although the finding of cicatrices in kidneys where symptoms of renal
phthisis have been present suggests that it is possible for caseous
masses in these organs, as well as in the lungs, to undergo absorption
and healing.
The TREATMENT must be, in the first place, constitutional by tonics and
reconstituents, and local by the use of such antiseptics as are
eliminated through the kidney, as boric or benzoic acid or the
benzoates. But little, however, is to be expected from it.
Parasites.
The most important parasite which is known to inhabit the kidney is the
immature tapeworm of the dog, or Tænia echinococcus. It is decidedly
rare in this country to meet with this affection in any part of the
body, and as the kidney is not one of the organs most likely to be
chosen as its habitat, the condition is not one which comes often under
the observation of physicians.
{66} It is hardly necessary to describe here the structure or contents
of the hydatid cyst which forms the home of the parasite, nor its
etiology, since these topics belong to general pathology, and the cyst
is the same in whatever organ it may be seated. When it affects the
kidney, it is usually the left--more frequently that of a man between
thirty and forty years of age.
A hydatid cyst may be situated upon any part of the kidney. If small,
it may never make its presence known. A larger one may give rise to
those vague pains in the back found with so many diseases of the kidney
and characteristic of none of them. A cyst may open in any direction,
but is more likely to empty into the pelvis of the kidney. When this
happens, the smaller cysts or pieces of the larger ones often enter the
ureter and give rise to renal colic, and possibly, later, to a
pyelitis. Other points of discharge are the intestines, the lungs, or
the abdominal walls.
After a hydatid cyst has reached a certain size its presence may be
recognized by palpation, but the diagnosis between it and other tumors
of the kidney must be very difficult unless characteristic fragments
make their appearance in the urine at the same time that the tumor
diminishes in size, or unless they can be obtained by puncture. The
hydatid thrill, if it can be obtained, will be an important factor in
diagnosis.
The TREATMENT of this affection in the kidney presents no special
points of difference from that of similar cysts in the liver; with this
important exception, that besides punctures with large and small
trocars, incisions, electrolysis, etc., the resource of complete
extirpation still remains. Cures have been obtained by repeated
punctures and subsequent suppuration, and by partial removal through
the abdominal walls and subsequent drainage.
Among the parasites of the kidney it is customary to mention the
Strongylus gigas, which is a worm somewhat resembling the ascaris and
inhabiting the pelvis. It is not very infrequent among the Carnivora,
but since only seven cases have been described in the human subject
since the seventeenth century, and only a part of these are admitted as
genuine by certain authors, its diagnosis, prognosis, and treatment
must depend more upon theory than upon experience. The diagnosis is to
be made, if at all, on the basis of a pyelitis and the discovery of the
eggs of the parasite in the urine.
The Distoma hæmatobium is a parasite found chiefly in the
blood-vessels, and especially those of the portal system. It is
occasionally, however, met with in the veins of the kidney and also in
the urinary passages. Its eggs pass into the pelvis and ureters, and
there begin their development, which, however, is soon arrested, as
they rapidly perish in the urine.
These parasites appear to produce either by a direct action or by the
occlusion of vessels, ulceration, and hemorrhages from the urinary
mucous membrane, including that of the bladder. These effects are
supposed to be due to the blocking of the smaller vessels by the worms
themselves. An adherent deposit consisting of masses of distoma eggs
and grains of uric acid sometimes forms in grayish-yellow patches
within the ureter, and gives rise to stricture, with dilatation and
hydro-nephrosis above. This parasite has been considered the cause of
the endemic hæmaturia of hot countries, but as cases of this affection
have been carefully examined {67} for the distoma with negative
results, it must be considered as only one among several causes.
Strongyli are said to have been found in some of the cases.
Nothing is known of an appropriate TREATMENT for the distoma. An
abundant flow of urine might perhaps carry off more rapidly such
individuals as have found their way into the urinary passages, and,
considering the character of the deposit described above as causing
stoppage of the ureter, treatment directed against the uric-acid
diathesis might diminish the risk of this particular form of trouble.
