THE SPECIFIC GRAVITY OF THE URINE IN DIABETES MELLITUS. By Surgeon-Captain J. H. Tull
Walsh, i.m.s.
general impression conveyed by
the notes of a case in which a patient suffering from chylous urine developed glycosuria. The urine at first (1876) had a specific gravity of 1025; it was milky in appearance, and it contained both albumen and sugar. On the 20th September, or about two months later, there was no sugar in the urine; but on November lltli the urine, with a specific gravity of 1012, contained sugar; on the 23rd, with a specific gravity of 1010, it still contained sugar. On the 5th February 1877, she passed nine pints of urine with a specific gravity of 1010; and, after fermentation, the specific gravity was 1006, giving about 730 grains of sugar. {B. M. J., vol. i, p. 209, 1880.) In the same volume of the British Medical Journal, p. 280, Dr. 11. E. Heath, of Torquay, gives notes of a case of diabetes in which the specific gravity was 1008 to 1010. Dr. Debout D'Estrees notes (Lancet, vol. i, 1886, p. 965) that a low specific gravity does not always imply the absence of sugar, and gives as an example a case which was under the care of Dr. Wilson Fox in 1880. Dr. Wilson Fox made the following analyses :?
the of most writers on Medicine would lead the student to conclude that diabetic urine luis necessarily a high specific gravity. In the second edition of Hilton Fagge's Principles and Practice of Medicine, 1888, we find it stated " that in diabetes the specific gravity of the urine is higher than normal. Instead of being betweeu 1015 and 1025, it is from 1030 to 1040 or 1045." Again, we are told by another -writer that in diagnosing a case of diabetes " the density of diabetic urine, however, is This fluid varies one of the best indications. in density from 1030 to 1074 (Becquerel); but, August 20. on an average and tolerably constantly, it is Albumen. Sugar. gr. Sp. 1040; and when the urinometer stands above 0*40 22-0 grammes. 1022 Morning that 1030, we may suspect 1'30 35*20 sugar is present.". 1026 ? Evening (Aitken's Science and Practice of Medicine, 26. August 15*40 0*30 1015 p. 1059, 1880.) Bristowe makes no allusion to ? Morning 0*50 17*60 1017 the possibility of sugar occurring in urine of a ? Evening low specific gravity, and it is only in a quite September 3. None. Traces 1010 recent work that the fact is partially noticed. Morning Traces. 0 25 " 1010 Evening The urine is increased in quantity, the amouut In vol. ii of the Lancet for 1880, Dr. Cameron, varying from three or four piuts to as many its its is of Chemistry and Hygiene at the colour Professor ; gallons; specific gravity pale ranges from 1015 to 1050" (A. A. Stevens, m.d.: Royal College of Surgeons, Ireland, wrote as A Manual of the Practice of Medicine prepared follows :? " especially for Students, p. 305, 1893.) Many years ago I examined several times a Dr. Stevens recognises the fact that diabetes week during some mouths the urine of a young may exist and run its course without the specific man (a patient of Sir George Bowens), who mellitus. As a gravity rising above that of normal, healthy ultimately died from diabetes ot his urine rarely rose the does but not even rule, hint specific gravity that urine, sugar may exist in a pale watery urine, the specific gravity higher than 1030. He had an incessant and often below is normal. During the past unallayable thirst. On one occasion I found of which his urine to have a specific gravity of 1005, cases have been recorded in which several years the specific gravity of the urine was extremely sugar being present in small but decided quanOf course the general symptoms might tity. The low gravity of the urine surprised the low. medical attendant, who indeed at first was inlead the student to suspect the presence of sugar credulous that diabetic urine could have so low in such urine, but in many cases of diabetes the The
teaching
...
strongly marked general symptoms are notofvery the disease. It is during the early phases to
draw attenthis account that I am anxious tion to the following cases which I have been able to collect ; I also take this opportunity of publishing a case which was treated by me in the Presidency General Hospital in June 1892. Diabetes is by no means a rare disease in India among the native community, and the importance of the early detection ot sugar in the urine cannot be overrated. At a Meeting of the Clinical Society on the 23rd January 1880, Dr. S. 0. Habershon read on
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gravity."
