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John W. Ridley
Fundamentals
of the Study
of Urine and
Body Fluids
Fundamentals of the Study of Urine
and Body Fluids
John W. Ridley
Fundamentals
of the Study of Urine
and Body Fluids
John W. Ridley
West Georgia Technical College
Carrollton
GA
USA
This Springer imprint is published by the registered company Springer International Publishing AG, part
of Springer Nature.
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
To my wife, acquaintances, and the
organizations to which I was unable to
provide my undivided attention while
completing this work. I also dedicate this
book to others who encouraged me as
employers, colleagues, patients, and students
from whom I learned so much.
Foreword
Although I have written other textbooks during the past 10 years, this attempt
focuses on a topic that differs from the previous two, although there were significant
references in the previous publications to the topic of body fluids. This time around
in writing this book seemed different from my previous publications even during the
beginning stages. I again felt like a novice, although I have delved into fiction and
nonfiction on a limited basis, but those creative manuscripts were entirely products
of my experiences with life, and nothing had to be verified except by my memories
and thoughts. Both were published, one with a traditional publisher and the other
self-published with Amazon, so I felt some measure of pleasure at having accom-
plished that childhood dream. But now I was forced to completely change tracks!
With this publication, Fundamentals of the Study of Urine and Body Fluids, every-
thing had to be reviewed, and I wracked my brain to insure coverage of all topical
material necessary to complete a book that was inclusive in both theory and practice
related to body fluid analysis.
My first attempt to publish this book met with approval, but reorganization of the
original publisher stymied my efforts for several years. Again, I began the mental
preparation for a new manuscript and read or consulted materials from a vast num-
ber of books and the internet to insure the material I had attempted to publish was
still valid and fresh. Much has been written on the topics of body fluids but all the
wording in this book is a compilation of what I have experienced, know, and have
studied, so any verbiage that is similar to other publications is purely coincidental.
Minor changes were necessary when reviewing the original manuscript. Visits to
several medical facilities to insure a product worthy of the student’s education or the
professional’s needs as a reference were an essential part of completing this
publication.
While most laboratory procedures are either fully or partly automated, it is still
relevant to understand the basics of the unlimited number of procedures, as birth is
given frequently to new tests and new approaches to previous methodology. When
automated procedures are performed, sometimes verification or confirmation is
needed, especially when test results do not correlate with the clinical picture.
vii
viii Foreword
Therefore, the procedures presented in this book use manual methodology, in order
to give the student or professional the basics of what goes into a laboratory
procedure.
For a significant number of years, the author of this book, Fundamentals of the
Study of Urine and Body Fluids, has studied, practiced, and taught the topics pre-
sented in this textbook. Having experience with diverse backgrounds in hospital and
clinic laboratories, private laboratories, and military facilities, including tertiary and
field settings, I have been involved with laboratory medicine and direct medical care
for more than 35 years. The significance of the characteristics ascribed to the vari-
ous fluids of the body has long been a subject of interest even among ancient medi-
cal practitioners. References are made as to the “humors (fluids) and vapors (exhaled
air)” in various writings of antiquity. The fluids of the body include chiefly blood by
volume. However, the specialized body fluids are associated with various systems
within the body and, in most cases, are derivatives of the blood plasma which is the
liquid portion of the body. But the study of hematology or study of the blood requires
an entirely different approach than that of the other body fluids and changes that
occur during disease processes. This book undertakes the study of the clinical sig-
nificance of the “minor” fluids of the body, or those other than blood.
This book is intended for use by entry level students for the diploma, associate,
and bachelor’s degree programs in laboratory technology. In addition, a copy of this
publication would be an invaluable resource in clinical laboratories in all settings,
including physician office laboratories (POLs), where test procedures for urine and
other body fluids are performed. Health care professionals other than laboratory
technical personnel would find this publication to be a valuable resource when seek-
ing information related to the testing of body fluids. Pertinent information relative
to all of the fluids that are routinely studied in the medical laboratory is introduced
along with step-by-step procedures that can be used in writing or revising procedure
manuals. Many pitfalls abound in the practice of laboratory medicine. The practitio-
ners of this profession must develop a sixth sense that causes each laboratorian to
look more intently at certain aspects of the practice, as errors are easily made while
performing the multitude of repetitious and mundane procedures. This requires pay-
ing attention to sometimes intricate processes required as new tests are developed or
new approaches to old tests that are developed continuously. The new discoveries
and even sometimes the dusting off old procedures must be dealt with in stride for
the technician, technologist, or scientist. The terminology used in identifying cre-
dentialed laboratory professionals is included in this publication.
