connection. In only a small proportion of his cases where an excess of
phosphates was noted was the quantity of the urine also increased, and
in these the symptoms seem as appropriate to the polyuria as to the
phosphaturia. It is worthy of note, however, that one series of his
cases is connected with disease of the nervous system; another
alternates or coexists, as does also diabetes insipidus, with diabetes
mellitus; and his fourth class closely resembles, with the exception of
the increase of phosphates (if this can be looked upon, after what has
been said above of the increase of solid urinary constituents, as an
exception at all), the affection last named--_i.e._ diabetes mellitus.
In fact, many of these cases of Teissier read like what would have
evidently been called, without a quantitative analysis, simply polyuria
or diabetes insipidus.
[Footnote 9: _Du Diabète phosphatique_, par L. S. Teissier, Paris,
1877.]
According to Teissier, the presence of an excess of phosphates in the
blood is sufficient to determine a polyuria. It is possible that in
many cases where a polyuria accompanies phthisis, as noted in many of
his cases, the symptom may be really due to actual organic (perhaps
amyloid) disease of the kidney.
The COURSE AND TERMINATION naturally vary greatly with its etiology and
the diseases with which it is associated. In some cases where nutrition
is but little affected, and no attempt is made to check the natural
appetite for water, the disease may go on for years with no essential
change or impairment of the general health, as in the remarkable one
quoted by Dickenson, where a French infant had at the age of three
impoverished her family by her demand for water, which seems to have
been an expensive luxury, and at a later period kept her husband--to
whom, however, she bore eleven children--in a constant state of
impecuniosity by the same depraved appetite. At the age of forty she
drank in the presence of a scientific commission within ten hours
fourteen quarts of water, of which she returned through her kidneys ten
to their astonished gaze.
{31} When polyuria is merely a symptom of cerebral inflammation, of
central tumor, of syphilis, or of phthisis, the course and prognosis
will of course be that of the primary disease. It occasionally comes on
during pregnancy, and in one such case it is stated to have ceased two
days after delivery, and in another the secretion, uninfluenced by
parturition, resumed its normal quantity when lactation was fully
established.
It is very rare, if indeed it ever happens, for life to be terminated
by diabetes insipidus unaccompanied by any other disease, although from
its association with many and severe affections, both of the nervous
system and of the kidneys, it must of course not unfrequently happen
that a patient dies in, though not on account of, the polyuric state.
It is strange to observe, however, as has been often before remarked,
how thin a shell of renal structure will suffice to carry on not only
the usual, but an excessive, flow of water.
The ORIGIN of diabetes insipidus has been found in several conditions.
Greater disposition toward it exists in early life, although it is by
no means confined to youth. After middle life polyuria is likely to
awaken the suspicion either of chronic interstitial nephritis or of
prostatic disease, or other affection of the urinary passages setting
up a sympathetic irritation of the kidney. It has been found to
originate during convalescence from acute diseases, with perhaps
preference for meningitis. Syphilis has its share of cases, as in most
other organic nervous diseases. Shocks of various kinds, including
fright, sudden or prolonged immersion in cold water, the rapid
ingestion of large quantities either of water or of alcoholic fluids,
are undoubted potent factors. In this respect, again, we may see the
resemblance between diabetes without sugar and true or saccharine
diabetes. It is favored by the hysterical diathesis. A very interesting
case of severe hysteria with hemianæsthesia and hemiplegia and other
marked symptoms varied for a time between almost complete anuria and
the most profuse discharge of over two hundred ounces per diem.
A most interesting group of cases has been recorded by Weil,[10] where
out of a family of 91, 28 were polyuric. The head of the family, a
polyuric, lived to the age of eighty-three, while his descendants were
robust, many of them attaining a good old age. There were no anomalies
of the circulation, and the persons affected were not alcoholics. Their
only complaint was of a troublesome thirst, and they declined
treatment.
[Footnote 10: _Cbl. für die Med. Wiss._, 1884, p. 263, from _Virch.
Arch._, xcv.]
