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CLINICAL LECTURES



ALBUMINURIA



CLINICAL LECTURES



ON



ALBUMINURIA.



THOMAS GRAINGER STEWART, M.D. Edin.

Fellmu of the Royal College of Physicians of Edinburgh ;

M.D. Honoris Causa Royal University of Ireland;

Hon. Fellow King and Queen 's College of Physicians in Ireland;

Physician in Ordinary to Her Majesty the Queen, for Scotland ;

Professor of the Practice of Physic and of Clinical

Medicine in the University of Edinburgh.



NEW YORK:
WILLIAM WOOD AND COMPANY.

1888.



EDINBURGH :

PRINTED BY LORIMER AND GILLIES,

31 ST. ANDREW SQUARE.



N" O T E.

The Lectures comprised in the present series have been
delivered at various times during the past two years, and
several have been published in journals.

It has often been suggested that I should issue a third
edition of my book upon " Bright's Diseases of the Kidneys/'
the second edition of which has now for many years been out
of print. I have sought to embody in these Lectures the
views which I entertain regarding the chief clinical questions
discussed in that volume.

My thanks are due to numerous friends for help, and
especially to Drs. Stevens and Gulland for aid in making the
observations. Dr. Gulland has also revised the sheets and
prepared the Index.

T. GRAINGER STEWART.



19 Charlotte Square,

Edinburgh, April, 188S.



Digitized by the Internet Archive

in 2010 with funding from

Open Knowledge Commons



http://www.archive.org/details/clinicallecturesOOstew



CONTENTS,



LECTURE I.

On the Forms op Albumen met with in the Urine, and their
Tests, Qualitative and Quantitative.

PAGE

Introduction.

The Varieties of Albumen — Serum Albumen —Serum Globulin
— Peptone — Propeptone or Hemialbumose — Acid Albu-
men — Alkali Albumen — Hsemoglobin— Fibrin— Mucin —
Lardacein — Composition of Albumen.

Tests for Albumen — Heat — Cold Nitric Acid — Metaphosphoric
Acid — Acidulated Brine — Picric Acid — Potassio-Mercuric
Iodide — Potassium Ferrocyanide — Dilution with Water —
Magnesium Sulphate — Fehling's Solution — Randolph's
Test.

Comparative Delicacy of Tests for Serum Albumen — Heat —
Cold Nitric Acid— Metaphosphoric Acid — Picric Acid —
Potassio Mercuric Iodide — Ferrocyanide of Potassium.

Quantitative Analysis of Albumen — Separation, Drying, Weigh-
ing — Esbach's Method — Robert's Method — Oliver's Percent-
age Method, 1—16

LECTURE II.

On the Incidence op Albuminuria among the Presumably
Healthy.

Introduction.

Contrariety of Opinions — Questions to be discussed — Is Albumen
a Natural Constituent of Urine ? — Proportion of presumably
Healthy People showing Albumen — Method of Testing —
General Result — Distinction between Soldiers and Civil
Population — Between Children and Old People — Condition
in New-born Infants — Results of Insurance Experience —
Effects of Diet, of Muscular Exercise, of Severe Exertion,
of Playing Wind Instruments, of Cold Bathing, of Mental
Excitement — Incidence of Peptonuria — Conclusions, . . 17 — 31



Vlll CONTENTS.

PAGE

LECTURE III.

On the Incidence op Albuminuria among the Sick.

Introduction.

Series of Cases Examined— Method Adopted— General Results
in Different Groups — Categories of Causes Denned — Series
of Cases taken together— Series of Private Cases — Series of
Indoor Hospital Cases — Outdoor Hospital Cases — Patients
in Royal Hospital for Sick Children — Fever House Patients
— Alcoholic Cases— General Conclusions as to Incidence of
Serum Albumen — Peptonuria in the Different Series, . . 32 — 48

LECTURE IV.