Dr. Cameron afterwards {Dublin Journal of Medical Science, April 1883) reported cases in which he had found sugar in specimens of urine of a specific gravity of 1015, 1008, and 1007. Sir Edward Sievking reported a case in the British Medical Journal for 1892, and others might no doubt be found if I had the necessary time for looking up references. The following caao was under my care in the
Presidency General Hospital, Calcutta:?G. A., Armenian, aged 55, admitted to hospital 1st
June 1892, for
a
large carbuncle
in tho middle
April
1893.]
TULL WALSH ON
GRAVITY
OP THE URINE IN DIABETES MELLITUS.
109
It would further appear from a study of several from several small cases that there is, as might be expected, some apertures. During the last six months has been relation between the specific gravity of the passing large quantities of urine, and has a freurine and the amount of sugar present; with a quent desire to micturate. Tongue coated with low specific gravity there will be relatively, and a white fur; somewhat constipated, and suffering perhaps actually, less sugar than with a high from great debility. Temp, evening 101*2? F. specific gravity ; but even here it is necessary to Skin very dry and branny. note certain points which shew how mistakes in June 2nd.?Morning temp. 100. The diameter judgment might arise if a high specific gravity of the area of the carbuncle and were taken as surrounding inimplying the certain presence of flammation measured about 12 inches. The sugar in the urine. Dr. Debout D'Estrees, of patient was put under chloroform, the suppuratCoutrexeville, reports cases in which, with a ing central portion, 3 inches square, was cut out, specific gravity of 1031, 1030 and 1034, no sugar and the was cavity scraped and swabbed with pure present; the rise in specific gravity being carbolic acid. Wound dressed with gauze and due to the presence of oxalate of lime. Urates, idoform. Evening temp. 99?. when present in large quantities, raise the speciJune 3rd.?Feeling easy; slept well; had fic gravity of the urine, and moreover will cause one stool ; reduction of cupric sulphate. That this is yesterday, pale and deficient in bilethe passed a large quantity of urine (not properly so may be illustrated by a case reported by Professor Cameron. He says : " A few months measured), pale; of neutral reaction; containing no albumen; specific gravity 1020; sugar ago I examined the urine of a man who had been treated for diabetes. The urine had a distinct, but in small quantity. June 4th.?Total amount of urine passed in specific gravity of 1035, and, on being boiled previous 24 hours 80 ounces; specific gravitywith Fehling's solution, it gave a copious precipitate of cuprous oxide. There was something in 1010; sugar present. On the 4th 90 ounces of urine were pass-the appearance of the precipitate and in the ed, having only a specific gravity 1006; sugarslow way in which it made its appearance that led me to suspect that it was not produced by slight trace. June 5th.?80 ounces; specific gravity 1010. sugar. This proved to be the case, for on treatJune 7th.?The yeast test applied to the urineing the urine with yeast no carbouic acid (save passed ou June 6th (70 ounces); shewed a graina mere trace) was evolved. " Dr. Cameron reof sugar to the ounce approximately. commends that when urates are shewn to be June 10th.?Carbuncle doing well ; tempera-present in any quantity in a suspected urine; ture from normal to 101*4 ; still passing a largethey should be precipitated with hydrochloric quantity of urine 80 ounces; specific gravityacid. The urine should be filtered and then 1010; presence of sugar very doubtful to-day. examined for sugar. Urine 80 ounces; June 15th.?Improving. no 1014 ; specific gravity sugar. June \%tli.?Urine passed during previous 24 I hours 64 ounces. June 24th.?40 ounces of urine; wound healing, and temperature normal. June 30th.?Patient left hospital feeling quite well. In this case, of course, the carbuncle, debility and dryness of the skin led to the immediate examination of the urine ; but the presence of sugar might have been overlooked had the symptoms been milder, and the specific gravity of the urine regarded as below that at which sugar should be suspected. The only special treatment adopted consisted in the restriction of diet, all starch and sugar being avoided, and the administration of large doses of opium. I saw this patient about four months after he left hospital ; he was then in fairly good health ; the carbuncle was healed, and [he was passing a normal quantity of urine. It will be noticed that the amount of sugar passed daily was small, taking the experiment of the 7th June as a guide. Since, however, sugar is not found in healthy urine, even a small amount is an evil and will give rise to pathological conditions. of the
back, discharging
Walsh, i.m.s.
