On bedside urine-testing: a clinical guide to the observation of urine in the course of work

Preface

^ The aim of this little work is to supply ^ in the compass of a pocket companion the leading data in regard to urinary observation, to point out what ought to be noticed in the course of work, and to indicate the readiest methods of testing by which the practical aspects of morbid urine may be brought home to the senses with the least expenditure of time and trouble : in a word, to facilitate that important part of clinical enquiry — the examination of urine in all cases.

My efforts in this direction having proved acceptable in England — this American edition being synchronous with the third English edition — I bring them forward on American soil with the hope that they may bear fruit on both sides of the Atlantic.

HavYogate,

Contents

INTRODUCTORY.

Page.

The aim of bedside urinary testing 13 — 15

The tests 14

CHAPTER I. The general characters of the urine 16 — 47

I. On selecting a specimen of urine for

examination 16

The urine has deposited 17

The specimen is turbid 18

II. The odour 18

Alkaline urine 18

Urine containing sugar, cystin, medicines, &c 19

III. The consistence 20

Alkaline purulent urine 20

Chylous urine 20

Albuminous urine 20

IV. The colour 21

Pale urines 21

Dark urines 22

(a) Indican 22

(6) Melanin 23

(c) Blood 23

{d) Bile 24

[e) Medicines, &c 24

V. On cloudiness and on deposits 25

1. Inorganic causes of turbidity 26

(a) Urates 26

(6) Phosphates 27

2. Organic causes of turbidity 28

(a) Pus. Mucus 29

The clinical significance 30

ib) Blood. Hasmaturia. Haemoglobinuria. 31

The clinical significance 33

(c) Oil-globules 33

B

Page.

{d) Organisms 34

3. Deposits 36

(a) Epithelial 36

(6) Uric acid 37

The clinical significance 37

(c) Light-coloured deposits 38

Earthy phosphates 39

Pus 39

Light-coloured urates 40

Oxalate of lime. Clinical significance 40

{d) Dark deposits 42

Urates 42

Blood-derived deposit 42

A tabular view of deposits 43

On collecting deposits for the microscope... 43

VL The daily quantity of urine 44

1. The quantity is excessive 45

(fl) The increase is temporary 45

(6) The increase is permanent 45

2. The quantity is diminished 45

3. The urine is suppressed 45

{a) Obstructive suppression 46

(b) Non-obstructive suppression 46

4. The nocturnal discharge of urine 47

CHAPTER n.

The specific gravity of the urine 48 — 71

Pocket urinometers 48

The author's method 48

The clinical use of specific gravity 5I

1. Total solids or ' solid urine ' 5^

The rule for an approximate calculation ... 53 Physiological causes of variation. (i)Food.

(2) Exercise and rest. (3) Body-weight... 54

Clinical variations 55

The urinary solids are deficient 55

{a) Urine normal or sub-normal in

amount 55

(6) Urine increased in quantity 59

The urinary solids are increased 59

[a) The amount of urine not increased... 59

(6) The urinary flow is excessive 60

IL Urea 60

The daily average mean amount excreted... 62

Vll

Page.

The chief physiological causes of variation.

(i) Weight.' (2) Diet. (3) Work 63

The variations of urea in disease 65

III. Sugar 65

Rules for calculating the amount when the daily discharge of urine (i) exceeds or (2)

is under 150 ounces 66

IV. The specific gravity of isolated specimens of

urine 68

Maximum solid urine 68

Minimum solid urine 69

Practical inferences ...*. 70

CHAPTER III. The reaction of the urine 72 — 81

The modes of determining the reaction... 72

Litmus papers 72

Alkalinized litmus paper. The author's

method '. 73

Degrees of acidity 74

Physiological variation of reaction 75

The clinical significance of the reaction ... 76

Urines highly acid 76

Urines alkaline 80

CHAPTER IV. The forms of proteid substance in the

urine 82 — 97

Class I. — Native Proteids 83

{a) Serum-albumin 83

ib) Globulin 83

The clinical significance 85

Class II. — Derived Proteids 85

(a) Albuminates. Acid & Alkaline albumin 85

[b) Peptones. Plemialbumose 87

The clinical significance of peptonuria 91

Local inflammation gi

Lobar pneumonia 91

General diseases gi

Disorders of the liver 93

Chapter V

Albuminuria : the detedion of albumin by aciduiation (citric acid test-paper) and heat 98-108

Vlll

Page.