On the Theory op Albuminuria.
Introduction.
Albuminuria may be ascribed to Changes in the Blood —

Hydrsemia — Inspissation — Excess of Salts — Deficiency of

Salts — Excess of Albumen — Altered Albumen.
Altered states of the Filtering Apparatus.
Abnormal Vascular Tension — Diminution of Tension — Increase

of Tension.
Changes in Epithelial Cells and Stroma of Kidney.
Conclusion, 49 — 67

LECTURE V.

On Albuminuria prom Inflammation op the Kidneys.

Synonyms — Case of Acute Inflammation with Uraemia — Varieties
of Features with same Lesion— Very Chronic Case — Non-
Infective Chronic Case — Case with Pericarditis — Explana-
tion of the Albuminuria, ....;.. 68 — 75

LECTURE VI.

Albuminuria prom Cirrhosis op the Kidneys.

Synonyms — General Features — Case of fully developed Disease
— Case in Early Stage— Renal Inadequacy — Explanations of
the Albuminuria, ........ 76 — 83

LECTURE VII.

Albuminuria from Cirrhosis op Kidney — (Contimied).

Clinical Importance of the Complications — Gastric Catarrh —
Constipation — Morbid States of Blood— Disorders of Circula-



CONTENTS. IX

PAGE

tion — Cardiac Hypertrophy— Degenerative Changes — Valvu-
lar Disease — Pericarditis — Changes in Arterial Tension and
in Vessels — Disorders of Respiration — Dyspnoea from Pul-
monary Causes — Uraemic Dyspnoea — Integumentary
System — Dropsy, 84 — 95

LECTURE VIII.

Albuminuria from Cirrhosis of Kidney — (Continued).

Headache — Its Varieties — Dimness of Vision — Uraemic — Due to
Organic Causes — Retinal Haemorrhage — Albuminuric Retin-
itis — Uraemia — Acute — Illustrative Case — Chronic — Differ-
ent Forms of Symptoms — Illustrative Case — Causation of
Uraemia — Paralysis and Aphasia — Illustrative Cases —
Remarks, 96—113

LECTURE IX.

Albuminuria from Waxy or Amyloid Degeneration of the Kidney.

Case of Waxy Disease in Early Stage — Grounds for the Diag-
nosis — Causal Complications — Concomitant Complications —
Polyuria — Termination of Case — Autopsy — Modes of Termi-
nation of the Disease — Stages of the Process — Explanation
of the Albuminuria, 114 — 122

LECTURE X.
On Albuminuria from Fever and Other Causes.

Febrile Albuminuria — Statements of previous Observers —

Explanation of the Albuminuria.
Albuminuria from Diseases of Circulatory System — Explanation.
Albuminuria associated with Diseases of the Alimentary System

— Explanation.
Albuminuria associated with Diseases of the Nervous System —

Explanation.
Albuminuria with Glycosuria, 123 — 137

LECTURE XL

Albuminuria — Paroxysmal — Dietetic — From Exercise —
Simple Persistent.

Four Categories — Sketch of Progress of Knowledge on this Sub-
ject — Christison — Jaccoud — Moxon — Gull — MorleyRooke —
Barney Yeo — Clement Dukes — Mahomed — Fiirbringer —

b



X CONTENTS.

PAGE

Runeberg — Saundby — Leube — George Johnson — Quain —
Stanley Kendall — Pavy — Magnire.

Paroxysmal Albuminuria — Illustrative Case — Relation to Par-
oxysmal Haemoglobinuria — Explanation — Treatment.

Dietetic Albuminuria — Illustrative Cases — Positive and Negative
— Theoretical Explanations — Treatment.

Albuminuria from Muscular Exertion — Illustrative Cases —
Summing up of Features — Theoretical Explanation — Treat-
ment.

Simple Persistent Albuminuria — Illustrative Cases — Summing
up of the Features — Theoretical Explanation — Treatment.

Prognosis in the Four Varieties, ...... 138—168

LECTURE XII.

Albuminuria — Accidental, &c.

Number found in Groups of Patients— From Catamenial and
other Discharges — Discharges from the Urethra — Haemor-
rhages and Discharges from Prostate — Seminal Fluid — From
Bladder — From Ureters and Pelvis of Kidney — Cases of
Renal Calculus — Haemorrhage from the Kidney.