general impression conveyed by
the notes of a case in which a patient suffering from chylous urine developed glycosuria. The urine at first (1876) had a specific gravity of 1025; it was milky in appearance, and it contained both albumen and sugar. On the 20th September, or about two months later, there was no sugar in the urine; but on November lltli the urine, with a specific gravity of 1012, contained sugar; on the 23rd, with a specific gravity of 1010, it still contained sugar. On the 5th February 1877, she passed nine pints of urine with a specific gravity of 1010; and, after fermentation, the specific gravity was 1006, giving about 730 grains of sugar. {B. M. J., vol. i, p. 209, 1880.) In the same volume of the British Medical Journal, p. 280, Dr. 11. E. Heath, of Torquay, gives notes of a case of diabetes in which the specific gravity was 1008 to 1010. Dr. Debout D'Estrees notes (Lancet, vol. i, 1886, p. 965) that a low specific gravity does not always imply the absence of sugar, and gives as an example a case which was under the care of Dr. Wilson Fox in 1880. Dr. Wilson Fox made the following analyses :?
the of most writers on Medicine would lead the student to conclude that diabetic urine luis necessarily a high specific gravity. In the second edition of Hilton Fagge's Principles and Practice of Medicine, 1888, we find it stated " that in diabetes the specific gravity of the urine is higher than normal. Instead of being betweeu 1015 and 1025, it is from 1030 to 1040 or 1045." Again, we are told by another -writer that in diagnosing a case of diabetes " the density of diabetic urine, however, is This fluid varies one of the best indications. in density from 1030 to 1074 (Becquerel); but, August 20. on an average and tolerably constantly, it is Albumen. Sugar. gr. Sp. 1040; and when the urinometer stands above 0*40 22-0 grammes. 1022 Morning that 1030, we may suspect 1'30 35*20 sugar is present.". 1026 ? Evening (Aitken's Science and Practice of Medicine, 26. August 15*40 0*30 1015 p. 1059, 1880.) Bristowe makes no allusion to ? Morning 0*50 17*60 1017 the possibility of sugar occurring in urine of a ? Evening low specific gravity, and it is only in a quite September 3. None. Traces 1010 recent work that the fact is partially noticed. Morning Traces. 0 25 " 1010 Evening The urine is increased in quantity, the amouut In vol. ii of the Lancet for 1880, Dr. Cameron, varying from three or four piuts to as many its its is of Chemistry and Hygiene at the colour Professor ; gallons; specific gravity pale ranges from 1015 to 1050" (A. A. Stevens, m.d.: Royal College of Surgeons, Ireland, wrote as A Manual of the Practice of Medicine prepared follows :? " especially for Students, p. 305, 1893.) Many years ago I examined several times a Dr. Stevens recognises the fact that diabetes week during some mouths the urine of a young may exist and run its course without the specific man (a patient of Sir George Bowens), who mellitus. As a gravity rising above that of normal, healthy ultimately died from diabetes ot his urine rarely rose the does but not even rule, hint specific gravity that urine, sugar may exist in a pale watery urine, the specific gravity higher than 1030. He had an incessant and often below is normal. During the past unallayable thirst. On one occasion I found of which his urine to have a specific gravity of 1005, cases have been recorded in which several years the specific gravity of the urine was extremely sugar being present in small but decided quanOf course the general symptoms might tity. The low gravity of the urine surprised the low. medical attendant, who indeed at first was inlead the student to suspect the presence of sugar credulous that diabetic urine could have so low in such urine, but in many cases of diabetes the The
teaching
...
strongly marked general symptoms are notofvery the disease. It is during the early phases to
draw attenthis account that I am anxious tion to the following cases which I have been able to collect ; I also take this opportunity of publishing a case which was treated by me in the Presidency General Hospital in June 1892. Diabetes is by no means a rare disease in India among the native community, and the importance of the early detection ot sugar in the urine cannot be overrated. At a Meeting of the Clinical Society on the 23rd January 1880, Dr. S. 0. Habershon read on
a
...
...
...
...
...
...
...
...
...
...
...
...
...
...
...
???
???
gravity."
