Complete Text (Part 4)

scarlet fever, very frequently in measles be- fore the rash, and sometimes in tuberculosis. It never occurs in rheumatic fever or meningitis. If the test is persistently positive in tuberculosis, it indicates a progressive lesion. Ehrlich's egg yellow test : This is due to the pres- ence of urobilinogen. This test is the same as the former, except that after adding the XH^OH the urine takes on a yellow color. Occurrence : Just prior to the crisis in pneumonia. Russo's test: 5 cc. of urine plus 5 drops of 1-1000 methylene blue. Positive reaction gives emerald green color. Blue color is negative. -Occurrence: It is said to be negative in miliary tb'c and positive in typhoid (Dr. Evans did not find it satisfactory). Positive reaction said to occur in measles, small pox and chronic and suppurative tbc. The reaction is said to be negative in varioloid, varicella, scarlet fever, miliary tbc, appendicitis and malaria. G. Medicines. Phenolphthalein, eosin, salol, methylene blue, etc. 46 H. Chijluria, characterized by the excretion of emulsified fat. Uriue varies from cloudy yellow to milky appearance. The surface is covered with a layer of free fat. Causes : 1. Parasitic. Observed in the Far East, due to infection by one form of filaria. Elephantiasis is often as- sociated with it. 2. Non-parasitic. Etiology unknown. Oc- curs spontaneously and intermit- tently in people otherwise well. Sometimes due to rupture or ob- struction of cysterna chyli. I. Lipuria. Characterized by the excretion of fat in microscopical quantities. Causes : 1. Large ingestion of fats. 2. Extensive bone injuries. 3. In diabetes. 4. Frequent in tbc. 5. After catheterization when oil is used. TABLE OF COLOR OF URINE AND ITS CAUSE. Yellow and Orange Pink and Red Normal Hematuria Urobilin Hemoglobinuria Choluria Hematoporphyrin Medicinal #when alkaline Rhubarb # Pyramidon Senna # Trional Santonin # Sulphonal Phenolpbtbalein# Eosin Cbrysopbanic ac# Rosanilic acid Cascara# Brotvn and Black Blue and Green Milky or Whitish Choluria Methylene blue Lipuria Melanuria Urobilin Chyluria Alkaptonuria Phosphates Phenol derv's. Bacterial infect. "Black Water Fever" Dirty container. Indicanuria Medicinal Salicylic ac Salol Resorcin 47 Optical activity of urine: Xorinally levo-rotatorv from .01 to .18 deg. Increased : 1 . In excretion of levnlose. 2. Glycnronic acid excretion. 3. Albnmin (I/2 gni. per 1000 cc). 4. Diabetes (B-Oxybutyric acid). INORGANIC URINARY CONSTITUENTS. The composition of tlie urine depends upon the diet of the individual, both in quality and quantity. Normally 1200 to 1500 cc. are excreted daily with 60 to 70 gms. of solids, organic and inorganic. Inorganic 25 to 30 gms. Organic 35 to 40 gms NaCl 10 to 15 gms. Urea 15 to 40 gms P205 1 to 5 gms. Ammonia .7 to 4.27 gms S03 1 to 3l^ gms. Creatiniii 1.0 to 1.5 gms COS 9 to ? gms. Uric acid .5 to 1.25 gms Na20 4 to 714 gms. Hippuric acid .7 gm. K20 2 to 4 gms. Other CaO .1 to .3 gm. constituent s 1.5 to 2.3 gms MgO * .11/^ to .4 gm. Fe 1 to 11 mg. Chlorides. The excretion of chlorides dep ends upon the intake in health. Source: (a) Vegetable foods in combination with K and Ca. (b) NaCl seasoning most important source. Chlorides are taken in order to prevent the ac- cumlation of K salts in the blood. There is a chloride balance as characteristic as the N bal- ance. Increased ingestion of NaCl is followed by increased excretion. Chloride poor or free diet gives a drop in the excretion to a certain extent, but no further. The proportion in the blood is a constant, as well as that in the tissues. 48 Eetention occurs : 1. Active stage of all fevers. In pneumonia there may be a suppression till the crisis. A chloride crisis also occurs. 2. Formation of transudates and exudates. 3. Profound and continuous vomiting and diarrhoea. 4. Hyperacidity. 5. Oedema (myocardial or nephritic). Theories of retention. 1. Histo-retention theory (Strauss -and Loeb) : Excess of salts in the tissues requires water to maintain osmotic pressure. 2. Colloidal (Fisher) : In cases of oedema the colloids in the tissues have increased hydrating capacity. Salt excretion: 1. Following febrile states. 2. Absorption of transudates and exudates. 3. Polyuria. 4. Pneumonic crisis. 