it.
Tungstate of sodium is another recent addition to the list, which it is
evident is already long enough for practical purposes.
Several of the tests mentioned have recently been prepared in the form
of papers saturated with known quantities of the reagent and dried.
They may be carried in the pocket-book and applied at the bedside, if
desired, in a test-tube small enough to be very conveniently carried in
the vest pocket. The iodo-hydrargyrate is perhaps the most useful. It
is the most delicate, and a plan has been proposed for making with it a
quantitative estimate of considerable accuracy by means of a standard
solution or piece of gray glass adjusted by such a solution, with which
the precipitate produced can be compared as to its opacity.
Exact quantitative examinations for albumen may be made by several
processes, but that by boiling, if carried out with the precautions
described in works on chemistry, is as accurate as any, and probably
the best adapted to the needs of the practitioner if he should wish for
such results.
For clinical purposes, however, it will rarely if ever be found useful
to determine the amount of albumen more accurately than can be done by
the various approximations mentioned above.
When even the smallest trace of albumen is discoverable by any of these
methods, the question of the integrity of the kidneys at once arises--a
question which a few years ago would have been considered as settled in
the unfavorable sense by the same occurrence.
It is necessary to distinguish, first of all, between an essential and
an accidental albuminuria, the first referring to that condition where
the albumen is secreted with the urine and forms an essential part of
it, and {38} the other to the accidental admixture from the presence of
pus or blood, which may have made its appearance at any point below the
secreting tubes. When hemorrhage takes place from the kidney, albumen
is of course present in the urine, but its signification under these
circumstances is entirely different from that which it bears when
unaccompanied by the corpuscular elements of the blood.
No means at present exist for determining whether a small amount of
albumen present in the urine is more than enough to be accounted for by
the pus or blood known to exist by the presence of its corpuscular
elements or of its coloring matter. An approximate estimate may be made
by one familiar with such examinations, but no rule can yet be laid
down. Such a rule might be approximately established by a succession of
counts with the hæmocytometer of the corpuscles found in albuminous
urine of known percentage, or estimates of hæmoglobin by color tests.
The exact conditions of the kidney or of the blood which may cause the
appearance in the urine of albumen without blood or pus--that is, of
true albuminuria--have been the subject of much experiment and
argument, which it would be impossible to reproduce, even in outline,
within the limits of this article; and this is the less to be regretted
since they have as yet led to no practical or generally accepted
conclusion. A few of the more important facts bearing on the question
may, however, be stated here.
Albumen other than serum-albumen, when introduced into the circulation
either by injection into the veins subcutaneously, or if in very large
quantity by the mouth, is rapidly excreted by the kidneys. This albumen
also, if collected from the urine of the first animal and injected into
the vein of a second, again comes through the kidneys. The albumen,
however, which is obtained from the urine of an ordinary case of
albuminuria--that is, serum-albumen--does not behave in this way, but
is not excreted through healthy kidneys. These facts seem to show that
the appearance of albumen in the urine in ordinary cases of renal
disease is not to be attributed to any change in its quality
approximating it to egg-albumen, for instance, but is due to the
condition of the kidneys.
Disturbances of the renal circulation, especially those giving rise to
venous stasis, are very likely to cause albuminuria; a temporary
ligature of the renal vein causes albumen to appear in the urine after
its removal, and ligature of the ureter has the same effect.
The albuminuria succeeding the collapse of Asiatic cholera or yellow
fever seems to have a somewhat similar origin, being the result of
re-establishment of the circulation after extreme anæmia of the kidney.
Clinical facts in general seem to point to simple disturbance of the
circulation and to alterations in the kidneys themselves as the usual
causes of albuminuria, though in many cases the lesion seems to be a
slight and temporary one.
