Guide to the examination of urine, with special reference to the diseases of the urinary apparatus

Front matter

o

Shelf.

UNITED STATES OF AMERICA.

Preface

The office of the translator has been not only to translate, but, also, in several places, to make slight additions or omissions, being guided therein by his experience as teacher of urinalysis in the Medical College of Ohio. In addition, he has supplied the illustrations, that have been drawn by his student, Mr. W. S. Christopher, and which, he hopes, will make the book more attractive as well as more instructive than it would have been ixi the German form.

" May the endeavors to increase the utility of this

work not be without result."

F. F.

Preface To The Second Edition

Comparison with the first edition of this work will show that very many changes have been made. The greater part of the translation has been entirely rewritten. The plates have all been retained, not because of their artistic merit, but because they have seemed to me to show what was wanted in order to bring out certain points. The index is entirely new, and has been written for the special purpose of making the book one that can be easily referred to. The flattering reception of the first edition, faulty as it was, leads me to believe that this, the second, with more notes and in its new form, will take that rank which the original deserves.

F. FORCHHEIMER, M. D.

Introduction

The complicated processes which go to make up the basis of organic life result on the one hand, in the building up of the body, and on the other, in changes which have been collectively termed "retrograde metamorphosis," an elimination of effete substances (which can no longer be utilized by the economy) ; either by the skin and lungs, principally in the form of gas; or by the intestinal tract and kidneys, in the form of solids, or in solution.

To obtain a correct conception of normal or abnormal nutrition, examination must be made into the functional activity of these organs, as well as its results, their excrementitious matter. In the healthy condition of the organism this is exceedingly difficult; in disease of any significance, it is simply impossible. The physician is compelled to restrict his studies, therefore, to one of these excretions — the urine — the most important, fortunately, since by means of qualitative and quantitative changes, it registers, at least approximately, the variations in the life of tissues.

Examination of the urine offers this additional advantage, the fluid can be collected without difficulty, and its analysis, so far as it interests the practicing physician, can be carried out by very simple

means.

2 INTRODUCTION.

Not being a lifeless filtering apparatus, the kidney is subjected to disease, to pathological changes, and as a result, substances are mixed with the urine, whose presence alone will lead the physician to a diagnosis of the disease. The urine, then, gives us an insight into the condition, not only of the urinary apparatus, but of the whole body.

On account of the fact that many substances have the peculiar faculty of leaving the system by means of the kidneys, it may be casually stated here that the urine is of great importance to the pharmacologist, and, in some instances, to the medico-legal expert as well as to the physician.

The desire to recognize disease from the appearance of the urine dates from the most remote past of scientific medicine. In his precise and objective observation of the sick, Hippocrates did not disregard its changes.

He instructed his pupils, in accordance with the condition of other sciences, in the semiotic and the prognostic importance of these changes. He demonstrated the physical properties of urine ; its quantity, color, and clearness, its cloudy or turbid appearance, and the apparent differences in its sediments, referring these to diseases of the urinary apparatus. Whilst his explanations for these appearances may be very unreasonable, his observations were in the main correct, and led him to conceive the influence of food and drink upon the condition of the urine, which he endeavored to show.

In the post-hippocratic descriptions of disease, we

INTRODUCTION. 6

find the condition of the urine taken into consideration, but the followers of the great Coic physician added nothing to his views. Galen developed these teachings, and systematized them, after which their infallibility was not questioned. But for a long time, no progress was made in this direction, and throughout the following centuries we scarcely find one author, who. through personal observations, has added to these transmitted treasures.

To the Arabian, Iben Sina — 980-1037, — usually called Avicenna, belongs the credit of having pointed out the fact that external causes (such as fasting, vigils, physical and mental exertions) influence the condition of the urine. It was he also, who demonstrated that drugs, taken internally, may cause its temporary discoloration. Beyond this, Arabic physicians did nothing of importance on this subject, notwithstanding the presence of an uroscopist at every oriental court.

