ON 
THE ABSOLUTE AND RELATIVE VALUE OF ALBUMEN 
AND CASTS, 
AND OF 
RENAL INADEQUACY, IN THE DIAGNOSIS AND PROGNOSIS 
OF DISEASES OF THE KIDNEY. ' 
BY 
ROBERT T. EDES, M.D., 
OF WASHINGTON, D. C. 
FORMERLY PROFESSOR OF MATERIA MEDICA, AND JACKSON PROFESSOR OF CLINICAL MEDICINE IN 
HARVARD UNIVERSITY. ON 
THE ABSOLUTE AND RELATIVE VALUE OF ALBUMEN 
AND CASTS, 
AND OF 
RENAL INADEQUACY, IN THE DIAGNOSIS AND PROGNOSIS 
OF DISEASES OF THE KIDNEY. 
BY 
ROBERT T. EDES, M.D., 
OF WASHINGTON, D. C. 
FORMERLY PROFESSOR OF MATERIA MEDICA, AND JACKSON PROFESSOR OF CLINICAL MEDICINE IN 
HARVARD UNIVERSITY. 
REPRINTED FROM THE 
TRANSACTIONS OF THE ASSOCIATION OF AMERICAN PHYSICIANS, 
SEPTEMBER, 1888. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1888. ON THE 
ABSOLUTE AND RELATIVE VALUE OF ALBUMEN AND 
CASTS, AND OF RENAL INADEQUACY, IN THE 
DIAGNOSIS AND PROGNOSIS OF DIS- 
EASES OF THE KIDNEY. 
By ROBERT T. EDES, M.D., 
OF WASHINGTON, D. C-, 
FORMERLY PROFESSOR OF MATERIA MEDICA, AND JACKSON PROFESSOR OF CLINICAL MEDICINE IN 
HARVARD UNIVERSITY. 
I. Albumen. 
Many of us can remember when the discovery and announcement 
of albumen in the urine were looked upon almost like a sentence of 
death, to be executed at an unknown but not very distant date, or, at 
any rate, as showing a condition of the system at which almost any 
medical accident might happen to the patient without further warning. 
Albuminuria has held a place in medical nomenclature almost 
equivalent to Bright's disease until quite recently. Pathological views 
were not altogether at variance with these clinical ones. Bright's dis- 
ease took the place of the older heart disease among the ready opinions 
of the coroner and policeman, and a kidney which was above reproach 
was among the curiosities of the post-mortem room. It was discovered 
however, that, whatever else albuminuria might mean, it did not point 
decisively and exclusively to well-marked renal lesions, but was found 
in many other diseases which need not be mentioned in detail, but 
which can largely be included in the two groups of febrile and asys- 
tolic. A step beyond this was the finding of albumen in the urine of 
persons in apparently good health, a part of whom, at least, continued 
to be so for months or years. 
This is the present status, which offers several questions for exami- 
nation, and this can best be made without preserving an exact histor- 
cal or chronological order. 2 
EDES, 
Is albumen to be found in the urine of persons in really good 
health ? The most extensive, and among the most recent, researches 
bearing on this question are those of De la Celle de Chateaubourg, 
supplemented by the observations, some of them considerably older, 
of Capitan, Kleugden, Clarke, Leube, Fiirbringer, Grainger Stewart, 
Van Noorden, and Munn ; besides a considerable number of smaller 
groups or isolated instances, which have often the added value of 
having been made upon the person of the author, and carefully followed 
out, by Marcacci, Edlefsen, Ultzmann, Simmons, and others. Ac- 
cording to De la Celle, albumen is to be found at times in the urine of 
seventy-six to one hundred per cent, of healthy persons, both young 
adults and children. Capitan found in soldiers forty-five and in chil- 
dren eighty-nine per cent.; Kleugden forty-three and a half per 
cent, among supposably healthy attendants in an insane asylum ; and 
Grainger Stewart gives a general average of thirty-one per cent., 
which, however, covers a range of from nearly eleven per cent, among 
civilians to sixty-five and a half among workhouse inmates aged in 
the neighborhood of sixty. 
The discrepancies shown by the accompanying table (Table I.) are 
very great, too great, in fact, to be accounted for by ordinary errors of 
observation or by any assumption of real differences in the classes of 
persons coming under the notice of the various observers; in fact, 
soldiers, students, and children in institutions furnish the bulk of the 
statistics. The discrepancies do not entirely disappear by any process of 
comparison of the method employed, because such a comparison cannot 
be accurately made for the different reagents. The figures cannot be 
quantitatively compared when very small amounts of albumen are in 
question, and even with the same method quantitative estimates of 
traces are only approximative at the best. The discrepancies are, 
however, greatly diminished by such a comparison, especially as ap- 
plied to the labors of the two modern French observers who used the 
extremely sensitive reagent of Tanret, or the potassio-mercuric iodide, 
on a layer of which the urine is floated and an estimate made by the 
density of the cloud. Taking the figures of De la Celle, and separat- 
ing the cases in which he found, by estimate, from twelve to twenty-five 
centigrammes to the litre, the percentage falls from seventy-seven to 
eighteen, from seventy-nine to twenty, from one hundred to thirty- 
two, and so on, as will be seen by the table. If we notice only albu- ALBU MINURIA. 
3 
men in the form of a flocculent precipitate, we find it in his tables only 
four times among one hundred and eleven soldiers who are stated to 
have given one hundred cases, or ninety per cent, of albuminurics. 
Other groups may be examined in the same way, and it is obvious 
that great allowance is to be made, not for errors in observation, but 
for the varying criteria by which the presence of albumen is affirmed 
or denied, whatever be the reaction employed. Some observers dis- 
tinctly state that doubtful cases are not included. It will be noticed 
that in the set of cases which give the highest percentages of albumin- 
urics the maximum, if we set aside the quite small number in which 
flocculent albumen by heat was found, is very small-i. e., from one- 
eightieth to one-fortieth of one per cent.; while there is a tendency to 
draw the line between physiological-or at least harmless-and patho- 
logical albuminuria, if such a line be possible, at a considerably higher 
point than this, namely, at one-tenth of one per cent. 
To the delicate test (Tanret) by which the most striking results 
were obtained, it has been formally objected that not only does it give 
reactions with peptone and alkaloids, errors which may be avoided by 
a little further testing, but also that when the quantities are small 
albumen is not to be distinguished from mucin. Roberts believes a 
frequent source of error with the more delicate tests to be mucin. 
The following conclusions may be drawn : 
That the presence cf albumen in minute traces, or something which 
gives a similar reaction with the most delicate reagents, is much more 
common than its absence. 
That an amount of albumen detectable by heat and nitric acid may 
be found in a much smaller proportion of cases taken at random. 
This proportion varies according to the shade of opalescence which 
the individual observer considers conclusive, and may be approxi- 
mately stated as from ten to twenty per cent, of persons examined, 
rising above it in certain classes to be afterward specified. 
The percentage of cases of presumably healthy persons in whose 
urine boiling gives a flocculent precipitate is much smaller still. 
