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fourth filled with baryta-water.

The urine is heated to 100° C. over a water-bath; any por-
tions boiling over go into the empty flask. The carbonic acid
comes off and forms a white precipitate of barium carbonate in
the flasks filled with baryta-water. Air is then drawn through
the apparatus, any carbonic acid in the atmosphere being
removed by the quicklime. The carbonate of baryta formed is
collected on a filter, washed with distilled water, dissolved in
hydrochloric acid, precipitated again by sulphuric acid, and
weighed as barium sulphate. From the quantity thus obtained
the amount of carbonic acid in the urine can be calculated :
196.65 parts of barium carbonate correspond to 232.62 parts of
barium sulphate and 44 parts of carbonic acid.

(6) The total carbonic acid may be similarly estimated after
strongly acidifjing the urine with hydrochloric acid.

The combined carbonic acid is the difference between the total
and the free carbonic acid.

Other Inorganic Constituents.

Iron occurs in the urine in small quantities, but its combination is
yet unknown. Free ammonia occurs in traces, greatly increased in
putrefactive changes of the urine. Hydrogen dioxide was first shown
in the urine by Schonbcn. It exists in small amount, and, so far as
known, is without special signification. It is detected by tetra-paper,
which, if immersed in its solution, will show the presence of ozone by
taking a blue color. 2. Dilute indigo solution is bleached by dioxide of
hydrogen in the presence of iron-sulphate solution.

Gases. — The urine contains small quantities of gases. Carbonic
aeid, 4 to 9 volumes free gas ; 2 to 5 combined. Oxygen, 0.2 to 0.6
volume ; and nitrogen, 0.7 to 0.8 volume. The gases of the urine may
be withdrawn by the air-pump.

CENTRIFUGAL ANALYSIS.

With the first edition of this work the author introduced his
method of centrifugal analysis for the ready approximate deter-
mination of bulk percentages of chlorides, phosphates, sulphates,
and albumin in the urine. Nothing was claimed for this methotl
at that time further than rapid approximate bulk measurement

5



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64 ANALYSIS OF URINE.

of these sediments, because the method was then new and un-
tried, save in the author^s laboratory, and it seemed a radical
departure from methods better known and considered more
accurate, such as titration, weighing, etc. Moreover, only bulk
percentages had then been worked out without any attempt hav-
ing been made to give corresponding gravimetric values, much
less corresponding values in CL, PjO^, and SO3 from tlie bulk
percentages of these combined as salts in the sediment. Since
its introduction, however, it has been demonstrated in the au-
thor's laboratory that centrifugal analysis of the urine, if car-
ried out by refined methods and improved apparatus, may readily
reach results that are entitled to rank with the older standard
methods, the gravimetric and volumetric included; that bulk
percentages of sediments may be worked out in their equivalent
values of their elements, not only with precision, but also with
a rapidity and facility that at once renders this method of the
greatest practical value in clinical work.

Tiie essentials for securing accurate results in centrifugal
analysis of urine are in no way complex or difficult of compre-
hension, much less to put into practice in the most ordinary
laboratory. The equipment consists of an efficient motor, capable
of the standard s[)eed, possessing a standard radius of arm and
tube (6f inches) accurately-graduated percentage tubes, and a
gauge to regulate the speed. The author's iraprovtd electric
motor (described in full at page 149) fulfills all requirements for
accurate work. Very recently a further improvement in the
author's percentage tubes has been adopted as follows: The
points have been drawn out finer, and the first 5 cubic centi-
metres have been more minutely graduated so as to indicate
measurements in 0.25 per cent. (J percentages) instead of 1 per
cent, (one per cent.) as before.^

For the determination of chlorides, phosphates, and sulphates
in the urine by the centrifugal method, the following standard
and tables are now adopted in the author's laboratory.

For determination of albumin see page 80.

Process. — The double arm of the motor is employed, carrying

* Messrs. £imer & Amend, of 2a5 and 211 Third Avenue, New York, mana-
facture and supply the author's improved standard percentage tubes.



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TABLE

Fob Chlorides in the Urinb,

showing the balk percentages of silver obloride (AgCl) and the correspond-
ing gravimetric percentages and grains per flnidoonce of
sodium chloride (NaCl) and chlorine (Cl).



Gr.

PER

Ox,.
Cl.



BOLK
PCR-


Per.


Gr.


Per-


Gr.


CBNT-
AOBOP

AaCu


OSIVT-
AGE,

NaCl


PER

Oz.,
NaCl.


cent-
age,

CL.

