WJ F837r 1850 v. :"X.„ v:n i/ i. ; :-H.:-i |!l::l ;li.: <;i ■■ < i , if..... !.>l''!ii 'ill' I H! llilllllllljl^'llliiM :' ' H!:,iii'«! Hi!:1 :!!'-'::ii' ■.':/-, Sfe..i!i!l||ili.,,mW:iiWi^-^'" ih::«; |iiii:i:r|«!f'ini..iili,i.i!- I /U: ilMijiJ*: Yfcv; , ' lii:,:ii >j 7,: .< . I ;i:r: li!':; *Hr9' "SJ. it———■ ! Surgeon General's Office f 02* A .3L> X\ x\ X I % ''« \ J \ n... yr// ffclJ" " -----:----—> ■/, • I EENAL AFFECTIONS. l\ I RENAL AFFECTIONS: DIAGNOSIS AND PATHOLOGY. CHARLES FRICK, M.D. r.ccn ^sril's '\ \; LILEASY. ... Kington D.°v PHILADELPHIA: LEA AND BLANCHARD. 18 50. MS/3 )850 Entered, according to Act of Congress, in the year 1850, BY LEA AND BLANCHARD, In the Clerk's Office of the District Court for the Eastern District of Pennsylvania. PHILADELPHIA: C. SHERMAN, PRINTER. DAVID STEWART, M.D., BALTIMORE, MARYLAND, €jrii Uttli ^nrk IS AFFECTIONATELY INSCRIBED, IN ACKNOWLEDGMENT OF THE MANY FAVOURS RECEIVED AT HIS HANDS BY THE AUTHOK. PREFACE. The design of the following little volume " On the Diagnosis and Pathology of Renal Affectiona/' was suggested to the author some time since, by the difficulty he experienced in referring medical students to some more elementary work than now exiats on this branch of Pathology; and a greater part of the present volume consists of the notes that were written from time to time to aid the studies of those under hia care. Having within the last few years paid particular attention to this branch of animal chemistry, he has thought, that the mode and resulta of hia in- vestigations arranged in what he thinka a more intelligible form than those presented to the public some few years back, might not prove unacceptable to those members of hia profesaion, who have wished to devote themselves to the study of Urinary Patho- logy, and who have been deterred from the pursuit by the formi- dable array of chemical changes, and the innumerable varieties of crystalline formations. It has occurred to the author, that the reason this subject is generally found to be distasteful to beginners, is owing in a great measure to the arrangement of the different works; in a majority of them the account of each component article of the secretion is entered into separately, and so the reader is required viii PREFACE. to go through the entire book, before he is able to make an ex- amination of the most simple specimen. This defect he has en- deavoured to remedy, and in the first chapter, therefore, are laid down directions to be pursued when a superficial examination 'only, is necessary. In the next, rules for a more exact analysis, and so on, progressively in the following chapters, so that the student may commence with the more simple cases, and go on by degrees to those requiring greater accuracy of observation. At the same time, as he wishes to avoid conveying a mere empirical knowledge, the rationale of each step and the indications it af- fords will be explained in turn. He of course, doea not aasume that all the matter contained in the text is original, but believes, that in every instance he has given due credit to the labours of those who have preceded him, and as every observer, however honest, is liable to err, he will at any future time gladly modify the opinions herein re- corded, should more extensive observation prove his results to be incorrect. In conclusion, the author would remark that, with some few exceptions, the figures accompanying the text have been copied by himself from the field of the microscope. Baltimore, Md., October 1850. CONTENTS. INTRODUCTION. Sources of the Urine, and its relations to Chemistry—Common Errors respecting the Appearance of the Secretion—Different Modes of appreciating its Condition, ------ 13 CHAPTER I. THE INFORMATION DERIVED FROM AN EXAMINATION AT THE BEDSIDE. Differences in the Secretion at different periods of the day—Fre- quency and infrequency in passing it—Colour—General Indica- tions to be derived from Appearance—Odour—Application of Heat,...........21 CHAPTER II. DIRECTIONS FOR A MORE EXACT EXAMINATION. Necessity for making an Examination soon after the Urine is passed—Specific Gravity, the indications it affords—Tempera- ture necessary to be observed—Reaction—To advance further, two modes of examination may be used, the Microscope and Chemical Tests—Have confined ourselves in the present chapter x CONTENTS. to the last-Estimation of the Urea-Uric Acid-Hippuric Acid- Phosphates-Mucus-Albumen-Blood-Pus-Sugar-Oxalate ^ of Lime—Cystin—Bile—Kyestein, - APPENDIX TO CHAPTER II. Liebig's Mode of obtaining Hippuric Acid-Tests for Sugar- Detection of Sulphate of Lime-Quantitative Analyses of Healthy Urine—Henry's Table of Solid Matters in Urine—Detection of Kreatine and Kreatinine,..... --48 CHAPTER III. MICROSCOPIC EXAMINATION OF THE URINE, WITH PLATES. Mode of selecting the Specimen for Examination—The Use of the Instrument—Uric Acid—Urate of Ammonia—Urate of Soda— Hippuric Acid—Phosphate of Magnesia and Ammonia—Phos- phate of Lime—Chloride of Sodium—Cystin—Oxalate of Lime— Mucus—Pus—Blood—Torulae—Sediment in Bright's Disease— Spermatozose, ----------55 CHAPTER IV. PATHOLOGY OF THE DIFFERENT SUBSTANCES IN THE URINE. Uric Acid—Urea—Phosphates—Mucus—Albumen—Blood—Pus— Cystin—Sugar—Oxalate of Lime—Spermatozose—Kyestein, - 86 CHAPTER V. ON THE PATHOLOGY AND THERAPEUTICAL JNDXCATIONS OF THE MORE !MPORTANT SUBSTANCES OF THE URINARY SECRETION. Composition of the Urine-Its derivation-Quantity of Water-Hys- teria- Urea and Uric Acid-Theiv derivation-Objections to CONTENTS. Liebig's Theory explained—Hlustrations of the Changes these Bubstances undergo in different diseases—Gout and Rheumatism —Difference between the two—Causes—Chemical Theory alone untenable — Influence of the Nervous System — Treatment— Colchicum—Blood-letting—Diet—Hydropathy—Internal Reme- dies—Hippuric Acid—Its derivation—Experiments on the changes Benzoic Acid undergoes—Case I., of Gout—Phosphates—Deriva- tion—Mode of combination—Relation of Phosphoric to Uric Acid —True and false Diathesis—Treatment—Stellar and Prismatic Crystals not different salts, as heretofore assumed—Albumen— Due to congestion—Objections to Prout's Theory—Treatment— Oxalate of Lime—Formed from Uric Acid—May be formed with- out Urea—Objections to Bird's Theory—Commonly found in the Urine of Convicts—In persons suffering from Spermatorrhoea— Dumb Bells probably not Oxalate of Lime—May be formed from Uric Acid—Relation of Ovals and Dumb Bells to one another— Uric Acid Theory insufficient to account for all cases of Oxalate of Lime—It is also due to defective conversion of Lactic Acid— Treatment—Case II.—Case III.—Case IV.—Diabetes—Pathology more obscure than the preceding—Professor Graham's Experi- ments— Bouchardat's Theory—Mialhe's Theory—Symptoms— Treatment, - - -....... CHAPTER VI. On the Analysis of Calculi, ---..... Table of the Chemical Constitution of the Principal Substances referred to,--------"" / INTRODUCTION. In all bodies endowed with animal life two processes are constantly going on, namely, waste and reparation; but the relation of these to one another varies at different ages of the individual's growth. In an animal arrived at maturity, these processes nearly equalize one another, while in early life, the addition of new material, in the form of vitalized tissue, more than counterbalances the waste that is produced by their disintegration. Both these changes are effected by the influence of oxygen; and of the substances thus formed, those destined for elimination are carried with the circulating fluid to the different excreting organs, each of which abstracts from it those materials, fully formed, which it is its province to excrete. The lungs and skin per- form a part of the function allotted to them by ridding the economy of carbonic acid, while the kidneys are the emunctories by which the effete matter, produced during the decomposition of the tissues, as well as those substances that can take no part in the animal economy, or whose retention would be injurious, are eliminated from the sys- tem ; and it is in the secretion of these organs, therefore, that we are principally to look for any derangement in the 2 14 INTRODUCTION. function of digestion, or of mal-assimilation in the processes of disintegration. For this reason a certain degree of attention has always been paid to the appearance of the urinary secretion, but it has only been within the last few years that investigations founded upon a scientific basis, have been made with a view of ascertaining the alterations that it undergoes in different abnormal states of the sys- tem ; for, like all the excretions and secretions of the animal body, this fluid has a healthy standard, and any de- parture from it indicates some morbid condition in one or more of the other functions. But we have as yet only arrived at the threshold: the few facts already ascertained, although affording very material assistance in the diagnosis and treatment of some obscure affections, constitute but a small portion of the immense field laid open for future researches. The objections that have been urged against Chemistry in its explanation of the various phenomena that take place in the animal body, as omitting in all these operations the influence exerted by the vital power, cannot be sustained when its laws are adduced to explain the physiology and pathology of the urinary secretion. For we are well aware that the presence of the different ingredients entering into this secretion is almost entirely due to the processes of eremacausis or decay. If vitality had continued in force, this change could not have taken place, and it is only when the influence of this power is entirely removed from the different particles entering into the composition of the tis- sues that chemical phenomena can be brought into play INTRODUCTION. 15 and effect the formation of those substances whose elimina- tion is the principal function that nature purposed the kid- neys to perform. With the exception therefore of the therapeutical indications, we are dealing entirely with effete matter, whose domain is far removed from the influence of vital laws. The physiology of this secretion in all its bearings, even at this time, is not entirely explained, and it can scarcely be a matter of surprise that many incorrect ideas should be prevalent among those who have given to this subject but little of their attention. Three of these opinions we have found to be very universal even among medical men, all of which are decidedly erroneous, and it shall be our first care to explain them away. In the first place, that an abnormal condition of the urine is always associated with some defect functional or organic of the kidneys; secondly, that a deposit is always indicative of an abnormal state of the secretion; and what is of more importance still, that a healthy ap- pearance of the urine cannot be associated with an un- healthy condition of that fluid. In regard to the first of these opinions the fact is, that the urine is never indicative of the physical condition of the kidneys any more than the blood is of the state of the heart except in two instances, and these are where it contains pus, or some of the ele- ments of the circulating fluid, as albumen, liquor sanguinis or blood; in all other cases the foreign materials present are dependent on mal-assimilation, either of some article of food or of the tissues entering into the composition of the body, or are derived from the ureters and coat of the 16 INTRODUCTION. bladder. In the second place, a deposit may very fre- quently occur from a precipitation of some healthy ingre- dient, by subjecting it to a lower temperature or to evapo- ration, or from decomposition where new elements are formed as will be explained hereafter; thus, when a por- tion of healthy urine is subjected to the air-pump, a dense cloud is formed almost immediately from the precipitation of urate of ammonia which is no longer held in solution when evaporation takes place, and the same result fre- quently occurs on any decided diminution of the tempera- ture ; thus during the winter healthy urine passed at night, and perfectly clear, from this cause often contains a sedi- ment in the morning. Again, in the third place, the urine may be loaded with albumen or sugar in solution, and yet present a perfectly healthy appearance on a casual exami- nation, or even with oxalate of lime in crystals,, which from their property of refracting light in a peculiar manner, are not discoverable until a drop of the fluid is placed under the field of the microscope. The normal constituents of the urine being dependent upon many different circumstances, such as the season of the year, the different periods of the day, and the kind of aliment used, it is impossible to lay down any exact standard of its composition which will be applicable in all cases, and in the examination of every specimen all these conditions must be taken into consideration. In the first place, just in proportion as the secretion of the skin is greater will that of the kidneys be less, so that an excessive or diminished secretion cannot in itself be regarded as an evidence of INTRODUCTION. 17 disease. Thus we find that a greater amount of urine is passed in the winter than in the summer; consequently, although we may find the relative amount of solids in two specimens to be very different, yet the absolute amount in regard to the whole quantity voided in twenty-four hours will be exactly the same. It has also been found that the average specific gravity of the urine passed at night is much higher than that passed in the morning, and it fre- quently occurs than an abnormal salt is present at one of these periods, and yet wanting at another, so that in all cases, unless an average of the whole passed in twenty-four • hours be examined, we may be led into an important error. The most frequent deposit met with in the urine is urate of ammonia, and its importance depends very much upon the fact whether it exists in a state of solution or not at the time of emission. Nearly all urine contains a greater or less amount of this substance, and as it is formed by the uric acid uniting with ammonia, derived either from decomposi- tion or deficient action on the part of the skin, it is evi- dent that it may be indicative either of one of these condi- tions, or merely of the amount of uric acid in the urine; and it becomes of great importance when it is present in so large a proportion as to be deposited while the secretion is still in the bladder. If it exists in any excess, a deposit of it occurs when the urine becomes cool from its being less soluble in cold than in warm water; and in cold weather, as just stated, we often observe it deposited from this cause in the morning in the urine passed the previous night; and again, as one of the functions of the skin is to 2* 18 INTRODUCTION. eliminate ammonia, a sudden check of perspiration is often followed by a deposit of this salt in the urinary secre- tion. It is also frequently met with in urine passed soon after taking a full meal. This is because the oxygen that should have been used for the conversion of the uric acid into urea, has been appropriated by the system to effect the necessary changes in the food by the formation of car- bonic acid and water. In this way an excess of uric acid remains unconverted into urea, which excess by uniting with ammonia derived from various sources forms a deposit if the quantity of water be insufficient to dissolve it, or the temperature undergoes any decided diminution. But this will be more fully explained at another place. • In any fluid containing urea and uric acid, a deposit of this salt is apt to occur after a time from decomposition. Urea resolved into its ultimate elements consists of carbonic acid, ammo- nia and water, and as this resolution takes place, the ammonia often unites with the uric acid to form urate of ammonia, while carbonic acid is given off. We are thus shown that the longer the period that elapses after the discharge of the specimen submitted for examination, the more unfit it is for exact analysis. It will be found that, with the exception of sugar and albumen, neither of which exist in healthy urine, the rela- tive proportion of the different ingredients is of little direct importance when they exist in a state of solution, except as indicating the derangement of system under which the patient is suffering. The quantity of phosphates, carbo- nates, urea, and uric acid is influenced very much by the INTRODUCTION. 19 kind of aliment used, and the amount of oxygen taken in, and whether they are deficient or in excess, their presence produces but slight inconvenience so long as they remain in solution. There are various modes of appreciating the properties of the urinary secretion, but they may all be included under three heads,—the physical, mechanical, and chemical. The first of these relates merely to those properties which can be detected by the use of the unaided senses, such as colour, odour, opacity, &c, and to these we have confined our- selves in the first chapter. The second enables us to ascer- tain the density of the urine, the proportion of solid con- tents to the water, and to one another. By the third, we learn what these different ingredients are composed of, and thus ascertain the normal amount of healthy substances, or the existence of abnormal elements. To tnese are also added the assistance afforded by microscopic observation, which often enables us at a glance to detect the existence of some abnormal product after all other means have failed. Each of these will be considered in detail. It is not to be supposed that these different modes of exploration can in any degree do away with close observa- tion of the other symptoms of the diseased state under consideration, any more than auscultation makes an ex- amination of the general symptoms of diseases of the chest unnecessary; nor must it be imagined that an exploration of the urine is of assistance in all diseases. It is as a general rule an addition merely to symptomatology, and has already been found an important aid in the diagnosis of 20 INTRODUCTION. some obscure dyspeptic complaints, in many of them affording what might almost be termed a pathognomonic symptom. And as in making up a diagnosis, each organ and its functions should be in turn subjected to an exami- nation, until we are satisfied as to the location of the disease, we shall endeavour to lay down in the following pages some directions by which the presence of the diffe- rent normal and abnormal ingredients in the urine may be detected, with their relative importance and pathological signification. RENAL AFFECTIONS. CHAPTER I. PRECAUTIONS TO BE OBSERVED IN OBTAINING A SPECIMEN OF URINE, WITH INSTRUCTIONS FOR A SUPERFICIAL EXAMINATION AT THE BEDSIDE. The urine voided at different periods of digestion and assimilation, possesses different properties, which for con- venience have been arranged under separate heads,—these are called urina chyli, urina sanguinis, and urina potus. The first generally contains some of the physical or chemi- cal substances of the food that have not been assimilated in the process of digestion; the second, those elements of disorganization which are derived from the tissues which can no longer subserve any purpose in the economy, and are consequently carried off by the kidneys after first pass- ing into the blood; and the third, which constitutes by far the largest source of the secretion, is derived from the watery portion of the fluid potations which are constantly taken into the system. Now, as the derangement which 22 PHYSICAL EXAMINATION. produces an abnormal condition of the urine may be resi- dent in but one of these sources, it is evident that an ex- amination made of a portion of it passed at one period of the day may contain no abnormal ingredient, while in that voided at another, ample evidences of a diseased condition will be found. For instance, an abnormal condition of the urina chyli which is wanting in the urina sanguinis, points to some error in digestion, and would be most perceptible in the urine passed a few hours after the principal meal; while any departure from the healthy standard in the urina sanguinis indicates a fault in secondary assimilation, and would be most apparent in that portion of the secretion passed on first rising in the morning. It is therefore necessary that the examination should be made at different periods of the day, or that an average of the whole should be taken. For all practical purposes it will be sufficient to take an average specimen of that passed on going to bed and on rising in the morning, or if we wish to be more exact, to examine these specimens separately. In a more superficial examination, however, such as we are at present detailing, if the patient be intelligent, it will be sufficient to rely upon his assurance for its character and appearance, unless the diagnosis of the case be obscure, or there are symptoms leading us to suspect derangement of the urinary organs. We first ascertain whether the urine is passed frequently, and if so upon what this frequency is dependent. "Fre- quent calls to urinate may be owing to a large increase of the renal secretion, and when attended with pain to a con- PHYSICAL EXAMINATION. 