Different modes of applying the test of

acidulation and heat 98

Boiling after acidulation 99

The method 100

ObjecStion 100

Acidifying after boiling 105

Heat not necessary as a routine preliminary

test 105

The modes of heating 107

CHAPTER VI. Albuminuria : the detedlion of albumin by

test-papers iog-130

The test-papers selec5ted 109

Mucin no

The mercuric test-paper 116

Bodies precipitated 117

The ferrocyanic test-paper 119

Bodies precipitated 120

The modes of testing 121

Method 1 122

The nitric acid range 123

The intermediate range 124

The heat range 124

Method n 126

The methods originally proposed 129

The test-papers dropped into the urine 129

The 'contact' method 130

CHAPTER Vn.

Albuminuria : quantitative albumin 131-140

The methods 131

Method I. — The quantity of albumin expressed as a fradtional part of the column olurine 132

The mode of testing 133

Method n. — The percentage estimation of

albumin 134

The mode of testing 134

The quantitative value of each test-paper 139

The quantity of albumin met with 139

The daily amount of albumin discharged 140

IX

Page.

CHAPTER VIII. Albuminuria: the clinical significance of

albumin 141-155

I. The albuminuria is intermittent 142

The fadl of intermission is of clinical

significance 142

Fundtional albuminuria 142

The albuminuria of adolescents, of

bronchocele, &c 143

II. The albuminuria is persistent 146

The cause is renal 146

III. The quantity of albumin 148

Minimal albuminuria 148

The quantity of albumin in the different forms of renal disease, and of fundtional albuminuria 149

IV. An epitome of the causes of albuminuria 151

CHAPTER IX. Glycosuria : the detedion of glucose by test-papers 156-179

I. The indigo-carmine test-papers 157

The indigo - carmine test solutions are valueless : but the test-paper is available

for clinical purposes 157

The readtion 160

Carbonate of soda papers to be used when (i) water hard or (2) urine excessively

acid 162

The mode of testing 164

Confirmation of results by Fehling's

solution 167

Experimental testings 168

Clinical advantages of the indigo-carmine

test-paper 172

II. The cupric test-paper 176

The reaction 177

Directions 179

CHAPTER X. Glycosuria: Quantitative glucose 180-193

The indigo-carmine provides quantitative

information igo

The mode of testing 183

Quantitative data 186

(i) The urine undiluted 186

(a) The reaction is incomplete „ 186

X

Page.

(Jj) The reaction is complete , i88

(2) The urine definitely diluted i8g

Conclusions 192

CHAPTER XL Glycosuria : the clinical significance of

glucose 194-198

Glycosuria is not synonymous with diabetes mellitus 194

The glycosuria is intermittent or temporary

Digestive or hepatic glycosuria 194

Diabetes mellitus 197

CHAPTER Xn.

Choluria : the detection of biliary derivatives

in the urine 199-220

The biliary elements that may appear in

the urtne 199

I. The bile-pigment 199

Visual characters of jaundiced urine 199

The reaction with a citric test-paper 200

II. The bile-salts 200

The urinary derivatives of the biliary salts 200

The unsatisfactoriness of the clinical tests hitherto employed for detecting bile-salts

in the urine ....'. 201

The proposed test is founded on a physiological reaction 204

The peptone test solution 209

The reaction 210

Delicacy of the test : objections 211

The mode of preliminary testing 215

Quantitative observation 217

The peptone test-paper 219

CHAPTER Xin.