0.02


PER

Oz.,
Ol.


i


0.03


0.15


0.1


i


0.07


0.31


0.04


0.19


f


0.1


0.47


0.06


0.28


1


0.13


0.62


0.08


0.38


u


0.16


0.78


0.1


0.48


li


0.19


0.93


0.12


0.57


11


0.23


1.09


0.14


0.66


2


0.26


1.24


0.16


0.76


2i


0.29


1.41


0.18


o.a5


2i


0.32


1.56


0.2


0.96


2}


0.36


1.71


0.22


1.04


3


0.39


1.87


0.24


1.13


3}


0.42


2.02


0.26


1.23


3i


0.46


2.18


0.28


1.32


3}


0.49


2.35


0.3


1.42


4


0.52


2.49


0.32


1.61


41


0.55


2.64


0.34


1.61


4i


0.58


2.8


0.35


1.7


4J


0.62


2.96


0.37


1.8


5


o.a5


3.11


0.39


1.89


51


0.71


3.42


0.43


2.09


6


0.78


3.73


0.47


2.27


6i


0.84


4.05


0.51


2.46


7


0.91


4.35


0.55


2.62


'i


0.97


4.67


0.59


2.84



Bulk
1 Pkr-

. CENT-

'aobop
1 AoCl.


Per-
cent-
age,
NaCl.


Gr.

PER

Oz..
NaCl.

4.98


Per-
cent

AGE,

Cl.




8


1.04


0.63


8J


1.1


5.29


0.67


9


1.17


5.6


0.71 '


»l


1.23


5.91


0.75


10


1.3


6.22


0.79 i


lOi


1.36


6.53


0.83




11


1.43


6.84


0.87




111


1.49


7.2


0.91




12


1.56


7.46


0.95




; 121


1.62


7.78


0.99




i 13


1.69


8.09


1.02




131


1.75


8.4


1.06




14


1.82


8.71


1.1




141


1.88


9.02


1.14




15


1.94


9.33


1.18 '


161


2.01


9.65


1.22 ;


16


2.07


9.94


1.26


161


2.14


10.27


1.3




1

17


2.2


10.51


1.34




171


2.27


10.87


1.38




18


2.33


11.2


1.42




181


2.4


11.51


1.46




19


2.46


11.82


1.5




19J


2.53


12.13


1.54




20

1


2.59


12.44


1.58





3.02

3.22

3.4

3.6

3.79

3.97

4.16

4.35

4.54

4.73

4.92

6.11

5.29

5.49

5.67

5.86

6.06

6.24

6.43

6.62

6.81

7.

7.19

7.38

7.56



(64a)



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TABLE

Foe Phosphates in the Urine,

showing the bulk percentages of uranyl phosphate (H[U02]P04) and the

corresponding gravimetric percentages and grains per

ounce of phosphoric acid (PjOj).



Bulk Per-


Pbrcent-


Gr. per


Bulk Per-


Percent-


Or. per


OBNTAQB OF


AQB,


Oz.,


OENTAGE OF


age,


Oz.,


H(U0,)P04.


P.O..


P.O..


H(U0,)P04.


P.O..


P.O..


i


0.02


0.1


11


0.14


0.67


1


0.04


0.19


12


0.15


0.72


n


0.045


0.22


13


0.16


0.77


2


0.05


0.24


14


0.17


0.82


2J


0.055


0.26


15


0.18


0.86


3


0.06


0.29


16


0.19


0.91


3i


0.065


0.31


17


0.2


0.96


4


0.07


0.34


18


0.21


1.


4J


0.075


0.36


19


0.22


1.06


5


0.08


0.38


20


0.23


1.1


6


0.09


0.43


21


0.24


1.15


7


0.1


0.48


22


0.25


1.2


8


0.11


0.53


23


0.26


1.25


9


0.12


0.58


24


0.27


1.3


10


0.13


0.62


25


0.28


1.35



TABLE
Fob Sulphates in the Ubine,
showing the bulk percentages of barium sulphate (BaS04) and the corre-
sponding gravimetric percentages and grains per
fluidounce of sulphuric acid (SO,).



Bulk Per-
centage OF
BASO4.


Percent-
age, SO..


Or. per
Oz., SO,.


Bulk Per-
centage OF
BASO4.


Percent-
age, SO..


Gr. per
Oz., SO..