Dr. Cameron afterwards {Dublin Journal of Medical Science, April 1883) reported cases in which he had found sugar in specimens of urine of a specific gravity of 1015, 1008, and 1007. Sir Edward Sievking reported a case in the British Medical Journal for 1892, and others might no doubt be found if I had the necessary time for looking up references. The following caao was under my care in the
Presidency General Hospital, Calcutta:?G. A., Armenian, aged 55, admitted to hospital 1st
June 1892, for
a
large carbuncle
in tho middle
April
1893.]
TULL WALSH ON
GRAVITY
OP THE URINE IN DIABETES MELLITUS.
109
It would further appear from a study of several from several small cases that there is, as might be expected, some apertures. During the last six months has been relation between the specific gravity of the passing large quantities of urine, and has a freurine and the amount of sugar present; with a quent desire to micturate. Tongue coated with low specific gravity there will be relatively, and a white fur; somewhat constipated, and suffering perhaps actually, less sugar than with a high from great debility. Temp, evening 101*2? F. specific gravity ; but even here it is necessary to Skin very dry and branny. note certain points which shew how mistakes in June 2nd.?Morning temp. 100. The diameter judgment might arise if a high specific gravity of the area of the carbuncle and were taken as surrounding inimplying the certain presence of flammation measured about 12 inches. The sugar in the urine. Dr. Debout D'Estrees, of patient was put under chloroform, the suppuratCoutrexeville, reports cases in which, with a ing central portion, 3 inches square, was cut out, specific gravity of 1031, 1030 and 1034, no sugar and the was cavity scraped and swabbed with pure present; the rise in specific gravity being carbolic acid. Wound dressed with gauze and due to the presence of oxalate of lime. Urates, idoform. Evening temp. 99?. when present in large quantities, raise the speciJune 3rd.?Feeling easy; slept well; had fic gravity of the urine, and moreover will cause one stool ; reduction of cupric sulphate. That this is yesterday, pale and deficient in bilethe passed a large quantity of urine (not properly so may be illustrated by a case reported by Professor Cameron. He says : " A few months measured), pale; of neutral reaction; containing no albumen; specific gravity 1020; sugar ago I examined the urine of a man who had been treated for diabetes. The urine had a distinct, but in small quantity. June 4th.?Total amount of urine passed in specific gravity of 1035, and, on being boiled previous 24 hours 80 ounces; specific gravitywith Fehling's solution, it gave a copious precipitate of cuprous oxide. There was something in 1010; sugar present. On the 4th 90 ounces of urine were pass-the appearance of the precipitate and in the ed, having only a specific gravity 1006; sugarslow way in which it made its appearance that led me to suspect that it was not produced by slight trace. June 5th.?80 ounces; specific gravity 1010. sugar. This proved to be the case, for on treatJune 7th.?The yeast test applied to the urineing the urine with yeast no carbouic acid (save passed ou June 6th (70 ounces); shewed a graina mere trace) was evolved. " Dr. Cameron reof sugar to the ounce approximately. commends that when urates are shewn to be June 10th.?Carbuncle doing well ; tempera-present in any quantity in a suspected urine; ture from normal to 101*4 ; still passing a largethey should be precipitated with hydrochloric quantity of urine 80 ounces; specific gravityacid. The urine should be filtered and then 1010; presence of sugar very doubtful to-day. examined for sugar. Urine 80 ounces; June 15th.?Improving. no 1014 ; specific gravity sugar. June \%tli.?Urine passed during previous 24 I hours 64 ounces. June 24th.?40 ounces of urine; wound healing, and temperature normal. June 30th.?Patient left hospital feeling quite well. In this case, of course, the carbuncle, debility and dryness of the skin led to the immediate examination of the urine ; but the presence of sugar might have been overlooked had the symptoms been milder, and the specific gravity of the urine regarded as below that at which sugar should be suspected. The only special treatment adopted consisted in the restriction of diet, all starch and sugar being avoided, and the administration of large doses of opium. I saw this patient about four months after he left hospital ; he was then in fairly good health ; the carbuncle was healed, and [he was passing a normal quantity of urine. It will be noticed that the amount of sugar passed daily was small, taking the experiment of the 7th June as a guide. Since, however, sugar is not found in healthy urine, even a small amount is an evil and will give rise to pathological conditions. of the
back, discharging