23 centrated state of the urine, to inflammation of the bladder, to the ingestion or absorption of the active principle of cantharides or of turpentine, to the presence of a calculus in the bladder, to enlargement of the prostate gland, to pressure of some adjacent organ or tumour, and to an ex- cited state of the nervous system."* If it is to the first of these causes, it will be dependent either upon the previous ingestion of large quantities of fluid, to hysteria, or to the fact of its containing sugar. The last of these three may be suspected when it cannot be traced to either of the other causes, when there is emaciation and inordinate appetite, or when the disease is of a chronic form. If the frequency is owing to any other of the above-mentioned causes, ap- propriate symptoms will easily lead to its detection. Our attention is next directed to ascertain if retention of urine exists, or if it is voided at longer intervals than usual. Infrequency in passing urine is owing either to its being scantily secreted by the kidneys or to its retention in the bladder. In the first case the whole quantity passed will be less than in a state of health, and is owing either to in- ordinate action of the skin, or to some cause which interferes with the secreting function of the kidneys. If the condi- tion is an acute one, it is most probably due to congestion or inflammation of these organs, and if chronic to granular degenerescence of the cortical portion. Infrequency, de- pendent upon retention in the bladder, is owing either to some physical cause which prevents its escape, or to the nervous sensibility of the patient being so blunted that the * Still's Pathology, page 286. 24 PHYSICAL EXAMINATION. presence of the urine gives rise to no sensation, and thus allows it to accumulate in the bladder. Our attention, in the third place, is directed to the ap- pearance of the urine. The healthy secretion, in colour, although generally of an amber hue, depends in a great measure upon the amount of concentration it has under- gone, and in many cases to the ingestion of different ar- ticles of food. Thus it is darker in summer than in winter, because more fluid is secreted by the skin, and consequently less by the kidneys, and it is also said to be darker in men than in women, from the fact of the former taking more ex- ercise and thus increasing the amount of the cutaneous ex- halation. Pereira brava, hgematoxylon, and beet-root, have the property of rendering the urine deep brown and red, rhubarb yellow, and indigo gives it a bluish tinge. Ner- vous affections and anaemia render it pale, while in febrile disorders it becomes darker. The following appearances as indicative of particular conditions may also be remarked. If it is of a deep yellow or orange colour, we may suspect bile; if citron coloured or yellowish-green, oxalate of lime; if of a pale straw colour with a bluish-green tint and hav- ing the odour of whey, sugar; if it is transparent when warm, but forms a deposit on cooling, lithate of ammonia; while if it is pale and cloudy when passed and becomes opaque on the addition of a few drops of vinegar, we may suspect albumen. But after all, so long as the secretion retains its transparency and is perfectly free from sedi- ment, the practical indications to be derived from its colour are of little importance. After taking turpentine for some days, the urine in many cases assumes an opaque and PHYSICAL EXAMINATION. 25 milky aspect, but soon clears up when the remedy is dis- continued. The presence of blood in the urine is indi- cated when the secretion is opaque and of a dirty brown, red, or black colour, and of pus when it is of a dirty yel- lowish-white ; but both of these will interfere with the trans- parency of the secretion, and if the vessel containing the specimen be allowed to stand, will form a sediment,—the first as a flocculent and easily-diffused mass, and the second resembling a layer of cream or oil. We stated that urate of ammonia was often found exist- ing as a deposit, sometimes as a result of decomposition, and at others before this had taken place. When not owing to decomposition or to a diminution of the temperature, it is principally indicative of some impairment of the functions of the skin, by which ammonia is retained in the system and uniting with the uric acid passes off as urate of am- monia. Its diagnosis is very simple : being perfectly soluble in warm water, we have but to heat the suspected urine by warming the vessel containing it, when it almost immedi- ately clears up, to be deposited when it again cools. The odour of the urine is influenced by articles of food and by different medicines, as asparagus, onions, garlic, juniper-berries, assafoetida, and copaiba. When sugar is present the odour is first that of whey, and then of alcohol, and when decomposition has taken place it is strongly am- moniacal. Urine may be perfectly healthy in appearance and yet contain albumen, sugar, or oxalate of lime. The first of these is readily recognised at the bedside. We suspect the 3 26 PHYSICAL EXAMINATION. presence of the second when an unusually large quantity is passed habitually, attended by thirst and emaciation; and the third is indicated by great depression of spirits, inability for mental or physical exertion, together with pain in the back and along the course of the urethra. After observing the colour, odour, &c, of the specimen, our next proceeding is the application of heat. This is readily done by immersing some of it, contained either in a spoon or a vial, in hot water, or holding it over a lamp. By this means we detect the urates, albumen, and the phos- phates. The first are dissolved, the other two deposited. Albumen and the phosphates are readily distinguishable from one another by the appearance the deposit assumes, the first being gelatinous, and the other crystalline. The preceding directions constitute all that can be given for an examination at the bedside. They can do little more than point out whether there be any necessity for further examination; and this should always be made when any peculiarity about the appearance of the secretion will allow us to suspect the presence of an abnormal ingre- dient. We would moreover remark, that inasmuch as albu- men, sugar, or oxalate of lime may be present in small quantities, without producing any change in the appear- ance of the urine, or giving rise to any particular symp- toms local or general, which would lead us to suspect them, we will scarcely have performed our duty to the patient, unless an examination for one or all of these substances be made in every case of disease where the symptoms are obscure, and the diagnosis uncertain. CHAPTER II. DIRECTIONS FOR A MORE EXACT EXAMINATION OF THE DIFFERENT INGREDIENTS OF THE URINARY SECRETION. Necessity of examining a specimen of Urine soon after it is passed— Specific Gravity, the indications it affords—Temperature necessary to be observed—Reaction—To advance further, two modes of exami- nation may be used, the Microscope and Chemical Tests—Have con- fined ourselves in the present chapter to the last—Estimation of the Urea—Uric Acid—Hippuric Acid—Phosphates—Mucus—Albumen— Blood—Pus—Sugar—Oxalate of Lime—Cystin—Bile—Kyestein. It will be seen by the preceding chapter, that all the information afforded by an examination of the urine at the bedside, can do little more than indicate to us the neces- sity of further examination, or otherwise. If the diagnosis of the disease under which the patient is suffering be evi- dent, and the urinary secretion is natural in appearance, there will be little necessity for proceeding further; but if the reverse is the case, we should, in all instances where it is practicable, obtain a specimen for more exact observa- tion. The same precautions in selecting it are to be ob- served as before, taking care that the examination is made as soon as possible after voiding it. We explained previ- ously, how readily urea became resolved into carbonic acid 28 SPECIFIC GRAVITY. and ammonia from decomposition; and from the same cause, after allowing a vial of urine to stand for some days, or even for twenty-four hours, we may often observe prisms of the triple phosphate formed by the ammonia uniting with the phosphate of magnesia, and occasionally crystals in the form of dumb bells, under the field of the microscope, which did not exist at the time of emission, thus evidencing the inutility of an examination after decomposition has taken place. Having observed these precautions, our first step should be to ascertain the specific gravity. This is done either by means of a specific gravity bottle, a. urinometer, or by fill- ing a vial, the weight of which is known, first with dis- tilled water, then with urine, and dividing one of these weights by the other. Of these different means the urino- meter is by far the most convenient; it is exceedingly simple in its construction, and its mode of application is obvious on inspection. The specific gravity of healthy urine varies between 1*022 and 1*028, and is greater in summer, when a large amount of fluid is passed off by the skin, and consequently less by the kidneys, than in winter. The amount voided by a healthy individual varies, for the same reason, between twenty-five and thirty-five ounces. We can readily understand then, that although the same amount of solids may be passed each day, the specific gravity will differ in proportion to the quantity of water in which they are dissolved. If therefore it should vary much either above or below these numbers, the amount of fluid passed remaining normal, we should be led from this TEMPERATURE—REACTION. 29 cause alone to make further examination. This step is not absolutely necessary, but it will be found, in many in- stances, to afford us very material assistance. It is also of importance, in many instances, to ascertain the temperature; and for this purpose, in some of the boxes intended for urinary examination, a thermometer with an elongated bulb is added. There are many sub- stances which remain dissolved at a certain temperature, but are precipitated at a lower; and in this way the specific gravity may become altered. We next proceed to test the reaction. Healthy urine is always acid, and this probably depends not on any free acid existing in the secretion, but on some of the phos- phatic salts which have an acid reaction. If litmus paper is changed from blue to red, showing an acid state of the urine, we gain merely negative results, but if changed from red to blue, indicating an alkaline condition which cannot be accounted for by decomposition or alkaline remedies, or sorne acute disease of the brain, we have reason to suspect the presence of albumen. After ascertaining the specific gravity of the specimen under consideration, we apply heat by means of a spirit- lamp until boiling commences, to a small quantity of the urine contained in a test-tube. By this means we detect urate of ammonia, albumen, and the phosphates. The first of these is dissolved by heat, the two latter pre- cipitated. The detection of urate of ammonia has been already detailed in the first chapter; the distinction be- 3* 30 CHEMICAL TESTS. tween the two others will be explained at an appropriate place in the present. For further proceeding, two different modes are brought into play,—chemical tests and the microscope. Neither of these can take the place of the other, but each serves to substantiate the results previously obtained. All speci- mens of urine submitted for examination, and allowed to stand for a few hours, are found to be either clear, or containing a deposit. If clear, chemical tests alone can afford us an insight into their condition; but if a deposit exists, their nature can be much more easily determined by the aid of the microscope; and in the present chapter we shall confine our remarks to the use of chemical tests alone. We stated in the introduction, that with the exception of sugar and albumen, there were no sub- stances that gave rise to decided therapeutical indica- tions, so long as they remained in solution in the urine; but still these substances are of importance in pointing out the particular diathesis, and thus enable us ofteii to ward off a direct attack of disease by timely treatment. For instance, in a gouty individual, however large the quantity of uric acid may be in the urine, as a general rule there will be no paroxysm, so long as it remains in solution, but still this excess is an indication to us for pre- ventive treatment. We say as a general rule, for it occa- sionally happens that the blood is loaded with uric acid, while the urine contains but a small quantity. This may be owing to simple congestion, or some other functional defect of the kidneys; and an attack of gout then takes UREA. 31 place, without any absolute excess of acid. But this will be explained more fully in its appropriate place. The qualitative estimation of the urea is the first sub- stance we take into consideration. Urea combines readily as a base with nitric or oxalic acid. The first is the one generally used for its detection. A small quantity, say about a drachm, of the urine is placed in a watch-glass; to this an equal bulk of nitric acid is added, and the mixture allowed to stand, taking care that the temperature is at a proper medium, for if it is too cold, crystallization is accele- rated, and if too warm, retarded. We should endeavour to allow the acid and urine to mix gradually, and instead of pouring them quickly together, we should by means of a pipette, or a small glass funnel, placed on the bottom of the watch-glass which already contains the urine, allow the acid to mix gradually from below. We sometimes see crystallization commence almost immediately, indicating a very decided excess of urea, provided the amount of urine passed was normal from which the specimen was obtained. If, however, at the end of half an hour we observe only a few crystals around the edges, and a few air bubbles on the surface, we conclude the amount to be either normal or deficient. This proceeding is an approximative one only, as we do not purpose to go into a lengthened detail of the exact quantitative analysis of these different ele- ments. Should albumen be present in the urine, its pre- cipitation on the addition of nitric acid would prevent us from ascertaining the amount of nitrate of urea formed. This is to be remedied either by coagulating the albumen 32 URIC ACID. by heat, or precipitating it with alcohol, then filtering and proceeding as before. Occasionally we may wish to isolate the urea from the other elements in the urine. This may be done by a very simple process. Evaporate very slowly a given quantity of urine to the consistence of syrup, and add gradually an equal bulk of nitric acid, taking care that the mixture be kept cool. After a few hours the vessel will be filled with crystals of nitrate of urea, which may be collected on a filter, if washed carefully from time to time with a few drops of diluted nitric acid. Dry these crystals by means of a gentle heat, then dissolve them in distilled water, and neu- tralize the solution by means of carbonate of potassa. By this means nitrate of potassa is formed, carbonic acid given off, and the urea liberated. Evaporate this solution by means of a gentle heat to dryness, and add boiling alcohol. This extracts the urea, which may be obtained in pure crystals by allowing the alcohol to cool and evaporation to take place. The next substance for' examination is the uric acid. This acid exists in all healthy urine, and bears a propor- tion to urea of about one to thirty-two, so that about eight grains are passed daily from a healthy individual. Nitric acid, although frequently used for the detection of uric acid, is liable to induce error, for although it first precipi- tates it from its combinations and takes its place, yet if more be added, as an excess has the property of dissolving uric acid, we may easily redissolve all that had been pre- viously thrown down. This is remedied by substituting hydrochloric acid, in which it is insoluble. The deposit URIC ACID. 33 will consist of fine reddish grains, easily distinguishable by the naked eye, coating the sides as well as the bottom of the test tube. But as these grains are sometimes so minute as to escape detection, it will be well in all instances to use a small feather along the sides of the test tube, which de- taching the crystals, allows them to fall to the bottom, where their quantity can be more easily appreciated. Should there be any doubt in regard to the nature of the deposit either existing originally or deposited with acid, we should take a small quantity and add to it a drop of nitric acid, then evaporate this by a gentle heat, and on holding it over the vapour of ammonia, if it consists of uric acid it becomes a rich purple colour. This is the murexid of Liebig. The most convenient way of performing this is to dissolve the acid in a watch-glass in a few drops of nitric acid, evaporate this, and then invert it over another watch- glass containing a few drops of strong ammonia. By applying a gentle heat, the rich purple colour will be per- ceived in the upper glass. Heated with liquor potassse, uric acid is readily made to dissolve from the formation of urate of potash. The specific gravity of urine containing an excess of uric acid is generally above the average, it is always acid, and usually of a deeper amber tint than natu- ral. In a small test-tube containing about half an ounce, the normal amount of this substance precipitated by hydro- chloric acid would not be more than sufficient to cover lightly the bottom of the vessel. If we observe but a few crystals after allowing the specimen to stand for some hours, for it does not form immediately, we conclude that 34 HIPPURIC ACID. this element is deficient, and vice versa. If the deposit occur spontaneously, we must not always infer that it is owing to an excess of this acid, unless we find at the same time an unusual amount held in solution, for an increased quantity of any of the other acids, particularly phosphoric, will, under certain temperatures, precipitate uric acid. Another organic acid, which of late years has been proved to exist in healthy urine, is the hippuric. Its de- tection is more difficult than uric acid, and the practical inferences to be derived from it are of much less import- ance. The following is the mode recommended by Dr. Day. " Evaporate the urine till there is a copious depo- sition of salts. Add strong alcohol, and place the mixture in a stoppered bottle. With the aid of a gentle heat (for instance, by placing the bottle in warm water), we insure the solution of the urea and the hippurates in the alcohol, while the urates remain with the insoluble constituents. When the supernatant fluid is perfectly clear it must be decanted, evaporated nearly to dryness, and redissolved in hot water. By gradual concentration and the addition of a little free mineral acid we obtain crystals of hippuric acid." This proceeding is laborious when compared with that necessary for the detection of the other elements; but in some cases where it exists in considerable excess the mere addition of muriatic acid throws it down in large quantity, but a certainty as to its nature and its diagnosis from uric acid can only be arrived at with the assistance of the microscope. We next proceed to the detection of the earthy phosphates. EARTHY PHOSPHATES. 