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Uric acid normally is excreted about a gram, or slightly less, daily. It is one of the end-products of protein decom¬position. Those conditions which cause an increase in urea cause an increase in uric acid. Other conditions that cause it are most general infections and especially leukemia. In gout there is an increase during an attack, but a decrease before and after the attack. Uric acid is decreased in anemia, dia¬betes insipidus, advanced kidney disease, lead-poisoning, rickets and scurvy and from the use of quinine.
Albumin in the urine may be of different kinds. Serum albumin, the most important, is the kind meant when the term albumin is used without qualification. With it may be asso¬ciated such other proteids as serum-globulin, albumose, nucleo-albumin and fibrin. There may be a physiological albuminuria in which albumin appears transiently in the urine and in which there is no apparent change in the kidney cells. This is why one urinalysis in which albumin appears in the urine cannot be considered positive indication that there is a kidney disease or kidney weakness. Ordinarily, however, the pres¬ence of albumin in the urine indicates a structural or func¬tional change in the kidney. Mild temporary changes in the kidney cells may cause a transient albuminuria. Bare traces of albumin in the urine are not now considered as grave indi¬cations, even though appearing frequently. It is the more or less constant presence of albumin that leads one to presume the existence of organic kidney disease.
Accidental albuminuria is that due to contamination of the urine from various substances, as blood, pus, semen, urethral-cells or bladder-cells, etc.Functional albuminuria is due to severe exercise, after a heavy meal or a cold bath, or intermittently in people of good health with no other evidence of kidney disease. Sometimes in pregnancy and adolescence there is functional albuminuria, though in these eases there may be considered to be a suscep¬tibility to kidney disease, probably to develop only after sev¬eral years and under special stress.
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Urea is the form in which most of the nitrogen is elimi¬nated from the body, there normally being about 30 grams daily. Proteins taken in as food and decomposition of the body tissues form the urea. Hence it varies much, depending upon the nature of the diet and the stress which the body undergoes. It is much increased in fevers, in wasting diseases, such as pernicious anemia, in acute rheumatism and pneu¬monia, in leukemia and in diabetes from the great intake of food usual in this disease.
Urea is decreased in abnormal liver conditions which prevent or interfere with its formation, as in cancer and in kidney conditions which prevent its elimi¬nation; also in Addison’s disease, anemia, general paralysis, lead-poisoning, chronic rheumatism, rickets, starvation and a few other abnormal conditions and diseases.
By quantitative estimates of urea or by estimation of the total solids in the urine the severity of nephritis may be fairly accurately gaged. When the urea is eliminated in deficient amounts there is likely to develop uremia, for the condition that causes deficient urea elimination also causes retention of other poisons which help to form uremia. It might be added that even small quantities of quinine decrease urea elimination.
Urinary solids normally amount to 60 to 70 grams in 24 hours. If there is a constant reduction below this the excre¬tion is radically defective and demands investigation. The elimination of solids is decreased in certain affections of the structure of the kidney concerned with excretion, but may be due to other abnormal conditions also. One may estimate with fair accuracy the number of grams of solids in the urine by multiplying the last two figures of the specific gravity (24-hour specimen) by 2.33, which gives the amount of solids in 1000 cubic centimeters.
Thus, if the specific gravity is 1.025 and the total quantity 1500 cubic centimeters (c.c), multiply 25 by 2.33, which gives 58.25 (grams), representing that in 1000 c.c. Since the total quantity of urine was 1500 c.c, add the half of 58.25 to 58.25, which gives 87.37 grams total solids for 1500 cubic centimeters.
The clinical significance of the chemical and microscopical findings in the urine follows:
Normally there should be 10 to 15 grams of chlorides in the urine. These are increased especially in convalescence from pneumonia and fevers, in diabetes insipidus and when large collections of fluid (dropsical effusions) are being ab¬sorbed. They are markedly decreased during starvation, in acute pneumonia, in most fevers, while dropsical effusions are increasing, in many serious digestive diseases and in melan¬cholia, nephritis, rickets, and acute rheumatism.