Some other conditions under which such disturbances and alterations may
arise, exclusive of Bright's disease, are the following:
Munn[15] found albumen in small quantities in 11 per cent. of cases
presenting themselves for life insurance, supposing themselves healthy
and having no lesions of heart or lungs. It is not stated whether casts
were found in these cases or not, and their value as representing
healthy {39} persons cannot, it is obvious, be correctly estimated
until some time has elapsed. It is well known that renal lesions may be
exceedingly slow in their progress, and it is by no means improbable
that a part of these cases may have been really in the early stages of
a chronic form of Bright's disease. Albumen has been found in the urine
of boys and adolescents, as well as in that of healthy soldiers, tested
immediately after rising: in most of these cases the amount was
extremely small. Certain conditions, moreover, may greatly increase the
proportion of cases in these same classes in which albumen is present.
Thus, fatiguing exercise will bring it on in some persons, and the
urine of a body of soldiers if examined late in the day after severe
drill shows a much larger proportion of albuminurics than if examined
after rising. The urine of the pedestrian Weston is said to have
contained not only albumen, but casts. It is certainly not true that
fatiguing exercise will cause albuminuria in everybody, and it is not
claimed, even by those who report these and similar cases, that they
prove albumen to be a normal constituent. Some of the cases are
distinctly described as delicate without being actually ill. Cases have
been reported where cold bathing has been followed by temporary
albuminuria. Here it is in the highest degree probable that a
disturbance in the circulation is produced by contraction of the
cutaneous arterioles; and it is possible that we may find in this
increased sensitiveness of certain persons an explanation of the
occurrence of acute dropsy as a sequel to scarlatina or as the result
of exposure in only a small proportion of the cases where the exposure
takes place. It is hardly necessary to admit, on the basis of these
observations, that albumen is a constituent of healthy urine, although
this may be shown at some future day by still more delicate tests, but
simply that the renal circulation may in certain sensitive persons be
sufficiently influenced by slight and transient causes to permit
albumen to pass into the urine. It is the almost unanimous conclusion
of practical writers, taking fully into the account these
recently-ascertained facts of albuminuria in alleged health, that the
presence of albumen in the urine in sufficient quantity to be detected
by any of the ordinary tests is a decidedly serious symptom.
[Footnote 15: _New York Medical Record_, xv. 297.]
The influence of many well-recognized pathological states in bringing
about venous stasis, and that delay of the blood in the renal--and more
especially the Malpighian--vessels which seems the most essential
factor in the secretion of albumen, is well known, and its recognition
is of much importance in diagnosis and prognosis, since the unfavorable
signification of albuminuria in certain cases is liable to be
overrated, and a diagnosis of chronic renal disease made to depend upon
symptoms which really belong to some other affection. How far
alteration in the capillaries and epithelium is in each case concerned
in the production of albuminuria it is often impossible to say, since
any alteration in these elements which can be observed after death is
almost certain to be complicated with lesions which can disturb the
local circulation.
Cardiac obstructive disease is very likely to be accompanied by
albuminuria, and the state of the kidneys by which this condition is
brought about is undoubtedly venous congestion. The urine in a case of
this kind is usually scanty, of high specific gravity, high colored,
often with a deposit of urates, while the albumen appears in small
quantity. A few {40} hyaline casts are not infrequently seen, and do
not materially increase the gravity of the prognosis so far as renal
disease is concerned. The kidney which furnishes this urine is usually
a little harder and a little denser than normal, but with a nearly
normal microscopic structure, exhibiting but little more than
capillaries well filled with blood, and in the interior of some of the
tubes casts similar to those found in the urine during life.
Doubt may occasionally arise as to the diagnosis between a congested
kidney consequent upon valvular disease of the heart and an
interstitial nephritis with hypertrophy of the heart. In the latter
case, however, the urine, although containing albumen, is usually much
more copious and of low specific gravity. Diminished power of the heart
without valvular lesion may have as a consequence albuminuria which
disappears if the heart recovers its vigor.
In many of the cases in which albumen appears in the urine temporarily
it is not easy to say whether an actual nephritis may not be present,
though not sufficiently severe to give rise to other symptoms.