Diseases of the Ureters.
Absence of the ureter may take place when one kidney is congenitally
absent, though this is not an absolute rule, since the ureter may
terminate above in a rounded sac. When a single kidney exists,
consisting of the fusion of two, there are usually two ureters opening
in the usual position. In one instance, in which only one kidney and
one ureter were present, the ureter opened into the bladder on the side
opposite to that upon which the kidney was situated.
Not very infrequently two ureters exist in connection with a normal
kidney, remaining separate for the whole or a part of their course to
the bladder. This condition is merely a sort of exaggeration of the
separation between the two branches of the renal pelvis.
A few instances have been noted where a ureter or a fistula connected
therewith has opened outside of the bladder at a point near the
urethra. This malformation gave rise to symptoms of incontinence of
urine, and in one case was remedied by operation.
Abnormal openings of the ureter into the uterus and vagina as the
results of pelvic inflammations, and upon the external surface as the
result of wounds, have occurred. They are more or less amenable to
surgical treatment, and belong to the domain of surgery and gynecology
rather than to medicine.
Occlusion of the ureter has already been spoken of in connection with
the hydro-nephrosis and pyelitis to which it gives rise. This occlusion
results from pressure exerted either at the vesical orifice from
cystitis; a little higher up from malignant disease connected with the
uterus or a fibroma surrounding the ureter; from contracting adhesions
resulting from pelvic inflammation; or from sharp flexions of the tube
itself, perhaps also from valvular folds of the mucous membrane.
Sometimes its obliteration seems to be the result of old inflammation
of the mucous membrane of the ureter itself in connection with that of
the renal pelvis. In the latter case the occlusion may be complete at
several points, while at others a collection of dry, cheesy, or
putty-like material occupies the cavity of the ureter as well as the
pelvis of the atrophied kidney.
Cancer is not known primarily to invade the ureter.
Tubercle is not infrequently found in the form of small granulations in
cases of general tuberculosis, and it is possible that this deposit may
be among the earlier ones; hence a chronic catarrh of the urinary
passages without some known cause should be looked upon with suspicion,
{68} and the development of phthisis as far as possible guarded
against. The presence of these small tubercles in the ureter, if none
are present or no ulceration exists in the kidney, are of little or no
local importance.
Inflammation of the ureter often exists in connection with cystitis and
pyelitis, and in fact constitutes the means by which the higher urinary
passages become gradually involved in the diseases below.
The DIAGNOSIS of this condition as a distinct disease is hardly
possible, and is besides unnecessary, as the treatment to be directed
thereto would be included in that called for by the more extensive and
obvious inflammation of the kidney and bladder.
{69}
DISEASES OF THE PARENCHYMA OF THE KIDNEYS, AND PERINEPHRITIS.
BY FRANCIS DELAFIELD, M.D.
CHRONIC CONGESTION OF THE KIDNEY.
SYNONYMS.--Passive congestion; Cyanotic induration.
It is now generally recognized that we must separate from the other
forms of kidney disease the condition of chronic congestion. Since
Traube first called attention to the causation and characters of this
lesion, all authors have recognized its special character, although
there are still minor differences of opinion concerning it.
ETIOLOGY.--Chronic congestion of the kidney may be produced by any
mechanical cause which interferes with the escape of the blood from the
renal veins. Thrombi of the veins, tumors pressing on the veins,
emphysema of the lungs, hydro-pneumothorax, pericarditis,--all may
produce this lesion. As to how often it is produced by the pregnant
uterus is still a question. But the most common cause of all is organic
disease of the heart. Practically, the lesion comes under consideration
as a complication of heart disease, of aneurism of the arch of the
aorta, and of emphysema of the lungs.
LESIONS.--If the congestion has not existed for a long time, we find
the kidneys increased in size and their weight great in proportion to
their size. They are of an unnatural hardness--a hardness which can be
imitated by injecting the blood-vessels of a normal kidney with water.