35 This is done by adding a few drops of ammonia, taking care that there be enough to render the urine at least neu- tral. These salts are never entirely deficient, and almost immediately after the addition the specimen becomes tur- bid from the deposition of the triple phosphate and the phosphate of lime. In a test-tube, containing about half an ounce, the normal amount, provided the usual quan- tity of urine be passed, would occupy nearly one-fifth of the lower part of the tube after standing a few hours. If it is wished to separate the phosphate of magnesia and ammonia from the phosphate of lime, it is readily done by adding a few drops of acetic acid, which dissolves the first. This deposition will also take place on the application of heat, if they exist to any great excess, but they are dis- solved again immediately on the addition of nitric acid. This may be explained by the well-known chemical princi- ple, that when substances exist in a fluid in so large a pro- portion as barely to be held in solution, almost any me- chanical cause which produces a sudden change in the re- lation of the particles to one another induces precipitation, and violent agitation such as shaking the tube forcibly, will often produce the same result. If these salts should exist as a deposit, they are easily recognised by being nearly always white, and on holding a drop of fluid containing them near a candle or in the sunlight, there may be ob- served a peculiar glittering appearance which belongs to them almost exclusively, although the same thing is some- times observed with a deposit of uric acid, but the last is of a reddish orange colour, while the phosphates are always 36 MUCUS. white. Another mode of detection when both salts are present is their fusibility: neither phosphate of lime nor the triple phosphate are changed under the blowpipe, unless a very great degree of heat be used, but when united in about equal proportions they are easily fused into a white enamel. This property has gained for the calculi composed of the two united, the name of the fusible calculus. They are also perfectly soluble in hydrochloric acid. A small quantity of mucus is present in all healthy urine, and in certain diseased conditions is found in considerable quantity; its detection is generally easy. Mucus contains no albumen, and therefore will not coagulate on the addi- tion of heat, and is always found in irregular gelatinous masses with air bubbles entangled. If, however, there be a large quantity of phosphates present they will give it a more opaque appearance. It sometimes happens that on adding nitric acid to a specimen of urine, we observe a co- pious white flaky deposit occurs, which immediately clears up on heating it. This we have observed in only a few in- stances, and have found it invariably to consist of mufcus in excess. The directions in this chapter thus far relate entirely to those ingredients which exist normally in the urine ; we will now consider the mode of detecting those which are found coexistent with an abnormal condition. The first of these is albumen. The detection of this substance is very easy. Albumen coagulates on the application of heat, and is de- posited by the addition of nitric acid and alcohol. It exists ALBUMEN. 37 as an albuminate of soda, from which combination the acid precipitates it on account of its affinity for the soda, and the alcohol for the water, which holds it in solution. This coagulation by heat may be observed in a spoon or a simple vial; yet if the quantity be very minute it may escape ob- servation when these means only are used. A small glass test-tube heated over a spirit-lamp, or plunged into boiling water, will obviate this difficulty, and should therefore be used. The white cloud formed under these circumstances is due either to the presence of albumen, or to an excess of phosphates. These latter are only deposited by heat when they are in so great an excess that anything which disturbs the relation between them and the water in which they are dissolved, causes them to be precipitated. Heat acts in this way, by increasing the space between the atoms of water, and also by producing currents in different direc- tions. But as we before remarked, the nature of the de- posit, as well as its solubility or insolubility in nitric acid, allows us readily to distinguish between the two. The de- posit in the first case is flaky, in the second crystalline; and phosphates are soluble in nitric acid, while albumen is insoluble. We must not however always conclude that when heat produces a deposit which nitric acid dissolves, that the pre- cipitate is necessarily albumen; for in many cases if a drop or two only of the acid be added, albumen will be dis- solved as well as the phosphates; but the difference is easily ascertained, for on adding a few drops more the albumen is thrown down while the other remains in solution. It often i 38 BLOOD. happens that nitric acid is used for the detection of this substance, and it is well that the errors likely to be induced by its employment should be understood. In the first place if the urine be alkaline, no precipitate will occur until it is rendered acid, and it will therefore require that sufficient acid should be added to give the urine an acid reaction before a deposit will take place. Dr. Rees has also observed that while taking copaiva a substance is deposited from the urine on the addition of nitric acid, which resem- bles albumen in almost every respect, and it is also said that in some states of fever, uric acid of a white colour and < resembling albumen very much, is often deposited on adding a few drops of nitric acid. This again may be distinguished by heating the specimen, when if albumen be present coa- gulation takes place. The next thing for our consideration is to ascertain whether blood be present. This principle is most frequently found in a state of solution in the urine, the fibrin and globules being perfectly separate. In proportion to the amount of it present will the secretion be more or less of a reddish colour, and if it be allowed to stand, a reddish opaque deposit will soon form. On heating the urine, the albumen of the serum coagulates and the red colour changes to a chocolate. Its detection is generally very simple, for although hsematoxylon, purpurin and beet-root give to urine nearly the same colour as blood, yet no change takes place on heating a specimen containing them. Should blood exist as it occasionally does in coagula, their appearance is at once sufficient for its recognition. PUS. 39 Pus is another abnormal element, which under certain conditions makes its appearance in the urine. When un- mixed with either blood or mucus, and if it exists in any quantity, its detection is by no means difficult. Urine con- taining pus is always somewhat turbid when passed, and if it be allowed to stand, the upper stratum becomes clearer from the subsidence of the purulent matter, but never per- fectly transparent. The reaction is generally either acid or neutral; if alkaline, the nature of the deposit is entirely changed. Pus contains both fat and albumen, and although unchanged by the action of acids, has the property of becoming gelatinous on the addition of ammonia or liquor potassae. This last change frequently takes place from the ammonia generated during decomposition, although, as a general rule, this fluid is less apt to decompose when it contains pus, than under other circumstances. If we sus- pect the presence of pus, the best mode of arriving at a certainty is as follows: after allowing the urine to stand for some hours, pour off the supernatant fluid, heat it over a spirit-lamp, and observe whether coagulation takes place; separate the remainder into two portions; to the one add ammonia, and to the other ether. Ammonia renders the first gelatinous, by uniting with the fatty matter present; and ether takes up the fat, which may be obtained in globules, by pouring it off and evaporating. If a small quantity of pus be mixed with a large quantity of mucus, its detection is almost impossible. The following peculiari- ties may however be of assistance. If mucus contains air- bubbles it will float, while pus always sinks. Mucus lying 40 SUGAR. in water appears as a homogeneous streaked viscid and tenacious mass, of a white or whitish-yellow colour ; while pus forms a stratum at the bottom of water, is easily dif- fused by agitation to subside again in a short time, and is of a white or greenish-yellow colour, sometimes tinged with blood. Our attention is now directed to ascertain whether there is any sugar in the urine. Many different methods have been proposed for the detection of this substance; but the most unfailing, so far as relates to chemical tests, is the one recommended by Trommer. It is founded on the fact, that a fluid containing sugar has the property of changing the colour of the sub-oxide of copper from a black to a red or brown. It is applied as follows : a few drops of a solu- tion of sulphate of copper are added to a small quantity of the suspected urine, and afterwards an excess of liquor potassse; on heating this the mixture becomes of a light or dark brown colour, in proportion to the amount of sugar present. This test is sometimes found to fail, for want of a few simple precautions. In the first place the liquor potassse should be free from lead, which unites with any organic matter present to form a black compound, and it should therefore be kept in a green glass vial instead of a white one. Again, if ammonia be present it impairs the action of the test, and Trommer recommends that the urine be evaporated previously to testing it. But this is scarcely necessary. Cappezuoli advises the following mode, which will be found to answer perfectly, when it is not necessary that the result should be known immediately. SUGAR. 41 Add a solution of potash to that of sulphate of copper in a test-tube, wash the blue precipitate with water, add it to the suspected liquid, and then enough potash to render the mixture distinctly alkaline. Set the whole aside in a tall glass vessel, no heat being applied. At the end of a few hours, if sugar be present the blue precipitate is changed in colour, at first upon its surface, and finally throughout the whole mass, assuming a canary-yellow tint; and this is succeeded in a short time by a red one, the protoxide of copper being reduced. In making use of this test, which we have never known to fail however minute the quantity of sugar may be, it will be well that the same amount of sulphate of copper and liquor potassse should be used in each instance. In this way the results obtained are always relative to one another, and we have in the changes produced by their addition, a standard of compa- rison. Moreover, if to a small quantity of urine a large proportion of each of these agents be added, the gelatinous mass formed by their reaction on one another, and which consists of undissolved hydrated oxide of copper, prevents the yellow tint from being equally disseminated throughout the tube. To prevent this, to about half an ounce of urine six drops of a saturated solution of sulphate of copper, and one drachm of liquor potassse should be added, a proportion we have been in the habit of employing for this purpose. A second test is that proposed by Moore, who recom- mends to boil the suspected urine in a test-tube with an excess of liquor potassse, when if it contains sugar, the mixture will assume an orange-yellow, or brown, or claret 4* 42 SUGAR. colour, in proportion to the quantity present, owing to the conversion of the diabetic saccharine matter into melassic acid.* Biot states that of the different modes of diagnosing diabetic urine, the most certain results are to be obtained by the use of milk of lime. He directs a small quantity to be added to a specimen of urine, and the mixture boiled for a few minutes, when a distinctly-marked orange colour will be observed if sugar is present. A third mode, for the detection of sugar, is to add a small quantity of yeast, which gives rise to the vinous fermentation, with the escape of carbonic acid in the pro- portion of about one cubic inch of gas to each grain of sugar present. The action of saccharine urine on polarized light, as proposed by Biot and applied by Bouchardat, is said to * This test is exceedingly marked, but in one instance that fell under our notice the same result occurred, although no sugar was present. We are not aware that any similar case has been spoken of. To the urine of a patient labouring under ansemia, to whom we were administering the muriated tincture of iron, we added a small quantity of liquor potassae. Immediately the mixture changed from a light- yellow to a dark-claret colour, which became more marked on boiling, and in a few hours separated as a black, amorphous deposit. The same result, although to a less degree, took place on the addition of strong ammonia. To this deposit was added a few drops of nitro- muriatic acid, and the whole evaporated, then dissolved in distilled water, and filtered. On adding a small quantity of the yellow prus- siate of potash in solution, the deep blue colour characteristic of the presence of iron was immediately perceived. This is the only instance in which we ever succeeded in detecting iron in the urinary secretion. 1 OXALATE OF LIME. 43 give more certain results than any mode yet used. But it is needless for us to enter into a description of this instru- ment, for we have never known with proper precautions, the test proposed by Trommer to fail. If any moderate amount of sugar be present, the physi- cal characters alone of the urine will often be sufficient for its detection. The taste and smell are generally sweet, resembling diluted syrup; the colour is a faint amber, in- clining to green, and often the consistency of the fluid is increased. The specific gravity is always high, much above the usual standard, and this is coincident with the discharge of an increased quantity. In addition to these characteristics, we find all the other solid ingredients very deficient, particularly the urea and uric acid. The detection of Oxalate of Lime, perhaps the most important of all the abnormal elements which are found in the urine, is at the same time the most difficult without the aid of a microscope. It never exists in a state of solution, and, from its property of refracting light to nearly the same degree as urine, cannot be seen when it is everywhere equally disseminated through it, unless it exist in very large quantities. Bird recommends when its presence is suspected, to set aside a specimen of the secre- tion in a tall glass vessel, and allow it to stand for a few hours. Then carefully to decant all but the lowermost stratum, which is to be poured into a watch-glass. This is gently heated to dissolve the urate of ammonia if any be present, at the same time gently performing a rotary motion, by which the crystals are collected at the bottom of 44 CYSTIN. the glass. All the supernatant fluid is then removed by means of a pipette, and its place supplied with distilled water or alcohol, when a shining powder will make its appearance. This we recognise to be oxalate of lime by its ready solubility in dilute nitric acid without any indi- cation being afforded of the presence of lithic acid; by its becoming white on incineration from being changed into carbonate of lime, which is dissolved by nitric acid with effervescence, and by its insolubility when boiled in liquor potassse or acetic acid. The physical characters of the urine afford very little assistance in the detection of this salt; the colour and the specific gravity, in the average of a large number of cases, are found to vary very little from the normal standard. Most specimens of urine in which oxalate of lime is to be observed, contain epithelium scales, and these alone, in undue proportion, should always make us suspect the existence of this salt. Another substance found occasionally, though very rarely, in urine is Cystin. We ourselves, have seen it in but one or two instances, and as Golding Bird has given the best description of its mode of detection, we transfer it from his work. Cystin "forms a nearly white, or pale fawn-coloured pulverulent deposit, much resembling urate of ammonia. It is never found in solution, the urine con- taining it being always turbid at the moment of emission, and it very soon deposits a copious sediment. Heat pro- duces no change, and it very slowly dissolves on the sub- sequent addition of hydrochloric or nitric acids. It is BILE. 45 readily soluble in ammonia and the fixed alkalies and their carbonates, but is insoluble in carbonate of ammonia. Heated upon platinum foil it burns, evolving a peculiar and disagreeable odour. It may be distinguished from urate of ammonia by being unchanged on the addition of heat; and from the phosphates by being insoluble in dilute hydrochloric, or nitric, or strong acetic acid," at the same time that it is perfectly soluble in ammonia. Cystin con- tains a large proportion of sulphur, and Liebig has pro- posed to detect it by means of an alkaline solution of lead, when a black precipitate, the sulphuret of lead, would be formed. But this test is very fallacious, for if albumen or any other animal matter containing sulphur were present, the same result would follow. The odour of the urine in some of these cases is very characteristic, resembling, to a remarkable degree, that of sweetbrier. Bile is occasionally present in the secretion under con- sideration, and may be recognised by the following pecu- liarities. Its colouring matter is insoluble in water, but soluble in caustic potash; the addition of water therefore, produces no change, but the other immediately renders the urine almost transparent, if its dark colour be owing to the presence of bile. Urine containing it, assumes a greenish tinge on the addition of muriatic and sulphuric acids; and nitric acid also produces a greenish tinge at first, but it soon changes to a red, violet, or pink colour. This greenish hue is produced by the colouring matter of the bile absorbing oxygen; and nitric acid effects it by supplying this gas. 46 KYESTEIN. Kyestein. Some years ago Nauche announced the dis- covery of a peculiar substance to be found in the urine of pregnant women, to which he gave the name of Kyestein. Its pathology and importance, in a diagnostic point of view, we will consider hereafter. Dr. Kane, who has made the most extensive observations on this substance, Btates that it never makes its appearance before thirty hours, or later than eight days, and in most cases is first observed on the third day. He also ascertained that it was present not only in women who were pregnant, but also in those who were suckling, in cases where the secre- tion was from any cause checked. It has the appearance of a cotton-like cloud at first, which soon changes into a number of minute opaque bodies, which rise to the sur- face and form a fatty pellicle. This pellicle, when held in a strong light, has often a glittering appearance from the presence of the triple phosphate. After remaining for three or four days the urine gradually becomes turbid, small flocculi fall off from the crust and sink to the bottom, and this goes on till the whole has disappeared. Pellicles are often observed to form on the surface of urine after standing for some days, under other conditions than those above mentioned, but they may be distinguished from Kyestein by the latter never becoming mouldy, or remain- ing on the surface more than three or four days. The preceding directions include all that can be said, in the limits to which we have confined ourselves, in relation to the chemical examination of the urine. They indicate the mode of detecting nearly all the substances that are KYESTEIN. 47 interesting in a pathological point of view, and all from which we can derive therapeutical indications. It will be seen by reference to the chapter on the microscopic exa- mination of the urine, that many of these substances can be more readily ascertained by its employment, than by the unaided assistance of chemical tests. APPENDIX TO CHAPTER II. MODE OF OBTAINING HIPPURIC ACID ACCORDING TO LIEBIG. Fresh urine is evaporated in a water-bath to the con- sistence of a syrup ; it is then mixed with some hydrochlo- ric acid, and agitated with its own volume of ether, which latter substance dissolves the hippuric acid. It usually happens that the mixture does not separate spontaneously, but that the ether remains enclosed in the fluid like froth ; the separation of the ether takes place immediately upon adding to the mixture, after having allowed it to stand at rest for an hour, one-twentieth part of its volume of alco- hol. In this case the froth disappears, and the fluid sepa- rates into two layers. The upper layer contains the hip- puric acid in solution; but it also contains urea, owing to the addition of the alcohol. This upper layer is carefully removed by means of a pipette or syphon, and agitated with small portions of water; the water removes the alco- hol and urea, whilst the hippuric acid remains in solution in the ether. By evaporating the ethereal solution the hippuric acid is obtained in crystals. The crystals pro- duced are usually of a yellowish or brown colour, arising TESTS FOR SUGAR. 