The PATHOLOGY of diabetes insipidus, so far as is positively known, may
be gathered from the previous account of its etiology and symptoms. It
is evidently of nervous origin in the great majority if not all cases.
It is often connected with distinct lesions of the nervous system, and
attended with other nervous symptoms. In some cases it occurs in
connection with a well-marked hysterical diathesis. The copious flow of
pale urine as a sequel to the hysterical paroxysm is well known, and
the same thing often attends a severe nervous headache in either sex.
It is probable that the polyuria attending lesions of the urinary
passages is a reflex nervous phenomenon, since it may be present when
there is no suspicion of organic renal disease.
Guyon[11] states that surgical polyuria occurs under three {32}
conditions--painful excitation of the sensibility of the deeper portion
of the urethra or the vesical mucous membrane; repeated attempts to
urinate during the night; retention of urine more or less complete, but
especially when there is distension of the bladder. Of the first cause
he gives an instance in the case of a young man who had a polyuria
whenever a bougie was passed beyond a urethral stricture.
[Footnote 11: _Leçons cliniques sur les Maladies des Voies urinaires_,
Paris, 1881.]
Where, however, polyuria, especially chronic, is due to habitual
over-distension, it is in the highest degree probable that it is at
least partly due to structural alteration of the kidney. The well-known
experiment of Bernard, by which an increased flow of urine was induced
by a puncture of the floor of the fourth ventricle, and those of
Eckhard on section of the splanchnic nerves, show how it is possible
for nervous affections to influence the secretion of urine, though the
path or paths of the influence are by no means completely made out.
One of the most noticeable points in the pathology of the more
excessive cases of polyuria is the disproportion which often exists
between the amount of fluid ingested and the amount discharged, the
latter often exceeding the former several times. The source of the
excess of water has not been satisfactorily determined, but it is
evident from a careful experiment of Watson, repeated by Dickenson,
that the body has under some circumstances the power of appropriating
water from the atmosphere instead of discharging aqueous vapor through
the lungs and skin as usual. In the experiments referred to persons
affected with extreme polyuria were weighed immediately after passing
water, and again after as long an interval as they were able to
restrain their thirst, of course being also without food and under
observation, when it was found that the weight had been increased by a
number of ounces. In Dickenson's case, weighing thirty pounds more or
less, where the amount of urine excreted daily was from seven to nine
liters, the gain in weight at several observations was as follows: in
three hours, 15½ oz.; in five hours twenty minutes, 19¾ oz.; in three
and a half hours, 3¾ oz.
The DIAGNOSIS of this affection rests, in the first place, upon the
determination of a permanent increase in the quantity of urine passed
considerably above the normal, and, as has been already remarked, may
require a measurement of the daily amount--a procedure which it is well
to make a matter of routine in any cases where urinary trouble may be
present. The increase being found, if it be very great it will only
remain to determine whether sugar be present, which will be indicated
by the specific gravity and the appropriate chemical tests. Traces of
sugar are sometimes found in cases of polyuria which do not present the
characteristics of saccharine diabetes, and can hardly be considered to
materially affect the character of the disease.
A specific gravity decidedly above normal, with an excessive quantity
of urine, is not likely to belong to anything but diabetes mellitus,
though the chemical tests should never be neglected. If, however, the
polyuria be only moderate, it becomes necessary to exclude surgical
affections of the urinary passages, especially an enlarged prostate,
often attended with retention and distended bladder. Pyelitis and
hydro-nephrosis may also give rise to the same condition of
over-activity of the kidneys. The appropriate surgical examinations
with the sound may be necessary, but the presence of pus, bacteria, and
the epithelium of the urinary passages {33} in the surgical urine, as
well as its frequent alkalinity, may direct a very strong suspicion
before the sound is used. The age of the patient also will be of
considerable weight in this connection.
A point of real difficulty of diagnosis, and great importance for
treatment and prognosis, is the distinction between simple polyuria not
excessive, but attended by constitutional symptoms, such as impaired
nutrition, dyspepsia, and severe headache, from chronic interstitial
nephritis, which often makes its appearance with similar symptoms.