In almost any febrile disease of sufficient intensity albumen is often
found, and when such a case terminates fatally without renal symptoms,
the condition of the kidneys, consisting in more or less granular
degeneration of the epithelium, is often spoken of as parenchymatous
nephritis. If it is correctly called so, it is certainly very different
from the idiopathic form, whether acute or chronic, since it is very
rare for typhoid fever, for example, either to present the symptoms of
acute nephritis during life or to terminate in chronic Bright's
disease. In scarlatina, and rarely in other fevers, a distinct
nephritis is present, but a degeneration of structure sufficient to
produce albuminuria is in many instances a result merely of a high
temperature.
Many applications to the skin produce albuminuria, but in almost all,
if not all, of these an actual nephritis has been found to exist. The
same is true of poisoning with strong acids, phosphorus, and arsenic.
A very important form of albuminuria is that found during pregnancy,
more frequent with a first child or with twin pregnancy, and often
associated with other symptoms of nephritis. It is probable, however,
that in many instances it is a result of impeded abdominal circulation,
although it is very rarely that the gravid uterus can press directly on
the renal veins. In the severer cases a well-marked parenchymatous
nephritis exists; but it should be distinctly borne in mind that if
every instance of albuminuria in pregnancy is due to nephritis, it is
certainly a form of the disease which may lead neither to severe
symptoms nor to chronic disease. On the other hand, the appearance of
albumen in the urine of a pregnant woman, though not necessarily
calling for active interference of any kind, should always be a
danger-signal, and put the physician on the lookout for other
indications of actual renal disease.
In many nervous affections albumen may be found in the urine. It can be
produced, as was shown long ago by Bernard, by a puncture in the floor
of the fourth ventricle near to the point where a similar puncture
gives rise to diabetes. Lesion of the cerebral peduncles, section,
destruction, or irritation of the spinal cord, and irritation of the
renal nerves are also causes of this symptom. It is by no means
difficult to account for this phenomenon by the changes which take
place in the {41} renal circulation under influence of the vaso-motor
nerves which originate or pass through the peduncles, pons, and spinal
cord, although it is highly probable that similar results might follow
irritation transmitted from a distance. These facts are not without
practical importance, for they give rise to very considerable chances
of error in diagnosis; as, for instance, where a patient suffering from
severe headache, with possibly gastric symptoms, is found to have
albumen and casts in his urine, which is also copious and of low
specific gravity. It might not be easy to decide that such a case was
not one of interstitial nephritis with symptoms far from unusual, and
yet it might perfectly well be a cerebral tumor. The diagnosis would
demand a thorough search for other symptoms, such as double optic
neuritis on the one hand, as indicating cerebral disease and cardiac
hypertrophy, with high arterial tension on the other, as connected with
nephritis. A careful consideration of the order of their occurrence is
also desirable.
After an epileptic attack albumen may appear in the urine for a short
time, disappearing within a few hours. This occurrence might lead to an
erroneous diagnosis of uræmic convulsions if the examination happened
to be made shortly after a fit and not repeated at a later period.
Transitory mania may perhaps be placed in the same category.
Chronic mental disease, like general paralysis of the insane, is
frequently accompanied by albuminuria, and even temporary mental
disturbance in a sensitive person has been known to excite the symptom.
In narcotic poisoning both by alcohol and by opium a similar state of
things sometimes occurs. With alcohol, however, distinction is to be
made between chronic cases, where a suspicion of parenchymatous
nephritis may be fairly entertained, and acute alcoholism or delirium
tremens, where the albumen appears and disappears within a few days. In
a patient profoundly under the influence of opium the urine may contain
not only albumen, but casts, and the diagnosis of uræmic coma is very
likely to be made if nothing is known about the history--an error which
might be of great consequence, as tending to discourage the efficient
treatment necessary in opium-poisoning or causing the waste of time on
inefficient measures.