49 from the presence of a resinous substance, which may be easily and completely removed by means of animal char- coal. TESTS FOR SUGAR. Among the many different modes proposed for the de- tection of this substance in the urine are the two following. They were omitted in the text because both are liable to induce error. HiinefeloVs Test is performed by placing in a glass ves- sel exposed to the sun's rays about four ounces of the urine, to which is added five or six drops of a tolerably strong solution of chromic acid. In a few minutes if sugar is present, the mixture previously orange-red, be- comes brownish, and soon after assumes a bistre-brown colour. This change takes place much more quickly if the mixture be gently warmed before exposing it to the light. It is produced by the deoxidizing power of the sugar upon the chromic acid, by which it is reduced to the oxide of chromium. The objection to it is a very serious one. All urine contains a certain amount of colouring matters, which have the same effect as sugar upon chromic acid, and it becomes deoxidized, although to a less degree. Runge proposes the following. Allow a thin layer of the suspected urine to evaporate on a white surface, a plate for instance. And whilst warm, drop upon the surface a few drops of sulphuric acid diluted with six parts of water. In healthy urine the part touched with 5 50 SULPHATE OF LIME. the acid becomes merely of a pale yellow colour; but if sugar is present, the spot becomes deep brown, and then black, from the decomposition of the sugar by the acid, and consequent evolution of carbon. This test is a very delicate one, but is unfortunately fallacious, because albumen in urine undergoes the same change on the addi- tion of sulphuric acid. SULPHATE OF LIME IN EXCESS IN THE URINE. All urine contains lime in an appreciable proportion; but it is always found in solution, unless existing as an oxalate. Its quantity is almost entirely dependent upon the quantity contained in different articles of diet, and we have occasionally seen it present in so large a proportion in individuals living in a limestone district, as to produce very unpleasant symptoms, particularly constant irrita- bility of the bladder, with pain and smarting during the act of micturition. It is readily detected by adding a few drops of a solution of oxalic acid, when it is immediately deposited as the insoluble oxalate of lime. In the in- stances just mentioned the lime was combined with sul- phuric acid in the form of sulphate of lime. This acid is readily detected in the urine by adding a solution of the nitrate or muriate of barytes. The latter is the preferable from its greater solubility. A white precipitate is formed, consisting either of the carbonate or the sulphate of ba- rytes, or both. This precipitate is collected by gravitation, and a few drops of sulphuric acid added. If it consists of QUANTITATIVE ANALYSES. 51 carbonate of barytes, effervescence ensues with the libera- tion of carbonic acid, but if no change takes place it exists in the form of a sulphate. QUANTITATIVE ANALYSES OF HEALTHY URINE. According to Berzelius. Water,.......933-00 Urea,.......30-10 Uric Acid....... 1-00 *Lactic Acid, Lactates, and Animal Matter, . . . 17-14 Mucus of the bladder, . 0-32 Sulphate of Potash, . . 3-71 Sulphate of Soda, . . . 3-16 Phosphate of Soda, . . . 2-94 Phosphate of Ammonia, . 1-65 Chloride of Sodium, . . 4-45 Hydrochlorate of Ammonia, 1-50 Earthy Matters, with a trace of Fluoride of Calcium, 1-00 Silicious Earth, .... 0-03 1000-00 Average of three Analyses by Lehmann. Water,......934-567 Urea,......32-424 Uric Acid,..... 1-064 Lactic Acid,* .... 1-520 Lactates,..... 1-565 Mucus,...... 0-107 Alkaline Sulphates, . . 7-308 Phosphate of Soda, . . 3-806 Phosphates of Lime and Magnesia, .... 1-142 Chlorides of Soda and Am- monia, ..... 3-653 Water extract, . . . 0-614 Spirit and Alcohol Extract, 10-267 In neither of these analyses has any attention been paid to the hippuric acid, which is always present in about the same proportion as uric acid, and it will also be seen that * According to more recent observations there is no lactic acid in urine, and Liebig thinks the extractive matters, which he terms kreatine and kreatinine, were mistaken for it. These latter contain nitrogen. 52 TABLE OF DENSITIES. Berzelius has omitted to detect any magnesia, a substance which is rarely if ever absent from healthy urine. DR. HENRY'S TABLE SHOWING THE QUANTITY OF SOLID MATTER IN URINE OF DIFFERENT DENSITIES. Specific gravity of the urine, Quantity of solid matters in a •water being 1000. wine Pint in grains. 1020 -.....382-4 1021.....401-6 1022 ------ 420-8 1023 ----- 440-0 1024......459-2 1025.....478-4 1026......497-6 1027.....516-8 1028 ------ 536-0 1029 ----- 555-2 1030 ------ 574-4 1031.....593-6 1032......612-8 1033 ----- 632-0 1034 ------ 651-2 1035 - - - - - 670-4 1036 ------ 689-6 1037.....708-8 1038 - - - # - - - 728-0 1039 ----- 747.2 1040.....- 766-4 1042.....804-8 1044 ----.. 843.2 1046 - 881-6 1048 ------ 920-0 1050 ..... 95g.4 KREATINE AND KREATININE. 53 LIEBIG'S MODE OF DETECTING KREATINE AND KREATININE.* The urine is first neutralized by milk of lime, and then a solution of chloride of calcium is added as long as it causes a precipitate of phosphate of lime. The liquid is then filtered, and evaporated till the salts crystallize out on cooling. The mother liquor is separated without the use of alcohol, from the salts, and mixed with a syrupy solution of neutral chloride of zinc in the proportion of about half an ounce to one pound of the extract. After three or four days, the greater part of the zinc compound is found to have crystallized in rounded yellow grains. This deposit is well washed with cold water, then dissolved in boiling water, and hydrated oxide of lead added to the solution till it acquires a strong alkaline reaction. By this means the zinc and hydrochloric acid are separated in an insoluble form, while the substance formerly com- bined with them, remains in solution. This is now acted on with blood charcoal, which removes a yellow colouring matter" and a trace of oxidt. of lead, and the filtered liquid is evaporated to dryness. By this process there is obtained a white crystalline sub- stance, which closer investigation shows to be a mixture of two compounds of different properties, which may easily. be separated by means of alcohol, one of them being easily the other very sparingly soluble in alcohol. When a por- tion of the mixed substance is boiled with eight or ten * Chemistry of the Food, page 51. 5* 54 KREATINE AND KREATININE. times its weight of alcohol, either a part remains undis- solved, or the solution is complete but deposits crystals on cooling. These crystals are found to be identical with the undissolved residue. When they are separated from the mother liquor, and the latter evaporated, a new crystalli- zation of different form and properties is obtained. The body which crystallized first or remains in the undissolved residue, contains water of crystallization and has no action on vegetable colours; the more soluble has in its aqueous solution a strong alkaline reaction, and its crystals do not effloresce when heated. The one that first crystallizes during this process is kreatine, the other kreatinine. CHAPTER III. ON THE MICROSCOPIC EXAMINATION OF THE URINE. We have already stated in the preceding chapters that, with the exception of sugar and albumen, so long as the different ingredients of the urinary secretion remain in a state of solution, their importance in a therapeutical point of view is not very great, except as indicative of the par- ticular diathesis under which the patient is suffering; and that in a majority of instances, an examination of the sediment alone will afford all the information necessary for practical purposes. This knowledge may be obtained nearly always by chemical analysis, according to the di- rections previously given, but it will be seen in the present chapter that by the use of the microscope, the same results may be arrived at with much more certainty, and with a less expenditure of time; that many substances, whose detection by means of chemical tests when in large quantities is very simple, is nevertheless impossible without the aid of this instrument when a few crystals only are present; and moreover, that where more than one sub- stance exists as a deposit, an estimation of their relative 56 THE USE OF THE MICROSCOPE. proportions is exceedingly difficult without the aid of a microscopic examination. Before entering into a detailed description of the ap- pearance that these different substances present, it will be well for us to give some simple directions as to the use of the instrument, and the proper selection of the urine for examination. A microscope with a power of two hundred and fifty diameters is the one we have usually employed, and this will be sufficient for all the purposes of urinary examination. With a less power, crystals of oxalate of lime, whose sides are sometimes even smaller than the 5^3 of an inch, cannot be observed with sufficient distinctness to decide upon their shape; and the more complicated arrangements belonging to an instrument of higher power render its practical application somewhat difficult to one unaccustomed to its use; besides, in many cases, rendering the size of the object greater at the expense of its distinct- ness. It must be remembered, however, that for the pre- sent purpose the value of a microscope does not consist so much in its magnifying power as its distinctness, and that in all cases an instrument is to be preferred whose mode of adjustment is simple, and whose power is of a medium range. The urine is selected as follows:—it is obtained, as for the previous examinations, either at separate periods, or an average specimen of the whole passed in twenty-four hours, is taken. And as nearly all the undissolved sub- stances in the secretion after a few hours gravitate to the bottom of the vessel, to obtain a specimen of the lowermost THE USE OF THE MICROSCOPE. 57 stratum we should allow the urine to stand for a few hours, then decant the upper five-sixths, and pour the remainder into a long and narrow test-glass. Here again, by gravi- tation, the substances will collect in larger quantity at the bottom of the glass, and on pouring off all but the lower- most stratum, we will have a greater number of crystals collected in a single drop than if it were selected indis- criminately. We have frequently observed a specimen of urine apparently clear, and in a drop of whose upper sur- face nothing could be discovered under the field of the microscope, present a considerable quantity of crystals after observing these precautions. There is one exception, however, to this in the crystals of oxalate of lime. These possess nearly the same specific gravity as the urine itself, and as a general rule will be found equally disseminated throughout the specimen, so that a drop of its upper sur- face will oftentimes present as numerous an array of crystals as that taken from any other portion. A single drop is amply sufficient for the detection of any substances present, and instead of pouring it into the hollowed glass provided with the instrument for the examination of fluids, it will be better to place it between two clear flat pieces of glass, and then subject it to the microscope. Putting the two pieces of glass together requires some little tact to prevent the formation of air-bubbles, which interfere with the exact sight of the object under examination. We should also mention that we have found the light of an ordinary study lamp far preferable to that obtained from the sun in the use of the microscope: it is more concentrated and there is less glare. 58 URIC ACID. It is often difficult, when a specimen of urine has to be sent from some distance, to make an exact examination of it. The time that must elapse before it can be received allows certain changes to take place, and crystals to make their appearance which did not exist at the time the spe- cimen was voided. One of our friends has been in the habit for some time of desiring his patients when thus removed, to filter their urine soon after emission, through a filter paper which he transmits to them in a letter envelope. This is dried and returned, and on moistening a portion of the sediment thus obtained with a drop of water, the substances may be observed under the micro- scope some days afterwards as they existed at the time the urine was passed. Even pus globules may be thus de- tected. We will now detail the different appearances that these substances present under the field of the microscope. Uric Acid.—There is no crystalline deposit which pre- sents under the microscope such an endless variety of forms as this. When found in urine, however, they have all one recognisable characteristic in their colour, which is usually some shade of orange or yellow, and this varies from the deepest orange to the lightest yellow. These crystals soon undergo a change by uniting with the am- monia liberated by decomposition, and have a tendency to become amorphous, so that occurring naturally as a deposit, they are rarely distinctly crystalline if retained for any length of time in the bladder or kidneys. When deposited either by the addition of acid or otherwise, the crystals are either separate or collected into clusters, and whatever URIC ACID. 59 be their shape they may all be referred to some modifica- tion of the rhombus, square or rectangle. The most com- mon form in which they are usually observed, is as a simple rhomb, square or rectangle, with a thickness equal to about one-fourth its length (fig. 1, 1, 2, 3, 4). It is often Fig. l. DIFFERENT FORMS OF URIC ACID. 1. Rectangular forms of uric acid. These are often flattened cylinders, and viewed in a plane at right angles to this, present the appearance of 4, and 5. 2. These may be cubes, or hare at right angles a similar section to the above. 3. A modification of the preceding. 4. The rhomboid form. These are generally flat. 6. This form is only deposited from very acid urine. The edges have a serrated appearance. 6. Same as above. But its surface is crossed by two crescentic borders. 7. A very common form. A white space in the centre, and the ends having the ap- pearance of projecting from it. These by time break up and become amorphous, at first along the edges, then in the body of the crystal. 8. This figure has an elevated ridge in the centre, and its section resembles somewhat fig. 2, 4. 9. This variety is nearly amorphous, and is rarely seen but in those specimens which have undergone decomposition. 10. This form is rare. Its section is rectangular. 11. Resembles somewhat the stellae of the triple phosphate. But it is made up of rectangles. This variety is very rare, and we have copied it from Griffith. 12. A number of rectangular crystals of uric acid grouped together to form a single one, having somewhat the appearance of a sheaf of wheat. 60 URIC ACID. difficult to appreciate the thickness of these crystals, from the fact of the microscope only presenting the view of a single face, but this may be remedied by adding a drop of ether or alcohol, which by evaporation, produces currents in different directions, so that the crystals are turned from side to side, and allow an accurate observation of each face ; in this way figures presenting a different appearance are often found to belong to the same crystal. The next most common form uric acid presents, is that of a rhomb, with the sides curved outwardly. These are flat plates, of a faint yellow colour (fig. 2, 4). Occa- sionally they are modified so as to resemble that figure which would be included between the segments of two equal circles (fig. 1, 8); and which in reality is nothing more than the previous rhomb, with the two obtuse angles rounded off. In a majority of cases this is the same crys- tal as those figured (fig. 1, 1), the view being in a plane at right angles to the preceding. The thickness of this form varies from one-eighth to double its length, and as a general rule the smaller the crystal the greater its thickness, and vice versa. These last are also occasionally modified by a rounding off at the ends and a bulging out at the sides, so as to give them somewhat the appearance of spindles (fig. 1, 10). Another quite common variety, forming in themselves a distinct group, is where the ends of the crystal have a serrated appearance. These may either seem to be made up of long needles, placed side by side, or have an apex in the centre, the two long sides of the pyramid thus formed URIC ACID. 61 being strongly shaded. Fig. 1, (5.) If simply composed of needles,- the striated appearance is variously modified. In the middle of some it is often entirely lost, and the surface being nearly smooth and squared off, the needles have the appearance of projecting from a rectangular surface. Fig. 1, (7.) Occasionally it is marked across by two crescents, placed with their convexities opposed. Fig. 1, (6.) Fig. 2. DIFFERENT FORMS OF URIC ACID. 1. If a number of crystals of uric acid are allowed to remain undisturbed for some time, aggregation will take place, and figures resembling this which is copied from the field of the microscope will often present themselves. 2. Is an amorphous crystal of uric acid, very commonly observed in urine voided some time previous to examination. 3. Another variety, usually observed some days after emission. 4. These crystals are either found in thin plates, or are sections of the rectangular figures above mentioned. 5. Is a section of the rectangular figures. 6 and 7. These crystals were deposited from a specimen of healthy urine, on the addi- tion of muriatic acid. The individual was apparently in good health. Their colour was a very faint yellow. All these crystals of uric acid, except Fig. 1, (11,) are of a yellow or orange-yellow co- lour. Fig. 2, (1, 2, 3,) present the deepest shade. 6 62 URIC ACID. These projections again are not always of a uniform length, in some specimens increasing from each "side to- wards the centre in steps, as it were, until at last they terminate in a kind of point. Fig. 1, (7.) Another variety very commonly found, particularly in a deposit allowed to stand for a short time, retains the striated appearance, but is no longer serrated at the edges, and the crystals are more amorphous in shape. Fig. 1, (9.) Fig. 2, (3,) represents a variety of uric acid somewhat similar to the above, and quite commonly met with if allowed to form very slowly. Its surface is striated in irregular short curves, each series of which seems to be elevated above the preceding. Others again present a stellated appearance, being made up of large rectangular crystals, either laid across one another, or radiating from a common centre. This variety is very rare, and is the only specimen of uric acid that we have ever observed to be perfectly colourless. Fig. 1, (2.) As a modification of this form, we may sometimes observe these long rectangular crystals lying irregularly side by side, with one or two additional ones crossing them in the centre at right angles, so that the whole figure is easily fancied to resemble a sheaf of grain. Fig. 1, (12.) If a deposit of uric acid be examined after the lapse of a few days, many of the crystals will have undergone more or less change. Some present an entirely amorphous ap- pearance, and are only recognisable by their colour. Fig. 2, (2.) Others again by aggregation form large crystalline masses without any definite form, and sufficiently large to URIC ACID. 63 occupy nearly the whole field of observation. One of these we have copied. Fig. 2, (1.) We have frequently observed in specimens of urine, after the addition of muriatic acid, flat round or rounded bodies of a faint yellow colour, Fig. 2, (6,) which dissolved on the addition of a drop of liquor potassse, and were in other respects similar to uric acid. Their surfaces are crossed irregularly by fine lines, and occasionally these lines radiate from a common centre. Fig. 2, (7.) The urine from which the figures in the plate corresponding to the above description were taken was perfectly healthy, but most frequently we have observed them deposited by acid in those specimens that exhibited under the microscope oxa- late of lime, and we rather incline to the opinion that they are some intermediate stage between this salt and uric acid. As a general rule, the colour alone of uric acid crystals is entirely sufficient for their recognition. The different shapes that they assume, although not entirely accounted for, appear to be influenced principally by the nature of the precipitating agent, the greater or less rapidity of crystallization, and the degree of disintegration that has taken place. The quadrilateral figures which are serrated at their extremities and marked by dark lines on their surfaces, are usually found in very acid urine, and have been observed by us to occur much more frequently in summer than in winter. The divergence of this same form towards a point at the end, seems to be owing to a portion of the crystal which was originally square falling off, and we have only noticed them in specimens of urine which 64 URATE OF AMMONIA. had been standing for some days, and where the crystals had begun to undergo decomposition. Urate of Ammonia occurs most commonly in small, mi- nute, transparent and amorphous grains, generally clustered together, but at times separate. Fig. 3, (1.) Occasionally Fig. 3. URATE OF AMMONIA, URATE OF SODA, CHLORIDE OF SODIUM, AND CYSTIN. 