Complete Text (Part 7)

glucose or .053 gm. of levulose. x cc. = .05 gm., .05 .05 1 cc. = gm. 1500 cc. = gm. X 10 X 1500. X X 2. Bang titration method. Urine is boiled in a know n excess of alkaline cop- Continued on Page 87 H a 0} Seliwanoff's Phenylmethylhy: drazine Phenylhydrazine after concentra- tion and ex- traction o a Ph ^ M. P. & Rot. of Osazone h4 o hi 2000 Inactive 1560 —1600 Inactive 1880-1930 D. 0.480 in Neuberg's pyridin alco- hol mixture § QQ O g (J Q Pheylhy. drazine 1 > Negative In Urine > <u > 1 .2 1 o eg Q OS Q Essential or Ideopathic inact. Al. & Diabetic slight D o 00 O 1 Ph 0) I 1) > a V ^ > Slow Positive ^ ^ «3 Z > 1 Ph Slow Positive Slow Positive 9S 1) 0 Ph > 1 Slow Positive Slow Positive Slow Positive D t-H 6 en 1 v O G Ph Galactose 87 Continued From Page 86 11 Phloroglucin Orclne After Hydrolysis Heat Urine First and It Does Not Reduce O tH S '^• See Glucose & Levulose > > .2 *en S 2 t O > > If 2 5) D. Rot Iv after Hydrolysis 1 Q 1 1) > 1 1) > ID > <u "A 4» > > I) 1 > 1 == 1 Positive or Negative > > 1 iz; > 1 4J 1 -s i 1 Positive or Negative > 1 o > 11 2 Conjugated Glycuronic acid % o 1 Homogentis- ic acid of Alkapton- uria 6 O 1 88 per, and the copper remaining is titrated with ft standard solution. Solution: A. 1. Potassium bicarbonate 100 gm. 2. Potassium carbonate 500 gm. 3. KSCN 400 gm. 4. CuS04 25 gm. 5. H2O qs. ad. 2000 cc. Dissolve 1, 2 and 3 in 1300 cc. of hot H^O in the order named. Dissolve No. 4 in 200 cc. of H2O separately. Mix while hot. Cool at room tempera- ture, add No. 5. Solution E. KSCN 200 gm. Hydroxylamine sulphate 6.25 gm. (accurate) H2O qs. ad. 2000 cc. Technique: Urine is diluted to not over .6% of sugar. 10 cc. of the diluted urine are placed in an Erlemeyer flask and 50 cc. of solution A are added and the contents boiled 3 minutes by the watch. All the sugar present is used up, but not all the coi^i^er present is reduced. Titrate the cop- per remaining with solution B until colorless. Calculation: 1 cc. of solution B equals 59.4 mg. of olucose. »' Summary of quantitative determination methods : Specific gravity method should be discarded where other instruments are available. Specific gra\ity- fermentation method is not very accurate unless one has a delicate urinometer. Fermentation methods are all right if sufficient controls are run. Lohn- stein method good. Titration method best of all. Estimation of sugar icith the polariscope. Principles : Light rays vibrate in all directions. Some sub- 89 stances have the power of double refraction, Iceland spar for instance. Light passing through this is resolved into two sets of rays, one of which vibrates in all directions, the other vibrates in but one plane. In the polariscope the entering rays are polarized and the ray vibrating in all directions is deflected by means of a Mchol prism. Another Mchol prism is used near the eye-piece as an analyzer. A quartz plate obscures half the visual field. Some substances have the power of turning this polarized ray to the right or left. The substance whose specific rotation is to be determined is put in a tube of a known length, 1 decimeter, and the polarized ray passed through it. After determining the zero point of the instrument the unknown substance is put in the pathway of the polarized light and the analysing prism turned until both sides of the field are of equal illumination. The degree of rotation is read on the scale. Specific rotation. This is the amount of rotation of 1 gram of a substance per cubic centimeter of water in a tube 1 decimeter in length. Formula : AX 100 P=: Sp. rt. X LD A = reading in degrees. Sp. rt. = specific rotation. LD = length of tube in deci- meters. P = percentage. P — A when the tube is of the proper length, viz : 188.6 m m for glucose. Technique : A mixed 24-hour specimen of urine is 90 ina<]e free from albumin and absolutely clear. To do this the following may be used : 1. Heat and acetic acid and filter. 2. Filter after adding kieselguhr. 3. Normal lead acetate, not basic, filter. 4. 