Mistakes between these two affections have undoubtedly occurred, and
can in many cases hardly be avoided except by reserving the diagnosis
for a time.
The similarity is rendered still more deceptive by the undoubted
occurrence of a trace of albumen or a hyaline cast or two in cases of
nervous disturbance, without justifying a diagnosis of progressive
renal disease. High arterial tension also is likely to be found in both
conditions. Nothing but repeated and careful examinations of the urine
and of the circulation, especially at times when the nervous symptoms
are less marked, and often a considerable amount of time, can fix the
diagnosis.
Hypertrophy of the heart, and even slight dropsy, will undoubtedly be
extremely decisive symptoms, but are not likely to occur until after a
time when the doubt no longer exists. In other cases it may be highly
important to carefully exclude organic cerebral disease before making a
diagnosis of simple polyuria.
It is hardly appropriate to speak of a diagnosis from azoturia or
phosphaturia, since these conditions are extremely likely to exist
coincidently with typical polyuria and to make a part of the same
disease. It is of much importance, however, to ascertain their presence
with reference to the probable effect of the disease on the nutrition.
In regard to the TREATMENT, it may be remarked, to begin with, that
restriction of water, although naturally diminishing somewhat the
discharge of urine, does not cure the disease, but, on the contrary, in
many cases augments not only the discomfort of the patient, but tends
to the dryness of the skin, dyspeptic and nervous disturbances, and
emaciation. Patients may recover flesh, strength, and spirits on being
allowed to drink ad libitum, even although the inconvenience of
excessive urination be thereby somewhat increased. Sufficient food and
drink should therefore be allowed, although a patient may be ordered to
observe such moderation as will not put his powers of endurance to too
severe a test.
Of the drugs proposed, nearly all have offered some prospect of
success, and have been accordingly reckoned almost specifics. Opium has
in some cases been found as useful in these cases as in diabetes
mellitus, and probably, as in that disease, by diminishing the
sensitiveness of the nervous system. Valerian and valerianate of zinc,
recommended by Trousseau and apparently successful in his hands, have
reckoned both failures and successes in the hands of others. Nitric
acid, in the dose of from 1 to 5 drachms per diem of the dilute in a
large quantity of water, is said to have been highly efficacious in one
series of cases.[12] It is given until aching of the jaws and teeth,
with some gingivitis, denoting its constitutional action, is produced.
It was more successful than any other drug in Marion's case, although
the specific symptoms were not produced, the patient being now in good
health or free from {34} her trouble. Atropia from its general action
in diminishing secretion has been tried, and with occasional alleged
success, but with many more failures. Pilocarpine from its action on
the skin might be of value in those cases where the skin is very dry,
but has no very general applicability.
[Footnote 12: Kennedy, _Practitioner_, vol. xx. p. 95.]
The drug most frequently employed, and which can claim a larger
proportion of successes than any other, is ergot in full doses, half a
drachm or a drachm (2 to 4 cubic centimeters of the fluid extract)
several times per diem. Its method of action is undoubtedly in the
contracting effect which it exercises on the renal arterioles. In many
cases it has decidedly diminished the amount of urine, and in some a
permanent cure seems to have resulted.
In estimating the value of drugs in certain cases of this affection its
not infrequent neurotic origin should be borne in mind, as well as the
very capricious effect of supposed remedies in the hysterical
diathesis. Unfortunately, many cases remain rebellious to all drugs,
and can only be rendered as little uncomfortable as possible.
What has been said of treatment applies only to the well-marked cases
of diabetes insipidus. Polyuria, as a symptom of other diseases or of
surgical affections, is hardly likely to call for treatment other than
that of the disease upon which it depends.
Albuminuria.
Albuminuria signifies a condition in which albumen appears in the
urine, and has by some writers been made of equal significance with
nephritis or Bright's disease. It is hardly necessary to say that this
coincidence is far from being an exact one, and that the symptom may
exist without Bright's disease, and also Bright's disease without the
symptom. For our present purposes albuminuria will be taken to mean
those conditions in which albumen may be found in the urine without the
existence of decided diffuse nephritis. As a symptom, and a highly
important one, of Bright's disease it will be considered elsewhere.