Choluria : the clinical significance of bile-derivatives in the urine 221-252

The bile-coloured urines of jaundice represent but a portion of the urines charged

with biliary derivatives 221

I. The bile-pigment 222

Jaundice 222

When the urine is pigmented there is always an excess of the colourless bile-derivatives 222

II. The bile-salts 223

Page Physiological variations of the renal elimination of the bile-salts 223

Bile-salts in healthy urine indicated by

the peptone test 223

Hourly variations 225

The effects of (i) digestion, (2) exercise,

(3) alcohol, &c 226

The clinical significance of the renal elimination of biliary salts 232

Data provided by experiments on animals 232 The balance between production and elimination 233

The bile-salts are increased 235

1. Jaundice 235

2. Functional disorders of the liver : biliousness, acute biliousness, chronic biliousness 236

3. Diseases of the liver 241

4. Diseases of the spleen 241

5. Fever 242

6. Haemolytic Diseases 242

(a) Anemia 243

Leucocythasmia 244

Hasmoglobinuria 244

(6) Scurvy 245

Haemorrhages 245

The urinary elimination of bile-salts is

insufficient 245

1. The production is increased, but the elimination is diminished or inefficient 246

2. The production is not apparently excessive, but the kidneys fail to keep

pace with it 248

CHAPTER XIV.

Apparatus 251-256

I. Graduated test tubes 251

1. For taking the specific gravity with

a glass bead 251

2. For urine-testing 252

n. Standard opacities 252

1. For quantitative albumin 253

2. For the quantitative observation of bile-salts 253

HI. Sundries 253

1. Nipple pipette 253

2. Metal clip 253

IV. Test Papers 254

INTRODUCTORY,

The Aim of Bedside Urinai-y Testing" is to ascertain, in the ordinary course of medical observation, the condition of the urine : either to detect leading pathological states of this excretion, as immediate aids to diagnosis and treatment ; or — as in the majority of cases — to definitely eliminate them from the clinical view.

Whether the evidence, thus revealed without delay, be positive or negative, it may be equalty valuable to the practitioner at the moment, either by giving a turn to his investigation, or by correcl:ing impressions suggested by other data : but, besides thus serving this immediate end, it enables the busy man to readily w^eed out on the spot the important urines for particular investigation at home, and reduces the liability

c

14 INTRODUCTORY.

to omission of that important part of clinical observation — urinary examination in all cases.

The testing of urine should, therefore, be rendered as ready and portable at the bedside as are other instruments of clinical enquiry — such as the thermometer, the stethescope, &c. To this end the following pages are devoted.

Tlie Tests I propose are in the form of test-papers^ : than which I cannot conceive of an3'thing more convenient for bedside work. The}^ are specially fitted for this service b}^ virtue of their possessing all the essential qualities which should pertain to such tests ; namety, trustworthiness, stability, portability, and freedom from causticity and other objectionable properties. The reader has merely to call to mind the miseries of nitric acid and of Fehling's solution — the urinary cases dilapidated, and articles of clothing spoilt by these destructive reagents — in order to realize how unsuitable are such caustic tests for pocket use ; and

iThe strips of chemically charged paper are but vehicles for the ready application of the reagents.

INTRODUCTORY.

he must then regard with some sense of rehef the neat and clean!}- methods provided by the test-papers, which can be as freeh' handled, and as harmlessl}^ — to the fingers and to the tests — as ordinary writing paper.

Then again, no other dr}- preparations — such as pellets, powders, &c. — can compare with test - papers in readiness for use, and in providing in so small a compass a series of tests for determining several points of clinical importance in the examination of urine.

Moreover, the test-papers, apart from ministering to the personal convenience of the observer, possess clinical advantages, such as the handy and time-saving methods which they provide for quantitative estimations.

Chapter I. The General Characters Of The Urine

I. On Selecting a Specimen of Urine FOR Examination.

Wherever practicable, the urine of the whole twenty -four hours should be reserved. If this, however, cannot be done, the observer should direct the portion passed two or three hours after breakfast, and that voided on rising, to be kept in separate vessels. These specimens will provide a fairly good average when mixed in equal porportions; and when examined separately will afford information as to the effects of digestion, and of fasting and rest. On no account should the observer rely on an examination merely of the urine passed in the morning before breakfast ; for it may be free from albumin or sugar, or nearly so, while the speci-

Chap. I.] ON SELECTING A SPECIMEN. 17

mens voided during the day (after meals) may contain these constituents in fair proportions, or in larger quantities. (See pages 144 and 195).

