Complete Text (Part 2)

to 60 deg.) It dissolves upon boiling and re- appears upon cooling. Coagulation depends upon the acid and salt concentration of the urine. 2. Urine treated with 25 per cent HXOg in the cold gives a cloud which redissolves at first until excessive acid is added. This precipitate is soluble at 100 deg. and insoluble at 60 deg. Any dilute mineral acid will do the same. 3. Urine plus 2 volumes of saturated ammonium 17 sulphate gives a complete precipitation at room tem- perature. This precipitate is readily soluble in water and does not pass through a dialysing mem- brane, differing from albumoses and pentoses. 4. Urine plus 2 volumes of a saturated solution of sodium chloride gives no precipitate unless the urine is previously acidified with acetic acid. The precipitate is not soluble in water. 5. Urine j)lus 2 volumes of 95 per cent alcohol gives complete precipitation. Immediately after precipitation, the precipitate is soluble in water, but if kept in contact with the alcohol for some time, it becomes insoluble in water, but is soluble in a dilute solution of ammonia. 6. It gives a positi'e biuret reaction. SEDIMENTS OF THE CRINE. Inorganic. 1. Acid urine a Uric acid. 6 Amorphous urates. c Calcium oxalate and sulphate. d Xanthine. e Cystiu. / Leucin. g Tyrosin. h Hippuric acid. i Bilirubin. / Cholesterin. 2. Alkaline urine. a Amorphous phosphates and carbonates. h Magnesium phosphate, c Triple phosphates. d CaCOg. e Ammonium biurate. One mav find anv kind of acid crvstals in an 18 alkaline urine i'or they may persist after the urine has become alkaline. Uric acid crystals. There are three conditions necessary for their for- mation : 1. Concentrated urine; 2. High acidity; 3. Cold. They form crystals brick red in color and have a tendenc}' to clins to the sides of the container. They mean nothing concerning purine metabolism. They take a variety of shapes, rhomboid, prisms, etc. When made arti-licially they are colorless. They are soluble in HCl and insoluble in acetic acid. Urate sediments. These also occur when the urine is : 1. highly acid ; 2. concentrated, and 3. cold. They take the urinary pigments with them, urochrome and uroerythrin. Their shape is amphorous, sometimes resembling needles. They are soluble by heating to 50 to 60 degrees, and with acetic and mineral acids. Calcium oxalate crystals. These are formed mostly from vegetables such as,.. rhubarb, celery, spinach, peas and beans, and also, from green fruits. A small portion is formed from: the body (nucleins — uric acid — oxalic acid). In ox- aluria as much as 20 to 30 grams may be excreted in a day on a mixed diet. Neurasthenia is often as- sociated with its excretion but not the cause. Its excretion is sometimes increased in jaundice, and hepatic disease, and definitely increased in gout 19 when it is most likely formed from uric acid. In this condition determine whether it is excreted fre- quently and whether it is associated with uric acid ])erversion and calculi formation. They occur as four-sided prisms with a square base and also in dumbbell crystals. They are perfectly white in color, are insoluble in acetic acid, but soluble in HCl. Calcium sulphate. These are perfectly white in color and rare in occurrence. Their shape is long and oblong. XantMn, white and somewhat egg shaped. (After Hawk) Tyrosin, colorless and in needles arranged in sheathes and rosettes. Leucin, never a spontaneous sediment. Cystin, colorless, four-sided or prism shaped crystal?. Insoluble in acetic acid and soluble in HCl. o^ 20 Hippuric acid. Occur rarely. They are irregu- lar, six-sided crystals. C^ Bilirubin crystals, yellow or reddish browu in color, occur rarely in hemorrhagic nephritis, after transfusion, jaundice, and acute yellow atroph}^ Oc- cur in needles and rhomboid shaped crystals. Cholesterin crystals, white, and, in the form of steps, one upon the other. Soluble in chloroform. AmorpTioiis pTiospliates and carbonates. These constitute the chief sediment of alkaline urine. Both are soluble in acetic acid, the car- bonates in addition give off gas. Magnesiutn pliosphate. These are generally amorphous but occasionally resemble triple phosphates. Triple phosphates. (MgNH^PO^) ^^ These are one of the commonest forms of xls found in standing urine, and are characteristic of am- moniacal urine. These are coffin-lid, or when eroded, fern-leaf in appearance. They are colorless and soluble in acetic acid. 21 Calcium carhonate crystals. These may be amorpiious or crystalline and are generally found with amorphous phosphates. In shape they are either dumb-bell or spheroidal with concentric radiations. They are colorless and solu- ble in acetic acid with evolution of gas. Ammonium blur ate crystals. / These occur in the shape of thorn-apples and are dark brown in color. They dissolve in acetic acid and give uric acid. They are of no significance. bCHEME FOR RUNNING DOWN INORGANIC SEDIMENTS. 