It is obvious from what has been said that the diagnosis of albuminuria
as a symptom is sufficiently simple with a little care in chemical
manipulation, but that its significance is not so easy to determine in
every case, since it is found in so many cases unconnected with chronic
or progressive renal disease, and on the other hand may be absent while
serious nephritis is going on.
Albuminuria, as defined at the beginning of this article--that is,
occurring in the absence of chronic and serious renal disease--is only
to be diagnosticated by the exclusion of such diseases, by careful
consideration of all the symptoms present, such as changes in the
quantity and specific gravity of the urine, in the force, rhythm, and
size of the heart, and of the arterial tension, as well as the relation
of the amount of albumen to the amount of urine and character of the
sediment as indicating one or the other form of nephritis. Thus a very
small amount of albumen with a highly concentrated urine is not likely
to be met with in the usual forms of nephritis, but is often found in
connection with valvular disease of the heart.
{42} Treatment is but rarely directed to this symptom, since, when
albumen is present in but small quantity, as usually happens, it is of
little or no consequence except as an important element in diagnosis,
while the few cases in which the amount is large enough to constitute a
serious drain upon the system are almost exclusively cases of actual
Bright's disease, and hence do not come under this head. The
administration of astringents, especially tannic and gallic acids, has
been found to diminish the quantity of albumen in the urine.
(A copious bibliography of this subject will be found in an article by
Ellis in the _Boston Medical and Surgical Journal_, vol. i., 1880.)
Renal Colic; Renal Calculus.
Renal colic is the appellation of a group of symptoms caused, in by far
the greater proportion of cases, by the passage of a renal calculus
through the ureter, or sometimes merely its engagement in the upper
extremity and impaction or subsequent falling back. Other foreign
bodies large enough to cause distension and obstruction, such as clots
of fibrin or portions of hydatid cysts, may give rise to the same
phenomena. Most physicians, however, have seen cases where the same set
of symptoms have not been followed either by the discharge of the stone
per urethram or by evidence of its continued sojourn anywhere in the
urinary organs. They may occur in persons of a neuralgic tendency in
connection with the uric or oxalic diathesis. The conclusiveness of
such cases, as proving the possibility of a purely neuralgic or
spasmodic attack, must of course depend upon the carefulness and
intelligence of the patient and the opportunities of the physician for
observation extending over years. As it is admitted, however, that
these symptoms may occur without the demonstrated presence of a
calculus, it would be perhaps better nomenclature to apply the term
renal colic to painful and spasmodic affections of the kidney and
ureter, however caused, and to describe the passage of a calculus or
other obstruction under its own name.
Calculi of various kinds, sizes, and shapes may be found in the pelvis
of the kidney. They are most frequently composed of uric acid, which
may exist alone or with layers of phosphates superimposed. They are
usually in concentric layers, more or less irregular in shape, and of a
reddish-brown color of various shades. Soft concretions of urates are
occasionally noted. Oxalate of lime is the material of many small
calculi, and may be the nucleus of a larger one or occur in alternate
layers with uric acid. These stones are of a dark grayish-brown and are
exceedingly rough and irritating. Among the most frequent constituents
of renal calculi are to be found phosphates, either of lime or the
triple salt of ammonia and magnesia. They may form layers with other
material, or constitute alone the largest and most curiously shaped of
all the renal calculi. Their surface may be smooth and almost polished,
or roughened, eroded, and almost crystalline in texture.
Cystine rarely forms a renal calculus, and xanthic oxide still more
rarely. Masses of fibrin resulting from renal hemorrhage are described.
They are said to be of the consistency of wax, tough and elastic.
Coagula of the ordinary form may also give rise to the same set of
symptoms. {43} On one occasion the writer saw the dilated pelvis of the
kidney filled with hundreds of spherical brownish soft masses from the
size of a mustard-seed to that of a pea, easily crushed in the fingers,
burning with the smell of albumen, and leaving but a small amount of
ash.