Tlie Urine lias deposited. — Urine reserved for examination has usually stood for some hours, and has consequently allowed any matters in suspension, that can subside, to settle. The observer will often require to examine separately the supernatant portion and the deposit ; and should, therefore, see that the vessel containing them is not shaken. Besides, this precaution has special reference to testing for albumin and bile-acids, when it is highly desirable, if not essential for accurate observation, to select a transparent portion of the urine.

The nipple-pipette (see chap, xiv.) is a most useful article at the bed-side ; for it enables the observer to take up a perfectly clear specimen of urine — 'perhaps otherwise unprocurable — and to examine separately the deposit, or an}^ particular portion of it.

l8 THE ODOUR. [Chap.l.

The speciiiieii is turbid. — If a

transparent specimen is not provided, and if the turbidity does not clear up on adding a citric acid test-paper, or with warmth, the observer had best filter it ; and, for this purpose, his urinary case should be furnished with a few pieces of filtering paper — one of which, rolled into a cone, and held over the test tube, will, in a minute or two, provide a sufficiency of transparent urine for albumin, bile-acid testing, &c.

II. The Odour.

Healthy urine emits a characteristic aromatic odour, varying, however, with different individuals, and with the degrees of concentration of the urine. A strong urinous odour is often emitted when the percentage of urea — and in fact of the total solids — is high. The urine of dyspepsia sometimes emits a sickly odour.

Alkaline Urine.— The urine, without being ammoniacal, often smells of the bladder, when feebly acid or alkaline, and when slight catarrh of the urinary

Chap. I.] THE ODOUR. 19

passages exists. When alkaline from fixed alkali, it exhales an odour like that of horse's urine. When the urine contains ammonium carbonate, derived from the decomposition of urea, the odour becomes * ammoniacal' : and this ma}^ be the case when it is voided, or shortly afterwards, or after standing some time in a warm room.

Urine emits a 'putrescent' odour, when it contains much decomposing organic matter, as in destructive disease of the bladder, kidneys, &c.

Siig-ar. — The presence of sugar is often attended b}^ a sweet smell, as that of new hay, or whey ; and in diabetic coma, the urine emits an odour like that of chloroform. Saccharine urine in a state of fermentation smells like ' turned ' milk.

Medicines, &c. — Certain medicines (turpentine, copaiba, cubebs, oil of sandlewood) and articles of diet (aspara-

:20 THE CONSISTENCE. [Chap. I.

gus, garlic) communicate their characteristic odours to the urine.

III. The Consistence.

Healthy urine is always watery ; but in disease, the consistence may be so increased, from the presence of mucus or muco-pus, as to prevent the urine from running into drops — for when poured from vessel to vessel it flows out en masse.

Alkaline Purulent Urine. — If the urine be purulent and alkaline there will be seen a glutinous mass — consisting of pus transformed by ammonium carbonate into a mucous looking substance — which adheres tenaciously to the bottom of the vessel.

Chylous Urine. — In chyluria the consistence of the urine is increased. (See

PP- 33. 34)- Albuminous Urine. — When albumin

is present in considerable quantity, though the consistence is not obviously, or is only slightly increased, the splash of the urine is softer and less watery ; and, after shaking, the froth remains intadl

Chap I.] THE COLOUR. 21

much longer than that of non-albuminous urine of the same specific gravity.^

IV. The Colour.

The tint of normal urine ranges from straw yellow [urina potus) to golden amber [urina sanguinis and tirina cihi) ; the depth of colour varying with the concentration — abundant and watery urines being pale, and diminished discharges of higher specific gravity being darker. This rule is of pretty general application.

Pale Urines. — When the urine is pale, the observer will bear in mind conditions that induce a copious flow ; such as cold weather, the free taking of fluids, hysteria and other neurotic ailments inducing paroxysmal attacks, anaemia and chlorosis, diabetes (mellitus and insipidus), and chronic Bright 's disease — especially the waxy and granular kidney. The urine of women is paler than that of men ; and also the urine of persons of feeble general health — as during convalescence from acute

1 "The reader will bear in mind that other than albuminous urines may provide a ' stable froth,' such, for example, as those well charged with solids — the sp. gr. being over 1020.