*


0.04


0.19 1


21


0.55


2.64


1


0.07


0.34


2i


0.61


2.93


0.1


0.48


0'


0.67


3.22




0.13


0.62


3


o.rj


3.5


J


0.16


0.77


3}


0.79


3.79


V


0.19


0.91


3i


o.a5


4.08


0.22


1.06


3|


0.91


4.37


1


0.25


M


4


0.97


4.66


1


0.31


1.49


4


1.03


4.94


1\


0.37


1.78


4


1.09


5.23


1


0.43


2.06


4i


1.15


5.52


2


0.49


2.35

i


5


1.21


5.81



(646)



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NORMAL 00NSTITUENT8 OF UBIN£. 65

four tubes. Three percentage tubes are filled to the lOcubic-
centimetre mark with the urine (the urine having been previously
filtered if not perfectly clear). To the first tube is added 1 cubic
centimetre of strong nitric acid and 4 cubic centimetres of stand-
ard solution of silver nitrate.^ To the second tube is added 2
cubic centimetres of 50-per-cent. acetic acid and 3 cubic centi-
metres of uranium-nitrate solution (5 per cent.). To the third tube
is added 5 cubic centimetres of the standard barium-chloride mixt-
ure.^ The tubes are next inverted three times to insure mingling
of the urine and reagents and then allowed to stand for three (S)
minutes to secure complete precipitation. In order to balance the
arm of the motor, the fourth tube is filled to the 15-cubic-centimetre
mark with water. The centrifugal is next operated at a speed
of 1200 revolutions per minute for three (3) minutes. The tubes
are then removed and the percentages of precipitates are read
off on the scale. No. 1 gives the bulk percentage of silver chlo-
ride (AgCl), No. 2 the bulk percentage of uranyl phosphate
(H[U0g]P04), and No. 3 the percentage of barium sulphate
(BaS04). ^'^6 ^w^J^ percentages are converted into their
equivalent values in gravimetric percentages by means of the
subjoined tables, and from these the grains or grammes of total
chlorine (CI), phosphoric acid (P30ft),and sulphuric acid (SO3)
are readily calculated by a glance at the tables. The results are
more accurate if the urine be diluted in the cases of chlorides
and phosphates if the bulk percentage of these exceed 15 per
cent. The time required to carry out these quantitative deter-
minations should not exceed ten minutes. As a rule, the more
rapid and ready processes in uranalysis are comparatively few,
and, for the most part, limited to qualitative rather than to quan-
titative data. The author, therefore, hopes that the above con-
tribution of centrifugal analysis to our resources, which he has .
worked out with great care and pains, will prove of equal
value to others in practical urinary work to that found in his
own laboratory. Indeed, the amount of practical information



* Standard Ditrate-of-fiilver solution consists of silver nitrate, 3j ; distilled
water, Jj.

'Standard barium-chloride mixture consists of barium chloride, 4 parts;
strong hydrochloric acid, 1 part ; distilled water, 16 parts.



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66 ANALYSIS OF tJRINB.

that tbis luetliod is c:ipnble of Inyiug before the clinician with-
out loss of time cannot fail to prove of inestimable value in
pi'actical work. Thus, the time require<l to carry out these
quautitative determinations centrifugally as described above
should not exceed ten minutes. It has, indeed, been repeatedl3*
demonstrated in the author^s laboratory that the use of modem
centrifugal methods has made it possible to make a fairly com-
plete analysis of urine, both qualitative and quantitative, in
from twenty minutes to half an hour which formerly required
twenty-four hours' time.



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SECTION III.

ABNORMAL URINE.

Proteids.

The four proteids of the blood — viz., serum-albumin, serum-
globulin, fibrin, and haimoglobin — are met with in the urine in
various pathological conditions of the kidneys, the blood, or the
system at large. Other proteids are sometimes met with in the
urine which do not exist in the. blood, such as egg-albumen upon
the liberal ingestion of eggs as food, and, under certain con-
ditions, also peptone. Finally, certain proteoses are met with in
the urine in pathological conditions, the more prominent of which
are pro-albumose, deutero-albumose, and hetero-albumose.

Albuminuria.

The chief clinical interest with regard to proteids in the urine
will probably always centre about serum-albumin. While albu-
min is doubtless the most common of all the constituents of mor-
bid urine, it still remains a debated question if it be present in
the urine in health. No doubts can further exist that the urine
occasionally contains a variable — usually small — but distinct
amount of albumin when the kidneys present no appreciable
alterations of structure; but, as will be shown, albuminuria
often arises from causes aside from the kidneys themselves.
Albuminuria, therefore, cannot be proved to be a condition of
health, so long as the kidneys alone are considered ; yet, the ab-
sence of renal lesions would seem to be the chief, if not indeed
the only, condition sought to be established by many advocates
of a so-called physiological albuminuria.