As a corollary to these conclusions it may be asserted that for 
clinical and practical purposes Tanret's test is worse rfian useless. 
There is no reason for taking great pains to discover a sign which 
to the physician can have no significance, and to the patient, if he 
becomes aware of it, probably a very erroneous one, and is likely 4 
EDES, 
to be the cause of groundless fears. It is chiefly in France that it has 
been widely used. Jaccoud says that " It is since this has become 
common that albumen has been so commonly found in the urine of 
healthy individuals." 
The second question is not so easy to answer-i. e., What signifi- 
cance is to be attached to a quantity of albumen, not large, but more 
than the faintest trace, occurring in a person who has no other signs 
of renal disease. From what has already been said, it is obvious that 
the number of persons in this class cannot be stated with great accu- 
racy, but that it is not a very small one. As to the amount of 
albumen on the one hand w'hich shall be considered small, we may 
take the limit to which many of those who have studied the subject 
on themselves or others, seem inclined to adopt-i. e., one-tenth of 
one per cent. But, on the other hand, as to what amount may be 
absolutely neglected we cannot speak in figures, but may take the 
limits of the heat and nitric acid tests carefully applied. Below this 
point, if other signs of renal disease are not present, the trace of albu- 
men proves nothing, and if they are, adds little or nothing to the 
diagnosis. 
Within this class two sub-classes may be separated off with tolerable 
distinctness, shading, however, as most exaggerations of subnormal 
processes do, into each other and into the groups which cannot fairly 
be included within them. 
First the albuminuria connected with a slight degree of anaemia, 
dyspepsia, headache, general depression, and disinclination to labor, 
bodily or mental, occurring in adolescents and often known as the 
albuminuria of adolescents. 
Not much weight is to be attached to the remark that this is more 
common in the male sex, for the reason that the examinations have 
been made much more largely in boy's schools; in fact, the same re- 
mark may be made in regard to the statistics of other groups, soldiers, 
older students, and young physicians. These cases seem to have been 
recognized as a distinct class with well-marked symptoms for a number 
of years. They are certainly not to be looked upon as presenting ex- 
amples of physiological albuminuria, and were, in fact, for a time 
thought to show a tendency to weakness of the kidneys, and to be 
especially liable in the future to develop a true nephritis. This sus- 
picion has not been justified in general, but in a.few cases, in which ALBUMINURIA. 
5 
the albumen was associated with casts, such a development has taken 
place. Ralfe says that, although some of these cases have .a florid 
complexion, the degree of ansemia is sufficient to be determined by 
the hemacytometer. The prognosis is no more unfavorable than 
would be indicated by the other symptoms. The relation of albu- 
minuria in these cases to a future nephritis is not unlike what that of 
a slight cough in the same patients would be in regard to a future 
tuberculosis; it would induce a search for other symptoms and call 
for attention to the general health. 
The second class includes the cases of " intermittent " or " cyclic " 
albuminuria. In these the urine presents certain tolerably constant 
peculiarities beyond that of containing albumen; it is usually scanty, 
high colored, with a large amount of urea, and very frequently a 
deposit of uric acid, or oxalate of lime, the latter being the more fre- 
quent. In these cases, which are very likely to be discovered by 
accident, and of which naturally a large number have been found 
among young physicians, who have made a careful study of them, the 
morning urine is usually free from albumen, which appears and 
reaches its maximum in the forenoon, decreasing during t*he latter 
part of the day, with not infrequently a secondary rise in the evening. 
Exercise has a very decided effect in increasing the quantity, cold 
bathing perhaps even more, and digestion comparatively little or some- 
times none. A few cases have, however, been noticed in -which the 
albuminuria seemed to be determined by indigestion. The character 
of the food has usually but little influence. This class differs from the 
preceding in the absence or slightness of the accompanying general 
symptoms. The patients are apparently, in a large number of cases, 
in perfect health, though in others there may be a little general 
depression. The pulse is likely to be of low tension. Some cases of 
this kind have been followed for years without the occurrence of any 
symptoms leading to a suspicion of progressive renal disease. In 
many the albumen has disappeared without special treatment and 
without the change being assignable to any particular cause. 
After subtracting these two classes and making some allowance for 
accidental cases in which there has been, perhaps, a temporary disturb- 
ance of the circulation, unusual liberties in diet, or even a slight 
nephritis, without alarming symptoms, which is without doubt possible, 
and where casts may be overlooked, we have still a number of cases 6 
EDES, 
by no means insignificant, in which albumen is continuously present 
in the urine of persons of various ages, but beyond that of adolescence 
or early youth. Is this to be disregarded as of no importance, or is 
it to be looked upon as the early stage of nephritis ? It is possible 
that in some of these a more minute examination, such as is by no 
means easy on a large scale, wrould bring to light casts, and settle 
the question of some renal disturbance, the question then becoming 
-What is the prognosis in slight cases of chronic nephritis ? 
Taking these cases, however, as they stand, and following them out 
carefully, as was done by Munn, we should be justified in regard- 
ing them with grave suspicion. Some of them seem to be instances 
of a real nephritis, running a very chronic course, and presenting 
at the time of their first examination no constitutional symptoms. 
Munn found in a considerable number of cases, in which at first only 
albumen was noted, that casts were subsequently present. Four of 
sixty-nine had died within three years, and in the majority a general 
deterioration of appearance was noticed. 
It may further be suggested that among them there were many 
overweights, a class peculiarly liable to nephritis, and also that middle- 
aged business men, such as are the majority of those presenting them- 
selves for life insurance, form a class especially liable to interstitial 
nephritis, a form attended with the least marked symptoms for a long 
time, perhaps for years. 
It has undoubtedly been noticed that no allusion has been made in 
this paper to the kind of albumen found in the urine. This is not 
because it is a matter of indifference, but because the investigations 
heretofore made upon this point have been only upon a few isolated 
cases and are, hence, not applicable in the criticism of the statistics 
under consideration. 
Two w'ell-marked varieties of albumen, at least, can be distinguished, 
serum albumen or seralbumen, and globulin, metalbumen, or Bence 
Jones albumen. Beside these, hemialbumose or albumen half changed 
to peptone, and peptone itself are found. Mucin, although not belong- 
ing to this group, may be a source of error when very small quantities 
are under consideration. Any minute discussion of the chemistry of 
even this small group would carry us too far for our time, and at 
present only into the region of hypothesis; but it is by no means im- 
probable that further experiments on the diff'usibility of albumen, and ALBUMINURIA. 
7 
on the points of coagulability by heat, will disclose even a larger 
number of varieties which will have a physiological and clinical sig- 
nificance. 
At present it appears from a small number of examinations that, 
when albumen in small amount is disclosed by the ordinary tests, it 
consists largely or even wholly of globulin, and that this has a less 
grave significance than serum albumen. This kind is to be detected 
separately from the other, by a saturated solution of sulphate of mag- 
nesia, added to the neutral urine, and the formation of a precipitate 
on standing. After this is filtered off the filtrate may be examined 
again for serum albumen. 