In ancient times, and during the middle ages, certainly no one attained such prominence in this specialty, as one Johannes, called Actuarius, who lived in the thirteenth century at the court of Byzantium. Adding his own experience to the work of the Hippocrates-Galen school, Johannes describes the physiological changes in urine most minutely, in the seven books of his work "irepl ovpuv" which are conspicuous for method and clearness of description. This production, which exhausted the possibilities of the allied sciences as they then existed, and the inadequate methods at their command, remained isolate,

4 INTRODUCTION.

and our division of symptomatology was more and more neglected in the time which followed. That it furnished material for satirical representations in Dutch genre pictures, as well as for many comedies of Moliere and other poets, is sufficient proof of its degeneration.

Up to this time all conceptions of the chemical composition of urine were highly defective, so that external appearances alone could be considered by authors of the age. Real progress could only be expected from an adequate development of chemistry and its methods of examination; with Lorenzo Bellini, of Florence, this progress begins. Bellini evaporated urine, and observed that as he again added water, the solids dissolved, returning gradually, step by step, through various intensities of taste and color, almost to the original condition. From this he concluded that the different color ahd taste of urine depended upon the relation the solid constituents bore to the water, a conclusion upon which, even now, Vogel's scale of colors is based.

Many important chemical discoveries followed soon after this. Willis discovered sugar in urine ; Brandt, phosphorus, which, Markgraff stated, came from the phosphates that were contained in the urine.

Rouelle, the younger, discovered urea in 1773, and found that calcium carbonate was present in the urine of herbivora, as well as a substance similar to the flowers of benzoe (hippuric acid). In 1770, Cotugno found albumin in urine; in 1798, Cruikshank connected this discovery with dropsy, and, in 1807, Bright

INTRODUCTION. O

finally demonstrated the connection between diseased kidneys and albuminuria.

At the same time, chemical analysis of gravel and calculi were undertaken. Among the many publications of merit on this subject, those of Scheele, Wollaston, Wetzlar, and Prout must be especially mentioned.

To two Frenchmen, however, is due the credit of having developed uroscopy to its present position. The researches of Rayer, as shown in his large work, " Les maladies des reins," form the foundation for our present knowledge of kidney diseases.

Becquerel, the son of the celebrated physicist, had for a long time occupied himself with urinalysis, under the direction of Andral, and modestly gives him all the credit of having inspired him with the thoughts for his observations. These observations having extended through many years, he finally published them in the work "Semiotique des urines." For the thirty years following the appearance of this book, many students have devoted themselves to the same branch, so that probably no other division of zoochemistry has so extensive a literature as this.

After this short sketch of the development of our subject, there remains only a brief discussion of the divisions that have been thought necessary for this book.

After a chapter on the microscopic structure and function of the urinary organs, [without a knowledge of which, comprehension of disease is an impossibility,] the physical character and chemical constituents of

6 INTRODUCTION.

urine, as far as they seem to us important to the practising physician, are treated of. Upon this follows a description of the microscopical part, i. e., the sediments.

Reviews will be of advantage to the beginner, for whom this little work is intended. The short key to the method of examination he will also find of value. Finally, a description of the simple (uncomplicated) diseases of the urinary organs will be found, in so far as they give signs that can be utilized for diagnosis.

Chapter I. Histology Of The Urinary Apparatus

I. The Kidney.*

If a kidney be cut from the papilla* to the fibrous capsules, two concentric layers will become distinctly visible to the naked eye: the central, striped medulla, and the peripheral, more granulated cortex. If the blood-vessels and uriniferous tubules be injected with

Fig i.

A longitudinal section of the kidney of a dog : blood-vessels and uriniferous tubules injected.

different coloring matters, other divisions may be seen.

p, Papillary portion, and (/, 1 )oundary zone of the mednlla ; the dark rays, 7i, are bundles of uriniferous tubules, which are continued, m } into the cortex, and the unshaded divisions of the medullary layer, b, correspond to the bundles of blood-vessels of the boundary zone, r, Is the cortex, or cortical layer ; m, the continuation of the uriniferous tubules of the medullary layer, and c, the unshaded part of the cortex occupied by dots (glomeruli), represents the labyrinth (after Ludwig).

The investigations of Kolliker, Schweigger-Seidel and Ludwig were taken hs a basis for this description of histological relations.

O EXAMINATION OF THE URINE.