Albumin belongs to the class of colloids which do not crys-
tallize, and under ordinary conditions do not penetrate animal
membranes ; but alterations from the normal conditions, as in the
integrity of the basement membrane, in the quality of the albu-
min itself, or in the pressure to which they are both subjected,

(67)



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68 ANALYSIS OF URINE.

may result in transudation. It is altogether probable that most
forms of albuminuria are referable to causes corresponding to
one or more of the above-named conditions. In other words, al-
buminuria may be due (1) to changes in the kidneys themselves,
which impair the integrity of the structures between the vessels
and the excretory channels of the organs ; (2) alterations in the
quality of the blood which render its serum-albumin more diflb-
sible ; (3) alterations in the degree of blood -pressure. Albumi-
nuria may depend upon one or, indeed, all three of the above con-
ditions.

Clinical Significance. — 1. The more common form of albu-
minuria, as well as the most serious in its clinical significance, is
that depending upon pathological conditions of the kidneys. The
most frequent of these are inflammatory and degenerative changes
in the renal structure, and include the whole class of disorders
commonly grouped together under the term of Bright's disease.

It is impossible always to estimate the gravity or progress of
renal changes by the quantity of albumin present in the urine.
Sometimes, however, as in acute inflammatory conditions, when
the amount of albumin ranges high, — 1 per cent, by actual weight
or more, — the quantity may be taken as a rough gauge of the ex-
tent of the lesions as well as the progress of the same from day
to day. The same may be said of certain degenerative changes
in the kidneys, notary of amyloid disease. This, however, by
no means applies to all diseases of the kidneys, for, indeed, in
certain renal diseases of the most serious character, — interstitial
nephritis^ — not only is the quantity of albumin in the urine
usually small, but it is often temporarily, and even occasionally,
absent throughout. The quantity of albumin in the urine,
therefore, is not a safe guide as to the gravity of the situation in
diseases of the kidneys, especially in cases attended by moderate
or even very slight grades of albuminuria.

2. The second class of albuminurias depend upon changes in
the constitution of the blood, which so alters the diffusibility of
its albumin as to permit it to pass into the renal tubules. The
hsemotogenic causes of albuminuria have been most ably ex-
pounded by Semola, and, although he probably claims too wide
a range for these causes, there remains no just reason to doubt



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ABNORMAL CONSTITUENTS OP URINE. 69

their existence. We often meet with such albuminuria in anaemia,
and in strumous and enfeebled individuals, when no lesions of
the kidneys can be made out. The effect of certain poisons upon
the blood probably so alters that fluid as to permit of tran-
sudation of its albumin into the renal tubules. The effects, also,
of some infectious fevers — micro-organisms in the blood — no
doubt seriously alters the constitution of the circulating fluid,
so that transudation of albumin is the rule, while the kidneys do
not always become damaged.

3. The third form, disturbances of the circulation, may bring
about albuminuria without inducing structural changes in the
kidneys, provided they be not too long continued. Circulatory
disturbances, in order to induce albuminuria, must include the
renal vessels. In nature they must consist of acxjeleration of
the arterial current or slowing of the venous current, in either
case resulting in increased blood-pressure. Probably this cause
is responsible for the majority of that large class of cases of
so-called " physiological or functional albuminurias.^^ This is
most marked upon prolonged or fatiguing muscular exercise.
Leube found albumin in the urine in 16 per cent, of soldiers
after prolonged march, and Chateaubourg gives the percentage
as even higher. A similar result sometimes occurs after the
application of cold to the surface of the body ; the blood being
driven to the interior, the renal vessels become overfilled and
albuminuria often results. Again, in some derangements of
the nervous system, which interfere with the vasomotor-nerve
regulation of the renal vessels, temporary albuminuria is not
an uncommon result. Albuminuria from increased blood-press-
ure is readily demonstrable by experimentation in the following
ways: 1. By pressure upon the renal veins. 2. Ligature of the
aorta below one kidney, and extirpation of the other. 3. Com-
pression of the trachea. The quantity of albumin in the urine
from disturbances of the circulation is for the most part smalL
It may be but temporarily present, or it may become a permanent
condition, depending upon the continuance of the cause. Thus
we may have temporary albuminuria after a seizure of epilepsy
which soon after the attack subsides, or when depending upon
organic disease of the heart it becomes permanent.



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TO ANALYSIS OF UBINB.

Finally, albuminuria often owes its origin to two or even all
three of the causes just considered. In fevers, for instance, all
the described causes of albuminuria are sometimes present. We
have, for instance, accompanying changes in blood-pressure, and
when long continued the febrile state is apt to iuduce structural
changes in the renal epitlielium, while profound changes in the
constitution of the blood are often induced by fevers, more espe-
cially the acute infectious ones, which without doubt are the
active cause of albuminuria.