1. Represents the ordinary appearance of urate of ammonia. 2. The same, but less frequently observed. 3. The same. The projecting points are most probably uric acid. This variety is very infrequent. 4. A rare form of urate of soda, after Griffith. 5. The most usual form of urate of soda, as it occurs in urinary deposits. 6. Chloride of sodium, as it crystallizes from distilled water. In many respects it resembles the octohedra of oxalate of lime, but the lines are less sharp, they are only found when no fluid is present, and never exist in urine. 7. The same, slowly crystallized from urine. Still somewhat like oxalate of lime but never found when any fluid is present. 8. Chloride of sodium, in combination with urea, and evaporated quickly from urine. These figures are a certain indication of the presence of urea. They are here represented one-third their usual size. y 11 Urfte" of" soot ' Aftel^ldingBirT. ^ ^ " * hot^««on of carbonate of soda. URATE OF SODA. 65 mixed with these there may be observed larger rounded globules, sometimes united two and two. Fig. 3, (2.) When uric acid and urate of ammonia exist together, the globules often present the appearance of being studded around with sharp and elongated points, these being pro- bably the projections of the uric acid. Fig. 3, (3.) The small amorphous variety of urate of ammonia may be readily mistaken for one form of phosphate of lime, but the latter is only found in neutral or alkaline urine, and dissolves immediately on the addition of a drop of hydrochloric acid, while the other is dissolved but slowly, and is replaced after a short time by small lozenge-shaped crystals, of uric acid. Urate of Soda presents itself under two or three diffe- rent forms. The most common is that of globules, with rectangular or prismatic projections arranged in stellar groups. Fig. 3, (4.) This form is liable to be confounded with one variety of urate of ammonia with uric acid inter- mixed, but Griffith states that they may be distinguished by the needles of the latter being acute at their extremi- ties, while in the former thoy are always obtuse. When artificially prepared by dissolving uric acid in carbonate of soda, they crystallize in tufts which bear a great resem- blance to the tufts of margarine obtained from human fat. Fig. 3, (11.) Golding Bird describes a third form, in which the processes are generally curved, and have some- what the appearance of the claws of an insect, Fig. 3, (12,) but this variety we have never seen. Hippuric Acid when perfectly pure, presents itself in * 6* 66 HIPPURIC ACID. long, shining, transparent figures, modified in various ways; but as it never exists in the urine as a deposit, but must always be thrown down by some other acid, it is rarely found in transparent crystals, and we have always ob- served it of nearly the same colour as uric acid. Most of these crystals, unless made to revolve, have the appearance under the microscope of long flat rectangles, and have a tendency after a time to arrange themselves side by side, and present somewhat the appearance of one of the forms of uric acid spoken of above. By aggregation, these sometimes become so large, that a single one is sufficient to fill up the whole field of the microscope, even when a low power is used. Fig. 4. HIPPURIC ACID. 1, 2. The ordinary forms that hippuric acid presents when mm!„.j ,„ *i. • , an individual during the administration of benzoic acid examined in the urine of 3, 4, 5, 6, 7. Different forms from the urine of a healthy individual. PHOSPHATE OF MAGNESIA AND AMMONIA. 67 If from the urine of an individual to whom large quanti- ties of benzoic acid have been administered, the hippuric acid be obtained by the mode previously mentioned, the figures are almost always more or less curved, and present but little traces of crystalline arrangement. Some have the appearance of long, slender, flattened bodies, the sides varying to a greater or less degree from a right line, and in length, from the eightieth to the one hundredth of an inch, Fig. 4, (1,) and at times they are so irregular as to be twisted spirally on themselves for three or even four turns. Fig. 4, (2.) When deposited from urine under ordinary circum- stances, their axes are always in straight lines. Some are very short, shaded at the sides, square at one extremity, and diverging to a point at the other. Fig. 4, (4.) Others are much longer, and diverge at both ends. The breadth of these latter is very variable; some specimens being as long and slender as a fine sewing needle. Fig. 4, (5.) At times the deposit is made up of long, shining, transparent, four-sided, obliquely truncated prisms Fig. 4, (6); while in other specimens the prisms are broader, and three or more are united at one end, and have the appearance of radia- ting from a common centre. Fig. 4, (7.) Tlxe Phosphate of Magnesia and Ammonia is always deposited in transparent and colourless crystals, and as- sumes very different forms, dependent upon the rapidity with which crystallization takes place. This difference has been heretofore explained by supposing that they were two separate salts, one monobasic, the other deutobasic, the 68 PHOSPHATE OF MAGNESIA AND AMMONIA. latter containing twice as much ammonia as the former. But this we think is not the case ; for if certain precautions be used in the formation of this salt, it may be shown that the difference is entirely due to the rapidity with which crystallization takes place, the stellar variety being first deposited, and the prisms subsequently formed by the aggregation around these of crystalline material. This change has been more fully entered into at another place, and Fig. 10 exhibits the mode in which it takes place. In the urine, however, we have never seen both these forms existing at the same time, nor have we ever observed the stellar variety to be formed spontaneously, although Grold- ing Bird has remarked it in some few specimens. The prismatic triple phosphate is found in both acid and alkaline urine, and is by far the most beautiful microscopic object presented in urinary deposits. Its primitive form is that of a prism, Fig. 5, (1); but after a short time its angles become replaced by facets, so that it presents in some instances an exceedingly compound appearance, but still referable to the same original prism. Fig. 5, (4.) A quite common form is where the upper portion of the crystal presents a smooth rectilinear surface parallel to the square orrectangle which composes the base, Fig. 5, (2); but it is not at all necessary that the base should consist of four sides only. The angles of some are squared off in such a manner that an eight-sided figure results, Fig. 5, (3,) and others again are even more complicated than this. All these modifications are found collected together, and com- t posing the same deposit. These crystals are at times so PHOSPHATE OF MAGNESIA AND AMMONIA. 69 large, particularly when they have formed slowly, that two or three are sufficient to fill the whole field of the micro- scope. The other variety of the triple phosphate is composed of elegant stellse, very variable in size; the perfect crystals Fig. 5. TRIPLE PHOSPHATE, AND PHOSPHATE OF LIME. 1, 2. Represent the most perfect crystals of the prismatic variety of the triple phos- phate. 3. Is a slight modification of the preceding. 4. Exhibits a more compound arrangement, still referable to the same form. These different varieties are all found in the same specimen. 5. The most perfect varieties of the stellas. More commonly the greater part of the deposit consists of less perfect crystals than these, and we have never seen them thus perfectly formed without the artificial addition of ammonia. 6. These foliaceous crystals are usually found when precipitated from very acid urine. They are more rare than the preceding; and both of these forms are observed occasion- ally to be tinted with pink and green colours. 7, 8. Are other varieties of the same; very rare. 9. Phosphate of lime. This salt is never observed in a crystalline form. It is either an amorphous powder, or collected in rounded particles similar to the plate, mixed with the triple phosphate. 10. These bodies are represented by Simon, as having occurred in a deposit of phos- phate of lime; but they are in all probability, as he states, some form of urate. 70 PHOSPHATE OF LIME. usually having six projecting rays, Fig. 5, (5) but sometimes only four. These rays are more or less serrated along the edges, and owing apparently to accidental circumstances, the crystals assume a variety of appearances, all referable to the same stellar form. The penniform crystals of this salt, Fig. 5, (6,) are not so commonly observed as the others. They are joined together, either at one end, so as to present the appear- ance of radiating from a common centre, or are in a con- tinuous line; but at times they are entirely separate. These crystals are all very transparent, and require a strong light to distinguish their outline clearly. Occa- sionally they are observed to be tinted with various hues, in which pink and green predominate. The crystals of this form of triple phosphate, as observed under the micro- scope, do not usually present the perfect forms we have just been describing. More commonly there are portions only of the crystal distributed irregularly throughout the field, which becoming agglomerated after a time, unite to form an entire stella. This salt when deposited from urine by the addition of ammonia, is found associated with numerous amorphous bodies, the phosphate of lime, which will be described directly. Phosphate of Lime always occurs in small, rounded, amorphous particles, often scarcely distinguishable from one of the varieties of urate of ammonia, Fig. 5, (9); after standing for some time we may occasionally observe folia- ceous bodies having more or less of a crystalline appear- ance, which have been described as phosphate of lime. ► .,.,„- , . • CHLORIDE OF SODIUM—CYSTIN. 71 Simon gives a representation of these, Fig. 5, (10); but they are in all probability some one of the forms of the urates. Chloride of Sodium is perfectly soluble in both water and urine, but on evaporation assumes certain figures which might be mistaken for either cystin or oxalate of lime, except that the latter are in solution. When this salt is dissolved in distilled water, and the solution allowed to crystallize by evaporation, it presents the appearance of octohedra, which resemble, in some respects, oxalate of lime, Fig. 3, (6); but if evaporated slowly from urine it unites with urea, and forms irregular six-sided figures, which might be mistaken for cystin. Fig. 3, (7.) When the evaporation is conducted more slowly, these transpa- rent lamina are replaced by a series of figures shaped like crosslets and daggers. Fig. 3, (8.) The diagnosis, how- ever, is very easily made. Chloride of sodium being per- fectly soluble is never found in a crystalline form when any fluid is present, and if the suspected crystals appear after evaporation, we have but to add a drop of water, when chloride of sodium is immediately dissolved, while oxalate of lime or cystin remain unchanged. The appear- ance of the latter form, that is the crosslets, may always be taken as an indication of the presence of urea. -/- Cystin when deposited from urine is always crystalline, and generally presents itself under the microscope in the form of round, flat plates, with irregular crenated edges. Fig. 3, (9.) Towards the centre of these plates there is a circular opacity, apparently made up by the aggregation 72 OXALATE OF LIME. of small, amorphous bodies, and at the same time, there is a circle of transparency near the circumference. Ac- cording to Simon, this crenated margin which gives these crystals the appearance of rosettes, is due to a number of hexagonal plates to be described presently, placed one on the other, and there is generally to be observed at the same time, a few of these six-sided crystals interspersed among the others. When a deposit of cystin is dissolved in ammonia, and the solution allowed to evaporate spontaneously, it crystal- lizes in the form of six-sided plates, which Golding Bird thinks are exceedingly short, hexagonal prisms. Fig. 3, (10.) These figures are generally transparent, but occasionally their surfaces are crossed by irregular lines, and bounded at their circumferences by a thick, irregular, and opaque margin. At times, particularly under a strong light, some of these crystals present a beautiful series of bright colours, which are the more marked in contrast to their dark, opaque borders. Griffith describes them occasionally as occurring in the form of long, flat rectangles, but this variety is not mentioned by other observers. Oxalate of Lime.—No urinary deposit, not even uric acid, presents under the microscope such a variety of forms as oxalate of lime. We are unable from our present knowledge, to state with certainty upon what this variety of form is dependent, but will endeavour to show that, as in the case of uric acid, many different appear- ances are to be explained by the views being in planes at right angles to one another. The double octohedra are by far the most common variety, and after these the dumb bells. But we have not found these last evidencing a severer form of disease, as has been heretofore stated, nor have we as a general rule remarked that they usually became replaced by the ordinary octohedral crystals ■/■ before convalescence was entirely established. When oxalic acid is added to urine, or any fluid con- taining lime, the oxalate of lime formed under these cir- cumstances, as observed under the microscope, consists of small, rounded masses, without any definite crystalline form, and, on boiling the fluid in which they are contained, minute octohedra become perceptible. When formed, how- ever, in the urine, owing to the mode in which ammonia is liberated, they are found much larger, and of a great va- riety of shapes, all of which are more or less crystalline. As stated above, by far the most common of these varieties is the octohedron, or double pyramid. At first sight these almost always resemble squares, marked across their sur- faces by two diagonal lines, but closer observation shows the point where the diagonals cross one another to be the apex of a pyramid with a square base, and usually bevelled along the edges. On adding ether or alcohol so as to pro- duce currents in different directions by evaporation, these crystals may plainly be seen to be double pyramids, each with a height equal to the length of its base. Fig. 6, (1.) Wollaston and others state that the octohedron is most frequently flattened, but this is merely owing to the parti- cular plane in which it is seen. Fig. 6, (2.) Their size is extremely variable; we have noticed crystals as small as 7 74 OXALATE OF LIME. the amorphous masses of urate of ammonia and scarcely more distinguishable, and again others with an apparent base of nearly three-quarters of an inch in length. Gold- ing Bird gives T*o and ^\^ of an inch as the extreme Fig. 6. OXALATE OF LIME. 1. The most common form of oxalate of lime. The sides of these vary from 1-5600 to 1-500 of an inch in length. 2. Same as preceding, viewed in a different plane. 3. Larger forms of the same. In all the large crystals of this salt the sides are ob- served to be bevelled. 4. Represents the oxalate as it appears when dried on glass. But this appearance is rare. It is necessary that the crystals should be very large, and we do not always then succeed in detecting them in this form. 5 and 6. Are the oval figures that this salt sometimes presents. They vary very much in size, and are the next most common form to the dumb bells. 7. Similar to the preceding, with the exception of the elevated ridge and the bevelled extremities. 8. Ovals, with dumb bells enclosed. These are usually found mixed with the pre- ceding, and are, in all probability, an intermediate stage of the change from ovals into dumb bells spoken of in the text. 9. Dumb bells. These, although included under the head of oxalate of lime, are in reality formed by the disintegration of uric acid, and there is no lime entering into their composition. In many cases also when observed at right angles to the present view, they are ovals similar to 5 and 6. 10. Dumb bells as usually observed when found with the oval». 11. More irregular forms of the dumb bell crystals. OXALATE OF LIME. 75 measurements of some of his specimens; but supposing the side of the largest observed by us to be one-half an inch in length under a microscope magnifying two hundred and fifty diameters, its real length would be as much as jfa of an inch. If this salt be allowed to dry on a plate of glass and then examined, each crystal resembles two superimposed, concentric cubes with their angles and sides opposed, the outer black, and the inner transparent, Fig. 6, (4,) but this appearance is lost unless the crystals be large, and a low magnifying power used. This is explained by Griffith as being due to the lateral rays being refracted beyond or without the field of the microscope. These octohedral crystals are not always of one uniform size in the same specimen, and often vary from day to day in the same individual. The next most frequent variety observed is the dumb bell, in length from g^ to y^u of an inch. Fig. 6, (9.) The degree of indentation of the sides of these is extremely vari- able, the figures being sometimes nearly oval, and at others so much depressed as to resemble tjvo kidney beans placed opposite one another, and connected in the middle. Their surfaces are more or less opaque, and at times are crossed by curved lines in the direction of their length. Occa- sionally as a modification of this form, the dumb bells are surrounded by an oval, the interval between the two being of a black colour. Fig. 6, (8.) These two appearances be- long in reality to the same figure viewed in planes at right angles to one another, and although included here under the 76 OXALATE OF LIME. head of oxalate of lime, we will show at another place that their peculiar shape is in all probability, entirely due to the disintegration of uric acid. (See Figure 7.) Fig. 7. CHANGE FROM URIC ACID INTO DUMB BELLS. 1. Crystals of uric acid in the act of breaking in half by disintegration. 2. Two perfect crystals of uric acid united at one extremity preparatory to the others falling off. 3. Same as preceding, except one end has become one of the balls of the dumb bell. 4. These are irregularly-formed dumb bells, found in another specimen of uric acid allowed to stand for a few days. 5. Crystals of uric acid just commencing to disintegrate. 6. Fully-formed dumb bells. 