Albuminuria of Pregnancy — Albuminuria from Hindered Out-
flow due to other causes.

Explanation of the Albuminuria in the Series of Healthy Indi-
viduals — Renal Disease — Accidental — Taking of Food — Vio-
lent or Prolonged Muscular Exertion — Playing upon Wind
Instruments — Cold Bathing — Mental Conditions, . . 169—176

LECTURE XIII.

On the Differential Diagnosis and the Prognosis in
Albuminuria.

Diagnosis — Is the Albuminuria Constant, Intermittent, or
Cyclic ? — Quantity of Albumen discharged — Variety of
Albumen present — Quantity of Urine passed daily — Specific
Gravity — Tube Casts — Other Urinary Conditions, Phospha-
turia, Oxaluria, Urates- — General Considerations — Aliment-
ary System — Haemopoietic System — Circulatory System —
Respiratory System — Integumentary System — Nervous Sys-
tem — Locomotory System.

Prognosis — Importance of the Drain of Albumen— Data for
estimating daily loss, and its proportion to amount of
Albumen in the Blood — Prognosis in Inflammatory Bright's
Disease — Cirrhosis of the Kidneys — Waxy Kidney — In
Febrile Albuminuria — In Albuminuria from Alimentary
Diseases — From Nervous Derangements — From Glycosuria



CONTENTS. XI

PAGE

—In Paroxysmal, Dietetic, Exercise, and Simple Persistent
Albuminuria — In Accidental Albuminuria — In Albumin-
uria from Blood Diseases, 177 — 192

LECTUEE XIV.

Ox Diet ix Albuminuria.

Introduction— Production of Albuminuria by Diet — Evidence
of Stokvis, Lelimann, Lauder Brunton, Maguire, Claude
Bernard, and Others — Experiments with Egg Diet ; Cheese ;
Walnuts — Diet in Bright's Disease — Views of Dickinson and
Bartels — Experiments — Various Diets — Results in Bright's
Disease and Mixed Forms of Albuminuria— Alcohol, . . 193 — 210

LECTURE XV.

Ox the Effect of Medicines in Albuminuria.

Introductory- — Treatment of Nephritis — Renal Cirrhosis — Waxy
Degeneration — Combined Forms — Febrile Albuminuria —
Albuminuria from Circulatory Disease — With Alimentary
Derangement — With Nervous Disease — With Glycosuria —
Functional Albuminuria — Accidental Albuminuria, . . 211 — 224



LECTUKES ON ALBUMINUBIA.



LECTURE I.

ON THE FORMS OF ALBUMEN MET WITH IN THE
URINE, AND THEIR TESTS, QUALITATIVE AND

QUANTITATIVE.

Introduction.

The Varieties of Albumen. — Serum Albumen. — Serum Globulin. —
Peptone. — Propeptone or Hemialbumose. — Acid Albumen. —
Alkali Albumen. — Haemoglobin. — Fibrin. — Mucin. — Lardacein.
— Composition of Albumen.

Tests for Albumen. — Heat. — Cold Nitric Acid. — Metaphosphoric
Acid. — Acidulated Brine. — Picric Acid. — Potassio-Mer curie
Iodide. - — ■ Potassium Ferrocyanide. — Dilution with Water. ■ —
Magnesium Sulphate. — Fehling's Solution. — Randolph's Test.

Comparative Delicacy of Tests for Serum Albumen. — Heat. — Cold
Nitric Acid. — Metaphosphoric Acid. — Picric Acid. — Potassio-
Mer curie Iodide. — Ferrocyanide of Potassium.