5. FolloAving oedema from salt retention. 6. After chloroform anaesthesia. Quantitative tests: 1. Volhard's method (1874) : Precipitation of chlorides in a known volume of urine by an excess of standardized solution of Agl^Og in HNO3, and then the titration of the excess of AgNOo with NH.SCN, using iron ammonia alum as indicator. (Objection to method is that it requires 4 solutions.) 2. Arnold's method, a modification of the former (1885). Differs from the former in the strength of the standard solution and fil- tration after addition of AgNOg. 49 Solutions: 1. AgXOg solution such that 1 cc. equals .01 gm. NaCl or 29.075 gm. AgNOg in 1000 cc. H^O. 2. jN^H^SCX solution such that 2 cc. equals 1 cc. Ag^S^Og sol. 3. Saturated solution of iron ammonia alum. 4. Pure HXOo. Procedure : Uriue 10 ce ^ Pl'^ce in a 100 cc. volumetric flaslv ' for 10 iniimtes. agitate from time to i time. Overcome coloring by 3 to 5 Std. AgXOs 20 cc. I drops of 10% sol. of potassium per- ^ mangnate. Add H,0 up to 100 cc. H>0 50 cc.) ,„^„ flij^^ To 50 cc. of the filtrate add 5 cc. of the iron am- monia alum sol. for indicator andi titrate with NH^SCN to end reaction, which is red-brown color. 3. Lutke Martins method (1S92) : Solution : A. AgXO.. 17.5 gms. 2d% HXO3 000.0 cc. 25% HXO3 equals 225 cc. con. XHO3 in 675 cc. of distilled H.O 10% iron ammonia alum 50.0 cc. Water q. s. ad. 1000.0 cc. B. X/10 XH.SCX Titrate solution A against a X/10 HCl solution. In making solution B dissolve 7.6 gm. of XH^SCN in less than 1000 cc. of water. Add water till 1 cc. of it equals 1 cc. of A, which is determined by titration. Method of performing determination: 10 cc. of urine plus 25 cc. of X/10 AgXOg plus water q. s. ad 100 cc. Add a few drops of potas- sium permangnate to decolorize urine if necessary. Allow to stand and filter or draw otf 50 cc. Titrate the filtrate with X/10 XH^SCX to the end point, using iron ammonia alum as indicator. 50 Calculation: Example 6.2 cc. :NV10 NH.SCN to produce end reaction. 2 times 6.2 equals 12.4 cc. AgNOg are uncom- bined in 10 cc. of urine. 25 minus 12.4. equals 12.6 cc. N/10 AgNOg are combined as AgCl in 10 cc. 1 cc. X/10 AgXOg equals .00585 gm. XaCl. 12.6 times .00585 equals gms. NaCl per 10 cc. (10 to 15 gms. per 21 lirs. normal), rrinciple : When X/10 XH.SCX is added it com- bines with the unused X/10 silver nitrate as long as there is any present. When it is all in combi- nation with NH^SCX it begins to combine with the iron ammonia alum, wliich gives a brown color and is the end point in the reaction. Purdy's centrifuge method : 10 cc. of urine, 1 cc. of NHOg and 4 cc. of a 5% solution of AgXOg are placed in a special centrifuge tube. Agitate and centrifuge at 1200 revolutions for three minutes. Eead the number of grams per 1000 on the scale. Bayne-Jones method : Either use a special flask or an ordinary 25 cc. graduate. In case tlie special flask is used, the urine is added to the mark U. Titrate with N/20 XH^SCN solution to the end point and read grams per liter on the scale (iron ammonia alum indi- cator). In case the 25 cc. graduate is used, add 5 cc. of urine and 10 cc. of X/20 AgXOg. Titrate as before with X/20 XH.SCX, and note the reading. 51 . Calculation : V equals total volume at eud of titratiou. Y-15 equals number ec. of N/20 NH^SCN V-15 equals number cc. N/10 AgNO^ uncombined 2 Y-15 10 equals number ec. N/10 AgNOg combined as AgCl 2 1 cc. N/10 AgCl equals .00585 gm. NaCl V-15 10 X .00585 equals gm. NaCl in 5 cc. urine 2 Y-ls 10 X .00585 X 200 equals gm. NaCl in 1000 cc. 2 20.475 minus .585 Y equals gms. per 1000 cc. (.1 to .3 gm. error) Phosphates. Excreted as sodium, potassium, cal- cium and magnesium salts of HoPO^ as well as with glycerin from the breaking down of lecithin. Source: 1. Food ingested. 2. Breaking down of proteins, ingested or endogenous. Nucleo-proteins most abundant source. Amount : 1 to 5 gm. per day expressed in terms of P2O5 Excretion : Depends upon amount taken. Greater on alkaline diet. Majority of earthy phosphates are excreted in the feces (Ca and Mg). Phosphate metabolism is still in a state of uncertainty, for it is not known where P2O5 is stored. Bone takes up a great amount, but does not account for amount ingested. Eatio between N excretion and PgOg is P :N : :1 :7. Increased : 1. Animal diet. 2. Ph^^sical exercise. 