ix
x Preface
xi
Contents
xiii
xiv Contents
Glossary������������������������������������������������������������������������������������������������������������ 405
Index������������������������������������������������������������������������������������������������������������������ 437
Abbreviations
xxiii
xxiv Abbreviations
xxv
xxvi Purpose of Publication
functions of the body are necessary and are advantageous for the student to gain an
advantage in becoming an effective health care professional.
Safety is paramount in the medical laboratory. Biohazards, toxins, electrical haz-
ards, and injuries from mechanical devices require surveillance, training, and cau-
tion to avoid becoming a victim of sustaining an injury or contaminating oneself
with toxins or microorganisms. Fortunately, many hazardous reagents have been
replaced with safer alternatives over the years, but care must still be exercised even
when using common materials. In past years, some procedures required boiling
with gas equipment to achieve a reaction, but that is rare today. Sharp instruments
and broken glass must be promptly and safely discarded to protect the laboratory
professionals, custodial employees, and others such as patients who may be exposed
to hazardous conditions. Regulatory standards, required by federal, state, and vol-
untary accreditation bodies, are a valuable component in the education and training
of laboratory professionals. These considerations relate to quality assurance pro-
grams used to insure valid test results for body fluids, as well as safety issues neces-
sary to provide for the safety and health of the employee as well as the patient
undergoing treatment. References to these requirements based on education stan-
dards and mandated safety practices are found in this publication.
Organization of Text
The book is organized in a logical sequence from the historical introduction of the
study of body fluids, progressing to the need for valid results based on standards of
quality assurance. As safety is a valid concern for anyone practicing any component
of medicine, particularly for those directly involved with specimens such as body
fluids, a single chapter is devoted to safety in the workplace. A systematic approach
to safety and the reasons for body fluid testing are not always found in many of the
currently available textbooks.
The metabolic origins of body fluids, their functions in the overall organization
of the human body, and the importance of these fluids as nutritive and protective
substances are thoroughly discussed prior to any instruction related to testing of the
materials. Constituents contained in the various fluids, some of which may be found
in many of the body sites where fluids are found, are outlined to provide information
related to metabolically formed components of a specimen, both of a normal and an
abnormal perspective. Further steps are provided to emphasize the importance of a
properly collected specimen, based on the anatomical differences of the various
body sites, completes the preparatory information necessary for the practitioner to
systematically incorporate this background material to the testing of body fluids.
A thorough understanding of the principles related to effective and accurate col-
lection of fluids that may be impacted by metabolic and infectious disease pro-
cesses, is necessary before body fluids testing pertinent to the various fluids and, in
some cases, groups of fluids is discussed. Acceptable testing procedures are pro-
vided where necessary for each of the types of fluids found in the human body that
are currently employed as manual procedures for determining the presence of
Purpose of Publication xxvii
disease based upon significant clinical findings in each type of specimen. A separate
chapter is devoted to each of the most commonly tested fluids, and in some cases,
groups of fluids with common components are logically discussed as a group.
And finally, a chapter is provided on testing of fluids and materials from the body
employing some of the previously presented techniques and practices, but includes
some of the lesser body fluids that are not as commonly tested for in many labora-
tories. A feature that is not included in many of the books related to body fluids is
that of the use of the microscope in the testing of the fluids from the body. This final
chapter is designed to acquaint the health care professional in the proper use and
maintenance of the various types of microscopes commonly used in microscopic
examinations and identification of solid constituents of body fluids.
This textbook should at first be used sequentially to set the stage for testing of body
fluids. The initial chapters are necessary to set the stage for the student or medical
professional to have sufficient appreciation for the clinical evidence body fluids
provide in the adequate assessment of the patient. Properly performed procedures
lead to cost effectiveness and efficiency, by providing timely and accurate clinical
results for use by the medical provider treating the patient. Later use of the book as
a reference can be useful in troubleshooting a procedure or determining the neces-
sity for further testing for confirmation.