Quantitative Analysis of Albumen. — Separation, Drying, Weighing —
Esbactis Method. — Roberts's Method. — Oliver's Percentage Method.

r\ ENTLEMEN, — In commencing a series of lectures on
^ albuminuria as a symptom, it is necessary first to go
over some ground familiar to many of you, for I must
indicate the various albuminous substances met with in the
urine. I purpose in the present lecture to enumerate these,
and briefly describe the source and nature of each, and then
discuss the value of the different tests by which they may be
discovered. In doing so I shall give you the results of a



2 ALBUMINURIA.

careful and prolonged inquiry which, along with Dr. Stevens,
I have made as to the comparative delicacy of the leading
tests for serum albumen, and as to the value of the different
methods of quantitative analysis by which the amount of
albumen may be determined. In the urine we may meet
with the following proteids, or bodies closely related to them.

I. Serum Albumen, a substance which, according to Ham-
marsten, (1) constitutes 4-516 per cent, of the blood serum.
It is almost constantly present in urine which contains any
variety of albumen. Although a less diffusible body than
serum globulin, it is capable of passing through membrane.

II. Serum Globulin or Paraglobulin, the globulin of the
blood serum, of which it constitutes 3 - 103 per cent. (1) It is
met with in almost all albuminous urines, its proportion to
the serum albumen varying in different instances.

III. Peptone, a product of gastric and pancreatic digestion
of albuminous substances, also occurring in the process of
transformation of tissues and of inflammatory effusions. It is a
readily diffusible substance, occasionally met with in the urine
in association with and probably apart from serum albumen.

IV. Propeptone, A Ibumoses, or Qlobuloses, a group of sub-
stances intermediate between proteids and peptone, consti-
tuting stages of transformation from the one to the other.
They are highly diffusible, and many varieties may be met
with in the urine. One of them is the peculiar form of
albumen which was discovered by Dr. Bence Jones (2) in the
urine of a patient suffering from osteomalacia.

V. Acid Albumen or Syntonin, one of the derived
proteids obtained by the action of acids upon albumen. It
is easily produced artificially by the addition of acid to
albuminous urine, but may occur naturally in certain cases.

VI. Alkali Albumen, another derived proteid, produced by
the action of alkalies upon albumen. It may be readily arti-
ficially prepared, but also occurs in the urine.



THE VARIETIES OF ALBUMEN. 3

VII. Haemoglobin, the combination of hsematin and
globulin naturally existing in the red corpuscles of the
blood. It sometimes appears in the urine, particularly in
cases of hematuria and hemoglobinuria ; also in certain
septic conditions, after inhalation of arseniuretted hydrogen,
transfusion of blood, and under other conditions.

VIII. Fibrin, a proteid substance which does not normally
exist as such in the blood. It is met with in the urine in
hematuria, in some cases of chyluria, and in certain varieties
of renal casts.

IX. Mucin, the chief constituent of mucus, is a derived
proteid substance, not an albumen but an albuminoid. As
mucus is secreted from the urinary tract in greater or less
quantity, it becomes superadded to the urine after its secre-
tion in the kidney.

X. Lardacein, Waxy or Amyloid Material, familiarly
known as a pathological substance within the body, is said
to be occasionally demonstrable in renal casts.

Of these ten varieties, the last four are evidently of little
practical importance — mucin alone being indeed worthy of
special comment, and that mainly because of the difficulties
which its presence raises in regard to the reliability of certain
tests for serum albumen.

As to the composition of the various albuminous sub-
stances, it is scarcely necessary that I should say anything,
but I may quote the statement of Hoppe-Seyler, (3) that their
percentage composition varies from

C51-5 H6-9 N15-2 S0"3 20-9 to
C 545 H 7-3 N 17'0 S 20 23-5



The Tests for the Albumens. — I have put in tabular form
the chief tests for the different varieties of albumen, with
their actions upon each variety.



ALBUMINURIA.



Table I. — Showing Tests for the Chief Forms of Albumen.





Serum
Albumen.


Serum
Globulin.


Peptones.


Propeptones,


Acid
Albumen.


Alkali
Albumen.


Heat, .


Opacity.


Opacity.














Heat with
HN0 3 .


Opacity.


Opacity.











Opacity.


Heat with A


Opacity.


Opacity.











Opacity.


Cold HN0 3 , .


Opacity.


Opacity.





Opacity
dissolved
by heat.


Opacity.


Opacity.