The capsules are not adherent, the surfaces of the kidneys are smooth.
Both the cortical and pyramidal portions are congested, and this
congestion gives the entire organs a peculiar reddish, livid color. No
lesions are found in the Malpighian bodies, tubes, stroma, or
blood-vessels, except that the epithelium of the convoluted tubes may
be a little swollen.
If the congestion has lasted for a longer time, the kidneys may
continue to be large or they may be somewhat reduced in size; the
weight remains out of proportion to the size. There are the same
unnatural color and consistence. The capsules are now often slightly
adherent and the surfaces of the kidneys finely nodular. In the cortex
there may be patches of new connective tissue enclosing atrophied
tubules, or there may be a more diffuse growth of connective tissue
separating the tubes from each other. In the convoluted tubules the
epithelial cells may be swollen and finely granular, or very much
swollen and coarsely granular, so as to nearly fill the tubes, or
flattened so that the cavities of the tubes are {70} unnaturally large.
The tubes may also contain cast-matter and detached and broken
epithelial cells. The capsules of the Malpighian bodies may be a little
thickened and the capsular endothelium swollen. In the pyramids the
epithelium of the straight tubes may be granular and detached, and
there is often cast-matter in the looped tubes. It is difficult to tell
whether there is any real change in the veins of the kidney.
As a result of the same interference with the venous circulation,
similar changes are found in other parts of the body--in the lungs,
liver, spleen, stomach, small intestine, and pia mater. In all these
organs there is, first, simply a venous congestion, then after a time
structural changes are added. Formation of new connective tissue and of
new functional cells of the particular organ, degeneration of these
cells, dilatation and tortuousness of the small veins and capillaries,
are regularly present. The kidney lesion, therefore, is only one of a
number of lesions, all dependent on a common mechanical cause.
SYMPTOMS.--Of the persons who die with chronic congestion of the
kidney, a large number present marked symptoms during life, but it is
difficult to determine how largely these symptoms are due to the
congestion of the kidney.
A congestion of the kidney of only a few days' duration does not seem
usually to give rise to any symptoms. Even if such a congestion is
prolonged to two or three weeks, as we see in some cases of
hydro-pneumothorax from perforation of the lung, there may be no renal
symptoms and no changes in the urine. On the other hand, it is
extremely rare for organic heart disease or emphysema of the lungs to
prove fatal without some disease of the kidneys.
The question is still further complicated by the fact that both in
cardiac disease and emphysema there may be either chronic congestion of
the kidney or chronic diffuse nephritis with the same symptoms.
After excluding the cases of cardiac hypertrophy secondary to kidney
disease and the cardiac diseases with complications, I find in my
casebooks 137 cases in which the patients died simply from heart
disease, changes in the viscera due to the disturbance of the venous
circulation, and kidney disease. Of these cases, 84 presented the
lesions of chronic diffuse nephritis; 53 were in the state of chronic
congestion. Of the cases of chronic diffuse nephritis, 27 were large
white kidneys, 29 atrophied kidneys, 28 could not be classed as either
large white or atrophied. In these cases there existed during life
certain regular symptoms. There were changes in the urine, dropsy,
headache, delirium, convulsions, coma, dyspnoea, vomiting, cough,
hæmoptysis, loss of flesh and strength.
As regards the quantity of the urine, there was a very great variety
until shortly before the patient's death; then the urine was usually
diminished in amount, sometimes suppressed. A very marked decrease in
the amount of urine was more constant in the cases of chronic diffuse
nephritis than in those of chronic congestion. But in several cases
both of chronic diffuse nephritis and of chronic congestion the
patients passed from thirty to forty ounces of urine up to the time of
their deaths.
Albumen and casts were often present--nearly always with the large
white kidneys, not nearly as constantly with atrophied kidneys or with
{71} the cases of chronic congestion. In cases of chronic congestion
the albumen was usually in small amount and often not accompanied with
casts.