22 THE COLOUR. [Chap. I.

diseases, &c.— than of the robust. Pale urines suggest the absence of fever.

l>ark Urmes.— On the other hand, dark urines are often also concentrated, as during warm weather, after active exercise, in diarrhaea, in fevers, and in disorders of the liver. Dark urines suggest increased tissue-change.

(a) Iiidicaii. — High coloured and concentrated urines frequently contain a large quantity of indican^ — a substance which yields free indigo when broken up by the per-acid state of the secretion ; hence the blue, or violet, or reddish violet, or green tint, which appears in such urines on standing, and best seen at the surface near the sides of the glass vessel containing them.

An increase of indican, and the occasional appearance of free indigo in the urine, have been observed in many pathological conditions : but they are, for the most part, such as disturb or delay intestinal digestion ; e.g.^ obstructive diseases of the bowels, dysentery, diarrhaea, typhoid

1 An excess of indican is also sometimes found in pale urines.

Chap. I.] THE COLOUR. 2^

fever, cirrhosis of the liver, cancer of the Hver, cancer of the stomach, peritonitis, the reaction of cholera, lymphoma and lympho-sarcoma of the abdomen, Addison's disease, and diseases and derangements of the entire central and peripheral nervous S3^stem.^ Js^ffe has shown that indican is greatly increased in obstruction of the small intestines and general peritonitis, but onty slightly so in obstruction of the large intestine. Senator has observed an increase in granular kidne3% but not in other forms of chronic renal disease.

(h) Melanin. — A black pigment (melanin) is present in the urine of patients suffering from melanotic tumours — especially of the liver and the skin — and sometimes also in ague. In these cases the urine ma}^ be of normal colour when passed, but becomes black on standing, or on the addition of an acid.

(c) Blood. — When the urine presents a smoky hue, the observer will suspect the

1 This statement summarizes the clinical observations of Jatfe, Neftel, Wyss, and Robin.

2^ THE COLOUR. [Chap. I.

presence of a small quantity of blood ; but when in larger proportion, blood communicates a distinctive red colour (see p. 31). When the colouring matter of the blood corpuscles is present (haemoglobinuria or hsematinuria) in large quantity, the urine is as dark in colour as port wine (see p. 32).

(d) Bile. — Bile is also a cause of dark urine. (See p. 199).

(e) Medicines, &c. — The urine may be dark, or even black, when carbolic acid or creosote has been taken in large quantity.^ Certain vegetable substances, in passing out by the urine, communicate their distinctive colours ; such as rhubarb, logwood, whortleberries, indigo, madder, &c. Santonin gives a yellow bile-like colour to acid urine, which moreover, further resembles biliary urine in staining the linen of the patient, but is easily distinguished by striking a crimson reaction on adding

1 Carbolic urine may be pale when voided, but becomes dark on exposure to the air. Pyrocatechin (a normal constituent of horses' urine) in rare cases appears in human urine, which is likewise of ordinary colour when passed, but darkens on standing, or immediately on adding an alkali. (Ebstein and Miiller).

Chap. I.] CLOUDINESS AND DEPOSITS. 25

a carbonate of soda test-paper to 60TIX of the urine. When chrysophanic acid (present in rhubarb and senna leaves) is ehminated by alkahne urine, it provides a red tint Hke that of blood ; but it differs from the latter, by at once paling into yellow, when a citric acid test-paper is dropped into 6oiix of the urine, and b}^ the red colour reappearing on alkalinizing the acidified urine by a sodae carb. test-paper.

V. On Cloudiness and on Deposits.

Healthy urine should be perfectly bright and transparent when voided, and should remain so — only in the course of a few hours permitting a light flocculent cloud to fall. The slight loss of clearness of a fresh sample should be carefully noted, by holding it in a test tube up to the light, and shaded by the hand ; and the cause of the opacity should be ascertained. The degrees of turbidity of course vary — from the merest trace to the most dense.