Metaphos-
phoric acid.


Opacity.


Opacity.


Opacity
diminished
or dissolv-
ed by heat.


Opacity
diminished
or dissolv-
ed by heat.





Opacity.


Acidulated
brine.


Opacity.


Opacity.


Opacity
diminished
or dissolv-
ed by heat.


Opacity
diminished
or dissolv-
ed by heat.


Opacity.


Opacity.


Picric acid, .


Opacity.


Opacity.


Opacity
dissolved
by heat.


Opacity
dissolved
by heat.


Opacity.


Opacity.


Potassio-mer-
curic iodide.


Opacity.


Opacity.


Opacity
dissolved
by heat.


Opacity
dissolved
by heat.


Opacity.


Opacity.


Potassium
Ferrocyanide
with A.


Opacity.


Opacity.





Opacity
dissolved
by heat.


Opacity.


Opacity.


Ammonium
sulphate.


Opacity.


Opacity.





Opacity.


Opacity.


Opacity.


Dilution with
water.


C


Slight
opacity.














Magnesium
sulphate.





Opacity.








Opacity.


Opacity.


Fehling's solu-
tion.


Brown-
ish-red
or
mauve.




Rose pink
or purple.


Rose pink
or purple.






Randolph's test,




...


Yellow Yellow
opacity. opacity.







The oldest test for albumen depends upon its coagulability
by heat. Heat coagulates the serum albumen (opalescence
occurring at 140° Fah., coagulation at 162° to 167°), and
also the serum globulin (opalescence occurring at 154° Fah.,
coagulation at 167°); has no effect upon the peptones or



THE TESTS FOR THE ALBUMENS. 5

propeptones, nor upon acid or alkali albumen, unless an
alkali or acid has first been added. It, however, produces
cloudiness with earthy phosphates, by driving off carbonic
acid, which holds them in solution, but the further addition
of nitric acid, by redissolving them, clears up the opacity.
A preliminary acidulation with acetic or nitric acid prevents
this cloudiness, but may convert albumen into acid albumen,
and so make the test fail. But, on the whole, if cautiously
employed, heat gives satisfactory results. A further security
may be obtained by using both acetic acid, and a concen-
trated solution of magnesium sulphate, or of sodic sulphate,
or of common salt, for these prevent the undue action of
the acid upon the albumen.

The Gold Nitric Acid Test ranks next in date of intro-
duction and in general popularity to that by heat. When a
layer of nitric acid is brought into contact with a layer of
albuminous urine, a white coagulum is formed at the line of
junction of the fluids. The acid coagulates serum albumen
and serum globulin ; has no effect upon peptones ; gives an
opacity with propeptones, which, however, disappears with
heat ; has no effect upon acid albumen, but gives distinct
reaction with alkali albumen. One or two sources of fallacy
must be kept in view when one employs this test. It may
give an opacity with urates (but it dissolves with heat), with
urea (but it occurs only in concentrated urines, and shows a
crystalline arrangement), or with resinous substances.

Metaphosphoric Acid is an excellent test for albumen, but
as it is only serviceable when pure, and difficult to keep in
that condition, it has not come into general use.

Acidulated Brine is also a test of considerable value,
acting upon all varieties of albumen, but it is not likely to
become greatly trusted, because of its frequently giving some
reaction with normal urine.

Picric Acid is a test which has been brought into use in



6 ALBUMINURIA.

this country mainly by the recommendation of Dr. George
Johnson. (4) It produces an opacity with all the forms of
albumen ; but while those with serum albumen, serum
globulin, acid and alkali albumen persist or become more
distinct with heat, those with peptone and propeptone
dissolve. It must be remembered, also, that alkaloids, such
as quinine, give a cloud with this reagent, but one which
rapidly disappears on heating. On the whole, I believe
this to be the most reliable and delicate test which we at
present possess.