25% HCl and animal charcoal, filter. The zero point of the instrument is determined by taking the ayerage of 5 readings, using a sodium flame. This point is indicated by both sides being equally illuminated. Carefully fill the tube so as to leaye no bubble within, place in the instrument and take the ayerage of 5 readings. Where a 188.6 m m tube is used each degree of rotation equals 1% glu- cose. Essential urinary findings in diahetes. There is generally a polyuria caused by the liyper- glycaeiiiia. Sugar in the blood, not in a colloidal state as nornuiUy, acts as a diuretic. The amount of urine excreted depends upon the amount of hypergiycaemia. From 5 to 8 liters are excreted per day. Polyuria with low specific grayity would indicate a possible development of both diabetes mollitus and insipidus. When polyuria of severe cases diminishes on restriction of diet it indicates a good prognosis. When low polyuria and high specific gravity occur together the prognosis is more favorable than great polyuria and low specific grav- ity. Variations in sugar excretion. By securing specimens every 2 hours it is found that the maximum output of sugar occurs at noon and late afternoon. The minimum output is in the early morning. If one should examine a 24-hour mixed specimen, the concentration of sugar may be so low that it may be missed; hence, keep 2-hour specimens separate in doubtful cases and examine. 91 Amount of sugar excreted. The average percentage of sugar in the urine in diabetes is from 2 to 3%. 3% at 3 liters a day would give 90 grams. Maximum output 1500 gm. 6 to 8% is considered high. More is excreted on a hot than a cold day. In febrile conditions there is a tendency for glycosuria to disappear. The amount of sugar is increased on a carbohydrate rich diet. Sometimes lactose or levulose are tolerated well. The amount of sugar excreted usually falls during diabetic coma. Specific gravity. The specific gravity is usually high, varying from 1025 to 1010. 1074 has been reached. In urines with 1060 readings and over, look out for frauds. Sugar may occur in urines with a specific gravity as low as 1007 to 1016. Color of urine. The color is usually a pale greenish yellow. A pale color with a high specific gravity is character- istic. Acidosis. The characteristics of the urine are : 1. Acid bodies are present, B oxybutyric acid acetone and diacetic acid. 2. The reaction is characteristically acid, rarely neutral or alkaline. By the Folin titration method there is increased alkali tolerance. JS^ormally an individual will excrete alka- line urine upon the ingestion of from 5 to 10 grams of sodium bicarbonate; in dia- betes it will require from 100 to 250 grams a day to make the urine alkaline. Nitrogen elimination in dia'betes. Normally 15 gm. are eliminated in 24 hours. In diabetes 20 to 30 grams are excreted. The nitrogen 92 pardtioii is inicliaiiged iiiitir acidosis appears, when the NHg increases. Severe symptoms are indicated Avhen the XH3 ontpnt reaches 2 or more grams per day. Amino acid nitrogen in diahetes. Xormally .1 gm. per day is excreted. In diabetes this is increased to abont .9 gm. Alhiimijiuria and casts in diabetes. Albnmin and casts are seen in patients passed middle life in whom there is arterial or nephritic change. Kolz's sign is showers of hyaline casts preceding acidosis or coma. Acid hodies in tJie iwinc. These inclnde 3 substances : B oxybntyric acid. Diacetic acid. Acetone. (^H, ' CH3 CH3 ( ^H( )II — H. = CO — COo = CO CH. CH2 CH3 (;00H COOH Although these bodies occur in diabetes, they also occur in other conditions. The}^ may arise from car})()hydrates, fats or proteins. From a carbohy- drate source there is no evidence, but there is a pos- sibility of their coming from the tyrosin group of protein. There is no parallelism, however, between their excretion and destruction of body protein as there is between their excretion and fat destruction. Tests for acetone : LegaFs. To about 8 cc. of urine add a few crystals of sodium nitroprussid and a few drops of NaOH or KOH, which gives a red color and which fades to a yellow both in normal and diabetic urine, except tliat the transition is sloAver in the latter. While still red add a few drops of glacial acetic acid, and if the urine changes to a purple or deep red color it denotes the presence of acetone. If it changes 93 to a green color it shows the presence of creatinin. Le XQble'!