7. Dumb bells formed from ovals. We have also observed some crystals of this salt having the appearance of dark ovals of the same size as the pre- ceding, with a transparent square, occupying half its sur- face, set in the middle. Fig. 6, (5.) Again, this latter form is sometimes modified by the oval appearing as though an MUCUS. 77 elevated ridge ran through the centre parallel to its long diameter, while the two ends are bevelled off by facets running in an oblique and opposite direction. Fig. 6, (7.) Still another form which we have observed but rarely, is two concentric ovals of different diameters set one within the other, the interval between the two being transparent, and upon the innermost, facets rising upwards in a pyra- midal point at the centre. Figures somewhat similar to these are included in Simon's plates under the head of uric acid. We have not seen a sufficient number of these dumb bells and oval forms of oxalate of lime to speak with certainty in regard to their comparative frequency, but will refer to this point at another place. In all cases the largest amount of crystals is found in the urine passed just before going to bed, and in some persons in whose urine it was observed in great abundance at night, it was entirely absent in that voided during the day. Mucus.—At the present day it seems to be agreed that the difference between mucus and pus consists not so much in the particles themselves, as in the fluid secreted by them and in which they float. And although as a general rule the particles of mucus as observed under the microscope, are entirely distinct from those of pus, yet occasionally in- stances present themselves where it is almost impossible with the aid of this instrument alone, to say to which of the two the rounded bodies are to be referred. Mucus ge- nerally presents itself in large, amorphous, semitransparent masses, mixed with epithelium scales and mucus corpuscles. Fig. 8, (2.) These epithelium scales are lamellated plates, 7* 78 MUCUS. of an irregular form and variable size, and generally have attached to their surfaces one or more of the mucus cor- puscles, which have the appearance of nuclei. Bird de- scribes them as nuclei, and as projecting always from the centre. We have observed their seat to be very variable, and have occasionally remarked them rolling over the sur- face of the scale and sometimes falling entirely off. The mucus corpuscles resemble in a great degree those of pus, except that instead of being round, they are rather elon- gated, and their internal nuclei and granular appearance are not so evident. Fig. 8, (1.) By some observers, they are supposed to be identical with pus globules, and Bird Fig. 8. EPITHELIUM, MUCUS, AND PUS GLOBULES. 1. Epithelium scales and mucus corpuscles. Some of these are observed in the centre of the scales, some free, and others almost in the act of rolling off. 2. Mucus, formed of an admixture of mucus globules and epithelium scales. 3. Pus globules, as they ordinarily appear in urine. * PUS. 79 suggests that the slight difference in their appearance may depend on the greater refractive power of the fluid portion of the mucus concealing the irregularities on the surface of the mucus corpuscle from ready observation; and it is Btated by Simon that if mucus be frequently observed, the transition of mucus corpuscles into epithelium scales may easily be seen, and by this transition we may explain the variety of appearances that a mass of mucus seems to be made up as observed under the microscope. Pus consists of roundish granules somewhat larger than blood corpuscles, and more transparent. They are roughly granular on their surface, and generally give indications of the presence of a nucleus. Fig. 8, (3.) Their appearance in the urine depends entirely upon the different substances present in the secretion. In dilute acids for instance, the globules become transparent and burst, rendering their nuclei very distinct; in a solution of common salt, they assume a contracted appearance, and present a plicated and clear outline; while in distilled water they swell, become larger, and assume a spherical shape. Now al- though the appearance of pus in urine never varies to the degree just spoken of, yet we may often notice a difference between the globules obtained from acid and those from alkaline urine ; but as a general rule we may describe them as about twice the size of blood globules, spherical in shape, and some irregular clustering at the centre may be distin- guished resembling a nucleus. This becomes more evident by adding a drop of dilute acetic or hydrochloric acid, which by dissolving the cell wall, shows the nucleus to be 80 BLOOD. composed of several minute granules, very transparent, and the whole forming a compound multiple nucleus. Blood.—When a drop of blood is placed between two pieces of glass, and examined under the microscope, the globules appear as flattened discs of a deep yellow colour, with an opaque point in their centre. Their flattened cha- racter is often rendered more apparent by their adhering together in rouleaus, but after desiccation commences, they lose their circular form, and appear irregular and con- tracted. Fig. 9, (1.) This latter appearance is never ob- served in the blood globules as they occur in urine ; on the contrary, they are larger and more rounded than under ordinary circumstances, from the imbibition of the surround- ing fluid. Fig. 9, (2.) It is also rare to meet with them in the rouleaus described above, and this never occurs except when blood has been effused very rapidly. A small quan- tity of this fluid may be present in a specimen of urine, and from the absence of any apparent colouring matter escape observation, and as blood globules after a few hours always gravitate to the bottom of the urine contain- ing them, we may in many cases detect their existence by examining a drop of the lowermost strata, where without this precaution they would have been entirely overlooked. Dr. David Stewart, of this city, suggested to us some time since, the propriety of adding a saturated solution of sulphate of soda to the urine, to aid in the detection of blood globules. The form they present in the urine of globular cells, is due, as we just stated, to the imbibition of the fluid in which they are contained, and the solution T0RUL.&. 81 of soda by giving to the urine nearly the same density as the serum of the blood allows these cells to assume their ordinary form, and they then present the appearance of flattened discs with the dark central appearance formerly described as a nucleus. By taking this precaution their recognition is easily accomplished. Torulce.—If any saccharine fluid be exposed to a tem- perature of seventy degrees for a few hours, certain Fig. 9. BLOOD GLOBULES, SEMINAL ANIMALCULE, SEDIMENT IN BRIGHl'S DISEASE, AND TORULE. 1. Blood globules, as they appear when dried on a glass. 2. The same in urine, they being much enlarged by exosmosis. 3. Seminal animalcules, or spermatozoae. . 4. Seminal granules. Some of these are usually found m urine intermixed with the PTeToruiae. Found in urine or any fluid that has undergone the saccharine fermen- ta6°Another form of the same. This last, according to our experience, is by far the most common. 7. Sediment found in Bnght's disease, after Simon. 82 TORUL^S. changes ensue, in the course of which oxygen is absorbed and carbonic acid given off, at the same time that certain fungoid vegetations make their appearance called torulse, and these pass through different stages of development. The same thing occurs when sugar is present in urine, and as it may be observed when a small portion only of this substance exists its detection often becomes of importance as an aid to chemical tests. The first appearance these torulse present is observed in a specimen of diabetic urine, a few hours after it is voided and subjected to the requi- site temperature. A slight whitish scum forms on its sur- face, which under the microscope is ascertained to be com- posed of minute oval bodies. These bodies soon become enlarged, and small granules are visible in their interior, which by enlarging, give the original vesicle an elongated form. By degrees these bodies unite at their extremities, the places of union having the appearance of joints. Fig. 9, (5.) These again, after a time, break up, and the whole is deposited in the form of oval figures at the bottom of the vessel. Fig. 9, (6.) The drawings made by different writers of these torulse, are not altogether similar, and this seems to be owing to the fact of the representation being made at different stages of the growth of the vesicles. Sediment in Bright"s disease.—In many cases of this disease a peculiar sediment, made up of different organic matters, and first accurately described by Simon, may be observed under the microscope. We have observed this appearance several times, but not often enough to consider it as important in the diagnosis of this disease. To the SPERMATOZOA. 83 naked eye it somewhat resembles mucus, but, according to Simon, is made up of five different substances: mucus corpuscles with a decided nucleated appearance, epithelium from the mucous membrane of the bladder, blood corpuscles, round dark vesicles apparently filled with granular matter, and tubes composed of an amorphous substance resembling coagulated albumen. Most of these tubes have an actual capsule, and are cylindrical, but some of them where the capsule seems to be absent, appear to be filled with an amorphous and finely granular mass, mixed up with cells and vesicles similar to mucus corpuscles. Fig. 9, (7.) Spermatozoce.—It is rare for a specimen of urine to contain semen in sufficient quantity to permit its detection by any other means than the microscope, and as the exist- ence of spermatozoae is the only certain diagnostic of the presence of this fluid, we do not think that any other means than microscopic observation is to be relied upon. They are rarely observed in motion in the urine, unless the examination is made soon after voiding the secretion, and they present the appearance of minute semitranspa- rent oval bodies, with a hair-like prolongation about twice the length of the body. Fig. 9, (3.) When in motion this prolongation is observed to move backwards and forwards, producing a forward motion, and they become much more distinct when the urine is allowed to dry on the glass. Mixed with these there are usually observed larger rounded bodies, which are in all probability the seminal granules spoken of by Wagner. Fig. 9, (4.) We are glad to be able to add our testimony to that of 84 CRYSTALLINE FORMS NOT INCLUDED HERE. Golding Bird in regard to the frequent existence of oxalate of lime with these bodies in the urine. In nearly every decided case of spermatorrhoea that has fallen under our notice we have been able to detect this salt, and in many cases where the disease existed as evidenced by constant nocturnal emissions, we have found oxalate of lime without being able to discover any spermatozose. The crystals have always been in the form of double pyramids, and generally very minute. We do not consider them as having any relation to one another more than that the habits of an individual addicted to. this mode of sensual gratification are generally those which would occasion the production of this salt, as will be explained in another chapter. It must not be supposed that the description of the diffe- rent substances as given in the present chapter, includes all the varieties of urinary deposits that the microscope presents. We have done little more than point out some of their more prominent features, and day by day new crystalline forms are revealed to us which it would be im- possible, in a work like the present, to detail. It is hoped, however, that the representations here given will afford a clue to all the varieties that may present themselves to the observer of this branch of pathology, and should he fail in being able to recognise those that he may see here- after by their peculiar shape, chemical tests will almost always enable him to decide under what head they are to be included. Again, it is rare to find a deposit made up of one sub- CRYSTALLINE FORMS NOT INCLUDED HERE. 85 stance alone. We may have several coexistent in the same field, but a little practice will soon enable the observer at a glance to distinguish them from each other, and to decide upon the relative proportions in which they are present. CHAPTER IV. ON THE PATHOLOGY OF THE DIFFERENT SUBSTANCES FOUND IN THE URINARY SECRETION. Uric Acid—Urea—Phosphates—Mucus—Albumen—Blood—Pus—Cys- tin—Sugar—Oxalate of Lime—Spermatozoa—Kyestein. In the previous chapters our attention has been entirely directed to the detection and estimation of the different constituents of the urine. We now purpose to examine the pathology and indications for treatment that each of them affords. In the present chapter we shall include only those elements which are most commonly met with, and confine our remarks to as brief a detail as is consistent with a general understanding. In the next we shall enter more thoroughly into particulars. Uric Acid.—This substance is formed during the de- struction of the tissues, and is the mode by which the effete nitrogen is eliminated from the system. When the influence of vitality has ceased, and the tissues become resolved into simpler elements, for the purpose of fitting them for being carried off by the different excretory organs, uric acid, choleic acid, and ammonia are formed. URIC ACID. 87 The kidneys eliminate the uric acid, the liver the choleic, and the skin the ammonia. After the formation of uric acid an additional amount of oxygen is brought into con- tact with it for the purpose of converting it into a more soluble substance, urea; and whenever this acid is found in excess it is not to be supposed that an additional amount has been formed, but that it has not undergone the ordinary change into urea. This substance in healthy urine, always exists in a state of combination, and is deposited only when the salt it forms is decomposed by some stronger acid, or when the excess is more than is sufficient to enter into soluble combinations. Urate of ammonia is its most common form, and although in solution at the time of emission, is often deposited after the urine cools, being much less soluble in cold than in warm water ; therefore this deposit by itself would be no indication of an excess of acid. The principal diseases with which uric acid is associated are gout and rheumatism, and although an excess is usually present in the urine before a paroxysm takes place, yet we find after the disease is once declared, and this excess deposited in one of the joints, the amount returns to its usual quantity. We can thus explain why an attack of gout so often relieves the many unpleasant symptoms that the patient laboured under before the attack. The excess of acid in the blood produced symptoms indicative of gene- ral disturbance, but after the deposition has taken place in the joints, these symptoms become entirely local. It is only after being subject for a long time to this accumula- 88 URIC ACID. lation of uric acid, that the system relieves itself by de- positing the superfluous quantity in one of the articulations ; and we shall find that almost all individuals have subjected themselves for some time to the causes which produce an abnormal amount of this principle, and have suffered with the symptoms indicative of it, before an attack of gout took place. The most common cause for the production of this dia- thesis is the continued and free indulgence in food rich in oil, together with the use of spirituous drinks, without suffi- cient bodily exercise; the oil and alcohol of the food re- quiring so large an amount of oxygen for their conversion, that there is not enough remaining to change the acid into urea. Another frequent cause is impairment of the func- tions of the skin, and we often find that an attack has been directly owing to suppression of the cutaneous exhala- tion, which being retained in the system, requires a certain amount of oxygen to change it into carbonic acid and water. We are thus shown the main difference between gout and rheumatism. The effects in both diseases are nearly the same, although very different morbid actions are brought into play to produce the causes. An excess may exist in the blood, and yet be deficient in the urine, from some functional defect about the kidneys; or the excess may be relative, that is, it exists in its usual amount in the blood, but is not excreted. This is the case in Bright's disease, where the deficiency of uric acid as well as urea in the urine, is found to exist in the blood. Urea.—The quantity of this substance passed from a UREA. 89 healthy man daily, amounts to a little more than one-third of the whole solid constituents, or about two hundred and seventy grains; and provided the assimilative organs are in a proper state of activity, its excess or deficiency is almost entirely dependent upon the amount of muscular exercise or oxygen that the individual is taking in. It is formed by the addition of oxygen to uric acid, and is increased or diminished in an opposite ratio to this sub- stance ; that is, it bears no proportion to the amount of uric acid originally formed, but is entirely dependent on the greater or less change that this substance undergoes by oxydation. It is influenced by diet, as we just explained, that is, some articles of food require more oxygen to con- vert them into carbonic acid and water than others, for instance, oil and alcohol more than sugar and starch; so that less oxygen would be presented to the uric acid with the same amount of exercise, if a man's diet consisted of rich food and spirituous drinks, than if he lived on fari- naceous substances alone. Different conditions of the blood also influence the amount of this substance. When the globules whose purpose it is to carry oxgyen, are defi- cient, urea must of course be diminished; while in plethora, where the opposite condition obtains, the same amount of diet and exercise being taken, it must be increased. Being perfectly soluble, its pathological importance is very small, and the information that it affords, is as to the amount of oxygen that has been brought into contact with the uric acid. Phosphates.—The physiology of the phosphates is ex- 8* 90 PHOSPHATES. plained as follows: all healthy urine contains a certain amount of fixed salts, namely, soda, potash, lime, and magnesia, in combination with hydrochloric, sulphuric, and phosphoric acids. They are derived partly from the food and partly from the transformations that are constantly taking place in the system. Dr. Jones thinks that the potash and soda are furnished by the blood and the albu- minous tissues, while the lime and magnesia are derived from the fibrous and muscular. The hydrochloric acid he supposes is produced from the common salt contained in the food, and the sulphuric and phosphoric acids from the oxydation of the sulphur and phosphorus contained in the albuminous and fibrinous tissues. But whatever may be the derivation of these inorganic substances, the only ones of direct practical importance are the phosphates. The compounds of soda and potash with phosphoric acid, being perfectly soluble, always exist in a state of solution, and we have only left then for examination the phosphates of lime and magnesia. These also are perfectly soluble in the urine under ordinary circumstances, but it often happens from some cause inherent in the solution, or when decom- position has taken place, that ammonia is liberated. This alkali then unites with the phosphate of magnesia, forming a phosphate of magnesia and ammonia, or as it is usually called, the triple phosphate, and from its being insoluble in water alone, or in an alkaline solution, its pathology becomes of importance. It will be seen by reference to the preceding chapter, that the crystals of this salt, when formed spontaneously PHOSPHATES. 