Albumen is secreted in the kidneys chiefly in the Malpighian capsules,
where, if at all abundant, it may be easily demonstrated after death by
hardening the kidneys by boiling. This coagulates the albumen in situ,
where it may be shown by sections prepared in the usual method. It has
been supposed that albumen is normally secreted in the capsules of the
healthy kidney, and afterward absorbed by the epithelium lower down;
but this view can easily be shown to be erroneous by subjecting a
kidney which has not secreted albuminous urine to the process just
described, which shows no coagulated albumen in the place where it
ought to be most abundant.
The albumen found in the urine is chiefly that which forms the most
important portion of the blood-serum, although other albuminoid bodies
have from time to time made their appearance and have some diagnostic
importance. Semmola[13] states that the albumen appearing in the urine
in true Bright's disease differs from that found with the cardiac or
amyloid kidney. The distinction can, according to him, be shown in {35}
the appearance of the precipitate to a practised observer, and also by
a more rapid diffusibility through animal membranes. He admits,
however, that he has in vain sought for any distinct and clear chemical
test by which the difference can be recognized.
[Footnote 13: _Archives de Physiologie_, 2d Serie, tome ix., and 3d
Serie, tome iv.]
Fibrin may occur in inflammatory conditions in the form of coagulated
masses, and hence cannot affect the question of the presence of
albumen. Casein has not been detected with certainty. Various
albuminoid bodies, called albuminose, paralbumen, metalbumen, and
serum-globulin, are occasionally met with in renal disease, and may
give rise to some confusion during an analysis. They are at present,
however, more suitable for chemical than for clinical study.
A variety of albumen is said to occur in osteomalacia which is not
coagulated by heat alone nor by heat and nitric acid. This has been
called Bence Jones's albumen, but has been seen by others. Peptone has
been found in urine, but usually in such specimens as have been or
which afterward become albuminous. Its exact signification when alone
cannot be more exactly stated, as it has appeared in a variety of
diseases, though not in perfect health.
Finally, a protein body, a ferment called nephrozymase, may be thrown
down from every urine by an excess of alcohol.
Hæmoglobin gives a dark-red color to the urine, which on boiling forms
a brown coagulum floating on the surface.
Hæmoglobinuria may be produced in animals by the intravenous injection
of large quantities of water, causing a dissolution of the corpuscles,
but the degree of hydræmia necessary to produce this condition is much
in excess of any met with in diseases of the human being.
Human hæmoglobinuria may be the result of various pathological
conditions, among which may be mentioned some infectious diseases,
jaundice, burns, and the effects of many poisons, as well as the
transfusion of sheep's blood.
Intermittent hæmoglobinuria, which is attended with fever, is usually
the result of cold acting upon predisposed persons. The color of the
urine and of the coagulum, together with the absence of red corpuscles
under the microscope, will distinguish urine of this character from
others which are also coagulable by heat.
Several methods are in use for the detection of albumen. Of these,
boiling is perhaps the oldest and most generally employed, and if
conducted with due care is a very delicate and useful test. The urine
to be tested should be clear and slightly acid, when on boiling the
albumen, if present, will be precipitated in whitish flocculi, more or
less abundant according to the amount, or, if the quantity is very
small, as a turbidity. The flocculi soon settle to the bottom of the
tube when it cools, and the thickness of the deposit formed gives an
approximation to a quantitative estimate. It is to the proportionate
thickness of this deposit that the terms 30 or 50 per cent. of albumen
are commonly but incorrectly applied. If the quantity is very small, it
may not be distinctly perceptible until after cooling.
If alkaline or very slightly acid urine is boiled, a deposit of
phosphates will be thrown down which closely resembles that from
albumen, while, on the other hand, the albumen remains undissolved
unless in large amount. These deposits of phosphates differ a little in
appearance from {36} an albuminous one, but in order to be accurate
acetic or nitric acid should be added, drop by drop, to the hot urine,
when the phosphates will be redissolved and the albumen, if present,
precipitated. It is better, however, to add the acid cautiously to the
point of slight acidity before boiling. A recent work[14] gives the
following directions for this reaction, which is then "absolutely
conclusive and surpassed in delicacy by no other:" "The urine is first
made distinctly acid with some drops of acetic acid, and then about
one-sixth of its volume of a concentrated solution of chloride of
sodium or sulphate of sodium or magnesium added. If the urine contains
albumen, a precipitate of coarser or finer flakes appears on boiling."