In the papilla, and in the neighborhood above it, the kidney seems to be uniformly radiate, colored only by the mass injected into the urinary tubes; this division is called the papillary zone of the medulla. Above this there is a section which is also radiate, but beginning to show the mass injected into the blood-vessels. There can here be seen alternate layers of the injected masses. This part is called the boundary zone of the medulla. The third, outer layer, finally? which encloses the others, is known as the cortical layer, and it shows narrow stripes of the tw r o injected colors, in alternate arrangement. Those colored by the mass injected into the uriniferous tubes are the direct continuations of the fibres of the medulla, and are called medullary rays. To the others (showing granules principally, seemingly colored by the mass injected into the blood-vessels), has been given the name of labyrinth, or cortical layer in the strict sense.

Accordingly, we find through the misroscope that the papillary layer is made up chiefly of straight uriniferous tubules ; the boundary zone, of these and blood vessels ; the pyramids, principally of the straight uriniferous tubules, and the labyrinth, of convoluted tubules, and of convoluted and tortuous blood-vessels.

This system of blood-vessels and uriniferous tubules is supported by connective tissue, which forms a very sparse stroma. It consists of a fine network of connective tissue corpuscles, and is better marked in the medullary layer than in the cortical. Upon the surface of the kidneys the stroma is condensed into a delicate membrane, which is only loosely connected with an

THE KIDNEY. 9

outer fibrous, investing membrane, surrounding the whole kidney, and attached at the hilus to its vessels and the pelvis. This investing membrane is made up of ordinary connective tissue, with a dense, fine, elastic network.

The Uriniferom Tubule originates in the labyrinth, in the form of a spherical dilatation (Capsula Malpighii).* "Then, through a contraction (the neck of the capsule) it progresses in the form of a dilated tube, which takes its course in manifold curves toward the medullary portion. When this large convoluted tube reaches the boundary zone, it contracts and penetrates more or less deeply, as a straight narrow canal (descending, or closed limb of the loop) into the medullary substance, turns back, making a narrow loop {Heinle's loo})), and runs directly upward, towards and into the cortical substance (ascending , or open limb of the loop). 1 '* "Upon returning to the cortex, the tubule, instead of seeking the exact place from which it came, seems to avoid the labyrinth and creeps close to the nearest bundle of medullary rays. Sooner or later, however, it abandons its straight course, enters the labyrinth, as the so-called intermediate portion, and proceeds, in more or less angular curves, between the tortuous canals. Soon it turns again, forming an arch whose convexity is directed towards the convexity of the kidney, towards the medullary rays, there to abandon its individual existence in a union with several other converging tubules into one larger and straight tube (collecting tubule)"

This quotation is taken from the classic description of C. Ludwig. (Handbook of Histology. Strieker.)

EXAMINATION OF THE URINE.

a uriniferous tube ; human kidney.

Such a collecting tubule holds a straight course

until it reaches the papillary portion of the kidney,

Fig 2 . where it unites dicho-

Schematie representation of the course of tomOUSiy, from time

to time, with neighboring collecting tubules, until finally it empties itself (ductus papillaris) upon the surface of the papilla.

p, Papillary layer; g, boundary zone of the medulla; r, cortical substance ( I ), capsule of glomerulus, which enters into tortuous portion (II), through its neck.

The tortuous portion contracts at # the boundary between medulla and cortical, into (III) the descending limb of the loop, and as such, goes through (h) Henle's loop, into (IV), the ascending limb of the loop. To this is added (V), the intermediate portion, which through (r) the external / P loop at the top, enters the collecting tubule., The collecting tubule unites with (VII) its neighbor of the same medullary

THE KIDNEY. 11

ray to form (VIII) the principal tube, and this in turn unites with others until it finally forms (IX) the ductus papillaris.

The walls of the Malpighian capsule are made up of mosaic cells, like those of blood and lymph capillaries. The external surface, or tuft, of the glomerlus is covered by a layer of cells, containing spherical nuclei, and not distinctly separated from each other, which prevent its being washed directly by the fluid contents of the capsule.