91 in the urine as a result of decomposition or otherwise, have a different shape from those formed by the addition of ammonia in a test-glass; the first being prismatic, while the latter are stellated. The reason usually alleged to explain this difference is, that in the last case the salt has double the quantity of ammonia that it has in the first; but at another place we will show the greater probability of its being due merely to the rapidity with which crystalliza- tion takes place. When these salts exist in the urine as a deposit, they are usually indicative of serious disturbance, and often of organic disease, unless they have occurred as a result of decomposition. But to this there are exceptions ; for in- stance, medical students, or those who breathe for any length of time an atmosphere charged with ammonia, are liable to suffer with a deposit of this salt in their urine. It has also been observed in convalescence from acute disease, and in some cases of indigestion. But with these excep- tions, it is most often found associated with a calculus in the bladder, or some organic mischief of that organ or the kidneys. There is always coexistent with the presence of this salt in the urine, a depressed state of nervous energy, sometimes local only, but at others general. For instance, we find it frequently in persons who are old and infirm, or in those who have received some blow or strain over the loins. The general symptoms are those which are conse- quent upon depressed nervous energy, and almost all per- sons suffering with this condition of urine, are regarded as labouring under hypochondriasis, or severe dyspepsia. 92 MUCUS--ALBUMEN. Mucus.—The conditions upon which an excess of mucus depends are entirely local, for the bladder and urethra like other mucous membranes, throw off a large amount of mucus in certain states of irritation and inflammation; and we find consequently that an excess is almost always coincident with some abnormal deposit, particularly phos- phates, a calculus in the bladder, or a stricture of the urethra. It may occur, however, from simple catarrh, as in other mucous membranes. Most frequently it is found associated with a deposit of monobasic phosphates, some- times as an effect by the irritation they have produced on the bladder, but most often as a cause. Mucus acts on the urine as a species of ferment, and quickly produces decomposition, by which ammonia is liberated, and the triple phosphate deposited. Albumen is the first abnormal element found in the urine, whose pathology we shall take into consideration. Its presence is always due to some obstruction in the circu- lation of the kidneys, so that congestion of these organs is produced, and the serum of the blood filters through in the same mode that the fluid of dropsy is effused into the cellular tissue of the extremities or the peritoneal cavity, when obstruction exists to the passage of the blood through the heart or liver. Now the cause of the obstruction in the heart or liver may be owing either to simple conges- tion, inflammation, or chronic organic change, and these same causes produce an effusion of fluid from the kidneys ; but the result of the effusion in the two cases is very diffe- rent. In the peritoneal cavity, or the cellular tissue of ALBUMEN. 93 the extremities, the serum remains unchanged until absorp- tion takes place, or artificial means are resorted to. But when effusion from the kidneys occurs, the fluid passes into the pelves of these organs, from thence to the bladder, and is discharged with the urine. For it must be remem- bered that in urine where albumen exists, the other elements of the serum are to be found at the same time, for it is not albumen alone that is secreted, as was formerly thought, nor is the serum due to any fault of secretion on the part of the kidney more than its mere physical condition. The most common organic change that these organs undergo, is in what is termed Bright's disease, or granular degeneres- cence, and here the albumen is produced in the same way. By the deposition of granules in the cortical portion of the kidneys, their secretory function is interfered with, and at the same time by pressure on the circulating vessels, ob- struction ensues, and the same result occurs as where con- gestion has been produced by other causes. Simple congestion is by far the most common mode by which this substance is produced in the urine, and may be dependent upon several conditions: such as external in- jury, the retrocession of a cutaneous eruption, certain febrile states of the system, checked perspiration, weak- ness of the renal vessels, pressure on the veins, and stimu- lating diuretics. It is very commonly found in the urine during the dropsy that occurs as one of the sequelae of scarlet fever. Here the functions of the skin having become impaired, additional duty is forced upon the kid- neys, which as a consequence become congested, and per- 94 BLOOD. form their functions with difficulty. Any accidental cause which increases this congestion, produces a corresponding difficulty in these organs for eliminating their proper se- cretion, until at last the serum of the blood only, with its contained albumen, filters through; while the urea and uric acid are retained in the blood, and the water, with a small portion of albumen in solution, is deposited in some of the loose tissues in the form of dropsy. It will be seen by this, that the presence of albumen is far from uniformly indicating Bright's disease, or granular degenerescence of the kidneys; and this is only to be suspected when the dis- ease is of a chronic form, and attended by symptoms point- ing particularly to that affection. Blood is found in the urine from a variety of causes; but its presence is always indicative of either active or passive hemorrhage. Should coagula be present, we know that there is somewhere a breach of surface, either from excessive congestion, or mechanical violence, as from the irritation of a calculus, or the introduction of an instru- ment into the urethra, and it may sometimes take place from fungoid disease. Its most common cause is conges- tion of the kidneys, produced by derangement of the cu- taneous function, or by pressure on the renal veins as in pregnancy. We invariably find in these cases that there is a great diminution of urea and uric acid, while at the same time, the quantity of urine passed, is much below the usual amount. The difference in the producing cause of blood or albumen in the urine, is one merely of intensity. If the obstruction is so great as to produce rupture, blood PUS. 95 is effused; otherwise serum alone. The natural secretion is of course diminished in both cases, because the secreting portion of these organs is unfitted for use by congestion; but on examination, these substances will be found in the blood, in a proportion sufficient to counterbalance. their deficiency in the urine. We have occasionally seen in a healthy individual after exposure to cold, while the skin was acting freely, this state of things occur, and be promptly relieved by warm- baths or any means that acted revulsively on the kidneys, and tended to diminish their congestion. Bloody urine has also been found to occur during the course of grave fevers, in scurvy, and in those diseases in which the blood is in an altered condition. It may also occur from vica- rious menstruation. Pus.—The presence of this substance in the urine is almost always indicative of the existence of suppurative inflammation in some part of the urinary apparatus. An abscess, however, in any of the adjoining organs, may by ulceration, discharge itself through the bladder or kidneys; and we should also remember that an inflammatory con- dition of the urethra, as in gonorrhoea or gleet, often pro- duces a purulent discharge without there being any evidence that ulceration exists. It is difficult to say in many cases, whether the pus found in the urinary secretion proceeds from the bladder, the kidneys, or the prostate gland; but the period at which it is voided will often afford material assistance. The patient should be directed to lay upon his back, and after remaining quiet for some time, to void 96 CYSTIN. different portions of his urine in three or four separate vessels. By examining these separately, we ascertain whether the pus is principally contained in the first or last portion. If in the first, we may reasonably conclude that the difficulty is seated in the prostate gland, which will be strengthened by ascertaining that this organ has under- gone some alteration in size or consistence. If on the contrary, the pus is contained in the vessel in which the last portion of the urine was voided, it proceeds in all probability, from the bladder; for this substance being heavier than urine, by gravitation falls to the lowest part of the bladder, which, in a recumbent position, is nearly opposite the orifice of the urethra; consequently the upper stratum of urine, or that first passed, would be nearly free from sediment. Cystin.—Our information in regard to the pathology of this substance is very limited, and little that is satisfactory is as yet known. Its composition is exceedingly remarkable, from the fact of its containing no less than twenty-six per cent, of sulphur. It was first recognised as a constituent of a calculus submitted for examination; and it is only within a few years past that it has been found existing as a urinary sediment. In a majority of cases it seems to be connected with a scrofulous diathesis, and often with or- ganic disease of the liver; but, nevertheless, is frequently found without being associated with any appreciable dis- order, except the formation and discharge of a calculus. In three well-marked cases spoken of by Garrod, one oc- curred in a young man affected with dyspepsia, a second SUGAR. 97 was suffering from an abscess in the perineum, and in a third the appearance of cystin was first observed during an attack of acute rheumatism, complicated with heart disease and pneumonia. We have observed it in one well-marked instance. The patient was a mulatto girl, with scrofulous enlargement of the cervical glands, who applied to be treat- ed for dyspepsia. Two specimens of her urine voided at intervals of a week, contained it in an appreciable quan- tity ; but she did not afterwards return, and further insight into her condition was lost sight of. It is no doubt formed during some of the processes of secondary assimilation; and is in all probability derived either from albumen, or from the tissues into which albumen is changed. Sugar.—Formerly all diseases in which the prominent symptom was an increased discharge of urine, were included under the head of diabetes; but a distinction was made between diabetes mellitus, and diabetes insipidus ; the latter consisting merely of an increased discharge of urine de- pendent upon a variety of circumstances which we have already explained, the other always characterized by the presence of a certain amount of sugar in the urinary se- cretion. Of late years, however, the term diabetes is con- fined entirely to the latter condition. The disease is com- paratively a rare one, and is much less frequent in this country than in England, where Dr. Prout states that in twenty-five years, more than five hundred cases of it have fallen under his observation. Its pathology, in spite of the attention that has of late 9 98 SUGAR. years been bestowed upon it, is still obscure in many points. We know that it is essentially a disease of diges- tion, and that the kidneys are not concerned, except in eliminating a material which can take no part in any of the various functions of digestion and assimilation. In a healthy individual all saccharine or amylaceous substances taken into the stomach, subserve the purposes of respiration, and are thrown off in the form of carbonic acid and water. But in the present instance, from some fault of primary digestion, this change does not take place, the sugar passes into the blood as sugar, and is eliminated by the kidneys as such. The most plausible explanation to account for this condition of things, is that offered by Bouchardat, who thinks that from the presence|[of a pecu- liar substance in the stomach of a healthy man, which he has isolated, similar to the diastase which produces the saccharine fermentation in barley, all the starch and sac- charine material contained in the food become changed into sugar while still in the stomach. And although in a healthy man this same conversion into sugar takes place from the same substances, yet the change is not effected until the addition of the pancreatic juice. For if the latter be forced to throw off the contents of his stomach shortly after a meal, before this latter secretion is added, we never find them converted into sugar, while in a dia- betic patient it is invariably present. Again in a healthy man, the sugar is formed slowly, enters by degrees into the circulation, and is readily gotten rid of as carbonic OXALATE OF LIME. 99 acid and water, but when formed in the stomach it passes quickly into the blood, and can then only be eliminated by the kidneys abstracting it in its original form. The quantity of urine voided in this disease almost always exceeds that of health, and is sometimes enormous. From ten to twenty pints are usually passed daily, and occasionally as much as forty or fifty pints, or even more, and this average may be sustained for weeks or months together. But this amount bears a regular proportion to the quantity of sugar excreted, which always abstracts sufficient fluid from the blood to insure its solution, and to supply this continual drain from the blood, enormous quantities of fluid are taken into the stomach. The skin is invariably dry, and the patient usually suffers from constipation, because all the fluid ingested is required to dissolve the sugar, and in this form is quickly abstracted by the kidneys. The urea and uric acid are always diminished, but this diminution is a relative one only. The normal proportions are excreted in the twenty-four hours, although the large quantity of water in which they are dissolved, reduces their amount in each ounce of fluid to very little. When the disease is far advanced there are three symptoms invariably present, these are thirst, emaciation, and the discharge of an increased amount of urine. When these are coexistent, and have been present for some time, we may always suspect the existence of the disease under consideration. Oxalate of Lime.—In the beginning of this chapter it was stated that urea was formed from uric acid by the ad- 100 OXALATE OF LIME. dition of a certain amount of oxygen, and that an excess of uric acid in the system was to be attributed, not to any additional amount being formed, but to the fact of its re- maining unconverted into urea. Now, if a less amount of oxygen be brought into contact with this acid, there re- sults the formation of a certain quantity of oxalic acid, and a smaller amount of urea. In other words, oxalic acid is intimately associated with uric acid, and is a disease produced by deficient oxydation. Lime unites with this acid in preference to any other, and as all urine contains a certain amount of it, this substance invariably exists as an oxalate of lime. It is the most common of all urinary deposits, but cannot always be looked upon as constituting a disease. Any cause which prevents an individual from' receiving a due supply of oxygen is liable to produce it, but it is only when it exists in sufficient quantity to occa- sion general symptoms indicative of its presence, that it becomes of sufficient importance to require treatment. Thus, in the urine of individuals leading a sedentary life, such as the inmates of a prison, or those whose profes- sional avocations require them to remain in close, ill-ven- tilated apartments, this salt is very commonly found. Oxalic acid may also be formed during the processes of primary digestion, and inasmuch as all the cases in which oxalate of lime is found associated with so decided a de- parture from health as to require treatment, are attended with more or less disorder of this function, it would seem that those cases only ought to be included under the head of " the oxalate of lime diathesis," in which the oxalic acid OXALATE OF LIME. 101 is formed in this way. In primary digestion, among the changes that take place is the formation of lactic acid, the carbon of which, if the requisite amount of oxygen is taken in, becomes converted into carbonic acid. But if a less quantity of this gas is presented to the lactic acid, carbonous or oxalic acid is formed. This in its turn pro- duces the same derangements of the digestive organs and depression of nervous energy, that are occasioned by its introduction into the stomach in the ordinary way. Ac- cordingly we find that the mere presence of oxalate of lime in the urine is not to be regarded as evidencing a diseased condition, unless at the same time there is some derange- ment of the digestive organs, accompanied with depression "of nervous energy. The reason for this difference is easily explained. When oxalic acid is formed in the stomach it enters the blood, and passes through the whole round of the circulation before it is eliminated by the kidneys. It consequently has ample time to produce its physiological effects upon the nervous system. Whereas, if it is formed in the blood from uric acid, although a part of it may pass through the entire round of the circulation, yet on the other hand the greater portion of it may be eliminated almost as rapidly as it is formed. Neither the quantity of urine passed, nor its appear- ance, afford us any particular evidences of the presence of this salt, nor are the proportions of urea and uric acid at all affected by it, they being influenced in a great measure by the quantity and quality of the aliment, as we have already explained in speaking of uric acid. 9* 102 SPERMATOZOA--KYESTEIN. Spermatozoa.—The presence of these animalculae in the urine has no connexion with the condition of the bladder or kidneys, and if micturition has not been preceded by sexual connexion, after which act some of these bodies would remain in the urethra, they denote the existence of seminal emissions. Their detection in the urine after con- nexion may be of importance, as proving the individual capable of procreation, but their absence under these cir- cumstances could not be alleged as evidence to the con- trary. Kyestein as yet, with the exception of the pulsations of the foetal heart, is the only decided evidence we possess of the existence of pregnancy. In a few instances Kane observed it during the first weeks, but it most commonly' makes its appearance during the seventh, eighth, and ninth months up to the period of delivery. It is not a constant symptom, although present in a large majority of cases. It also makes its appearance during lactation, but this rarely happens, unless from some cause the secretion of milk becomes checked. In eighty-five cases of pregnancy reported by Dr. Kane, it was absent only eleven times, and was present in thirty-two out of ninety-four cases exa- mined during lactation. This substance has a very close relation with casein, and it would seem that it is in the course of preparation during pregnancy, being eliminated by the kidneys until the mammary glands are prepared for the performance of their functions. Simon observed it but once on the surface of a man's urine, and that after KYESTEIN. 103 standing three days, and he remarks in relation to its value, " From the observations of Kane and myself it seems to follow that pregnancy may exist without the oc- currence of kyestein in the urine; if, however, there is a probability or possibility of pregnancy, and kyestein is found, the probability is reduced almost to a certainty." / CHAPTER V. ON THE PATHOLOGY AND THERAPEUTICAL INDICATIONS OF THE MORE IMPORTANT ELEMENTS OF THE URINARY SECRETION. Composition of the Urine—Its derivation—Quantity of Water—Hysteria —Urea and Uric Acid—Their derivation—Objections to Liebig's Theory explained — Gout and Rheumatism — Difference between the two— Chemical Theory alone untenable — The Influence of the Nervous System — Treatment—Diet—Hydropathy—Internal Remedies—Hip- puric Acid—Experiments on the changes Benzoic Acid undergoes— Case I. of Gout—Phosphates—Relation of Phosphoric to Uric Acid —True and false Diathesis—Treatment—Stellar and Prismatic Crys- tals not different salts, as heretofore assumed — Albumen — Due to congestion—Objections to Prout's Theory—Oxalate of Lime—Formed from Uric Acid—May be formed without Urea—Objections to Bird's Theory—Commonly found in the Urine of Convicts—In persons suffer- ing from Spermatorrhoea—Dumb Bells probably not Oxalate of Lime— May be formed from Uric Acid—Relation of Ovals and Dumb Bells to one another—Uric Acid Theory insufficient to account for all cases of Oxalate of Lime—It is also due to defective conversion of Lactic Acid— Treatment—Case II.