3. Starvation. 4. Conditions where protein disintegration is sroins: on. 52 5. Phospliatic diabetes, where urine lias char- acteristics of diabetes, but no sugar. There is associated with it dryness of the skin and excessive thirst. The c-h metabolism is not abnormal. G. Phosphorous poisoning. 7. Meningitis and tuberculosis. 8. Emotional states. 9. Mental work. Decreased : 1. Vegetable diet. 2. Certain diseases : Addison's disease, Hepatic cirrhosis. Certain types of nephritis. Acute yellow atrophy, Chronic lead poisoning, Certain types of bone disease. 3. Pregnancy. 4. Euns parallel with uric acid excretion in gout. Phosphaturia is characterized by the frequent and constant excretion of cloudy urine at the time of voiding. It is noticed mostly in nervous, sexual neurasthenics of the male sex. Noticed also in cyclic vomiting of children and hypoacidity. This condi- tion represents not a disease, but a condition in which the amount of acidity of urine is diminished, now called alkalinurin. Stilpliates. Excreted in three forms: 1. Preformed or neutral. 2. Conjugated or ethereal. 3. Xeutral, unoxidized or organic. Total excretion about 2l^ gm. in 24 hours on a mixed diet, expressed in terms of H2S0^. Source: Amount in diet relatively small. Most 53 of it arises in the destruction of protein. Amount excreted increases with increase in protein cata- bolism. Ethereal sulphates result from the conjugation of indol, saktol and phenol ^Yith sulphuric acid, and can be taken as a fair estimate of protein decompo- sition. Occurrence : 1. Excessive intestinal putrefaction. 2. Kich protein diet. 3. Hypoacidity. 4. Massi'e pus formation anywhere in body. Neutral sulphates : increased in jaundice and cys- tinuria. Ckirhonates : Yarj with the amount of carbonate forming material in the food. Vegetables contain organic acids whicJi are easily converted into car- bonates. Generally sedimented as CaCOo. SocUuin and potassium : Excreted as salts, amount determined as XaoO (-1 — Ti/o) and ICO (2 — 4). Sources : 1. NaCl in the food. 2. Potassium in vegetable foods. The excretion is of little significance clinically. Calcium and magnesium: Excreted generally as phosphates (CaO .1— .3) (MgO .U/2— .4). Source : Food, most of it is lost in the feces ; bone destruction, diabetes ; excretion is little understood ; its significance is increasing. Iron : Always present in small amounts. Increased in blood destruction, such as fever, malaria, perni- cious anameia. In diabetes it runs parallel with the sugar output, 2% mg. of iron to 100 grams sugar. Heavy metals : Mercury, lead and arsenic found pathologically. 54 NITROGENOUS BODIES OF URINE. Amount normally excreted varies between 10 and 16 grams a day. Amount excreted depends upon : 1. Amount of food ingested. 2. Tissue metabolism. In health there is a nitrogen equilibrium, i. e., the N. excreted equals the N ingested. In starvation a level is reached on the fourth or fifth day, which will last three or four weeks. When food is again taken the amount of excreted N is less than the ingested N. People feel best on from 4 to 6 grams of N excretion. To determine the N excretion the following factors must be taken into consideration: 1. Total N of food. 2. Character of food in terms of ability to produce alkaline or acid urine. 3. Age of patient. 4. Previous state of nutrition. 5. Previous diet. Previously there should be seven days of diet with regulation of : a. Diet, b. Exercise, c. Amount of food intake. d. The condition of the intestines. iSiitrogen Partition : Mixed D. N-free. Mixed. N-free. Total N 16 gms. 3.6 gms. 100% lOOfo Urea 13.9 2.2 86.87 61.7 NH3 .7 .42 4.37 11.3 Uric Acid 12 .09 .75 2.5 Creatinin 58 ..6 3.63 17.2 Undetermined.. .7 .29 4.37 7.3 Urea N represents great bulk of total N output in 24 hours. In N free diet, urea N decreases; am- monia and creatinin are increased, at expense of urea. 55 ^^itrogcn excretion : Physiological — Increased : 1. On heavy protein intake. 2. Fonr to 6 days after birth. 3. Excessive intake of water. 4. Exercise. Decreased on diets rich in fats and carbohy- drates. Pathological — Increased : 1. In acute febrile conditions with high fevers. There is no relation between the height of temperature and the amount of N excreted. N balance can be maintained by proper diet. 2. Chills. 