The size of renal calculi may vary from almost microscopic grains,
which then usually take the collective name of sand or gravel, and are
most commonly composed of uric acid, up to masses of some ounces in
weight, completely filling a dilated pelvis.
It is doubtful in what way renal calculi originate, their constituents
being always present in the urine, but rarely crystallizing out. The
uric-acid infarction of new-born children can hardly be considered as
accounting for any large number of cases, although it might be the
basis of calculi in young children. The uric and phosphatic deposits
sometimes found in the tubes of the more mature kidney may possibly,
when dislodged, be a point upon which additional quantities of the same
substances are deposited, but anything which delays in the pelvis or in
some of its calices a concentrated urine, especially if much mucus be
present, may be regarded as favoring the agglomeration of deposits. A
previous pyelitis is perhaps the usual cause of phosphatic deposits.
Small uric-acid calculi may sometimes be found in considerable numbers
in the sulcus surrounding some of the papillæ, and of a size which
could hardly afford any marked symptoms in passing down the ureter.
These, if any inflammation were to arise, would form a mass with pus or
mucus which might serve as a nucleus for a phosphatic calculus. These
suppositions are, however, rather theoretical and fragmentary, and do
not cover all the cases. Constitutional predisposition has been much
discussed, though not a great deal is known about it. A gouty tendency,
however, undoubtedly favors the production of uric-acid calculi.
A small renal calculus, when formed, may be the beginning of several
quite different sets of phenomena. Of these, the simplest and most
favorable event is its descent through the ureter into the bladder,
with its subsequent expulsion with the jet of urine from the urethra.
If the calculus be small and smooth, the passage through the ureter may
be attended with little or no uneasiness, but if it is large enough to
fill or distend the tube, and especially if the stone be irregular and
rough, its descent gives rise to excessively severe symptoms. These are
pain in the back at the level of the kidney, in the side and groin
corresponding to the ureter affected, sometimes shooting down the
thigh; with retraction of the testicle; usually no fever, but much
general depression; feeble pulse, coldness and paleness of the surface,
fainting, and vomiting. The beginning of the attack is usually sudden,
corresponding to the entrance of the calculus into the ureter, and the
pain continues without intermission, though with some remissions, until
its discharge into the bladder. The pain is usually of the severest,
and is described as cutting or tearing in character. It is probable
that an attack may sometimes end by the calculus, which has become
engaged in the ureter, falling back into the pelvis instead of
advancing through the ureter. In this case the pain ceases for the
time, to be perhaps subsequently renewed, or, if the stone grow larger,
so that it cannot re-enter the ureter, giving place to the symptoms due
to irritation of the pelvis.
The urine is usually diminished in amount until the arrival of the {44}
calculus at the bladder, when the fluid that has been retained is
suddenly discharged with the stone. Constant attempts to pass water
during the passage downward of the calculus are the consequence of
sympathetic irritation of the bladder, and not of accumulation of urine
therein. The urine is likely to be bloody, but is not necessarily so.
The smoothness or roughness of the surface of the stone is of much
importance as determining the presence of this symptom.
The DIAGNOSIS of renal colic is usually not difficult, but it may not
always be readily distinguished from hepatic or intestinal colic. The
suddenness of the attack and intensity of the pain, its location in the
side and downward to the groin, will in most cases make the condition
very characteristic.
From hepatic colic or the passage of a gall-stone the situation of the
pain, which is in the latter affection naturally somewhat farther
forward, the tenderness on pressure in the same region, and often the
whitish color of the stools or the presence of jaundice, as well as the
history of former attacks, will usually make the distinction a matter
of a high degree of probability.
Intestinal colic is usually referred to the middle of the abdomen, is
accompanied by constipation, while the movements of the intestines and
of flatus are often distinctly perceived by the sensation of the
patient or the ears of the bystanders, and on the whole the attack is
less severe and the pain less intense.