"From the neck of the capsule to the commencement of the papillary duct, the wall of the tubule is composed of a tunica propria, and a layer of epithelium resting upon its inner surface." The tunica propria is homogeneous, transparent and elastic. The epithelium, which invests the inner surface, consists of one layer, which is possessed of nuclei, w r hose form is everywhere the same; spherical and sharply defined, and whose contents show many granules. The body of the cell, on the contrary, varies largely in shape. In the arched, tortuous tubules the epithelium forms a collected, gelatinous, cloudy mass, in which nuclei are imbedded at equal distances from each other; a division into cells corresponding to these nuclei, seems to be entirely absent.

a This epithelial pulp sits very loosely upon the basal membrane," and the w r hole substance can be easily forced out of the cut tubules in the form of a cylindrical mass. With the microscope, this is found to contain many oil globules, as well as other dark corpuscles (cloudy swelling of the epithelium), which, upon the addition of dilute acid, are cleared up; but, after being thus cleared, it is often impossible to distinguish anything, except the nuclei of the cells in the mass.

In the small tubules, which form the limbs of the loop of Henle, there appears, instead of the dark and bulky epithelium already described, a light and meager one, covering the walls of the tubule, with a continuous layer of cells, which are much bulged out by the nuclei.

Beyond Henle's loop, where the diameter of the tube increases, the epithelium appears to consist entirely of cylindrical cells, arranged like the shingles of a house, the one above the other, and following the direction of the tube, from the medullary to the cortical layer.

The gelatinous layer, which is common to the tortuous canals, is again found in the intermediate portion.

In the collecting tubules, including the papillary duct, the epithelium is composed of distinctly separated cylindrical cells, with their bases upon the tunica propria, and their blunted points toward the lumen of the tube.*

*[B. Heidenhain (Handbuch der Physiologic Hermann, Bd. V. p. 284-288), who, for over ten years, has been able to distinguish differential markings pi cells, describes the lining of the uriniferous tubules, as follows :

In the tortuous canals he finds epithelial cells of a peculiar character; their protoplasm cousists of fibrils or rods agglutinated by unchanged protoplasm. They form a broadened base, which rests upon the membrana propria, and towards the lumen of the tubule they end in undifferentiated protoplasm which surrounds the cell nucleus. This undifferentiated protoplasm is continuous with that forming the cement substance of the rods. Some of the rods seem to pass the unclear zone, but they never reach the lumen of the canal. In the descending limb of Henle's loop, the epithelium consists of very flat spindle-shaped cells, with badly-defined outlines, whose nuclei project far into the lumen of the canal. In the ascending limb of the

THE KIDNEY. 13

Blood-Vessels of the Kidney. — The renal artery sends the greater part of its blood through the cortical portion. Its branches penetrate to the boundary of the cortex without forming a network, and then rapidly divide into very minute arteries; the arteriolae interlobularis and arteriolar rectte. The interlobular arteries run between two medullary rays, i. e., where several primitive bundles are found together. Arrived in the layer of tortuous tubules, they give off' a branch to each Malpighian capsule. This branch (Vas afferens glomeruli) perforates the spherical end of the tubule (or, according to other authorities, pushes the same before it), and here terminates " in a pendulous bundle of capillaries (glomeruli), which in their turn, are collected within the capsule, into one venous branch (Vas efferens glomeruli).''

This venous radical comes out of the capsule at the place where the artery enters it. After leaving the capsule ki it proceeds toward its medullary ray; or,

loop the epithelium is the same as in the tortuous canals, differing only in the length, both absolute and compared to the size of the cells, of the rods. In the intermediary portions th*at have the same diameters as the tubuli eontorti, are found highly refractive cylindrical cells, with large nuclei and a small amount of protoplasm. Where the cell rests upon the tunica propria the protoplasm spreads, so as to form processes which lie upon processes coming from neighboring cells. In intermediate tubes of smaller diameter the epithelium is lower. In the collecting tubule, within the medullary ray, are found cells approaching the cylindrical in type, but presenting the same peculiarities as described in connection with those of the intermediate portions of large diameters. As we descend, we find typical columnar epithelium, becoming higher the nearer we approach the papillary duct. Heidenhain divides the uriniferous tubule into two portions — the secretory and the efferent. The secretory portion consists of those parts included between the Malpighian tuft and the beginning of the medullary; the efferent, those between the beginning of the medullary ray and the opening of the ductus papillaris."]

where this is lacking (as in the outermost layer of the cortical substance), directly to the tortuous tubules, and splits up into a number of capillaries, which immediately combine to form a network," thus producing meshes which surround the uriniferous tubules. All the efferent vessels communicate with each other by means of their capillaries, forming a continuous capillary network, which occupies the whole cortical substance; this, in its turn, anastomoses with the meshes around the pyramids, and a connection is thus established between the capillaries of the medullary and cortical portions.