This reaction may be used as a quantitative test by diluting and
acidifying, if necessary, a known quantity of urine, washing the
precipitate on a weighed filter, drying, and weighing the whole.
[Footnote 14: _Die Lehre vom Harn_, Salkowski und Leube.]
An exceedingly delicate and convenient test is that by nitric acid. The
acid is placed in the bottom of a conical wine-glass, and the urine,
filtered if necessary, allowed to flow on top of it from a pipette, so
as to disturb the plane of junction of the two fluids as little as
possible, and leave a distinct line of demarcation. At this plane of
union, if albumen be present, will be formed an opaque white line
varying in thickness according to the amount of albumen, so that after
some practice and with care an approximate estimate of the percentage
may be made. A deposit of urates may sometimes be formed a little above
the plane of union, but it may be distinguished by its position, by its
less distinct limitation on the upper surface, and also by its
disappearance on warming. In a very concentrated urine and in cold
weather this error may be conveniently avoided by previous warming of
the urine and of the reagent. The same remark applies to the brine
test.
A crystalline precipitate of nitrate of urea may give rise to error if
the urine be very concentrated or the experiment conducted in the cold.
This may be distinguished by its disappearance on warming or by the
microscope. The action of the nitric acid on the coloring matter of the
urine, forming a dark band at the point of junction, may obscure the
reaction, but with care will not give rise to mistakes.
Another test recently introduced, which presents some advantages over
the nitric acid, and is certainly quite as delicate, consists in a
saturated solution of common salt in water acidulated with about 5 per
cent. of the dilute hydrochloric acid of the _Pharmacopoeia_. This
solution should be used exactly in the manner described for nitric
acid. There is no change of color at the line of junction, and no
precipitate takes place there except albumen or peptone, or resins when
they have been administered. The opaque line of precipitate may, if the
amount of albumen present be small, require a short time to form, so
that in cases of doubt it is well to allow the test-glass to stand for
a few minutes. It will, however, show very distinctly in any cases in
which nitric acid shows any precipitate. The line does not, however,
increase in thickness and density in proportion to the amount of
albumen so exactly as that produced by nitric acid, so that the brine
test is not so useful for approximately quantitative use as the nitric
acid, although fully as delicate. If it be desired to distinguish
peptone from albumen, it may be done by a comparison of this test {37}
with the nitric acid, which does not throw down peptone. If a deposit
occur, which may consist of resin, the addition of more urine will
dissolve it if resin, while albumen will not be affected.
Picric acid is a delicate and often a convenient test. The dry acid may
be dissolved in the urine, or a saturated solution used into which the
urine may be slowly dropped, each drop making a slight whitish cloud as
it slowly falls through the yellow solution.
The iodo-hydrargyrate of potassium is perhaps the most delicate test of
all: Potassii iodidi, 3.32 gm.; Hydrarg. bichlor., 1.35 gm.; Acidi
acetici, 20 c.c.; Aq. destill. q. s. ut fiat 100 c.c.--Tauret's test.
It may be used in the same way as the nitric acid or brine, or simply
intermixed. Its only disadvantage is that it throws down alkaloids, but
as this will not happen unless the alkaloid be taken in large
quantity--as might happen, for instance, in the case of quinine--the
chances of error from this source are not very great if this
peculiarity be borne in mind.
Ferrocyanide of potassium in an acid solution has recently been
proposed as a convenient test. It may be made up into pellets with
citric acid or used in the same combination in the form of papers.
The phenic-acid test is prepared as follows:
Ac. phenic. glacial. (95 per cent.), drachm ij;
Ac. acet. puri., drachm vij;
M. Add liq. potassæ, ounce ij-drachm vj.
Millard.