Urine ma}^ be cloudy when passed, or it may become so as it cools. In the latter

26 INORGANIC TURBIDITY. rchap I.

case the cloudiness is almost invariably due to urates falling out of solution — a source of turbidity which does not apply to freshly voided urine, unless the urine is passed into a cold vessel/

The suspended matters, which destroy the transparency of urine, may be inorganic, or organic, or both.

I. Inorganic causes of tuvhidity.

These are for the most part Urates and Phosphates.

[a] lji*ates [amorphous] form the common cause of the turbidity of urine ; and are distinguished from others by quickly vanishing when the urine is merely warmed, even by a comparatively low degree of heat, e.g. loo^ F.

As a rule the opacity settles pretty quickly and completely; slowly, however, if the specific gravity is above normal, ^ or

1 An exception to this rule is found in the comparatively rare cases, in which chrystalline urate of soda falls out of solution in the urinary passages — as occasionally happens in gouty subjects, and in children.

•^ Dr. Garrod tells nie, that he lately met with a urine of sp. gr. 1054, in which urates fell out of solution, and remained as a permanently diffused opacity.

Chap. I.] INORGANIC TURBIDITY, 27

the urine contains organic constituents. Albuminous, mucous, or bloody urine may remain for some time hazy from this cause. The colour of the turbidity varies from a fawn to a flesh tint (see p. 42).

It is characteristic of urines which deposit lithates, to provide on standing a bluish scum on the surface, best seen at the sides. Urines that let fall red-tinted urates generally contain indican (see p. 22).

The clinical significance of a turbidity due to amorphous urates ma}^ be ////, as when it arises from concentration of the urine, and an increase of the acidity : as from violent exercise with perspiration, from abstinence from fluids, or from a bilious attack, or from cold weather; when it is onl}^ occasional. When frequent or persistent and of a flesh-tint (lateritious) there may be fever (inflammatory or not), organic disease, or some cause of rapid wasting of tissue.

(h) Phosphates (earthy.) — Every now and then the reader will come across a urine which when voided is milky, but

28 ORGANIC TURBIDITY. [Chap. I.

which clears up complete^ on dropping into 6onx of it a citric acid test-paper. In such cases the cause of the opacity is due to earth}" phosphates, which do not dissolve simply because the urine is of an alkaline, neutral, or merely of a feebly acid reaction. No other form of cloudiness is removed by a citric acid test-paper ; hence, w^hen it is only in part removed by this means, some other source or sources of turbidity exist, such as pus, blood, bacteria, &c. Phosphatic cloudiness (either consisting entirely of earth}" phosphates, or of these along with pus) is distinctly white or milky, and is increased by heat.

2. Organic causes of Turbidity,

The principal organic products that impair the clearness of urine are —

(a) Pus and muco-pus.

(b) Blood.

(c) Oil-globules.

(d) Organisms.

The loss of transparency due to these causes is apparent in the freshly voided

Chap. I.] ORGANIC TURBIDITY : PUS. 29

urine ; and differs from cloudiness referrible to urates and phosphates, by not clearing up either with heat, or with a citric test-paper.

(a) Fits, — A very small amount of pus suffices to give a haziness to the urine held up to the light ; though it is true the haze induced may be only slight. The presence of pus is pretty certain if the fresh urine contains bacteria (see p. 35) and a small quantity of albumin. The opacity due to pus differs from that caused by blood, in being whitish or greyish.

If purulent urine contain much mucus or albumin, the pus will subside but slowly — the turbidit}^ remaining for hours ; while, on the other hand, if mucus or albumin is present onty in small quantity, the subsidence will be rapid, the urine being left clear, or perhaps only slightly turbid from bacteria (see p. 35.) Purulent urines ahvays contain albumin — in proportion to the amount of pus — in the absence of any other source of albumin.