We cannot take leave of this branch of the subject without refer- 
ence to the highly important views of Semmola, according to whom 
albuminuria is not the early symptom, but the cause of nephritis, and 
finds its origin not in the anatomical changes in the kidney, but in an 
alteration of the serum of the blood, which alteration is in its turn the 
consequence of deficient action of the skin. The altered serum is, 
like a foreign body, eliminated through the kidneys, and on its way 
sets up a gradual degeneration of the renal structure. The nature of 
the alteration is shown by a greater diffusibility of the serum, and 
can only be demonstrated by physical experiments, and, as Semmola 
himself repeatedly points out, not by any well-marked chemical 
reaction. 
The dyscrasic theory of Bright's disease is by no means a new one. 
It was held by Bright himself, and, indeed, something like it before 
him by Blackall. It is certainly not in disagreement with many 
clinical facts, but in the form advocated by Semmola it is difficult to 
harmonize with some of the facts we have just been considering. In 
the absence of clear chemical data, it is almost impossible to follow up 
the statements of Semmola carefully in a clinical way, but it may be 
remarked that his assertion that a continued subcutaneous injection of 
egg albumen produces renal changes obvious to the microscope, has 
been denied by subsequent observers. If albumen, passing for a con- 
siderable time through the kidneys, causes nephritis, the cases of 
innocent albuminuria, intermittent, cyclic, accidental, the albuminuria 
of adolescence, ought not to exist, but would inevitably lead to well- 
marked Bright's disease, and the question we have been discussing 
would never have arisen. This difficulty may be met by the state- 8 
E DES, 
ment that only the altered albumen (heteralbumen) is to be looked 
upon as an irritating agent, and that which passes in these accidental 
cases, and also that accompanying renal congestion, are not of this 
kind, but more normal and less toxic. Such a statement is, from the 
reasons above given, not easy to refute absolutely; but it is, on the 
other hand, no more easy to prove. If nothing is the matter either 
with the albumen or with the kidneys in these cases, why does it keep 
coming through ? 
It seems probable that the form of albumen, so far as we can now 
distinguish the forms, or, to speak more correctly, so far as they are 
usually distinguished clinically, which has the worst prognostic sig- 
nificance, is that which most nearly resembles that of the blood serum. 
Stokvis considers pathological albumen to be serum albumen chemi- 
cally. That it differs in its diffusibility is the theory of Semmola, 
which has not as yet the support of other experiments than his own, 
which are difficult to repeat in the absence of precise details of their 
performance. 
Egg albumen has not been shown to have any special connection 
with the albumen of Bright's, and was arbitrarily chosen by Semmola 
as a representative of a foreign albumen. Whether it passes into the 
urine or not, as asserted by Stokvis and denied by Van Noorden, it 
cannot be considered to represent fairly the process taking place, 
according to Semmola, in the development of Bright's disease. Stokvis 
found that albuminous urine from a case of Bright's, injected sub- 
cutaneously into a healthy dog, produced no albuminuria, and when 
injected into the blood did so in only one out of several instances. 
This experiment is certainly more to the point as to the discharge of 
heteralbumen than Semmola's own, in which egg albumen was used. 
Hayem {Bull, et Mem. de la Soc. Med. des Hop. de Paris, March 
21, 1888), though finding that egg albumen injected directly into the 
blood may be excreted by the kidneys, does not think that this is a 
fair representation of a physiological process, but that the secondary 
albuminuria is a result of changes produced in the blood of the recipient 
animal. Ascitic (albuminous) fluid could be introduced into the peri- 
toneum of a dog in large quantity without causing albuminuria with 
any constancy, and when it did occur it was slight and transitory. 
His last experiment was more decisive than anything so far published 
as regards the correctness of Semmola's claims. lie transfused from 9 
URINARY CASTS. 
a dog which had parenchymatous nephritis, as diagnosticated before, 
and verified after, death, a considerable quantity of blood into a 
healthy dog previously bled. This experiment was repeated twice 
with the same result, that the recipient dog had a little fever, which 
is usual after any transfusion, but on neither occasion albuminuria, 
and recovered completely. 
II. Casts. 
The significance of urinary casts or cylinders is a question upon 
which there is perhaps less necessary obscurity than in regard to 
albumen, but, on the other hand, less statistical information as to their 
presence in a state approaching health. Easy of recognition when 
seen, and presenting fewer doubtful appearances, the question can never 
arise, with a reasonable amount of experience, as to whether they have 
been seen or not; but as the search for them may be laborious, and the 
most laborious when least successful, the approximation of an unsuc- 
cessful search to a negative result depends upon the patience of the 
observer, and can seldom be an exact coincidence. 
I can add only a few short rules to those ordinarily laid down. 
Give the specimen time enough to settle, but not enough to decom- 
pose. 
If a flocculent cloud appear in the middle of the liquid, look in this 
for casts as well as in the sediment properly speaking. 
Do not use too high a powrer in searching for them. Find them 
with a low power, and examine them afterward with a high one, if 
necessary. 
Casts are easier to class and to identify than different forms of 
albumen. We have first the exudative, divided into mucous, hyaline, 
and waxy; and the cellular, comprising pus, blood, epithelial, and de- 
generated epithelial. The appearance of very transparent casts, some- 
times branching, irregular in diameter, and with a longitudinal stria- 
tion, there is no reason to suppose has any significance, certainly no 
more than that of their chemical complement mucin, although it is 
highly probable that they are formed in the urinary tubes. These 
occasionally at one end appear somewhat firmer and rounded, resembling 
a hyaline cast, to which they seem to form a sort of transition. I have 10 
EDES, 
not, however, seen that their unfavorable meaning is at all increased 
thereby. 
I presume there can be little doubt in the mind of any one that epi- 
thelial casts indicate some form and degree of renal lesion. Normal 
renal epithelium is not thrown off in quantity to be recognizable, and 
still less in the form of casts. The significance of their appearance in 
regard to the diagnosis of different forms of renal disease is quite well 
understood. As the degeneration of the epithelium in the casts is more 
advanced-that is, as they become granular or fatty, so, it may fairly 
be inferred, is that of the kidney tubes from which they arise, except 
that during recovery from acute nephritis a slight degree of degenera- 
tion may affect the cells which are thrown off, while those that replace 
them are normal. 
There is probably no form of cast more thoroughly unfavorable in 
its significance than the long, large, straight casts, highly granular and 
fatty, so as to be almost black by transmitted light, and with a very low 
power, or even to the naked eye, looking like fine white threads. These 
appear to be made up of degenerated cells welded into a more or less 
homogeneous mass, and are probably moulded in the straight tubes, 
although the material may have come from higher up. Smaller casts, 
coarsely granular, or with very distinct fat granules, can come from 
the remoter portions of the tubules, but an inspection of sections of 
pathological kidneys which contain casts in the cortical portion makes 
it seem highly probable that the most thorough degeneration may take 
place in the secreting tubes without the products getting into the urine 
in the form of casts, except as these are afterward formed by their 
being moulded together or enclosed in a mass of the exudation thrown 
out in the lower tube, and which, without the detritus floated down, 
would become a fibrinous or waxy cast. Some of the casts formed in 
the secreting tubes are undoubtedly never dislodged as such. 