Although there is a somewhat lengthy history of diagnostic testing, laboratory
testing in the recent past is becoming increasingly important in diagnosing illness
and in determining the prognosis of those suffering from diseases. Clinical findings
in body fluids are correlated by the physician with the physical signs observed by
the medical practitioner along with the symptoms. Results of these laboratory pro-
cedures provide diagnostic information that may not even have been suspected from
the initial signs and symptoms. Proper collection and handling of specimens for
safety and for preserving the integrity of the samples are provided in this book. Case
studies are provided and end-of-chapter tests are available for the learner and the
practicing professional who wishes to refresh his or her technical expertise.
It should be understood by laboratory and other medical professionals that labo-
ratory testing of body fluids is perhaps the single most important entity in the iden-
tification or confirmation of a specific disease and is certainly the most widely used
method for these purposes. The menu of tests offered and the research leading to
more tests and more refined procedures will undoubtedly grow over the years.
Therefore, it is the author’s wish that this book will meet the needs of the laboratory
student and the laboratory professional for the foreseeable future.
Introduction to the Study of Body Fluids
1
Objective(s)
Discuss the beginnings of laboratory medicine through the examination of urine,
chiefly
Demonstrate an understanding of the importance of performing examinations of
body fluids
Describe the beginning studies of urine and how they evolved into a more compre-
hensive evaluation of urine and other body fluids
List body fluids other than blood that are examined to determine disease states of
the body
Provide the three types of evaluations of urine as found in a modern laboratory
Discuss the correlation of laboratory tests and the clinical condition of the patient
Initially, blood and urine were the only body fluids with which ancient medics were
acquainted. The early practitioners of the healing science referred to “humors” and
“vapors” when discussing clinical findings related to illness. The term “humors” has
become more widely known as fluids or bodies, such as that of the vitreous humor
of the eyeball that is now known as the vitreous body. The other major fluids of the
body were not well known in early practice of medicine, but they along with urine
are ultrafiltrates of the liquid portion of the blood called plasma, except for cerebro-
spinal fluid (CSF). Arguments occur over the site and mechanism of cerebrospinal
production. The fluid contains similar chemical constituents as that of blood plasma,
but at lower levels that found in the plasma, chiefly glucose and protein fractions.
Studies in some instances have shown that the fluid is mostly formed by active
secretion and transport by the choroid plexuses of the brain, with production of the
cerebrospinal occurring in the cerebral ventricles of the brain. Urine is comprised of
approximately 95% water, while some additional body fluids are more concentrated
and contain protein along with other elements not found in detectable amounts in
normal urine samples.
The earliest practice of examining the urine of a patient was called uroscopy, a
practice that dates to ancient Egypt, Babylon, and India. Around the twelfth century,
with the development of glass in Egypt and perhaps in Germany, the practice
evolved into a procedure in which the specimen could more easily be visualized.
The uroscopy, a procedure that was performed during the Middle Ages, utilized a
transparent glass flask or a cup-shaped container called a matula (Fig. 1.1).
Physicians would then visually examine the urine as illuminated by sunlight. The
urine sample could be compared with a chart to distinguish levels of color, clarity,
foam, and sediments. The odor of the urine was also thought to provide important
diagnostic information, and in some cases probably did where aromatic materials
such as acetone were present. In addition, the growth and metabolic processes of
certain bacteria also imparts a characteristic odor to the urine in which microorgan-
isms are found. Even though many research efforts were halted during the Middle
Ages when many diseases were attributed to demonology, the examination of urine
seemed to persist to some extent during this span of history.
Hippocrates was perhaps the first to postulate that diseases are a natural result of
a malfunction of the body and was not caused by the anger of gods or by demons
that possessed the victim of a disease. This belief again reared its ugly head during
the early Middle Ages and almost halted any medical or other scientific advances.
Hippocrates appears to be the first to venture a theory that correlates the intake of
fluids with the output of urine, a basis of modern fluid balance that plays an impor-
tant role in medical practice today. The weakness in this early use of urine as a
diagnostic tool discounted evidence such as clinical signs and focused primarily on
the appearance and physical factors associated with the specimen. But other body
fluids except for “vapors and humors” were paid scant attention at that time in
human history.