1. Warm sediment. a Urates readily soluble. 6 Calcium sulphate soluble with difficulty. 2. If not soluble by (1) add 3 to 5 drops of glacial acetic acid. Solution indicates : a Amorphous phosphates and carbonates. h Triple phosphates. c Calcium carbonate. Non-solution indicates : a Uric acid. h Calcium oxalate. c Calcium sulphate. d Organized sediments. e Tyrosin. / Cystin. g Leucin. 3. Add from 3 to 5 drops of concentrated HCl to insoluble sediment. Solution indicates: 22 (/ Calcium sulphate. h Cystin. \ c Tyrocin. ( These are also soluble in d Leucin. ( IS^H^OH. e Xanthin. ) 4. Uric acid is insoluble in acids and ammonia; but is soluble in KOH. 5. Cliolesterin is soluble in chloroform. 6. Hippuric acid is soluble in alcohol. ORGANIZED SEDIMENTS. Mucus threads. Poorly refractile, interlacing, fibres found nor- mally and of no significance. Kesponsible for the nubecula formation. Epithelial cells. These may arise from any part of the genito- urinary tract, viz. : pelvis of kidney, bladder, ure- thra, prostate. Irregular cells occur in the bladder and vaginal tract. Sheets of cells are more fre- quent from the vagina. Kenal cells tend to be romid or cuboidal, a little larger than a pus cell, and i.a\e a large vesicular nucleus. They may occur in av) type of nephritis, but are more apt to occur in larger nimibers in acute nephritis. Similar cells arise from the ureter and prostate, those from the latter being about twice as large. One cannot tell the type, location or extent of the lesion by the type of cell found, although renal epithelium does nr t oc- cur normally. Tailed cells were formerly thoiiglit to arise from the pelvis of the kidney, but they are also found in the deeper layers of the bladder and vagina. Pus cells. A few may be encountered in normal sj)ecimGn,-^., especially in women. Large numbers indicate patho- 23 logical conditions either of tlie G. U. tract or outside. The number of pus cells occurring in diseases of tlie cortex of the kidney is few ; the number occurring in pyelitis, pyelonephritis, and kidney abscess is many. Cystitis is the most frequent cause of pus in the urine. They are better identified in acid urine, so accordingly, if the urine be alkaline as it usually is in cystitis, it will aid in identification by adding a lew drops of acetic acid under the cover slip, which will bring out the nuclei. Tripperfadcn. Are shreadlike bits which float about. Micro- scopically they are masses of pus cells in the meshes of mucus. They occur in chronic urethritis. Red Wood cells. These never occur normally except in women dur- ing menstruation. They disintegrate very rapidly, tend to be slirunken and crenated in concentrated urine, laked in urine of low specific gravity, and are often difficult to recognize. When they arise from the kidney they tend to be mixed with the urine, when from the bladder they tend to occur in clumps. In alkaline urine they tend to go to pieces very quickly. Spermatozoa. Disintegrate very rapidly. Found occasionally in adult males. Tissue jragments. Kenal or bladder new^ growths. Casts. ( Cylindruria ) . Descending tubular elements from the kidney. Theories of origin: 1. Casts represent visible coagulated albumins which have escaped from the kidney. 2. Irritated kidney cells excrete a colloidal sub- stance which is coagulated in the tubes and may en- 24 gulf any cellular substance present there at the time. They indicate a condition of renal irritation and are more indicati\ e of it than albumin. TA'pes of casts. 1. Cellular. 2. Granular. 3. Amorphous. Cellular casts. a Epithelial. & Pus or W B C. c Eed blood cell. Granular casts. a Fine and coarsely granular. & Fatty. G Urate. d Bacterial. Amorphous casts. a Hyaline. 