Miictts, quite apart from pus, is in itself not a cause of turbidity; but it

D

30 ORGANIC TUDBIDITY : PUS. [Chap. I.

becomes so, b}^ forming a nidus, as it were, for the deposition of cellular elements — pus, blood, &c. — and of amorphous urates and phosphates. When present in excess, mucus communicates a glairy or glutinous character to the urine throughout, and does not specially provide a deposit. The faint cloud that forms in the body of the urine shortly after being voided, and then slowly subsides, is mucus along with epithelium derived from the genito-urinary passages. It is larger in women, the vagina providing mucus and cellular elements (epithelium and pus).

The Clinical significance of Pus. — Pus is the common source of the small quantities of albumin so frequently encountered in urine, especially in that of women ; the slightest vaginal discharge, even in children, leading to the contamination.

An inflammatory irritation of any portion of the mucous lining of the urinary passages creates a purulent exudation which mixes with the urine, e.g., of the urethra (gonorrhaea and gouty urethritis),

Chap. I.] ORGANIC TURBIDITY : BLOOD. 31

bladder (cystitis from any cause), pelvis of the kidney (pyelitis).

The observer will also bear in mind the bursting of an abscess into the urinary passages, ^.^., perineal, peri-vesical, peri-renal.

(h) Blood. — The presence of blood, even in very small quantity, impairs the transparency of the urine, and generally communicates a distinctive colour: a reddish tinge, if the reaction of the urine is alkaline, or the quantity of blood is more than ^ of a per cent. ; and a dull smoky appearance, if the urine is acid, or the amount of blood is small. When the blood is of renal origin, the urine is usually smoky, and lets fall a dirty brownish deposit ; but when otherwise, the urine is more distinctly red, and clots may be detected.

Urine containing blood is always albuminous ; and when coagulated the clot is brown-tinted.

If the urine is muddy and dark — even as dark as porter or port wine, but devoid of the clearness of jaundiced urine of that depth of colour — and has let fall an abund-

32 ORGANIC TURBIDITY : BLOOD, [chap. I.

ant chocolate - looking deposit, and is, moreover, highly albuminous — the albumin coagulating into brownish instead of the ordinar}^ white masses on boiling, and on separating leaving the urine as dark as before — in all probability the observer is dealing with a case of hcBmoglohinuria — a paroxysmal disease in which the red-corpuscles are dissolved, and the liberated haemoglobin thus passes out with the urine. There are lesser degrees of this ailment, in which, during the paroxysms, the urine may be merety dusky, providing a smaller deposit — of the same character however — and containing proportionately less albumin.

If the observer wishes to examine a suspicious urine at home for blood by the guaiacum test, he will find a slip of white blotting paper, dipped in the urine and dried, a convenient vehicle : then it \A\\ only be necessary to let fall a drop of the tincture of guaiacum on it, followed by a drop or two of ozonic ether or of spirits of turpentine ; when the characteristic blue colour will appear if blood is present.

Chap. I.] OIL GLOBULES. 33

The clinical significance of blood. — Blood may proceed from any part of the urinary apparatus — from the tubuli uriniferi to the urethra. The principal causes of urinary haemorrhage may be classified thus :

Traumatic. External injury. Renal calculi. Diminutive concretions in tubuli uriniferi.

Renal Congestion^ &c. Passive (heart disease). Active (acute nephritis, effects of turpentine, cantharides) . Chronic Bright's disease (blood in microscopic proportions as a rule).

Symptomatic. Haemoglobinuria. Purpura. Scurvy. Malaria. Eruptive fevers, &c.

Vicarious. Menstrual.

(c) Oil-globules. — Urine containing

particles or globules of fatty matter

presents a milky appearance, always

contains albumin, and often blood (then

the urine has a slight rose tint), peptones,

and sugar. Chyluria is the principal

clinical example of this kind of urine ;

the characteristic feature of it is a

fibrinous clot, which rises to the surface,

forming there a white or pinkish jelly-like

layer, and leaving the urine below still

34 ORGANIC TURBIDITY: [Chap. I.

turbid, though less so than when voided ; and the consistence of the urine is increased in proportion to the number of fatt}^ molecules. Sometimes in this ailment the fat globules are absent ; but there is fibrin (as indicated by the formation of a coagulum like that of calf's foot or currant jelly) and also albumin ; in other words the urine is lymphous not chylous'^.