1.1 History of the Analysis of Body Fluids 3
In early medical history, clinical laboratory tests were rudimentary and often
consisted merely of a macroscopic opinion as to the quality of the urine. But it was
not until 1694 when an actual chemical procedure was performed on urine, when
Frederik Dekkers found albumin, a fractional component of protein, in urine by
boiling the specimen and obtaining a cloudy color at certain temperature levels.
Then almost two centuries ago, some rudimentary tests were developed for certain
qualitative tests for metabolic products found in the urine of diseased individuals. A
solution which is actually a combination of two solutions that are called Fehling A
and B, provided a test for glucose found in the urine and the blood plasma, which
prior to this time was supposedly measured by an attraction of ants to urine contain-
ing sugar, or by the taste of the urine that indicated an abnormal presence of glu-
cose. Richard Bright in the early 1800s developed the premise that edema and
protein are interrelated in certain conditions where the kidney is abnormally spilling
protein into the urine.
Concurrently with some of the other developments related to the study of body
fluids, Anton van Leeuwenhoek (October 24, 1632–August 30, 1723), a Dutch
tradesman and scientist, unwittingly contributed to the modern examination of urine
sediment as he is credited with the improvement of an older version of the micro-
scope. His work in the observation of microorganisms and one-celled organisms
undoubtedly were the forerunners of the modern microscopic examination of urine.
The second component of a complete analysis of body fluids, following a macro-
scopic or visual examination of the urine or body fluid, is the chemical analysis of
the specimen, which originally required a work-intensive individual testing for each
of the basic chemical components found in a complete urinalysis. These chemicals
are also important in varying levels in body fluids other than urine. A more efficient
advancement toward the modern analysis of urine occurred in the 1950’s with the
development of chemically impregnated strips, which gave a quick chemical analy-
sis without the cumbersome individual testing required for each of the constituents
being tested for. This was accomplished by chemically-treated pads that react in the
presence of specific constituents of the urine and provide a semi-quantitative evalu-
ation of certain chemical components such as glucose and protein, as well as other
analyses.
Today, the modern procedures performed in a urine analysis, or urinalysis, con-
sists of a scientific process that includes a series of macroscopic, microscopic, and
chemical tests, while uroscopy only involved a visual examination of the urine sam-
ple. But uroscopy was the forerunner of modern examinations of body fluids.
Testing these fluids is helpful as a tool for providing preliminary evidence for many
illnesses, particularly those that affect the urinary system such as infection and hem-
orrhage beginning as much as 2000 years or more ago. In modern medicine of
today, three areas of examination are employed for the complete and systematic
evaluation of urine as well as for various other body fluids except for whole blood.
The initial or macroscopic examination of body fluids, including urine, refers to
the physical appearance of the fluid. This preliminary survey is followed by a sec-
ond step, that of evaluating the urine sample for the presence or absence of
4 1 Introduction to the Study of Body Fluids
Urine samples are most likely studied more frequently than any other body fluid,
even that of blood, as a routine evaluation and will be discussed more at length than
the other body fluids. A urine sample provides clues for diagnosing disease for all
the organs of the body, while other body fluids generally relates to only one organ
or one system of the body. As a simplistic view of urine, it is used as the vehicle for
ridding the body of waste products resulting from metabolic processes of the body
of humans and other mammals. Since urine is only a waste product, it would appear
that urine is insignificant and serves little or no purpose. But it is now considered a
vital specimen for providing diagnostic screening data for functions not only of the
kidney but other organs and provides clues for many disease states of the body. It
will be shown that a urine sample and its physical appearance and its chemical and
solid constituents often yield a great deal of clinical data relative to the health of an
individual.
Since a urine sample is the most commonly analyzed body fluid and appears to
have been the first body fluid used for medical diagnosis, it most likely preceded any
study of blood as a body fluid. The processes relevant to the analyzing of urine
samples will be treated first and separately from the other major fluids of the body.
Although early in the beginning of laboratory medicine, when sophisticated testing
procedures were not available, certain diagnostic bits of information which are still
used today were available through direct visualization. Observation of a urine sam-
ple’s color and clarity, along with its smell and sometimes taste has been around for
perhaps more than 2000 years. Some medical conditions incidentally discovered
through using uroscopy (Table 1.1) as shown.