Venous trunks are formed by these capillary nets. In that part of the cortical in which no glomeruli are found, the veins originate in the form of stars (Venae stellatse). The common trunk penetrates that part of the cortex which is supplied with tufts and tubules, seeks the neighborhood of an interlobular artery, where it takes up many veins from the surrounding cortical portion.

The veins of the medulla (venule rectse)' run in those spaces which are occupied by the arteries, and unite at the border of the cortex, with the veins coming from the latter, to form large trunks.

The capsule of the kidney receives its blood-vessels partially from the interlobular arteries, and partially from other neighboring trunks (the phrenic, lumbar and supra-renal arteries). Some of their capillaries enter the stellate veins ; some enter veins corresponding to the arteries that have supplied the blood.

The Nerves of the kidney are derived from the

THE BLADDER. 15

coeliac plexus of the sympathetic. They follow the course of the larger vessels, as well as the lymphatics that enter the lumbar glands. Their final terminations are not known.

II. Efferent Passages.

The Ureters, Pelvis of the Kidney and the Calyces are made up of an external fibrous membrane, a layer of unstriped muscular tissue, and a mucous membrane. The fibrous coat is continuous with the albuginea of the kidney, and consists of connective tissue and elastic fibres. In the ureters, the muscular layer is made up distinctly of three divisions : the inner one runs longitudinally, the middle one transversely, and the outer, which is the thinnest, again longitudinally. In the pelvis the relations are the same, except that in the calyces the muscular layers become thinner and finally disappear where they touch the papillae. The mucous membrane is thin, rather rich in blood-vessels, without glands or papillae. The epithelium is present in layers, and is characterized by the varied form and size of its elements. In its deep layers, the cells are round and small ; in the middle layers, cylindrical or spherical, with prolongations; and at the surface, rounded, many cornered, or frequently flattened, and of larger size.

The Bladder possesses the same membrane as the ureters. The muscular layer is frequently quite thick, but the individual fibres are distributed so irregularly that their schematic course cannot be described. Internallv there is usually found a net of circular bundies which cross each other at acute angles, thus forming meshes which lie transversely. These circular fibres are thickest at the opening of the bladder, and there form its sphincter. Upon these circular bundles, follow longitudinal fibres which are of inconstant distribution. The trigonum consists simply of a thickening of the connective tissue layer, extending from the opening of the ureter to the caput gallinaginis. The mucous membrane (except at the trigonum), especially at the neck and fundus of the bladder, has a thick sub-mucous layer, which is rich in blood-vessels and nerves.

At the neck of the bladder, and towards the fundus, are found simple racemose glands, having cylindrical epithelium and mucous contents.

In the bladder the epithelium is found arranged in several layers. Innermost are found cells of a decidedly flattened form, but differing largely both as to size and shape, the one from the other. The middle layer is usually composed of young conical cells, with their apices tow r ard the cavity of the bladder, and whose processes can be frequently traced into the deeper layer. The outer layer is made up of ovoid cells; irregular, and frequently drawn out, where they are in contact with the middle layer.

The superior and inferior vesical arteries (branches of the hypogastric) supply the bladder with blood. They pierce the wall of the bladder at the fundus, pass obliquely through the muscular coat, giving off branches to the same, and then divide into capillaries in the connective tissue under the epithelium.

THE URETHRA. 17

In the connective tissue at the fundus, nerve fibres are not very numerous, but the medullary sheath can be detected in all of them; their terminal branches are not known. The vessels and nerves of the ureters are analogous to those of the bladder.

The Male Urethra has a corpus cavernosum whose structure is like that of the penis, fibrous membrane and meshes, only much more delicate; and a glandular organ — the prostate gland, which forms its support. Under the mucous membrane, throughout its whole extent and below it, there is a well developed connective tissue layer, rich in elastic fibres ; there are also to be found here organic muscular fibres, arranged both longitudinally and transversely.