3. Increased respirations. Urea is relatively decreased, while ammonia salts, organic acids and uric acid are increased. 4. Toxic conditions, such as cancer, leukemia, exophthalmic goiter. 5. Diabetes mellitus and insipidus. 6. Absorption of exudates. 7. JS'ephritis, especially in albuminuria of marked degree. Decreased : 1. Convalescence after fever. 2. Dysentery. 3. Formation of exudates. Methods of N determination. Kjeldahl : The principle of this method is the oxidization of the organic products with the production of sul- phates. XH3 plus HoSO^ equals (NHJ^SO^. The NH3 is liberated by the addition of strong NaOH and is received in a known amount of standard acid. 5^ Procedure : luto a pyrex kjeldahl flask place Urine 10 cc. K2SO4 10 grams or a teaspoonfiil (oxi- dizer). CUSO4 1 medium-size crystal (caty- litic action). Con. H2SO4 15 cc. Heat gradually to the boiling point and continue to boil till the solution takes on an absolutely green color, and boil five minutes longer. Allow the solu- tion to cool and then add the following : Water 250 cc. Talcum 2 tablespoonsful. 40% NaOH 120 cc. This should be added last and in such a manner that it does not mix with the solu- tion. Pour on side of tilted flask and it will go to bottom. Connect the flask with a distilling apparatus and mix the contents by shaking. Either distill 30 min- utes or distill over 150 cc. This distillate is re- ceived in 25 cc. of N/4 H2SO4 and the excess of acid is titrated with N/10 NaOH, using phenolphthalein as an indicator. 1 cc. N/10 H2SO4 equals .0017 grams NH3. 1 cc. N/4 H2SO4 equals .00425 grams NH.. N equals .823 XNH. by weight. .00425 X. 823 equals .003497 grams N for each cc. of N/4 H2SO,. .0017X.823 equals, .0014 grams N for each cc. of N/10 H2SO4. Folin's method: This is a colorimetric test. 1 cc. of urine is put through the oxidizing process and received in 57 N/HCl. 5 cc. of Nessler's reagent: Hgl 10 grams KI 5 NaOn 20 H.O 100 cc. are added. The color of this is compared with a standard color made up of 5 cc. of the reagent plus 1 mg. of N. TJrea. About 80 to 90% of the total N in a mixed diet is excreted in the form of urea. GO to 65% of the total N is excreted in the form of urea in an N-free diet. From 15 to GO grams, or an average of 30 grams, are excreted in a mixed diet per day. Modes of formation : 1. NHo salts. (Protein — hydrolTsis — amino acids — NH3.) Action of bacteria and enzyme action of tissues. 2. Deamidization method. (Protein — amino acid — blood — tissues — protein.) When amino acids are in excess NH3 is split off in the liver and oxy-organic acids are formed. The liver protects the body from NH3 poisoning. 3. Arginin plus arginase gives urea and or- nithin. Variations in excretion. 1, Physiological 1 Increased and decreased same 2. Pathological J as total N. 3. Relation of urea to liver function. 4. Relation of urea to renal function. One can't determine the renal function by the esti- mation of the urea alone, but one must take 58 into consideration the amount of urea in the blood. 5. Kelation of urea to acidosis, formal reac- tion of blood alkaline. The fixed alkalinity of the blood can't be reduced beyond a cer- tain point without certain things happen- ing. As an excess of acids is formed^ an excessive amount of NH3 salts is formed. Urea decreases as output of NHg increases. Qualitative tests for urea. (Not used clinically.) 1. Biuret. Crystals of urea heated to boiling give cyanuric acid and biuret. Add CuSO^ and XH4OH and get blue color. 2. Furlurol. 1 to 2 drops of furfurol plus 1 to 2 drops con. HCl, plus 1 to 2 drops urine. Positive test gives dark blue to black color. (Quantitative estimation of urea : Knop-Hufner method. This test relies upon the decomposition of urea v\irh sodium hypobromide and the measurement of the N evolved. The reaction takes place according to this equation : CO(XH2)2 + SNaOBr = 3NaBr -f 2X + COo -f '2Ii.A\ The COg is absorbed in an ex- ce:^s of alkali and the amount of N gas measured. Doremus Ureometer. The principle of the Knop-Hupfer method is used and a graduated ureometer measures the amount of gas. Solutions : 1. 20% XaOH. 2. Bromine.