1.4 Clinical Relevance of Body Fluid Examinations 5
It is important to correlate the clinical findings that include laboratory testing versus
signs (the appearance of the patient) and symptoms (subjective complaints or
remarks about how the patient feels). Since symptoms presented by a patient may
be misleading, objective methods such as laboratory testing which excludes any
psychological aspects of a disease state must be employed. The urine of a patient is
not only tested for metabolic diseases and for infectious conditions of the urinary
tract, but is useful in tests of toxicology, therapeutic drugs and drugs of abuse and
for appropriate physiological processes in which the kidneys are involved. Testing
of urine is typically used as a convenient, cost-effective and reliable method for
accomplishing the following:
Since urine is the most commonly tested body fluid and reflects many clinical dis-
ease conditions, the urinalysis will be the most practical means for screening of both
individual and of large populations of patients prior to utilizing perhaps the use of
blood tests, which number in the thousands. Two unique characteristics of a urine
specimen enable rapid screening of all patients:
1. Urine is a readily available and easily collected specimen but must be collected
properly, including timed or random specimens. Tests have now been simplified
to the extent that they are suitable for screening large numbers of individuals.
2. Urinary changes that may occur will contain information about many of the
body’s major metabolic functions. This information can be obtained by simple
and rapid laboratory tests. These characteristics fit well with the current trends
Exploring the Variety of Random
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(Larger)
CHRISTKINDCHEN.
(Larger)
LITTLE JACK HORNER.
(Larger)
CHRISTMAS FLIRTATION.
(Larger)
THE DOMESTIC EXPRESS.
Old Bachelor: “How glad I am that I don’t have to
cart round endless bundles for greedy brats during
the holidays.”
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OLD MOTHER GOOSE MELODIES.
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NURSERY TILES.—“There he is.”
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THE CRUSTY OLD BACHELOR WHO IS
BOUND TO HAVE SOMETHING IN HIS
STOCKING.
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A CHRISTMAS STORY.—“I am Cinderella, and you are the wicked
sisters.”
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MERRY CHRISTMAS.
(Larger)
MERRY OLD SANTA CLAUS.
(Larger)
SANTA CLAUS’S REBUKE.
“I’ll never do it again.”
(DEAR SANTA CLAUS
TOMMY HAS BEEN SUCH
A NAUGHTY BOY THAT
WE THINK YOU HAD
BETTER NOT BRING
HIM ANY·THING
THIS CHRISTMAS
PAPA AND MAMA.)
(Larger)
THE CHRIST CHILD.
(PEACE ON EARTH
AND GOOD WILL
TOWARD MEN)
(Larger)
THE DEAR LITTLE BOY THAT THOUGHT CHRISTMAS CAME OFTENER.
(Christmas
COMES BUT
ONCE
A YEAR.
THEREFORE, LET’S BE
MERRY.)
(Larger)
MOVING DAY.
(Larger)
“For he’s a jolly good fellow, so say we all of us.”
(MERRY CHRISTMAS
WORDS & MUSIC BY SANTA CLAUS.
( U S
WELCOME
SANTA CLAUS)
(Larger)
CHRISTMAS SUPPLEMENT TO Harper’s Weekly
(BLUE BEARD
RED RIDING HOOD
TOM THUMB
SANTA
CLAUS
PUSS IN BOOTS.
PEACE ON EARTH AND GOOD WILL TOWARD MEN!
CINDERELLA.)
(Larger)
A MERRY CHRISTMAS.
(Larger)
“Merry Christmas to all, and to all a good-night.”
(Larger)
“Wishing you a Merry Christmas and a Happy New Year.”
(Larger)
’TWAS THE NIGHT AFTER CHRISTMAS.
Transcriber’s Notes
Punctuation, hyphenation, and spelling were made
consistent when a predominant preference was found in the
original book; otherwise they were not changed.
Simple typographical errors were corrected; unbalanced
quotation marks were remedied when the change was
obvious, and otherwise left unbalanced.
This book does not have page numbers.
Transcriber added sequence numbers to the entries in the
Table of Contents.
When illustrations did not have captions, Transcriber
added them by using part of the corresponding entry in the
Table of Contents, or text within the illustrations themselves.
Transcriber added words and phrases that were within
some of the illustrations to their captions, and enclosed them
in parentheses to indicate they were not parts of the original
captions.
The first illustration is the cover.
The original book was autographed. A copy of that is
included in this eBook as the second illustration.
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