Changes in urine or blood values were followed in hundreds of subjects for long periods, even years. It appeared essential to plot the data graphically. An average value, obtained from a significant number of normal subjects, was represented in graphs as a reference line. In normal subjects, as a general rule, relatively wide oscillations occur around the average value line. By contrast, in disease states, there is a fixation of the curve on one or the other side of the average value, the curves exhibiting only slight, or even no, variations. Two opposing patterns are thus evident in disease states for each type of analysis of blood and urine. The dualism indicates once again the existence in systemic metabolism of two kinds of abnormal changes with antagonistic characteristics. It is important to note that the advanced cancerous condition is characterized by a marked dualistic pattern at the systemic level.

Blood

In blood analyses, the concentrations of potassium and calcium, the presence of C reactive proteins, the number of leucocytes and of circulating eosinophiles, (Note 7) and the red cell sedimentation rate, have been studied, using classical methods. They all show the same dualism. Figs. 40 to 43 show some of these curves with the average values as reference lines. With the intention of obtaining information concerning the amount of potassium present in cells, we investigated the content of this cation of the red cells. (Note 8)

Urine

In urine studies, measurements were made for pH, specific gravity, surface tension, oxido reduction potential, excretion of sodium, potassium, calcium, chlorides, phosphates, sulfates, sulfhydryl, indoxyl, glucuronic acid, peroxides, etc. Most studies were carried out by routine test techniques. For some analyses, however, conventional techniques were found to be inadequate and new tests devised.

For the urinary excretion of sulfhydryl, a new technique was devised by M. Bier and P. Teitelbaum in our laboratories. Using the Warburg micromanometer, the nitrogen liberated from sodium azide in a buffered solution in the presence of free iodine was found to be directly related to the amount of sulfhydryl present. The amount of nitrogen freed at a determined momentó13 minutesówas most indicative. (Note 9)

For the information which we needed concerning the amount of calcium in urine a very simple method was devised. (Note 10)

For measurement of urinary surface tension, we devised a new technique. We used a capillary so calibrated as to give the surface tension in dyne/cm for a fluid with a specific gravity of 1.015. In this method, several arrests or slowdowns of the descending column are noted and make it possible to obtain information about an extremely important factor which is usually not considered in the measurement of surface tension with other methods. It is known that urine is formed of different constituents, some of them with the tendency to move toward the surface while others tend to move toward the bulk of the fluid. Changes in the distribution of these constituents take place. They induce changes in the value of the surface tension of the urine which occur even during the time measurements are taken. The descending column in a capillary will indicate these changes which are important for precise measurement of surface tension of urine. (Note 11)

Curve of the value of the K+ in blood serum

Fig. 40. Curve of the value of the K+ in blood serum in a case with periarteritis nodosa. The values remain above 4.5 mEq, which represent the average value obtained from series of normals.

Curve of the values of K+ in the blood serum of a subject with carcinoma of the breast

Fig. 41. Curve of the values of K+ in the blood serum of a subject with carcinoma of the breast, liver metastases and jaundice. The values remain almost constantly below the 4.5 mEq line.

The curve of the number of blood leucocytes

Fig. 42. The curve of the number of blood leucocytes of a case of breast adenocarcinoma shows constantly values above 7.000, considered as the average value for normals.

The curve of the number of blood leucocytes of a case of breast carcinoma

Fig. 43. The curve of the number of blood leucocytes of a case of breast carcinoma shows persistently values below the average line of 7.000.

Two methods were employed to measure the oxido reduction potential of urine. In one, the measurement was made with a potentiometer using a platinum electrode, first at the pH of the urine and once again after bringing the pH to 7 by adding the necessary amount of NaOH or HC1. (Note 12) In the second technique, differences in potential were measured through the time necessary to discolor a solution of toluidine blue in an acid medium at 100°C. The value was determined in seconds, the concentration of the dye having been chosen so that discoloration in 100 seconds represented an average value for normal subjects. More rapid discoloration indicated higher potential, while a low potential corresponded to slow or even no discoloration. (Note 13)

The presence and relative amounts of oxydizing substances in the urine were also investigated by means of two reactions: in one, through the passage of indoxyl into indigotine and indigorubine under the influence of sulfuric acid (Note 14); in the other, through liberation of iodine from iodides in the acid medium.

It is interesting to mention at this moment, the variations encountered in the metabolism of nitrogen and the form under which it is excreted through the kidney under normal and pathological conditions. We could show that in general the form of excretion is determined by the amount of water also excreted by the organism. High amounts of water will thus induce the excretion of nitrogen principally as ammonia, low amounts as uric acid. This relationship was explained by data found in comparative physiology. The availability of water in the environment of various animals was seen to determine the form under which these animals excrete nitrogen. The occurrence of similar conditions concerning the excretion of water in pathological states, furnishes an interesting explanation for the form under which it is excreted in these pathological conditions. In Note 15 this problem is discussed in more details.

In all tests requiring quantitative measurements, an important problem arose. It appeared practically impossible to obtain 24 hour urines routinely for periods of months in large groups of individuals in order to note the continuous changes in excretion of the different substances studied. Measurements of various substances eliminated in urine could be made under these circumstances only by using isolated samples. The values so obtained express the concentrations of the substances in the sample and consequently were directly related not only to the amount eliminated by the kidney but also to the amount of water excreted at the same time. The values varied greatiy from one specimen to the next, according to the amount of water excreted. Therefore these data could only be of relative usefulness. Since specific gravity is also a direct function of the amount of water excreted in a urine sample, we related the concentration of a substance to the specific gravity of the same sample. This ratio provided a new value which is independent of the amount of water in the sample and is more closely related to the amount of the other substances which vary much less in amount than water. From the physiopathological point of view, the data obtained were seen to correspond to the degree of active reabsorption of a given substance by the kidney. While the ratio of the concentration over specific gravity would vary directly with the excretion of the substance, the inverse ratio would represent an index of retention, which increases with the retention of the substance in the body. Such indices were routinely applied for the different substances tested in urine to obtain more reliable values than could be obtained from the concentration data alone. (Note 15)