The epithelium of the male urethra is cylindrical and arranged in layers ; with the exception of the exterior part of the fossa navicularis, where papillae and flat epithelium are already to be found. The cells of the accessory glands, those of the prostate, Cowper's and Littre's glands, and of the vesicula prostatica are conical and can hardly be distinguished from those of the urethra.

The Female Urethra has no corpus cavernosum; its mucous membrane is rich in vascular supply, and has flat epithelium in layers. In addition there are very few glands of Littre to be found in it.

k. it.-

CHAPTER II. Secretion of the Urine

The function of the kidney is to secrete the urine : that of the bladder and ureters, on the other hand, to collect, retain, and carry it off. A theory which is entirely satisfactory, and explains all facts concerning the secretion and excretion of urine, does. not, as yet, exist.

Bowman, basing his views upon the anatomical structure of the kidneys, thinks that the epithelial cells are secretory organs, and that w r ater only is excreted by the tufts, which washes the constituents of urine out of the epithelial cells.

Ludwig bases his theory, on the one hand, upon the different amount of blood pressure in the various blood-vessels of the kidney; on the other, upon the different capacity that substances possess of passing through animal membranes. He assumes that the pressure upon the glomeruli is greater than in the capillaries surrounding the uriniferous tubules. As a result, an abundant transudation of water and salts in solution, (serum of blood, little albumin and fat) must take place from the blood into the Malphigian capsule. Thus, very dilute urine is to be found in the uriniferous tubules, and highly concentrated blood, in the capillaries surrounding the tubule.

SECRETION OF THE URINE. 19

These two fluids, differing so widely in density, and separated from each other by animal membrane, produce active currents of diffusion : as a result, water is added to the concentrated blood, on the one side, and on the other, products of retrograde metamorphosis (urea) and salts, are added to the dilute urine in the uriniferous tubules. In this way the watery urine becomes more concentrated, richer in urea and salts; becomes urine. The absence of albumin is to be explained, in that this substance does not easily pass through animal membranes, and then only as a result of increased pressure (the walls of the blood-vessels and tubules are animal membrane) : accompanying pathological conditions, with increased pressure in the glomeruli < stasis in the veins of the kidney) albumin is always found in the urine, but under normal pressure this is never the case. Although this theory explains many physiological and pathological facts, yet it does not explain how an alkaline serum of the blood produces an acid urine. According to this mechanical theory of Ludwig. the secretion of urine is a process of filtration taking place in the glomerulus and a process of diffusion throughout the course of the tubules; the epithelial cells lining the tubules are not taken into consideration at all.

According to Goll and Max Hermann, the difference in pressure between the contents of the vessels and urinary tubules, is the principal. force that causes the transmission of the constituents of the urine from the blood to the tubules. According to this, when pressure is increased in the renal artery the quantity of urine immediately increases; but when the pressure in the artery is diminished, or when pressure in the ureters is increased, blood pressure remaining normal, secretion diminishes, and may cease entirely, long before the pressure in the ureters equals that in the renal artery.

Ustimowitsch and Grutzner have elaborated this theory, in so far that they showed by experiments on . dogs, that the local pressure in the glomeruli only, not the general blood pressure, must be taken into consideration.

Upon section of the medulla in a dog, and electric irritation of the same producing increased blood pressure, secretion of urine ceased entirely, because the smaller vessels of the kidney contracted. If, in addition, the nerves going to one of the kidneys were divided, there would follow on that side a profuse flow of urine, whilst on the other no urine would flow from the ureter. By means of division of the nerves going to the kidneys, its smallest arteries become dilated and relaxed, thus increasing pressure in the smaller vessels and stimulating the flow of urine.

In addition, Ustimowitsch demonstrated that an increase in secretion of urine can take place, even when the general blood pressure is diminished. If the splanchnic nerve (which contains the vasomotoric tracts for the kidney) be divided, the pressure in the aorta is diminished ; at the same time, however, dilatation of the smaller arteries in the kidney ensues, so that an increase in secretion can be verified.

Heidenhain and Wittich support Bowman's views

SECRETION OF THE URINE. 21

concerning the secretive function of the epithelium in the tortuous uriniferous tubules, for they show by experiments with indigo sodium sulphate, sodium urate and ammonium carminate, that these substances are principally secreted by this epithelium.