Returning to the exudative casts, that known as the waxy, or some- 
times the amyloid (although the name is badly chosen, as tending to 
imply a relationship, which does not exist, with the amyloid kidney), 
indicates a high degree of usually chronic degeneration. I have never 
known but one instance of apparent recovery in which these casts were 
present. It was that of a young woman who entered the Boston City 
Hospital with "inflammation of the bowels after childbirth," and had, 
in addition, a copious greenish expectoration with rales, general ana- 11 
URINARY CASTS. 
sarca, headache, and scanty, smoky urine, with albumen and large 
casts, among which were many waxy. She was discharged apparently 
well, although still with some albumen, and much fewer casts. She 
was seen in the street some time afterward, apparently well, but further 
search has only resulted in my finding that she has not since died in 
Boston. 
With the elimination of these forms, and the admission, which I 
presume few would hesitate to make, that a considerable number of 
casts of any kind means a distinct and more or less extensive renal 
lesion, the seriousness of which can be estimated by their number only 
in connection with other symptoms, we find ourselves in the presence of 
a problem not unlike that presented by a light or moderate albuminuria 
of the apparently healthy. Many authors speak as if the two condi- 
tions were nearly commensurate, but I believe them to be so in neither 
direction; that we very frequently meet with one without the other. If 
both mucin and mucous casts were left out of the comparison, I sus- 
pect the association would appear still less close. It is possible that a 
few casts may accompany a very slight amount of albumen, and, per- 
haps, have no more meaning than this; but it will be noticed in looking 
over the tables (especially Table II.) of cases of albuminuria not accom- 
panying renal disease, that the reports of " no casts " are most fre- 
quent, and that when a statement of their presence is made it is usually 
in connection with the classes which border most nearly on the patho- 
logical limit. 
Where hundreds of persons have been examined, the statement of 
" no casts" is to be received with a certain amount of allowance, but 
in a great many of the cases given in the second table there were small 
groups of persons under observation at a time, and frequently under 
circumstances to excite anxiety, or much scientific interest, so that we 
may be morally certain that many and careful microscopic examina- 
tions were made, and the statements may be accepted as being as nearly 
conclusive as negative ones can be. 
This negative statement is made in regard to a great many of the 
cases of cyclic albuminuria. Where, however, the urine is distinctly 
irritative, i. e., concentrated, and containing oxalate of lime, the pres- 
ence of a few' hyaline casts can hardly add to the importance of the 
presence of albumen. It is interesting to note that in oxalic acid poi- 
soning (among others) albumen and casts were found in the urine by 12 
EDES, 
Miirset (Arch. f. exp. Path, und Pharm., xix. p. 335), and by Robert 
and Kiissner (Virchows Archiv, Ixxviii.), and by von Frankel (Zeit- 
schrift fur klin. Med., 1881, Bd. 2), quoted by Miirset. In the albu- 
minuria of adolescence, which is certainly not a physiological condi- 
tion, hyaline casts have been not infrequently noted. 
In old age, it is well known that the kidneys undergo a certain 
amount of atrophy, especially near the surface; but so long as it does 
not progress so rapidly that they are unable to carry off all the results 
of a metamorphosis, which is also, and perhaps as rapidly, decreasing, 
there is no reason why symptoms of any kind should arise on the part 
of these organs. The arterial and cardiac changes which are usually 
going on at the same time, are quite as likely to come into the fore- 
ground, and, perhaps, put an end to life, while the kidneys, although 
slowly atrophying, are still able to do all the duty likely to be required 
of them. Thus it comes, and very properly, that in the presence of 
other important symptoms referable to other organs, slight amounts of 
albumen and casts may be disregarded, and it is an error in diagnosis 
to attribute to latent Bright's disease, even when it may be actually 
present, everything which may happen to the patient under these cir- 
cumstances. 
Taking albumen and casts together, we may at first separate all the 
conditions of local irritation, congestion, and senile atrophy, which 
have before been spoken of, and in which small amounts of albumen 
and casts may be found. In these, neither diagnosis nor prognosis 
is specially affected by the combination of these two signs more than 
by one of them alone. If the amounts become larger, the symptoms 
are correspondingly important. In cases, however, in which these 
symptoms are the leading ones, and which cannot be brought under 
any of the classes already discussed, even a few casts in addition to 
albumen should be looked upon with suspicion, and as making the 
prognosis more serious. A considerable number would make renal 
disease highly probable, or at any rate probable enough to be taken 
into consideration in the treatment, and many, especially if carrying 
with them epithelial elements, make a diagnosis of Bright's disease 
almost certain. 
When we have casts of epithelium, more or less degenerated, or the 
large homogeneous and waxy ones, we have got beyond the point at 
which there is room for discussion as to the presence of renal disease RENAL INADEQUACY. 
13 
of an advanced kind. Its form and acuteness are to be determined 
partly by the urine alone, and partly by the other symptoms which 
are not likely by this time to be absent. 
What the nature of the lesion may be when it is clear that one exists, 
but when it is evident, from the length of time that the urinary signs 
have been present without other symptoms having arisen, that it is 
not a rapidly progressing one, can in many cases only be surmised. 
An inflammation limited to a part of one kidney, is not a purely 
gratuitous assumption. The evidence of this is occasionally plain at 
the post-mortem. Even in the well-marked contracting kidney, the 
interstitial inflammation is present in patches. A small area of inflam- 
mation might for a long time furnish pathological products without 
extending enough to produce further symptoms. 
Old renal disease may either recover or leave behind a condition 
which does not grow either better or worse. I have had under occa- 
sional observation a patient whose urine twenty years ago, after puer- 
peral convulsions, contained albumen and casts. She has had one and, 
I think, two children since without convulsions, but the morbid ele- 
ments have been found from time to time ever since. The patient was, 
a few months ago, when I saw her, quite as healthy looking as most 
women of her age, and had no definite symptoms to complain of. 
An attack of scarlatina so slight as hardly to be diagnosticable other- 
wise, may leave behind, for some time aftei' the patient is apparently 
well and after albumen has disappeared, a few casts. 
The atrophy of old age has already been spoken of. 
The difficulties of diagnosis may be considerably increased by the 
presence of other symptoms, and the resemblance between a case pre- 
senting the signs under consideration, with, for instance, severe head- 
ache, and a case of genuine Bright's is very close. No general rule 
can be laid down. A diagnosis depends upon the study of the indi- 
vidual case, and it may require the lapse of time to make it sure. 
III. Renal Inadequacy. 
The phrase renal inadequacy, used upon our programme, may be 
made to bear several shades of meaning, one of which, attached to it 
especially by one whom we hoped would be our guest, I shall for a 
moment omit from consideration and, for the earlier purposes of this 14 
EDES, 
discussion, shall consider only a supposed inability of the kidney, arising 
from incipient organic disease, to perform its function of excreting water, 
urea, or the total solids. I must make this limitation, because the data, 
which are none too abundant as regards even these substances, are very 
deficient for any other of the constituents. 