It remains to consider the significance of a form of albumi-
nuria which is often intermittent in character, to which Pavy's
" Cyclic Albuminuria^^ and Moxon's ^^Albuminuria of Adoles-
cence " doubtless belong. In a large percentage of these cases
the albuminuria is intermittent ; if not, usually it is remittent ; the
intermission or remission occurring during rest, as at night.
On rising in the morning the urine is often free from albumin,
but soon after rising, and especially upon exercising, the urine
contains albumin, which may or may not wear away toward
evening. A large percentage of these cases is observed in
youths and 3'oung adults.

In another class of these cases the albuminuria is more con-
stant, and if an intermission occur it is usually measured by
weeks or months instead of hours. In these cases the age of
the patient is less constant, although the albuminuria is still most
common before middle age.

For the most part all these cases possess certain features in
common : 1 . The quantity of albumin in the urine is small, usually
ranging from one-half to one-tenth or two-tenths of one per cent.
2. The urine either contains no renal casts or very few perfectly
hyaline ones. 3. The specific gravity of the urine is somewhat
above the normal standard, — 1024 to 1030. 4. Evidences of car-
diac and general vascular changes of a permanent nature are
absent. 5. Close observation will usually reveal evidence of
some local or general impairment of the functions, as measured
by the standard of vigorous health.

The causes of this group of albuminurias are identical with
those already considered, only operating perhaps in milder de-
grees. To changes in the renal structures, alterations in the



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ABNORMAL OONSTITUKNTS OF URINS. tl

quality of the blood, or abnormal increase of bloodpi^essure, — to
one or more, or all of these combined, we may with great prob-
ability refer every case of albuminuria as to its essential cause
or causes.

It will be seen, from the preceding considerations, that albu-
minuria is a symptom of the most variable clinical significance,
and therefore, in itself, should never be accepted as proof of
the presence of renal disease. As has been truthfully said, " this
was the error of former times." It can only be positivelj' as-
serted that albuminuria is the result of renal changes when it is
accompanied by those products in the urine which are a conse-
quence of renal lesions, such as casts, epithelium, etc. On the
other hand, it must be remembered that albumin in notable
quantity is not present in healthy urine. On the whole, it will
be safer to accept albuminuria as an evidence of an existing ab-
normal state, the gravity of which must be determined by its
accompanying symptoms. The author holds that so-called func-
tional albuminuria forms no exception to the above rule, inas-
much as he has never met with a case of albuminuria in which
the patient did not present more or less evidence of departure
from the normal balance of perfect health, either local or general.

It is only necessary here to allude to the occurrence of albu-
min in the urine derived from sources other than the kidneys.
Such albuminuria has been variously termed adventitious, false,
or acciderttaL In such cases the urine on leaving the kidneys is
perfectly normal ; but, meeting with the products of inflamma-
tory changes in the urinary passages, — the renal pelvis, ureters,
bladder, or urethra, — it becomes albuminous. As a rule, in such
cases, the source of the albumin may be determined by chemical
and microscopical investigation, together with local symptoms.

Detection of Albumin in the Urine.— 1. Heat: Boiling the
uiine constituted the first test employed to detect albumin, b}'
Contugno (1770). The more common method of application of
this test is in conjunction with nitric acid. A test-tube of ordi-
nary size is filled half full of the suspected urine, and heat is
applied until boiling occurs throughout the whole. If a precipi-
tate occur, it consists either of albumin or earthy phosphates.
A few drops of nitric acid are next added, and if the precipitate



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72 ANALYSIS OF UBINS.

remain undissolved it is due to the presence of albumin. If, on
the other hand, the precipitate disappear upon the addition of
the acid, it consists of the earthy phosphates, and the urine is
free from albumin. In testing, tlie acid should be added in small
quantity, at first, — say, 2 to 5 drops, — and the urine should then
be re-boiled. If now no precipitate occur, acidulation should be
continued until precipitation occur or a limit of acidification be
reached of about 15 to 20 drops. Some prefer to reverse this
order, and first acidify the urine before applying the heat.

The heat and nitric-acid test is subject to certain errors.
Thus, if there be little albumin present and the acid be in excess,
the albumin may combine with the acid, forming a soluble acid
albumin, — syntonine ^—"wiuch is not precipitated hy boiling. If,
on the other hand, the acid be insufficient to distinctly acidify
the urine, and if the phosphates be in excess, a part only of the
basic phosphates may be acidified, while the albumin may com-
bine with the remainder, forming a soluble alkali albuminate,
which will not be precipitated by boiling. The heat and acid



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