Phosphates normally are present in urine to the amount of 2 or 3 grams. They are decreased particularly in pregnancy, nephritis, gout, during an attack of malaria and on a vegetable diet. There often is an increase in dyspepsia, phosphatic dia¬betes, some digestive disorders and in general in serious nerv¬ous diseases, as of the brain, the spinal cord and in bone diseases.
Sulphates normally constitute 2 grams of total solids. They are increased in wasting diseases, since they are derivedfrom the breaking up of albuminous substances in tae body. In cancer of the pylorus, both forms of diabetes, fevers and pneumonia they are increased.
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Normal urine gives an acid reaction. A total acidity of a 24-hour specimen of urine approximates one or two grams of hydrochloric acid. Increased acidity results from a meat diet and mineral acids. It also occurs in gout, rheumatism, many fever diseases and in such digestive disturbances as are associated with decreased stomach acidity.
An alkaline urine that persists usually is due to decomposition of the urine in of the bladder, as in cystitis. A vegetable diet rich in alkaline substances will cause an alkaline urine, but only for a short time after each meal. Any condition causing retention of the urine causes an alkaline urine. Reaction of urine is taken with litmus paper. Acid urine turns blue litmus red, while alkaline urine turns red litmus paper blue. An amphoteric urine, which contains certain acids and alkalies, will turn red litmus blue and blue litmus red. This condition has no im¬portance.
The specific gravity is the weight or density of the urine as compared with distilled water. The specific gravity is taken with a urinometer. In single specimens of urine the specific gravity varies from 1.001 or 1.002 (as after drinking much water or beer) to 1.040 in case of high fever or as high as 1.070 in diabetes. But in health the average specific gravity of a 24-hour specimen is between 1.015 and 1.025. High spe¬cific gravity is fouud in diabetes mellitus, acute gout, high fever, kidney congestion, acute kidney disease, leukemia; also after heavy meals and heavy physical exertion, long retention of the urine, vomiting, diarrhea, and profuse perspiration. Low specific gravity (under 1.010) is found in anemia, cir-’ rhosis of the kidney, diabetes insipidus, hysteria, nervous poly-uria, after an epileptic attack; after fasting, copious drinking, in convalescence from acute disease and from taking diuretics.
The normal color of urine is amber. Pale urine usually is due to anemia, cirrhosis of the kidney, diabetes, or hysteria, or a large intake of fluid. A high color is present in severe prolonged constipation, peritonitis, gangrene, suppuration, gout and lithemia. Bile pigment gives a yellowish, brownish or almost blackish color, with a yellowish foam on shaking. A red urine may be due to fresh blood, a reddish urine to rhubarb, senna and certain other drugs.
Blood pigment dis¬solved in the urine gives a reddish brown, coffee-colored or black shade to the urine. Milky urine may be caused by neu¬rasthenia (an excess of phosphates in the urine), by foods, especially starches in excess, rarely in nephritis, and sometimes by obstruction of the thoracic duct from tumors or injuries.
The normal odor of urine is characteristic. An odor of ammonia may result from decomposition of the urine, as in case of cystitis (inflammation of the bladder). In diabetes there is a fruity odor from acetone (as of over-ripe apples), which may pervade the entire room if the bedding has been stained with the urine. Asparagus, cubebs, turpentine, co¬paiba, menthol, valerian, asafetida, saffron and other sub¬stances give peculiar odors to the urine, each more or less
characteristic.
Normal urine is transparent, though upon standing there may settle a slight cloud of mucus. After a heavy meal the urine may be alkaline and phosphates may be precipitated, making the urine cloudy. The transparency may be destroyed by pus, epithelial cells, chyle and milk, or there may be merely a turbidity from any of these.
Most people know nothing of what certain tests and ex¬aminations of the urine mean. If they have a urinalysis made and receive or see the report, they must ask what certain things mean before they have any idea as to whether their urine shows normal or abnormal conditions. It is not expected that lay readers will make their dwn diagnoses from urinalyses, nor from other tests and examinations. But following will be given the meaning of certain findings upon urinalysis, that they may know whether or not there are conditions that should receive attention.