What is to be learned from the diminution of any of these con- 
stituents that is of value in the diagnosis or prognosis of renal disease? 
It is, of course, acknowledged, and it is unnecessary to dwell further 
upon this fact, that an extreme oliguria or anuria is a symptom calling 
for an immediate investigation, probably, but not necessarily, con- 
nected with renal disease, and which may carry with it an extremely 
serious prognosis. A continued diminution of all the constituents 
may have less weight in the same direction, but its existence is not 
to be assumed on the basis of a single hasty examination. 
A point of much greater interest, as being less well determined, is 
whether we can diagnosticate the early stage of chronic nephritis by a 
moderate diminution in the amount of any of the urinary constituents. 
The quantity of water is well known to be subject to such individual 
differences and such fluctuations under various influences that no 
slight and temporary changes can prove anything, and when the 
urine in any form of nephritis is permanently diminished to a point 
decidedly below the physiological limit the diagnosis is usually to be 
made on other grounds than the quantity of the urine or of any of its 
constituents alone. Such a condition is likely to occur long after the 
diagnosis has been clearly made out, but a knowledge of it may be 
of service in anticipating the onset of other symptoms. 
There is, however, a statement made which I believe to be mis- 
leading, if not baseless. Polyuria is now a well-recognized symptom 
of many lesions of the genito-urinary tract, and, barring certain 
nervous conditions which may produce it by changes in the blood- 
pressure, and surgical lesions, which act either in a similar way or by 
the direct effect of back pressure on the secreting structure, and not 
infrequently lead to a form of nephritis, it is strongly significant of 
chronic interstitial nephritis. It is one of the most important symp- 
toms, should always lead to further investigation, and the reality of 
its presence should always be determined by measurement. 
This urine is of low7 specific gravity, and is often said to be deficient 
in urea. This statement may mean that the percentage is below the 15 
BENAL INADEQUACY. 
average, which, of course, may be understood of itself, and has no 
value whatever for diagnosis, so far as single specimens go, or it may 
mean that the total daily amount of urea is below a certain quantity 
fixed upon as a standard. The latter ought to be the invariable 
meaning, but it is not so, and unfortunately it is impossible to tell, in 
a great many analyses, which of these is intended by the chemist. 
When, however, the statement is made in this correct sense, it is not 
to be accepted without reserve until we know what is to be the standard. 
The statement of many text-books is that from thirty to forty 
grammes is a normal, daily excretion of urea for a healthy man on an 
ordinary diet. This, however, is subject to many corrections, of which 
the most important (in health) is food. Some French writers assign 
a lower figure, and intimate that there may be differences of race or 
habits between the Germans and English on the one hand, and the 
French on the other. It is much more probably a difference in habits 
of diet than of race, for there are series of French observations (Roux, 
Archives de Physiologic, vol. vi. p. 593) in which the daily urea is 
never below 30 for days together, and not infrequently rises above 40. 
Without attempting to gather a large number of determinations for 
the purpose of establishing an average, I have found enough in books 
upon which I can easily put my hand, to show' that a much smaller figure 
than this is not below the physiological limit: Lehmann {Physiological 
Chemistry}, vegetable diet, 22.5 ; non-nitrogenous, 15.4.1 Eustratiades 
(quoted by Rabuteau), averages of successive weeks, 22, 20, 24 ; under 
coffee, 19, 17. Rabuteau {Elements de T herapeutique, p. 96), 20, 
22, 18, 19. Bocker (quoted by Marvaud, AZmente d' epargne}, 
22.27 ; under coffee, 12.58. Mason {Boston Med. and Surg. Journal, 
1882, vol. cvii. p. 222), 20, 22.44. Brouardel {Arch, de Phys., vol. 
viii. p. 388), 18 to 20, or 22. Debove and Flamant {Gaz. Heb. de 
Paris, June 18, 1886) give two tables of the excretion of urea, the 
first of a patient weighing 58 or 59 kilos, who had a daily quantity of 
urine varying from 440 to 1240 per diem, with urea from 13.38 to 
24.42, and total solids from 24.64 to 39.6. With the second, weigh- 
ing about 40 kilos, the quantity was from 510 to 1010, and the urea 
from 13 to 22.58, and total solids from 31.62 to 53.76. 
In The American Journal of the Medical Sciences for Oct. 1867, 
Noyes presents several elaborate and interesting tables concerning 
1 These and the subsequent figures refer to grammes in twenty-four hours. 16 
EDES, 
the elimination of urinary constituents by four persons, two males and 
two females, whom he apparently considered to be in health, or, at 
any rate, fair subjects for a physiological determination. That he 
was right in the latter opinion is evident from the fact that none of 
the numerous figures was sufficiently different from the others to be 
thrown out, but there are some points about one of them which will 
make it especially interesting for our purpose. The averages for suc- 
cessive weeks for these four persons were : mixed diet, 15.56 grammes; 
animal diet, 41.98; vegetable diet, 10.55; exercise (not excessive), 
10.32. On two other weeks Noyes determined on himself averages 
of 15.55 without, and 16.80 with coffee. A seventh week to determine 
the influence of sleep gave 6.50 for the night, and 8.61 for the day, a 
total of 15.17. Total solids, corresponding to these weeks, calculated 
from the specific gravity, are, omitting fractions, 43, 64, 37, 29, 40, 
41, 47. It is universally stated that a low diet may reduce these 
figures much further, so that we may find a patient excreting less than 
ten grammes of urea per day, without special reference to the condition 
of the kidney. 
It is well known since the recent advances in abdominal surgery 
that the secreting substance of the kidney may be reduced at least 
one-half without prejudice to the elimination, and it is, therefore, to 
be expected that chronic nephritis should have advanced to a con- 
siderable degree of atrophy before it begins to make itself manifest by 
diminution in the secretion. So far as water is concerned, we know 
that the destruction may be extreme, while the kidneys are still carry- 
ing on a discharge of two or threefold the normal amount. For the 
solid elements it is probable that the capacity may not go quite so far, 
but the following figures will show that long after nephritis can be 
clearly diagnosticated the discharge of urea and of total solids may be 
well above the physiological minimum; indeed, in some cases they 
may run side by side with the corresponding figures for healthy per- 
sons on the same diet. The physiological variations in the urea dis- 
charge would indicate very plainly the probability of this. Organs 
which can, on occasion, double their capacity of discharge as do the 
kidneys on a full meat diet (take, for instance, cases of diabetes as well 
as Noyes's figures just given) without harm, certainly ought to be 
able to lose a considerable percentage of secreting surface before they RENAL INADEQUACY. 
17 
become unable to take care of the much smaller but still normal 
quantity which is formed on a much less nitrogenous diet. 
The cases given here are, of course, selected. It is not meant 
that under all circumstances, in nephritis, the kidneys carry off all 
the solids formed, but that they can continue to do so long after a 
diagnosis is possible on other grounds, unless in certain cases in which 
a nephritis makes considerable advances without the detection of albu- 
men or casts or any other decisive symptoms. Such cases are talked 
about and are conceivable, but are much more likely to be the results 
of examinations not having been made than of their having given 
negative results. 