^\ This test is better than Legal's, for it eliminates aldehyde bodies and creatinin. To about 8 cc. of urine add a few crystals of sodium nitroprussid and a fcAV droj^s of NH^OH. Before the red color fades to a yellow add a few drops of glacial acetic acid as before. A deep red or purple color indicates the presence of acetone. Lieben's. Depends upon the formation of iodoform crystals. To about 5 cc. of urine add a small quan- tity of Lugal's solution or tincture of iodine and a few drops of XaOH. Warm slightly and examine the precipitate for iodoform crystals. Gunning's modification of Lieben\s is a more spe- cific test. To a small quantity of urine add about 5 cc. of either Lugal's solution or tincture of iodine, and then NH^OH till a permanent precipitate forms. Upon standing this turns to a yellow or yellowish brown color, and upon microscopical examinati<-n hexagonal crystals of iodoform are found. It is preferable to set the solution aside for 24 hours be- fore examination. Frommer's. This test is the most specific, being sensitive in dilution 1 — 1,000,000. The reagent used is a 10% alcoholic solution of salicylaldehyde. To a small quantity of urine add a few drops of NaOH or KOH and 10 to 12 drops of the reagent. Keep in water bath at 72 degrees for 3 or 1 minutes. A purple or dark red color indicates a positive reaction. Le Noble's modification of Legal's test and Gun- ning's test are best clinically. Diacetic acid. Gerhardt's test. Reagent: 10% ferric chloride solution. Add reagent to urine in slight excess, whereupon a precipitate of phosphates forms. Either filter at 94 this point or continue adding the reagent without filtering. It is better to filter. Upon the addition of more reagent the previous reddish-brown color is changed to a Burgundy red. This test is also given by salicylates, conjugated glycuronates, after taking phenacetine, antii)yrene, acetates and trionate medi- cation. These can be differentiated, however, by first heating. Diacetic acid is broken up and color dis- appears ; drugs, on the other hand, continue to give the reaction. B oxybutyric acid. There is no satisfactory test for this. The urine shoAvs a greater titration determination than is in- dicated by the polaroscope. It is L-rotatory, specific rotation being — 24.12 degrees. Urine after fermen- tation still L-rotatory also points to B -oxybutyric acid. Autoketo)iogemc junction of carbohydrates. 1. Administration of carbohydrates diminishes ketones. 2. Lipaemia is associated with maximum excre- tion of acetone bodies. 3. Administration of fatty acids is followed by excretion of acetone bodies in animals. This occurs also in people on an insufficient diet or who have an error in metabolism where carbohydrates do not spare fats. This condition is characterized by the following : A. 1. Large amounts of acetone bodies 2. Increased NHg. 3. No characteristic anatomical lesion This condition is found in diabetes, starvation and cachexia. 95 2. Excess of XH.. o. Large amounts of uuoxidized X and lactic acid This condition is found in plios. poisoning, cliloro- form poisoning, toxaemia or pregnancy and cyclic vomiting. Coma supervenes when acetone bodies are in the greatest concentration, in both the blood and the urine. Coma does not occur in their absence. Acidosis is further proved to be the cause of coma : 1. There is decreased alkali in the blood. 2. Concentration of CO^ in the blood reduced from 36 m m to as low as 3.2 m m tension. 3. There is a greatly increased alkali tolerance. 4. Administration of alkali results in improve- ment. Allen's theory of diabetes. 1. Pancreas is the seat of the trouble. 2. Diabetes is a specific disease. 3. It is explained by a lack of amboceptor, which is necessary to produce blood colloidal sugar. Sugar free in the blood and not in a colloidal state acts as a diuretic. Treatment. 1. SuiDply deficient amboceptor. 