A* qualitative test is one made to determine the presence or absence of certain urinary constituents. Any quantity of urine above an ounce or so may be sufficient. A quantitative test is one for determining the amount of certain constituents. All the urine passed within 24 hours is required for such a test. In adults the daily (24-hour) amount passed is about 50 ounces. Normally, more is passed by day than by night.
An increased quantity of urine is caused usually by the final stage of cirrhosis of the kidney (chronic interstitial ne¬phritis), sometimes enormous quantities, by diabetes mellitus (sugar diabetes) and diabetes insipidus, and hysteria; also following an attack of epilepsy or of angina pectoris, when convalescing from acute diseases, and occasionally in numer¬ous other conditions, as well as after copious drinking, after eating watery foods, such as watermelon, after eating foods containing- citrates or tartrates and after using diuretics (agents that increase urine flow), including certain drugs, tea, coffee, beer and whisky. The quantity becomes greater at night instead of by day especially in diabetes, but also in arteriosclerosis, heart disease and kidney disease. In case of enlarged prostate gland in the male there is disturbance of sleep from frequent urination, the enlargement preventing complete emptying of the bladder at each time.
The quantity of urine is decreased especially in .diarrhea, prolonged vomiting, lead colic and acute nephritis (kidney disease) ; but also in numerous other conditions, such as ab¬dominal tumors which interfere by pressure, late in ascites or abdominal dropsy, kidney congestion, chronic gastritis, gout, intestinal obstruction, melancholia, peritonitis and pleurisy with effusion; also after abstention from fluids and after ex¬cessive perspiration. It naturally is reduced in summer and increased in winter, as the skin is more active in the former and less active in the latter.
By the Mood-count is meant the counting of the number of blood-cells in certain minute fields on the glass slide under the microscope and from this estimating the number of Llood-cells in a cubic millimeter of blood. We do not need to go into this exami¬nation, as it is more or less in¬tricate. The ex¬amination is made to determine the degree of anemia or the normal con¬dition of the blood and to determine the condition of the cells themselves. Both the red cells and the white cells are counted, but by different tests on the same or on different slides. There are different kinds of white blood-cells, so the determining of the percentages of each kind is called a “differential count.”
Generally it is considered that the normal number of red cells in the blood of a man is 5,000,000 to the cubic milli¬meter, while in a woman the number is 4,500,000. In high altitudes the count increases by 500,000 to 1,000,000. Starva¬tion also raises the count. Dilution of the blood by eating and drinking reduces the count, as does obesity.
In anemias the count is reduced.’ The white cells in adults are normally about 7,000, but vary from 5,000 to 10,000 to the cubic millimeter. Numerous conditions increase or decrease both red and white cells, but alter the count of the two types of cells not necessarily in the same direction. Infections increase the white cells greatly, as these are the scavengers or policemen of the body and are called out to combat the bacteria. Color index is the term used to express the relationship between the amount of hemoglobin actually present in a per¬son’s blood and the amount that theoretically should be present with the same number of red blood-cells. The normal color index is 1.0, meaning that there is 100 per cent, of hemoglobin associated with 5,000,000 red blood-cells. Diminishing both the hemoglobin and the red cells proportionately will still leave a color index of 1.0. But if the hemoglobin is reduced more markedly than the red cells the color index will be below 1.0, as it is in chlorosis (green-sickness) and splenic anemia. On the other hand, in pernicious anemia the cells are reduced in greater proportion than is the hemoglobin and the color index is above normal, sometimes as liigh as 1.9. The usual color index is about .85.
Urinalysis (urine analysis) is routine with a great many physicians and always in hospitals and sanitariums. By this much can be learned of the individual’s general condition. The urine is tested for several conditions and contained substances: color, transparency, odor, reaction; solids: chlorides, phos¬phates, sulphates, oxalates, urea, uric acid, albumin, various forms of albumin or protein, blood, sugar, acetone, diacetic acid; microscopically, for blood, leucocytes, pus, spermatozoa, parasites, bacteria, sediment, epithelial cells, tube casts (which may be granular, epithelial, blood, fatty, waxy, pus, fibrinous).