Fleischer (Deutsches Archiv fur Idin. Med., xxix., 1881) reports 
the following cases: 
A woman, aged thirty-five years, with abundant urine containing albumen 
and casts and having slight oedema, headache, vertigo, and pain in the back 
and limbs, had the urine carefully examined daily with comparison with a 
healthy person on the same diet (Control-person). The urine was always 
more abundant, although that of the Control-person was quite copious, while 
for twenty-one days the urea discharged was 32.38 as against 32.33 of the 
healthy person. The respective quantities of phosphoric acid were 1.64 
and 2.51 per cent. 
A woman, aged twenty-one years, with a diagnosis both before and after 
death, of extreme granular atrophy of the kidneys, had for two days 26.2 and 
25.2 per cent, of urea, which was less than that of the Control-person but not 
below the physiological limit. Then there was a period of diminished excre- 
tion corresponding to an uraemic attack and, subsequently, on three successive 
days, it amounted to 43.1, 40.8, 29.7 per diem. This was about three weeks 
before death, and shows that a very badly damaged kidney can, for a time at 
least, get rid of a superfluity of urea, and also that in the production ot 
uraemic attacks by retention of the products of secretion something more than 
the structure of the kidney must have been at fault. The phosphates went 
through a similar fluctuation. 
Another " Schrumpfniere," without a Control-person, passed 30.07 per cent, 
of urea for seven days. Another, an average of 24.7 per diem. 
In another case which seems peculiarly fitted to show the value of different 
means of diagnosis at an early stage, a man of thirty-one who had albumen 
and casts but no hypertrophied heart, gave an average for seven days of 40.9 
per diem. After a year there was still albumen and his aspect was less 
blooming, but no symptoms of hypertrophy of the left ventricle could be 
made out. 
A weakly child, eight years old, with great oedema and ascites, the urine 
containing much albumen, casts, and fatty epithelium, whose post-mortem 18 
EDES, 
diagnosis four months later included pleurisy, peritonitis, fatty and amyloid 
degeneration of various organs, as well as of the kidneys, passed a daily 
average of 8.88 per diem of urea against 9.91 per diem of the Control-person. 
In these as well as in other cases examined by Fleischer, the dimi- 
nution of uric acid and phosphoric acid was more constant than that 
of the urea or the chlorides. 
In the interesting tables by Noyes, already cited, the second of 
the four persons under observation, aged fifty-eight years, constantly 
passed a urine of low specific gravity and in quantity considerably larger 
than that of the other persons upon the same diet, being most of the 
time near or above 2000 c. c. His total daily urea did not fall below 
that of the others, nor did the proportion per kilo of body-weight 
constantly do so, and when the amount of meat was much increased, 
his excretion of urea increased as much as that of the others and 
became as much above the physiological average as (with the others) 
it had been below on a vegetable diet. 
No examination of the urine for albumen and casts is noted in any 
of these cases, but so constant an increase of quantity and diminution 
of specific gravity in a person not stated to have any peculiarity in 
the matter of beverages, would certainly, at present, be considered of 
itself alone, very strong presumptive evidence of interstitial nephritis, 
and when it is learned that this person had hemiplegia two months 
afterward, it seems highly probable that the author was making some 
observations of a very valuable kind without realizing that they were 
pathological. At that time polyuria was not so well recognized a 
symptom as it is now. 
Oppenheim (Inaug. Thesis, Bonn, 1881) in a case of acute neph- 
ritis found the urea constantly increased-twenty-nine to forty-eight 
grammes. 
In a case of my own, a man of thirty-five, who had been known 
to have interstitial nephritis for at least two years, I have found 
this summer, calculating that the two specimens he has each time 
sent me were fair representatives of the day and night respectively, 
and that the larger portion is passed during the day, in June, 25.7 
per diem of urea and 43 per diem of total solids (the solids by calcu- 
lation from the specific gravity); in July, 34.4 of urea and 54 of 
solids; and in August 30 of urea and 53 of solids. As the urine con- 
tinues to be in about the same quantity 1 presume that these figures RENAL INADEQUACY. 
19 
represent nearly an average of what has been passed for some months. 
Some days after a hemiplegic attack, the 24 hours urea was 22.5. 
We may add to these cases some others in which the urea was not 
determined but in which the total solids may be calculated from the 
quantity and the specific gravity. 
Phillips's {Lancet, Dec. 12, 1885) patient, set. sixty-seven years, 
cirrhotic kidneys, 67 grammes solids. 
Charpentier's {These de Paris, 1880) patient, mt. forty-seven years, 
headache, hypertrophy of heart, tuberculosis, diagnosis of interstitial 
nephritis. Total daily solids, 69. 
Female, set. fifty-five years, arterial nephritis. Solids 48. 
Female, set. fifty-five years, interstitial nephritis without albumen. 
Solids 28. 
A male, set. fifty years, with lead poisoning, emaciated, anaemic, 
with osteitis of ribs and beginning pulmonary tuberculosis. There 
was a diagnosis of some renal lesion, the urine was in quantity 2500 
and of specific gravity 1.010, which gives the solids as 57 grammes. 
In a thoroughly typical case of my own there were found at various 
times, the last not long before death, 87, 77, 51, 18, 100 of solids. 
These cases are certainly enough to show that the excretion of urea 
and of the total urinary solids does not necessarily fall below that of 
a person in health on a diet of moderate nitrogenous richness. These, 
however, are all cases readily diagnosticated, and some of them of long 
standing and far advanced, so that it may safely be concluded that in 
cases which are less so, in which the diagnosis is still doubtful, the 
determination of urea is still less likely to give us assistance. 
A suggestion, offered by some of Fleischer's cases, is worth following 
out: whether some of the other constituents, like uric acid, the phos- 
phates, or sulphates, would give more valuable results. I have made 
no special examination in this direction, but certainly a deposit of uric 
acid in urine of low specific gravity is no unusual condition in Bright's 
disease. 
This argument might be much strengthened, if it needed it, by 
reference to other conditions in which urea is found diminished. In 
disease of the liver it may fall below the normal, and in some acute 
affections of this organ it is said to have been absent. In these latter, 
however, it is highly probable that the kidneys also were profoundly, 
though rapidly, affected, as in phosphorus poisoning. 
Impaired nutrition in general, with anaemia in its various forms, is 20 
EDES, 
the most frequent cause of diminished urea. It is not passed, simply 
because it is not made, and its deficiency in a given case, in the absence 
of other symptoms which may fix the diagnosis more exactly, justifies 
us only in supposing that it is due to some one of many diseases in 
which nitrogenous metamorphosis is interfered with, of which Bright's 
disease is only one. In a large proportion of cases a considerable 
diminution of urea is more significant of disorder of appetite, digestion, 
and tissue metabolism, than of any failure of the kidneys. There may 
come a time, and, as wre occasionally see, it may come unheralded, 
when a new set of symptoms indicate that even a small amount of uri- 
nary solids can no longer be taken care of by the atrophied, or degen- 
erated, or paralyzed kidneys. 