2. Protection. Restrict carbohydrates up to a point of no sugar in the urine and blood sugar not greater than .17% and no ace- tone bodies in the urine. By restricting the carbohydrates you attack acidosis. There is no explanation for this except that by starvation you make the body learn to metabolize sugar properly. Dia'betes insipklus. This is a condition characterized by the excretion of large amounts of urine with a low specific gravity 96 without any demonstrable kidney lesion. The con- dition frequently shows a hereditary disposition. Symptomatic group. 1. Polydypsia (excessive fluid intake). 2. Central nervous system injuries. Lues r^ften found at autopsy. Ideopathic group. Lately some internal glandular pathology has been determined. Sometimes the posterior lobe of the hypophysis has been found diseased, especially in distrophia adiposa genetalia. The inability of the kidney to concentrate urine is the chief symp- tom. When salt is given to a normal individual he excretes it with a rise in the specific gravity of the urine. In this condition the concentration in the urine remains unchanged, but a greater quantity of fluid is excreted. The total solids are the same, but more fluids are required in the latter condition. Characteristics of the disease. 1. Polyuria with 5 to 49 liters a day. 2. Excessive thirst. 3. Urine: a. Low specific gravity. b. Practically colorless. . c. Weakly acid. d. Hypotonic (bl6od cells rapidly disin- tegrate). e. Polyuria greater at night. f . Free from albumin and sugar. Ferments in the urine. Pepsin. Normal in small amounts and easily de- tected. It is absent in gastric carcinoma, subacidity and occasionally in achylia gastrica. It is increased in pneumonia and is of some prognostic value. Test for pepsin. Fibrin is washed and then soaked in the urine 97 for from 5 to 6 hours. It is then placed in a weak solution of HCl and incubated. If pepsin is present digestion will take place. Lipase. NormallT present, but in smaller amounts than pepsin. It is increased in jaundice, diabetes mellitus and hemorrhagic pancreatitis. Test for lipase (Castle and Loevenhart). Flash A Flash B Flash C Urine 5 cc. Boiled urine 5 c c. Urine 5 cc. Phenolphthalein x cc. N'/IO XaOH x cc. y/iO NaOH N710 NaOH to a .25 cc. ethylbutyrate .2." cc. ethyllnityrate pink color — x cc. 1 cc. toluol 1 cc. toluol Incubate flasks B and C for 21 hours at 37% degrees. At the end of this time add % cc. more of X/10 HCl than X/10 XaOH, extract with 25 cc. of alcohol and 50 cc. of ether. Titrate to end point, using phenolphthalein as indicator. 1 cc N/10 XaOH equals .0088 grams butyric acid. Diastase. Origin not known. It may have its origin from polvmorphoneutrophils of the blood, the pancreas, or the liver. It is formed from great meas- ure from the pancreas, for removal of this organ causes a great diminution in the amount of diastase. Wohlgemuth's test. Keagent : 1% starch solution free from precipitate. Dilute 2 cc. of urine with 6 cc. of distilled water. Into each of 9 test tubes add 5 cc. of the 1% starch solution and then the following amounts of the diluted urine : Tube 1, .88 cc. ; tube 2, .72 cc. ; tube 3, .50 cc. ; tube I, .10 cc. ; tube, 5, .32 cc. ; tube 6, .24 cc. ; tube 7, .16 cc. ; tube 8, .08 cc, and tube 9, .00 cc. x\dd sufficient distilled water to each ttibe to make the volimie up to 6 cc, and a small amount of toluol to prevent bacterial action. Cork tubes and incubate at 37I/2 degrees for 21 hours. At the end of this time check action of ferments by chilling in ice Avater. Fill tubes nearly to top with cold water, 98 add 3 drops of X/10 iodine solution and shake. Determine the highest dilution which shows no blue color, and the amounts of starch and urine therein. For instance, if tube 5, with .32 cc. of diluted urine, should be the first tube not to show the reaction, it would mean that .08 cc. of undiluted urine were capable of completely si)litting 5 cc. of 1% starch. Formula : .08 : 5 : : 1.0 : x or x = 62.5 99 STOMACH ANALYSIS. The study of gastric analysis divides itself into four subdivisions, dependent upon the four chief functions of the stomach: 1. That of a mixing chamber in which the food is prepared for the later intestinal digestion — hence a study of Secretion. 2. That of digestion — hence a study of Ferments. 3. That of a reservoir from which food passes fur ther along,