The temper-ature of the human body undergoes less fluctuation in health than almost any other feature. The usual normal, taken by mouth, is 98.6 degrees F. When taken by rectum it is neces¬sary to deduct one-half degree to obtain the mouth tempera¬ture; while when taken in the armpit it is necessary to add one degree. Unless specified otherwise, mouth temperature is referred to when the temperature is given. Numerous ab¬normal states cause an elevation of temperature, or fever. A subnormal temperature appears in conditions of lowered vi¬tality.
The temperature drops suddenly in certain conditions, especially in the crisis of some diseases. . For instance, it may drop from 106 to 96 within ten hours in the crisis of pneu¬monia. The temperature is low in chills, but rapidly rises if a fever stage follows. For convenience, temperatures are classed as: Subnormal, below 97.2 degrees; normal, 97.6 to 99.00 degrees; subfebrile, up to 100.5 degrees; slight fever, up to 101.5 degrees; moderate fever, morning 101.5 degrees, eve¬ning 103.0 degrees; high fever, morning 103 degrees, night 105; hyperpyrexia, over 106 degrees.
A diminished frequency of pulse may be present without any evidence of disease. A rapid heart-beat is called tachy¬cardia. A heart-beat markedly below normal is called brady-cardia. In the most pronounced degree this usually follows injury to the eleventh cranial nerve (the accessory or spinal accessory nerve). Sometimes degeneration of the heart-muscle causes abnormally slow pulse. An infrequent pulse usually comes on in the latter half of life.
In health, the pulse-beats are regular in rhythm and volume. A slight variation may exist without any pathologi¬cal condition being present, nervous conditions not infre¬quently causing irregularity. Arrhythmia is the term used to denote irregularities of heart-action.
The pulse may be large or small, relating to the sensation imparted to the examining finger. A large pulse indicates that a large volume of blood is being forced into the arteries at each heart-beat, and denotes or points to a powerful ven¬tricle and unobstructed vessels. A small pulse may be present in some heart-valve diseases which weaken the effect of the ventricle action, or when there is obstruction between the ven¬tricle and the wrist (aneurysm, tumor, aortic stenosis); or the artery may be abnormally small. A weakly beating heart is the most obvious cause.
Quickness of the pulse refers to the suddenness of the ex¬pansion of the vessel, not to the rate of the pulse. The quick pulse gives a sudden tap to the finger, while in the slow pulse there is a gradual lifting or heaving of the artery, the pressurelasting for an appreciable time. In quick pulse the blood pressure usually is low, there be¬ing reduced re¬sistance to the heart - action. The slow pulse is due to some manner of ob¬struction some¬where along the line, as in re¬duced size of the heart - opening into the aorta or contracted sur¬face vessels.
The pulse is examined for its rate, regularity, size and quickness. The rate is determined by counting the beats by a watch for not less than one-half minute. If there is any irregularity it should be counted for a full minute, preferably counting the number of beats in each period of five or ten seconds, to note variability. If it is too rapid to be sure of correct count, it should be counted every second beat and the result doubled. If some of the beats are too light to record with the finger, the heart should be auscultated (lis¬tened to with the stethoscope) and the count made in this way. Slight influences modify the pulse-rate.
In many cases, the mere fact that it is being counted sends it speeding. The pulse usually is five to ten beats more a minute in the after¬noon and the evening than in the forenoon. It is faster for an hour or two after meals, especially hot meals or full meals, after drinking tea, coffee and alcohol and after smoking. Changing from lying to sitting raises the pulse from three to eight beats a minute, and from sitting to standing raises it from four to eight beats a minute. Exercise has marked influence upon the rate, slight exertion often sending the beat up 30 more a minute, and strenuous exercise may double or more than double the rate. In those debilitated the pulse may in¬crease out of all proportion to the physical effort made. The rate should drop down’to normal within three minutes after discontinuing ordinary exercise. It is to determine the time required for this restoration to normal that the pulse is taken both before and after exercise. Those in whom the pulse rate increases out of proportion to exertion or is reduced to normal markedly slower than normal usually are denied participation in sports of a competitive nature for which physical examina¬tions are required.
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