The term renal inadequacy has been recently employed in a sorae- 
what special sense, not exactly corresponding to that in which I have 
been considering it, by a gentleman who was expected to give us his 
views in his own words. Sir Andrew Clarke says: "By renal inade- 
quacy I mean that state of the kidney in which it is unable, without 
material diminution of quantity, to produce a urine containing the 
average amount of solids, and of a specific gravity greater than 1.014." 
The urine is described as pale, almost invariably free from albumen, 
and depositing no casts. The (conjectural) state of the kidneys is one 
of slight withering and induration. The physiognomy is like that of 
pernicious anaemia, on the one hand, and, on the other, like that of 
chronic Bright's, and yet seems distinct from both. 
What interpretation are we to put upon this description ? If there 
really are withering and induration of the kidneys, what can they be 
due to but interstitial nephritis? The account of some of the symp- 
toms would not be inconsistent with the hypothesis of a slowly ad- 
vancing cirrhotic kidney. We know that this progress may take place 
without albuminuria for a time, and it is said for a long time; but too 
much has been made of some exceptional cases. If one were to lay 
great stress on these exceptions, and view them in the light of the dis- 
coveries of the general distribution of albuminuria detailed in the 
earlier part of this paper, he might be led to the conclusion that but 
few people fail to present the symptoms of Bright's disease except 
those who really have it. 
With a not inconsiderable experience with chronic nephritis in 
various forms, I must say that I have not met with many, and I 
should not be much afraid to say any, cases in which albumen and casts 21 
RENAL INADEQUACY. 
could never be found, and although a few such cases are detailed as 
exceptionally interesting, they are not at all common even in literature. 
I think it has been very clearly shown that the kidneys are able to 
carry off the full amount of solids formed long after more than slight 
shrivelling and induration have taken place; so that if we admit this 
to be a special form of disease, and if there is any special obstacle to 
the passage of the urinary solids, it must be of a functional, and not 
of an organic character, the existence of which is a pure hypothesis, 
so far as any chronic condition is concerned; or else the lesion is one 
already advanced, and one which has been making its progress with 
very few symptoms. 
Another very strong point against the assumption that a diminished 
discharge of the urinary solids in such cases means any inability of 
the kidney, either functional or organic, is, that it is specially stated 
that if the supplies of food and wine are cut down, the amount of urea 
increases. This is easily to be accounted for if we suppose the dimin- 
ished urea to be due to a form of dyspepsia, or, in other words, if a 
large amount of food passes off by the intestines without ever being 
received into the blood, where it can further undergo the metamor- 
phosis into urea. A proper regulation under these circumstances 
would, undoubtedly, lead to improved nutrition and increased secre- 
tion. The specification of wine is somewhat significant in this point 
of view, since alcohol furnishes but little to the solids of the urine, but 
may have a very decided effect in impairing the digestion, and is well 
known, when taken in considerable quantities, to reduce the amount 
of urea with a possible, but not proportionate, increase of uric acid. 
If the kidneys are already inadequate to carry off a small amount of 
urea, how can a change of diet in the direction of restriction increase 
it ? If more nitrogenous material gets into the blood because the 
digestion is improved, as has just been supposed, and the kidneys are 
already inadequate to carry off the smaller amount of urea the only 
result can be an accumulation and not increased discharge. If, how- 
ever, the previous digestion has been complete it is difficult to see how 
a smaller amount of excrementitious solids in the blood can make the 
amount which passes off any greater. If the kidneys are carrying off 
all they.are capable of, then neither increasing nor diminishing the 
urea of the blood can make them do more. If they are not carrying 
off all they can, then a diminished amount proves no inadequacy on 
their part to their task, and the deficiency is to be sought in the 
limited formation. 22 
EDES, 
Author. 
Reference. 
Class of cases. 
Num- 
ber 
exam- 
ined. 
Albu- 
men 
found 
Per 
cent. 
Albumen 
in larger 
amounts, 
or by ordi- 
nary tests 
12-25 
c.gr. 
per 
litre. 
Less 
than 
12, 
trace. 
Remarks 
Clarke, 
Brit. Med. Journ., Aug. 16, 1887, 
Persons expecting 
20 
• 3 
15 
examination, 
Leube, 
Virchow's Arch., vol. 72, 
Healthy soldiers, 
119 
19 
16 
Not more 
After exercise. Before exercise, morn- 
than 0 1 
per cent. 
ing urine 4 per cent, albuminous. 
Cylinders and blood corpuscles not 
Fiirbringer, 
Ztschr. fiir klin. Med , 1879-80, 
Children, 
61 
7 
11.5 
found. 
Munn, 
Medical Investigations in Life In- 
Applicants for life 
630 
59 
10.6 
Tested by boiling. 
suraiice. 
insurance, 
Kleugden, 
Arch, fiir Psych., 1880-81, 
Attendants in 
32 
14 
43 5 
8 
6 
asylum, 
Grainger Stewart, 
Brit. Med. Journ., June 11, 1877, 
• Soldiers, 
205 
37.6 
« ll 
il il ll ll 
Civilians, 
Children, 
74 
10.8 
ll ll 
Cl < I ll ll 
40 
17.5 
ll il 
il it il ii 
Workhouse inmates 
40 
67.5 
aged about 60, 
Van Noorden, 
Deutsch. Arch, klin Med.,1885-86, 
Soldiers, 
53 
8-10.5 
Mucous threads. 
Capitan, 
Inaug. These, Paris, 1883, 
Soldiers, 
98 
44 
45 
• * 
•* it H H 
Children, 
97 
86 
89 
De la Celle, 
«< ll ll ll 
Infantry, 
120 
92 
77 
22 
ll ll 
41 Cl ll ii 
Cuirassiers exercis 
ing, 
Soldiers returning 
88 
70 . 
79.5 
1 
17 
... 
Cl ll 
111 
100 
90 
4 
ll ll 
CC ll CC It 
from review, 
Cuirassiers just 
31 
31 
100 
10 
De la Celle In 701 persons in health, 
vaccinated, 
17 give more than 30 cgr. per litre; 
ll ll 
ll ll Cl ii 
Students, 
50 
46 
92 
29 
152, 12 to 25 cgr. per litre. 
ll ll 
ii il ll ll 
Children, 6 to 15, 
61 
49 
80 
9 
ll ll 
ii ll ll cl 
Children, 6 to 15, 
81 
62 
76.5 
5 
ll ll 
•• U M H 
Infantry (cold bath) 
53 
53 
100 
io 
17 
ll ll 
H fc k kk kk 
Soldiers after food, 
94 
74 
79 
9 
Leroux, 
Revue de Med., Paris, 1883, 
Children, 
330 
19 
5 
Roberts, 
Urinary and Renal Diseases, 
Candidates for life 
31 
29 
0 
No albumen by nitric acid or heat. Acid 
insurance, 
brine (11), picric acid (14), tungstate 
(28), mercuric iodide (29). Author 
suspects mucin. 
