloride may be said to be precipitated on adding silver nitrate to the urine.

MICROSCOPE. — The microscopic examination of urine is by no means formidable. Urinary sediments containing crystals are easily recognized and it is only in the case of tube casts, blood, pus, etc., that any great care or experience is necessary. Any achromatic microscope provided with " objectives " and "eye-glasses" giving a power of from 200 to 600 diameters will suffice; the so-called "students' microscopes," if from the hands of a good maker, are all that are required for urinary work.

The object to be examined is placed on a glass "slide" or in a "cell" covered by a thin glass cover to keep out dust, etc., and placed on the "stage"; by means of the " objective " (a lens placed on the lower part of the instrument near the object) and the " eye-glass" (a lens in the upper part near the eye), the magnifying pow T er used may be determined as follows: if the magnifying power of the "objective" is 20 diameters and that of the "eye-glass" 10 diameters, 20x10 or 200 diameters is the total magnifying power of the microscope. Hence a number of different "objectives" and a number of different "eye

INTRODUCTORY.

pieces" will give a great variety of powers, but for urinary work two objectives are sufficient, namely, a " two-third inch" and a "one-fifth inch"; the "two-third inch" with different eye pieces will give a magnifying power of

Fig. 5.

from 75 to 150 diameters, and the "one-fifth inch" 250 to 700 diameters ; in case it be not convenient to obtain these, the one-half inch and one-fourth inch may be used. Physicians, not familiar with the technical terms used by

IXTK0DUCT0KY. 17

opticians, in ordering a microscope for urinary work need only specify the kind of objectives mentioned above with eye-pieces necessary to produce a magnifying power of from 75 to 150 and 250 to 700 diameters. The microscope is so constructed that one "objective" can be taken out and another put in with but little loss of time.

The glass " slides" already mentioned are merely rectangular, flat pieces of glass upon which to place the objects to be examined ; they should be kept scrupulously clean. The " covers " are of thin glass and are placed over the object when the latter is on the slide ; they should not press against the object lest it be flattened or crushed. In most cases in examining sediments shallow glass or gum-dammar <- cells " are better than " slides" since being hollowed in form they admit of a stratum of fluid of any degree of thickness and the cover when placed is not so likely to press the objects.

Things Necessary for the Microscopical Examination of Urinary Deposits. — Microscope, two-third inch objective, one-fifth inch objective, several drop pipettes, any number of glass slides, thin shallow cells of o-lass or orum-dammar and thin glass covers, a flask of distilled water, a piece of old linen, a paste-board cover for the microscope, and a soft camel's hair pencil. The whole on a table having a couple of drawers and placed before a window. Arrange the microscope before a window whose aspect is opposite to the side on which the sun is shining. Obtain a good light at the left hand, then in examination of an urinary depositproceed as follows : if you have the apparatus described under pipette (b.), and have done as described, press the pinch-cock and let a drop of the sediment fall on one of the shallow cells, cover it over with one of the thin glass 2T

18 INTRODUCTOR. T

covers and remove any urine which may exude at the margin of the cover with blotting paper ; next place the cell under the microscope, manipulate the mirror so as to obtain proper light and examine with a low power, 75 to 150 diameters, first, as this enables you to see more of the deposit, focussing by turning the movement or adjustment gently until the eye is suited. In case the ordinary drop pipette is used close one end firmly with the forefinger and dip the tapering end down to the very bottom of the test-glass in which you have allowed the urine to settle, raise the forefinger a little so that about an inch of the pipette is filled with the sediment, close the finger over the aperture tightly, take out the pipette from the test-glass, cautiously loosen the finger a little so that about one half the sediment drops out, close it again, wipe off the pipette with a piece of new linen or muslin held in the left hand, then gently raise the fo finger so that a drop of the sediment falls on the shallow glass cell, when examine as before. This latter method of preparing a drop for examination is very troublesome and the physician will do well to obtain the instrument described under pipette (b.), as it can be ordered of any dealer in chemical apparatus in the large cities ; three or four pieces of india-rubber tubing fitted with glass jets are supplied with each instrument and these when not in use are to be kept in a bottle of dilute hydrochloric acid to prevent their becoming encrusted, being carefully rubbed dry before using.