1) Waxy. Theory. Hyaline casts are the fore-runners of all the others, and are the matrix upon which the others are built. They have straight sides, rounded ends, are uniform caliber throughout, narrow, may be short or long, and are poorly refractile. One can build all the other forms around them. Any cast containing even but one cell is called a cellular cast and designated b}^ the type of cell it contains. They are encountered in a number of conditions, acute and chronic nephritis, etc. Cellular casts change into granular casts, going through a stage of fatty degeneration. Coarsely granular casts are yello^^- ish in color and finely granular casts are colorless. Granular casts can finally revert to the hyaline form. Waxy casts differ from hyaline casts in being 25 highly refractile. They seem brittle, have irregiilai' ends, aud may be wavy in outline. They tend to be broader and have transverse lines of fission. They stain with Lugal's solution but are not necessarily limited to amyloid disease. They are a fairly good indication of tubular stasis and probably represent metamorphosed hyaline casts. Occurrence of casts. Casts are occasionally encountered in normal in- dividuals, but whenever they are found they should be regarded as evidence of renal irritation, whether slight, transitory, and of no importance or persist- ent and of serious import. They occur after strenu- ous exercise and in febrile states. Neither the type nor the number allows one to judge the extent of the renal injury, for the more normal the kidney the greater is the response to irritation. Casts tend to appear and run parallel with albuminuria but are more sensitive. The occurrence of albuminuria without casts usually indicates that one has not looked long enough or that the urine has become alkaline and they have disintegrated. Albumin without casts does not predispose to the development of nephritis. It gives some evidence of tuberculosis and other diseases higher up. Albumin with few casts represents in general the same thing as above. There is, however, a higher mortality incidence. Albumin with granular casts indicating cardio- renal disease, has in ten years a much higher mor- tality incidence than the two previous. Casts tend to be more cellular the more acute the condition. Waxy casts are indicative of tubal stasis. It is not so much the type nor the number of casts, but it is their relation to other clinical evi- dence that is of importance. (Read in Osier's book 26 of rcprLiits "On Ike Advantage of a Trace of Albuiuin and a Few Tnbe Casts in the Urine of Certain Men Above Fifty Years of Age.") Cylindroids. These may possess any and all the characteristics of casts. They are usnally straight and hyaline and larely Avaxy. References. Atlas der Clin. Mic. des Harnes, Rieder. Micro- scope der Harnes Sediment, A. Daiber, BACTERIOLOGY OF THE URINE. BaciUuria. Indicates bacilli in the urine irrespective of their sonrce. Types found : 1 . Tubercle bacilli. They may be excreted through the kidney and not represent a lesion of the G. U. tract. When associated Avitli r. b. c. and w. b. c, their local source is more likely. Don't confuse with Smegma bacilli. To obtain a more certain dagnosis inoculate a guinea pig intraperitoneally, keep 3 or 4 weeks, kill, and look for typical findings in the retro-peritoneal lymph glands, spleen or liver. Blad- der tbc. is often associated with an acid urine and sterile pus. 2. Gonococci. Gram negative and intracellular. Difftcult to find them in ^eisser cystitis. 3. Typhoid bacilli. Found during the disease and often for weeks or months after recoverj^ May be due to a bacillaemia or due to local lesion. 4. Colon bacillus. Common invader and cause of pyelitis and cystitis. 5. Paratyphoid. Infrequent cause of pyelitis. C). Cocci often found with Neisser infection. 7. Streptococci often occur from systemic infec- tion, nephritis, etc. o H Q O a. B Improves as Heart May Get Infarction B. P. Nor- mal Oedema (Face 1st) Uraemia Cure Rare Oedema Anasarca Uraemia Cardiac Fail B. P. Incr. Dropsy Rare. Car. Hyper Apo- plexy B. p. Norm or Below Oe- dema Com. Ureamia Rare Associated Willi Fever & Cachexia May Lead Amyloidosis, Septic- aemia or feritoiiltis From Perforation o 03 < CO C V ^ 2 en rs] C en a; en en l2 > o ^^1 c(5 <U C 5 = g 1.o|„ III ir 'r^ c: S h h" o-ti 2 J_ O CiO o H 'a? 5 '" O ^ V} 03 en =: 55 II 5 s a> +j _ Xi O w ^ 03 Q < Ph o s ^ S^ ^ IS «J ^ a; ^ v-i ? V = en ■T. 2; < 5 ^ en en en (U -^ < 03 « en rt 2 5 O Ah" ;/5 "to a o 2; 'So o o 03 O 5 ii c o o t-r 8 03 03 ^J3 13 2 D o <1 III 3 -, Vh Z^ (d ^ IS Oh .2 1 ^ ■ ■ <^ in 03 o '5 s 27 8. Any organism in the blood may be swept through the kidney. This may be the cause of much nephritis due to kidney injury. The general methy- lene blue stain detects all the bacteria except two : 1. Acid fast bacilli. Use carbo-fuchsin. 