It has been objected to this test, that it precipitates mucin
as well as serum albumen, and that this is a source of fallacy,
particularly when it is used by the contact method. As this
question appeared to me important, I have taken a good deal
of pains to satisfy myself regarding it. By the kind per-
mission of Dr. Sinclair, I examined, along with Dr. Stevens
and Dr. Boddie, the urine of a number of inmates of Craig-
lockhart Poorhouse, in whom previous examination had
shown that minute traces of albumen were frequently
present, and in which, as in most urines, mucin was also to
be found. My object was to see how far the reactions of the
characteristic tests for mucin corresponded to, and how far
they differed from those of picric acid. The specimens,
fifty-four in number, derived from twenty-seven individuals,
were tested with nitric acid, picric acid, a solution of citric
acid of specific gravity 1005, and the solution of citric and
picric acids together used in Esbach's method for determin-
ing the quantity of albumen. The contact method was
adopted in all cases as being the most delicate. The nitric
acid was used in order to show when albumen was
present in considerable quantity ; the picric acid to discover
minute traces of albumen, and with the special view of
watching for the reaction with mucin ; the citric acid as the
best test for mucin ; and the combined citric and picric acids



THE TESTS PICRIC ACID. 7

for the purpose of comparison with the reactions obtained
with the other tests. Of the fifty-four specimens, twelve
showed a reaction with nitric acid, thirty-four with picric,
thirty-eight with citric, and forty-one with Esbach's combined
solution. The most important fact which we ascertained
was that, while a large number of the specimens gave distinct
reactions both with picric and citric acids, there were three
which gave an opalescence with picric and not with citric, and
seven of those which reacted with citric acid gave no reaction
with picric. From these facts we conclude that mucin may
be demonstrated by citric acid when no reaction is produced
with picric, and that picric may show minute quantities of
albumen in urines in which citric acid fails to show mucin.

But, on the other hand, picric acid often produces an
opalescence in urine apparently free from albumen, and Dr.
Stevens made a series of careful experiments with the view of
getting at an explanation of this fact. He selected a urine
which gave a faint and slowly developed reaction with picric
acid, and a distinct opacity with citric acid. Having coagu-
lated its mucin by means of citric acid and filtered off the
coagulum, he found that the urine no longer gave any
reaction with picric acid. Again, to another specimen of the
same urine he added picric acid and then filtered off the precip-
itate ; he found that the urine then gave either no reaction, or
a very slight one, with citric acid. These experiments seem
to indicate that picric acid does act upon mucin, although
more slowly and in a less degree than citric acid. I suspect
that the degree of acidity of the urine is an important element
in relation to this reaction with picric acid ; that where acid
is present in quantity the opalescence is distinct, where it is
in slight amount it is comparatively or completely absent.

On the whole, we seem to be warranted in believing that
although picric acid often affects mucin, it does not do so
in such a way as to render it unreliable as a delicate test for



ALBUMINURIA.



albumen. Its precipitate with mucin is, even when applied
by the contact method, a slight, slowly developed haze. A
precipitate indicating albumen is more marked and more
quickly produced. A little practice in the use of the test
will soon render you familiar with the degree and rate
of formation of the opacity which indicate albumen as
distinguished from those which mark the presence of mucin.

Potassio-Mercuric Iodide, which was first proposed as a
test by M. Tanret, (5) corresponds in its action to picric acid,
giving opacity with serum albumen, globulin, acid and alkali
albumen, and an opacity dissolved by heat with peptone and
propeptone. But it will be found to give a reaction with a
very large proportion of normal urines, and as the addition
of an organic acid — citric or acetic — is required to bring out
the reaction, it is clear that mucin must, in many cases
give a degree of opalescence. It may be that other sources
of fallacy exist in regard to these slighter reactions. It is
true that Dr. Oliver's (6) method of applying this test greatly
reduces the chances of error, but it has disadvantages which
render it, in my opinion, inferior to picric acid.

Potassium Ferrocyanide, first suggested by Dr. Pavy, (7)
also resembles picric acid in its action, except that it does not
give any indication with peptones. The objections to the
reagent last described apply equally to this.

Ammonium Sulphate has been shown by J. Wenz (8) to be
a valuable test for proteids, for it precipitates all of them,


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