The microscope can be kept in good order, etc., (i.) if a pasteboard cover be placed over it each time after it has been used, (ii.), if strong acids like nitric and hydrochloric are not added to the objects on the slides or cells (acetic acid will answer in most cases), if (in.) fumes of chlorine, ammonia and sulphuretted hydrogen do not take up their abode near it, if (iv.) any dust on the lenses be removed by the camel's-hair pencil, if (v.) spots or finger-stains be gently rubbed off the lenses with a piece of moistened, soft old linen or kid glove, if (vi.) the surfaces be dried with dry, soft old linen, if (vii.) during cold or excessivelv damp weather the room be heated so that moisture may not form on the lenses, and if (viii.) nobody but the owner dust or wipe it. It is perhaps needless to remark that "objectives" should not be given to teething children wherewith to soothe their aching gums ; various rubber appliances of much less cost will answer that purpose with less damage to both child and microscope.

If dust or moisture should have settled on the mirror it can be readily wiped off. If any spots should show themselves on the field of view when it is illuminated by the mirror these are probably due to particles adherent to one of the lenses of the eye-piece : and this may be determined by turning the eye-piece round which will cause the spots also to rotate, if their source lies in it. It may very probably be sufficient to wipe the upper surface of the eye-glass (by removing its cap), and the lower surface of the field-glass ; but if, after this has been done, the spots should still present themselves, it will be necessary to unscrew the lenses from their sockets and to wipe their inner surface ; taking care to screw them firmly into their place again, and not to confuse the lenses of different eye-pieces. Sometimes the eye-glass is obscured by dust of extreme fineness which may be carried off by a smart puff of breath ; the vapor which then remains upon the surface being readily dissipated by rapidly moving the glass backward and forward a few times through the air. " And it is always desirable to try this plan hi the first instance ; since, however soft the substance with which the glasses are wiped, their polish is impaired in the end by the too frequent repetition of the process. The best material for wiping glass is a piece of soft wash-leather from winch the dust it generally contains has been well beaten out If the object-glasses (objectives) be carefully handled and kept in their boxes when not in use they wall not be likely to require cleansing. One of the chief dangers, however to which they are liable in the hands of an inexperienced microscopist arises from the neglect of precaution m using them with fluids ; which when allowed to come in contact with the surface of the outer glass should be wiped off as soon as possible. In screwing and unscrewing them great care should be taken to keep the glasses at a distance from the surface of the hands ; since they are liable not only to be soiled by actual contact, but to be dimmed by the vaporous exhalations from skin which they do not touch This dimness will be best dissipated by moving the glass quickly through the air. It will sometimes be found on holding an object-glass to the light that particles either of ordinary dust, or more often of the black coatins of the interior of the microscope have settled upon the surface of the back lens ; these are best removed by a clean and dry camels-hair pencil. If any cloudiness or dust should still present itself in an object-glass, after its front and back surfaces have been careful y cleansed it may be unscrewed, cleansed, and screwed together

again. — Carpenter. u

S If the microscope be used at night a flat-wicked lamp fed with one of the best varieties of paraffine oil will prove the most useful light ; place the lamp at the left hand so that no light, save that through the microscope, may enter the eye.

INTRODUCTOKY. 21

MICRO-CHEMICAL REAGENTS. — The chemicals necessary for the identification of sediments described in this book are, acetic acid, ether, carmine solution, iodine water (one grain of iodine, three grains of iodide of potassium, one ounce of distilled water).

Acetic acid should be (i.) concentrated and (ii.) diluted with from three to five parts water ; for some work the strong undiluted acid may be needed, but ordinarily the dilute is all that is necessary.

Carmine solutions may be made in various ways : An ammoniacal solution is obtained by dissolving a few grains of pure carmine in a little ammonia and diluting with distilled water. Filter into a flask, and neutralize the solution with a few drops of acetic acid until it has only a very slight ammoniacal odor.