2. Gonococci. Use gram stain. Animal jjarasifes in the urine. 1. Amoeba. 2. Echinococcus (look for hooks and laminated membranes ) . 3. Filarial larvae. 4. Eggs of Schistosoma hematobium (human blood fluke) or Bilharziasis (Egyptian hematuria). 5. Oxyuris (pin worms, occasionally found in young girls. Wanders through urethra into bladder), G.. Trichomonas vaginalis (of no importance). GENERAL CONSIDERATIONS. Urine examined for the folloicing considerations : 1. Renal and G. U. conditions. 2. General metabolism of the body. 3. Food metabolism. Urine examination criteria. 1. Single voidings are of no practical importance. 2. Should be carried out on 24-hour specimens and in some instances the day and night specimens should be kept separate. 3. Fluid intake and general diet should be taken into consideration. 4. Correlate urinary and clinical findings. 5. Abnormalities should be confirmed at subse- quent examinations. Single voidings examined for: 1. Albumin. If but a faint trace is present, ex- amine two specimens, one at night and one in tlie morning, to see whether it is orthostatic. 28 "2. Gross abnormalities, blood, pus, etc. 3. Microscopical elements, such as blood, casts, and various forms of cr3^stals, pathological cells, and parasites. -. Constituents requiring chemical analysis, such as bile, urobilin, blood, indican, acetone, diacetic acid, sugar, etc. c. Specific gravit}' determination. (). Keaction, acid, alkaline, or amphoteric. Collections of 24:-hour specimens : 1. Establish hours between which the specimen is to run. If the hours determined are between 7 A. M. and 7 P. M., have the patient void at 7 A. M. and throw the specimen aAvay. Collect all voidings, including the one at 7 A. M., the following morning. 1. Containing vessel should be clean at the start, cool, corked and clearly labeled with: Xame of patient. Date, Hours of collection. Total intake, Preservative used. 3. Day and night specimens should be kept sepa- rate in some cases. 29 Preservatives used for urine : Tj^ie. Amount. Advaiitasro. Disadvantage. Chloroform 2 to 3 drams No Inilk. easily Not good for casts, perlirer. removed, crys- Reducing agent, tals preserved. Formalin. 1/. to 27c by Preserves Adds bulk.reducin-.- volume or 5 casts. agent, error in sugar to S drops test, form^^. crystals per L. with urea, inter- feres with urobilin and indican tests. Thymol. A few crys- Preserves False tests for hile tals. sediments and Heller's albu- min. Toluol A thin layer. No volume. Expensive and in- urinecnnbe flammatory. secured below. Common preservatives in nse are chloroform and tolnol. Physical properties of urine, normal and abnormal. 1. Normally it is a cleav, tranparent shade of yellow. After standing 15 to 45 minutes a "nubec- ula;" or fog, settles to the bottom, Avhich is com- posed of mucus and epithelial cells. 2. Urine cloudy when voided. (a) Frequently voided after heavy meals of vegetable*^. Due to excess of phosphates. Not abnormal. (b) Px'esehce of some kind of organized sedi- ment,'blood," desquamated epithelial cells, pus, bacteria. (c) Cloudy, with the smell of ammonia, indi- cates cystitis. 3. Urine becomes cloudy on standing. (a) Development of bacteria. (b) Precipitates of calcium, phosphorus, and carbonates. Formation of ammonium carbonate bv bacteria. 30 (c) Concentrated nrine, becoming quickly cooled, deposits amorphous urates. Odor of urine. The normal urinary odor is due to aromatic sub- stances. The urinous odor is due to the action of bacteria. A fruity odor occurs in diabetes, due to the excretion of acetone. A foul odor occurs in urines containing large amounts of albumin, as in cancerous and inflammatory conditions in the lower G. U. tract. The ingestion of asparagus giyes a peculiar odor, due to methyl mercapton. Drugs, such as asafedita and yalerian, giye their charac- teristic odor. Turpentine giyes the odor of yiolets; menthol that of pepperment; cubebs, copaiba, tolu and saffran that of spices. Amount of urine excreted depends upon : 1. Indiyidual himself. (a) Sex, males more than females. (b) Children yoid proportionately more, yiz: adults 1 cc per kilo body wt., children 4 cc per kilo. (c) Weight of indiyidual. 2. Fluid