Note.-The writer hoped to be able to include the extensive statistics of Dr. Shepherd, of Hartford, but they are not yet published 
Table I-Albuminuria among Persons supposedly Healthy. DISEASES OF THE KIDNEY. 
23 
Author. 
Reference. 
Class of cases. 
Num- 
ber 
exam- 
ined. 
Casts found. 
Remarks. 
Moxon, 
Guy's Hospital Reports, xxiii. 
Young man, 
Very few', 
Albumen of adolescence ; later renal calculus. 
Dukes, 
Brit. Med Journ., Nov. 12, 1881, 
Young men, 
• 
...... 
Some transient; some recover after years, large proportion first 
After bathing [stage Bright's disease. 
Johnson, 
Brit. Med. Journ., Dec. 6, 1873, 
Young men, 
... 
None, 
Vogel, 
Virchow's Handbuch, vi. 
... 
None, 
Cases observed by the year. No symptoms. May be slight or- 
Lancet, Oct. 17, 1885, 
Brit. Med. Journ., i. 271, 1876, 
ganic changes. 
Pavy, 
Pavy, 
Men mostly young, 
None, 
Cyclic and intermittent Oxalate of lime. No bad health. 
Weston (the pedestrian), 
Abundance, hya- 
During walk. In 1888 in active business. 
line and granul. 
Ultzmann, 
Wiener med. Presse, Jan. 23, 1870, 
Physicians, 
8 
None, 
Urine clear, dark, acid, 1025 to 1035 ; nothing else abnormal. 
Albumen after exertion. Supposes no renal disease (excludes 
Edlefsen, 
Mittli. Ver. Hehl Hoist. Aertz , 
3 
Not mentioned; 
1866 to 1881, 
a few times. 
doubtful opalescence). 
Fiirbringer, 
Zeitschr. klin. Med., 1879-80 
Officers, young physc'ns, 
Small cylinders, 
Officers after exertion, urine scanty, saturated, containing uric 
blooming young people. 
acid gravel. 
Marcacci, 
L'Imparziale, May 12,1878, 
Young physician (self), 
None, 
Albumen absent from night urine ; present in day ; increased by 
exercise [by rest. 
Rooke, 
Brit. Med. Journ., Oct. 19, 1878, 
Young woman, 14 to 16, 
Intermittent; none in morning; always at night ; disappeared 
Kinnicutt, 
Arch, ot Med., 18s2, 
Young persons, 
... 
None, 
Transient; some associated with high specific gravity ; uric acid, 
oxalate of lime ; arterial tension low'. 
Simmons, 
Sacramento Med. Journ., April, 
Young physician, 
None, 
Cyclic ; none in early morning ; concentrated, four years' stand- 
ing ; now' absent; oxalate of lime ; uric acid. 
Cyclic ; none in early morning ; maximum at 8 A. M , and in 
1887, 
Canfield, 
Phila. Med. News, 1887 
Man, aged 32, 
None, 
evening ; well. 
Klemperer, 
Deutsch. Arch. f. klin. Med., xii. 
Student, 
Cyclic; maxima very nearly as above. 
(as quoted by Canfield), 
[also. 
Stokes, 
Lancet, .March 10, 1888, 
Lancet, March 10, 1888, 
None, 
Four years; lithiasis from beer : when lithiasis abates albumen 
Albumen twenty years ; now prostatic and cystic trouble. 
Stokes, 
Athlete, 
Ralfe, 
Lancet, ii., 1886, 
Man, 
N one, 
Albumen six years ; urine pale, abundant, density high, much 
pigment 
Fergusson, 
Brit. Med. Journ , ii., 1878, 
Youth of 17, 
Not mentioned, 
Albumen five years ; puffiness of eyelids. 
Rendall, 
These de Paris, 1883, 
Very rarely, 
None in those in 
Albuminuria from digestion (hematogenous). 
Engel, 
N. Y. Med. Rec., Oct. 1882, 
Several young men, 
Occasional albuminuria after unusually heavy meal. 
which mention'd 
Engel, 
N. Y. Med. Rec., Oct 1882, 
Two young men, 
Present, 
Later symptoms of renal disease more marked. 
Merklen, 
Med. Press and Circular, p 7, 1885. 
Young man, 16 (symp- 
None, 
Rather weakly ; albumen from noon to midnight; more in night. 
toms acute), 
Fisch 1, 
Deutsch Arch, klin Med., xxix. 
Patients mostly with 
10 
None, 
Albumen temporary. 
217, 
gastric or hepatic colic, 
• 
jaundice, 
Fi sclil, 
Deutsch. Arch.kl in. Med., xxix. 217, 
Metrorrhagia, collapse, 
4 
Few, 
Albumen temporary. 
Bull, 
Nordiskt Archiv, 
Physician, aged 27, 
Continued at least two years. 
Kinnier, 
N Y. Med. Record, June 19, 1886, 
Young men, 
3 
None, 
Albumen during middle of day. 
Coupland, 
Lancet, July 10, 1886, 
Girl of 16, 
... 
None, 
No albumen in morning; later, irregularly present; no crystals 
of uric acid or oxalate. 
- 
- 
- 
Table II.-Albuminuria of Adolescents, Cyclic and Accidental Albuminuria. 24 
EDES, DISEASES OF THE KIDNEY. 
Table III.-Albuminuria among the Sick. 
Author. 
Reference. 
Class of cases. 
Number 
examine 
Albumen 
found. 
Per 
cent. 
Saundby, 
Brit. Med. Journ., May 10, 1879, 
Out-patients, 
145 
105 
Stewart, 
Brit. Med. Journ., Oct. 15, 1887, 
Private patients, 
150 
36 
Stewart, 
Indoor infirmary, 
150 
74 
Stewart, 
• i ll U Cl 
Outdoor infirmary, 
100 
19 
Stewart, 
Cl Cl ll ll 
Sick children, 
50 
7 
Stewart, 
Cl ll ll ll 
Fever hospital, 
50 
33 
... 
Stewart, 
ll ll CC ll 
Maternity, 
25 
18 
Kleugden, 
Arch, f Psych., 1880-81, 
Blale epileptics, 
33 
13 
Kleugden, 
>< <> « 
Insane, 
60 
11 
Capitan, 
Van Noorden, 
Inaug. Thiise, 
Deutsch. Arch. f. klin. Bled. 
Various diseases, 
mostly acute, 
Surgical and 
ophthalmic cases, 
? 
112 
Large 
number 
31.3 
Table IV.-Opinions. 
Gull, 
Guy's Hospital Reports, xxiii. 
(Reported by Moxon ) 
Albuminuria as common as spermatorrhoea. 
Johnson, 
Brit. Med. Journ., Dec. 13, 1879. 
Latent albuminuria means serious trouble. 
Teissier, 
Lyon M6d., 1887. 
Subjects of cyclic albuminuria ; probably all 
destined to become gouty. 
De Haviland Hall, 
Lancet, Feb. 18, 1888. 
Albuminurics should not be assured. 
Pye-Smith, 
Guy's Hospital Reports, vol xix. 
No person who has albuminous urine (by usual 
tests) cau be considered eligible for life in- 
surance.