—Case III.—Case IV.—Diabetes — Pathology more obscure than the preceding—Professor Graham's Experiments— Bouchardat's Theory—Mialhe's Theory—Symptoms—Treatment. The kidneys are the emunctories by which the effete materials, which can no longer subserve any of the pur- COMPOSITION OF THE URINE. 105 poses of nutrition, and the accidental substances, whose retention would be injurious, are eliminated from the sys- tem. In the performance of this function they allow the passage of certain substances with little or no change, as water, uric, and hippuric acids, urea, and certain salts; while they decompose others, and eliminate the products of this decomposition in certain forms which in all proba- bility, did not previously exist in the blood. We have already explained the variety of causes that influence both the quality and quantity of the urinary secretion, and, in the present chapter, do not purpose to go into a minute account of the pathology of all the different elements pre- viously mentioned, but shall speak only of those whose importance demands a more detailed account than has been already given. We have found that the urine consists of water and solid contents; the last may be divided into an organic and an inorganic portion, and the organic portion be again divided into several elements. These are mucus, epithelium, urea, uric, and hippuric acids, kreatine and kreatinine, extractive and colouring matters. Of these mucus and epithelium are derived from the urinary passages; kreatine and krea- tinine are nitrogenous bodies, whose properties have been closely studied by Liebig within the last few years. They are both found as constituents of muscular tissue, and krea- tine contains in union with other substances, the elements of urea. Their pathology in relation to the urinary secre- tion, is as yet but little understood, but they are in all probability due to defective conversion, and hold an inter- 106 COMPOSITION OF THE URINE. mediate place between the devitalized tissue and uric acid. They were mistaken by Berzelius for lactic acid, and de- scribed as such by him, but the latter contains no nitrogen. Of the extractives and colouring matters little satisfactory is known. Garrod thinks the latter are derived from the blood, because, when suppression of urine exists, the uric acid thrown down from the blood is strongly tinged, while in those cases where the acid alone is retained, it is precipi- tated of a light colour. There remain then of these for our present consideration, urea, uric, and hippuric acids. The derivation of the inorganic matters is more easily explained. They consist of soda, potash, lime, and mag- nesia, in combination with hydrochloric, sulphuric, and phosphoric acids. The alkaline phosphates are derived from the food and the oxydation of the albuminous textures, the earthy phosphates and sulphates from the food also, and the disintegration of the tissues, while the presence of the chlorides being in part due to the muriate of soda taken in with the food, is found to be much influenced by the quantity and quality of the aliment used. We have seen that both the quantity and the compo- sition of the urine vary greatly, not only in different indi- viduals, but in the same individual at different times; and, inasmuch as one of the important offices of the kidneys is to preserve the amount of fluid in the blood in proper pro- portion to the wants of the economy, and at the same time to be a counter-balance to the perspiratory function, it will be found that the amount of water contained in the urinary secretion, will be greatly influenced by the quantity of fluid COMPOSITION OF THE URINE. 107 taken into the system, and the condition of the cutaneous exhalation. In addition to this, the amount of salts con- tained in the ingested fluid, determines its action at one time upon the alimentary canal, and at another upon the kidneys. If it contains less salts than the blood, on the principle of exosmose, the fluid enters the blood; but if more, the fluids of the body pass out, and purgation en- sues. All the inorganic acids and their bases, with the exception of the phosphoric and sulphuric acid, which owe their origin principally to the transformations of the tissues, are contained in the food, and are removed by the kidneys from the blood because they are no longer useful for any of the purposes of the economy. An excess of water in the urinary secretion from any of the above-mentioned causes cannot be considered as abnor- mal ; but instances of a more permanent character are occasionally met with, not owing to hysteria or to the pre- sence of sugar, which produce great discomfort to the in- dividual, occasion thirst, and are persistent for a long time. The pathology of these cases is extremely obscure, but we find that they frequently produce great debility and loss of flesh. They occur in excitable nervous individuals, particularly dyspeptics, and Willis relates an instance of a man, who for some time, passed on an average in the twenty-four hours, thirty-four pounds of urine, while the fluid taken in amounted to a much smaller quantity. In hysteria, we find that the patient voids a large amount of nearly colourless urine, which on examination is found to be of an exceedingly low specific gravity, and containing 108 UREA AND URIC ACID. scarcely any of the usual materials in solution, although, after the paroxysm has passed, this deficiency is counter- balanced by the secretion of an increased amount of solids. This can only be explained by supposing that during an attack, there is such an abnormal distribution of nervous energy, that the usual amount is not sent to the kidneys, which merely allows the water to filter off without their eliminating the solid materials, which it is their function to excrete. These of course accumulate in the blood, and are excreted in increased quantity after the paroxysm has subsided. UREA AND URIC ACID. The phenomena of increase and waste in the animal body may be divided into three different stages. The first of these is nutrition, during which the matters capable of subserving the purposes of respiration, or of being trans- formed into living tissue, undergo digestion in the alimen- tary canal, and pass from thence into the circulation. The second, which may be called the transition stage, in- cludes all the primary formations of secondary assimila- tion ; such as kreatine, kreatinine, and sarcosin, with lactic and inosinic acids. The properties of most of these are still very obscure, and although two of them, kreatine and kreatinine, always exist as constituents of healthy urine, it is probable that their presence is only accidental, and en- tirely dependent upon defective conversion. The third of these stages is the excretory, and includes all these pro- URIC ACID. 109 ducts which, being fully formed, it is the purpose of the different excretory organs to eliminate from the system. These are, urea, uric acid, ammonia, carbonic acid and water. According to Liebig's formula 0 N H 0 C N H 0 1 atom of blood, . 48 6 39 15 A r 38 1 32 11 , . 1 atom choleic acid, 1 " water, . 11/ \ 10 4 4 6 . 1 " nric acid. 1 " oxygen, l s = = J 13 1 " ammonia. 48 6 40 17 J (^48 6 40 17 Now, choleic acid by combining with soda constitutes bile, which, after being poured out into the duodenum to effect certain changes in the chyme, which it is not our province to explain here, enters the circulation, becomes oxydised and is eliminated by the skin and lungs in the form of ammonia, carbonic acid, and water. Thus : c n h o 1 atom choleic acid, 38 1 32 11 90 " oxygen, . . 90 38 1 32 101 C N H O 38 72 38 atoms carbonic acid. 29 29 29 " water. 13 1 " ammonia. 1 32 101 The ammonia of both formulas is eliminated by the skin as lactate of ammonia, and although this alkali is always found in a certain amount in the urine, it is doubtful whether it ought to be considered as a healthy product, or rather as owing to defective secretion on the part of the skin. But this subject we will discuss at another place. The physiology of uric acid is then the only one we have 10 110 FORM IN WHICH IT EXISTS. left for our examination at present. We have just shown without going through the intermediate steps, that accor- ding to Liebig's formula, this acid, together with the other elements destined for excretion, is formed by the oxydation of the effete tissues over which the influence of vitality has ceased, and we shall assume the same author's hypothesis to explain the changes that this substance subsequently under- goes. Uric acid requires nearly ten thousand parts of water for its solution. It cannot therefore exist in an un- combined state. Golding Bird supposes that, " at the mo- ment of its separation from the blood, it meets with the phosphate of soda, and ammonia, and forms lithate of am- monia, while phosphoric acid is liberated, giving to the urine its acid reaction." Liebig on the contrary asserts, from the well-known property which the bibasic phosphate of soda possesses of dissolving uric acid at high tempera- tures, that this acid exists in the urine under the form of urate of soda, while the monobasic phosphate thus formed gives to the secretion an acid reaction, and this to us seems more reasonable than the explanation offered by Bird, for, we find that the quantity of ammonia in the urine is exceedingly variable and dependent upon various circum- stances. In an individual lightly clad, following a labo- rious occupation in the open air, and in whom the functions of the skin are freely performed, this alkali, either free or combined, is rarely present; while on the contrary, if the reverse is the case, and the individual warmly clad, leads a sedentary life, the cutaneous exhalation is retained, and a portion of it eliminated by the kidneys. It is probable, RELATION TO UREA. Ill that were man again in his primitive condition, and forced to gain his bread by the sweat of his brow, neither am- monia or uric acid would ever be found as constituents of healthy urine; the first, being eliminated by the skin, and the other entirely changed by the action of oxygen into urea. Let us now examine the relations of this acid to urea, and the conditions necessary for the conversion of the one into the other. This the following formula explains. CNHO CNHO 1 atom uric acid, . 10 4 4 6 ^ /'44842 atoms urea. 4 " water, ... 44 6 " oxygen, . . 6 K = 0 figures. PHYSIOLOGY. CARPENTER'S PRINCIPLES OF HU- MAN PHYSIOLOGY, edited byClymer, 1 vol. 8vo., over 300 illustrations, 3d edition, with many additions. CARPENTER'S ELEMENTS, OR MAN- UAL OF PHYSIOLOGY, 1 vol. 8vo., 560 pages, many cuts. CARPENTER'S COMPARATIVE ANA- TOMY AND PHYSIOLOGY, revised by the author, with beautiful engravings (preparing). CONNECTION BETWEEN PHYSI OLOGY AND INTELLECTUAL SCIENCE, 1 vol. 18mo., paper, 23 cts. LEA AND BLANCHARD'S PUBLICATIONS. MEDICAL BOOKS. CYCLOPAEDIA OF ANATOMY AND PHYSIOLOGY, based on the large work of Todd, in two vols, large 8vo., numer- ous cuts (preparing), DUNGLISON'S HUMAN PHYSIOLOGY, 6th edition, 2 vols. 8vo., 1350 pages, and 370 wood-cuts. HARRISON ON THE NERVES, 1 vol. 8vo., 292 pages. MULLER'S PHYSIOLOGY, by Bell, 1 vol. 8vo., 886 pages. ROGET'S OUTLINES OF PHYSI- OLOGY, 8vo., 516 pages. SOLLY ON THE HUMAN BRAIN, ITS STRUCTURE, PHYSIOLOGY, AND DISEASES (preparing). TODD AND BOWMAN'S PHYSIOLO- GICAL ANATOMY AND PHYSI- OLOGY OF MAN, with numerous wood- cuts (publishing in the Medical News), to be complete in one volume. WILSON ON THE SKIN, 1 vol. 8vo., 370 pages ; a new edition. Same Work, with coloured plates. WILLIAMS' PATHOLOGY, OR PRIN- CIPLES OF MEDICINE, 1 vol. 8vo., 384 pages. WILLIAMS ON THE RESPIRATORY ORGANS, by Clymer, 1 vol. 8vo., 500 PATHOLOGY. ABERCROMBIE ON THE STOMACH, new edition, 1 vol. 8vo., 320 pages. ABERCROMBIE ON THE BRAIN, new edition, 1 vol. 8vo., 324 pages. ALISON'S OUTLINES OF PATHO- LOGY, &c, 1 vol. 8vo., 420 pages. ANDRAL ON THE BLOOD, translated by Meigs and Stille, 1 vol. small 8vo., 120 BERZELIUS ON THE KIDNEYS AND URINE, 8vo., 180 pages. BENNET ON THE UTERUS, 1 vol. 12mo., 146 pages. BUDD ON THE LIVER, 1 vol. 8vo., 392 pages, plates and wood-cuts. BILLING'S PRINCIPLES, 1 vol. 8vo., 304 pages. BIRD ON URINARY DEPOSITS, 8vo., 228 pages, cuts. HASSE'S PATHOLOGICAL ANATO- MV, 8vo., 379 pages. HOPE ON THE HEART, by Pennock, a new edition, with plates, 1 vol. 8vo., 572 pages. HUGHES ON THE LUNGS AND HEART, 1 vol. 12mo., 270 pages, with a pi ace. PHILIP ON PROTRACTED INDIGES- TION, 8vo 240 pages. PHILIP?* N SCROFULA, 1 vol. 8vo., 350 r es, plates. PROLP ON THE STOMACH AND RE- NAL DISEASES, 1 vol. 8vo., 466 pages, coloured plates. RICORD ON VENEREAL, new edition, 1 vol. 8vo., 256 pages. VOGEL'S PATHOLOGICAL ANATOMY OF THE HUMAN BODY, 1 vol. 8vo., 536 pages, coloured plates. WALSHE ON THE LUNGS, 1 vol. 12mo., 310 pages. PRACTICE OF MEDICINE, ASH WELL ON THE DISEASES OF FEMALES, by Goddard, 1 vol. 8vo., 520 pages. BARTLETT ON THE HISTORY, DIAG- NOSIS AND TREATMENT OF TY- PHOID, TYPHUS, BILIOUS REMIT- TENT, CONGESTIVE AND YELLOW FEVER, a new and extended edition of his former work (nearly ready). BENEDICT'S COMPENDIUM OF CHAPMAN'S LECTURES, 1 vol. 8vo., 258 pages. CHAPMAN ON THORACIC AND AB- DOMINAL VISCERA, &c, 1 vol. 8vo., 384 pages. CHAPMAN ON FEVERS, GOUT, DROPSY, Sec. &c, 1 vol. 8vo., 450 pages. COLOMBAT DE L'ISERE ON FE- MALES, translated and edited by Meigs, 1 vol. 8vo., 720 pages, cuts. : COATES' POPULAR MEDICINE, a now edition, brought up to the day, many cuts (preparing). : CONDIE ON THE DISEASES OF CHIL- DREN, 2d edition, 1 vol. 8vo., 658 pages. CHURCHILL ON THE DISEASES OF FEMALES, by Huston, 4th edition, 1 vol. 8vo., 604 pages. CHURCHILL ON THE MANAGEMENT AND MORE IMPORTANT DISEASES OF INFANCY AND CHILDHOOD (preparing). CLYMER AND OTHERS ON FEVERS, a complete work, in 1 vol. 8vo., 600 pages. DEWEES ON CHILDREN, 9th edition, 1 vol. 8vo., 548 pages. DEWEES ON FEMALES, 8th edition, 1 vol. 8vo., 532 pages, with plates. DUNGLISON'S PRACTICE OF MEDI- CINE, 2d edition, 2 volumes 8vo., ]:i22 pages. ESftUIROL ON INSANITY, by Hunt, 8vo., 496 pages. MEIGS ON FEMALES, in a series of Letters to his Class, with cuts (a new work, nearly ready). THOMSON ON THE SICK ROOM, &c, 1 vol. large 12mo., 360 pages, cuts. WATSON'S PRINCIPLES AND PR AC- TICE OF PHYSIC, 3d improved edition, by Oondie, 1 very large vol. 8vo., over 1000 pages strongly bound. LEA AND BLANCHARD'S PUBLICATIONS. MEDICAL SURGERY. BRODIE ON URINARY ORGANS, 1 vol. Bvo., 214 pages. BRODIE ON THE JOINTS, 1 vol. 8vo. 216 pages. BRODIE'S LECTURES ON SURGERY, 1 vol. 8vo., 350 pages. BRODIE'S SELECT SURGICAL WORKS 1 vol. 8vo., 780 pages. CHELIUS' SYSTEM OF SURGERY, by South and Norris, in 3 large 8vo. vols., over 2000 pages, well bound. COOPER ON DISLOCATIONS AND FRACTURES, 1 vol. 8vo.,500 pp.,many cuts. COOPER ON HERNIA, 1 vol. imp. 8vo., 428 pages, plates. COOPER ON THE TESTIS AND THY- MUS GLAND, 1 vol. imp. 8vo., many plates. COOPER ON THE ANATOMY AND DISEASES OF THE BREAST, SUR- GICAL PAPERS, &c. &c, 1 vol. impe- rial 8vo., plates. DRUITT'S PRINCIPLES AND PRAC- TICE OF MODERN SURGERY, 3d ed., 1 vol. 8vo., 534 pages, many cuts. DURLACHER ON CORNS, BUNIONS, &c, 12mo., 134 pages. DISEASES AND SURGERY OF THE EAR, a new and complete work (pre-; paring). FERGUSSON'S PRACTICAL SURGERY I ] vol. 8vo„ 2d edition, 640 pages, many i cuts. ! GUTHRIE ON THE BLADDER, 8vo.,i 150 pages. ! HARRIS ON THE MAXILLARY SI- NUS, 8vo., 166 pages. JONES' (WHARTON) OPHTHALMIC MEDICINE AND SURGERY, by Hays, 1 vol. royal 12mo., 529 pages, many cuts, and plates, plain or coloured. LIS TON'S LECTURES ON SURGERY, by Mutter, 1 vol. 8vo., 566 pages, many cuts. LAWRENCE ON THE EYE, by Hays, new edition, much improved, 863 pages, < many cuts and plates. ! LAWRENCE ON RUPTURES, 1 vol.; 8vo., 480 pages. M ALGAIGNE'S OPERATIVE SUR- GERY, with illustrations (preparing). MILLER'S PRINCIPLES OF SURGERY, 1 vol. 8vo., 526 pages. MILLER'S PRACTICE OF SURGERY, 1 vol. 8vo., 496 pages. BOOKS. MAURY'S DENTAL SURGERY, 1 vol. 8vo., 286 pages, many plates and cuts. ROBERTSON ON THE TEETH, 1 vol. 8vo., 230 pages, plates. SARGENT'S MINOR SURGERY, 1 vol. 12mo., with cuts (preparing). MATERIA MEDICA AND THERA- PEUTICS. i DUNGLISON'S MATERIA MEDICA AND THERAPEUTICS, a new edition, with cuts, 2 vols. 8vo., 986 pages. DUNGLISON ON NEW REMEDIES, 5th ed., 1 vol. 8vo., 653 pages. ELLIS' MEDICAL FORMULARY, 8th edition, much improved, 1 vol. 8vo., 272 pages. ! GRIFFITH'S^ MEDICAL BOTANY, a ! new and complete work, 1 large vol. | 8vo., with over 350 illustrations, 704 { pages. 'GRIFFITH'S UNIVERSAL FORMU- ' LARY AND PHARMACY, a new and complete work, 1 vol. large 8vo. (at press). PEREIRA'S MATERIA MEDICA AND THERAPEUTICS, by Carson, 2d ed., 2 vols. 8vo., 1580 very large pages, nearly 300 wood-cuts. ROYLE'S MATERIA MEDICA AND THERAPEUTICS, by Carson, 1 vol, 8vo., 689 pages, many cuts. STILLES ELEMENTS OF GENERAL THERAPEUTICS, a new work (pre- paring). UNIVERSAL DISPENSATORY, with many wood-cuts, 1 vol. large 8vo. (pre- j paring). OBSTETRICS. CHURCHILL'S THEORY AND PRAC- TICE OF MIDWIFERY, by Huston, 2d ed., 1 vol. 8vo., 520 pages, many cuts. DEWEES' SYSTEM OF MIDWIFERY, 11th edition, 1 vol. 8vo., 660 pages, with plates. RIGBY'S SYSTEM OF MIDWIFERY, 1 vol. Svo., 492 pages. RAMSBOTHAM ON PARTURITION, ; with many plates, 1 large vol. imperial > 8vo„ new and improved edition, 520 j pageB. LEA AND BLANCHARD'S PUBLICATIONS. MEDICAL BOOKS. CHEMISTRY AND HYGIENE. BRIGHAM ON MENTAL EXCITE- MENT, &c, 1 vol. 12mo., 204 pages. DUNGLISON ON HUMAN HEALTH, 2d edition, 8vo., 464 pages. FOWNE'S ELEMENTARY CHEMIS- TRY FOR STUDENTS, by Bridges, 2d edition, 1 vol. royal 12mo„ 460 large pages, many cuts. GRAHAM'S ELEMENTS OF CHEMIS- TRY, 1 large vol. 8vo. (new and im- proved edition at press), many cuts. MAN'S POWER OVER HIMSELF TO PREVENT OR CONTROL INSANITY, 18mo., paper, price 25 cents. PRACTICAL ORGANIC CHEMISTRY, 18mo., paper, 25 cts. SIMON'S CHEMISTRY OF MAN, 8vo., 730 pages, plates. MEDICAL JURISPRUDENCE, EDUCA- TION, &c. BARTLETT'S PHILOSOPHY OF MEDI- CINE, 1 vol. 8vo., 312 pages. DUNGLISON'S MEDICAL STUDENT, 2d edition, 12mo., 312 pages. TAYLOR'S MEDICAL JURISPRU- DENCE, by Griffith, 1 vol. 8vo., 540 pages. TAYLOR'S MANUAL OF TOXICO- LOGY, edited by Griffith (at press). TRAILL'S MEDICAL JURISPRU- DENCE, 1 vol. 8vo., 234 pages. NATURAL SCIENCE, 8vo. ARNOTT'S ELEMENTS OF PHYSICS. new edition, 1 vol. 8vo., 484 pages, many : cuts. ANSTED'S ANCIENT WORLD—POPU- LAR GEOLOGY, with numerous illus- trations (nearly ready). BIRD'S NATURAL PHILOSOPHY, from a new London edition, 1 vol. royal 12mo., many cuts (at press). BREWSTER'S TREATISE ON OPTICS, 1 vol. 12mo., 423 pages, many cuts. BABBAGE'S " FRAGMENT," 1 vol. 8vo., 250 pages. AUCKLAND'S GEOLOGY AND MINE- RALOGY, 2 vols. 8vo.. with numerous plates and maps. j BRIDGEWATER TREATISES, with many plates, cuts, maps, &c, 7 vols. 8vo., 3287 pages. CARPENTER'S ANIMAL PHYSIOLO- GY, with 300 wood-cuts (preparing). CARPENTER'S POPULAR VEGETA BLE PHYSIOLOGY, 1 vol. royal 12mo., many cuts. DANA ON CORALS, 1 vol. royal 4to., with an atlas of plates, being vols. 8 and 9 of U. States Exploring Expedition (at press). DE LA BECHE'S NEW WORK ON GEOLOGY, with wood-cuts (preparing). GRIFFITHS' CHEMISTRY OF THE FOUR SEASONS, 1 vol. royal 12mo., 451 pages, many cuts. HALE'S ETHNOGRAPHY AND PHI LOLOGY OF THE U. S. EXPLORING EXPEDITION, in 1 large imp. 4to. vol. HERSCHELL'S TREATISE ON ASTRO- NOMY, 1 vol. 12ino., 417 pages, numer- ous plates and cuts. INTRODUCTION TO VEGETABLE PHYSIOLOGY, founded on the works of De Candolle, Lindley, &c, 18mo. KIRBY ON ANIMALS, plates, 1 vol. 8vo., 520 pages. KIRBY AND SPENCR'S ENTOMO- LOGY, 1 vol. 8vo., CJJ large pages ; plates, plain or coloured. METCALF ON CALORIC, 1 vol. large 8vo. (preparing). MULLER'S PRINCIPLES OF PHYSICS AND METEOROLOGY, with five hun- dred and fifty wood-cuts, and two co- loured plates (nearly ready). PHILOSOPHY IN SPORT MADE SCI- ENCE IN EARNEST, 1 vol. royal 18mo., 430 pages, many cuts. ROGET'S ANIMAL AND VEGETABLE PHYSIOLOGY, with 400 cuts, 2 vols. 8vo., 872 pages. TRIMMER'S GEOLOGY AND MINE- RALOGY, 1 vol. 8vo., 528 pages, many cuts. VETERINARY MEDICINE. CLATER AND SKINNER'S FARRIER, 1 vol. 12mo., 220 pages. YOUATT'S GREAT WORK ON THE HORSE, by Skinner, 1 vol. 8vo., 448 pages, many cuts. YOUATT AND CLATER'S CATTLE DOCTOR, 1 vol. 12mo., 282 pages, cuts. YOUATT ON THE DOG, by Lewis, 1 vol. demy 8vo., 403 pages, beautiful plates. YOUATT ON THE PIG, 1 vol. 12mo., oages. beautiful plutes. 1-tNiii m -few fell $ ^KiV r mm. lira Ww