The specific gravity of the urine was apt to be low with chronic
diffuse nephritis and high with chronic congestion, but there were many
exceptions to this rule. With large white kidneys, atrophied kidneys,
simple diffuse nephritis, and chronic congestion the specific gravity
might be either normal, high, or low up to the time of death.
Transudation of the serum into the subcutaneous connective tissue and
the serous cavities was a very constant symptom. It was a little more
constant, and perhaps usually reached a greater degree, in the cases of
chronic diffuse nephritis than in those of chronic congestion.
Headache, delirium, convulsions, and coma occurred in a moderate number
of all the cases.
Dyspnoea was a very frequent symptom in all the cases.
Vomiting was also present in many cases.
Cough, with mucus or muco-purulent sputa, sometimes with hæmoptysis,
was a very common symptom.
Many of the patients lost flesh and strength and became anæmic.
COURSE OF THE DISEASE.--There is a great deal of similarity in the
histories of patients who suffer from the combination of cardiac and
renal disease. There is first the history of the heart disease. A
patient goes on for a number of years, sometimes apparently perfectly
well and unconscious that his heart is diseased, sometimes more or less
troubled with cough, cardiac dyspnoea, and palpitation. But after a
longer or shorter time there is a marked change for the worse. Either
gradually or rapidly the cough becomes worse, the dyspnoea greater, the
functions of the stomach are disturbed, the patient loses flesh and
strength, dropsy is developed, and finally cerebral symptoms. Some die
suddenly, some with exhaustion, some with dropsy, some with dyspnoea,
some comatose. It is always possible for the patient to recover from
the first attack of this kind, sometimes even from a second, but
eventually there comes an attack which proves fatal.
The most striking cases are those in which cardiac disease exists for
many years without giving any symptoms, and then the symptoms are
developed rapidly. Such persons, although they have organic disease of
the heart, may seem to enjoy perfect health. They may even be able to
take long walks, climb mountains, or perform laborious work. On some
day they suddenly become sick. Sometimes the exciting cause of the
attack is a pleurisy or a pericarditis, sometimes there is no apparent
cause. The first symptom is usually dyspnoea, and this is not an
ordinary cardiac dyspnoea. It is a very distressing and constant
dyspnoea, which does not allow the patients to lie down. They pass days
and nights sitting in a chair, fatigued, ready to sleep, but kept awake
by the constant dyspnoea. Some of these patients will die at the end of
a few days; others live longer and develop dropsy, anæmia, and cerebral
symptoms.
When the chronic congestion of the kidneys is secondary to emphysema of
the lungs, the course of affairs is much the same. The patient goes on
for a number of years with the ordinary symptoms of emphysema, and then
gradually or suddenly becomes worse. Dyspnoea, dropsy, {72} anæmia,
cerebral symptoms make their appearance, and the case terminates in the
same way as the cardiac cases.
DURATION.--How long congestion of the kidneys may exist without
producing symptoms it is hard to say. Certainly it may exist for a
number of days without any apparent disturbance of the functions of the
kidney. Whether it may exist for a time, give symptoms, and then
disappear, is uncertain; the rule seems to be that the lesion, when
once well established, persists up to the death of the patient.
TREATMENT.--It must be acknowledged that we can hardly hope for a cure
of the lesion of the kidneys, and that even alleviation of the symptoms
is not always possible. The mechanical cause of the obstruction to the
venous circulation cannot be removed, and it is not only the functions
of the kidneys that are disturbed, but those of the lungs, liver,
spleen, stomach, and small intestine. Still, we can do something. The
iodide of potassium, convallaria, caffeine, and digitalis may be of
service in equalizing and strengthening the heart's action, and at the
same time act as diuretics. Inhalations of the nitrite of amyl dilate
the arteries and capillaries, and so unload the veins. Opium is the
great remedy for the dyspnoea, although it must be given with caution.
Inhalations of ether may render the patient's last days more
comfortable.
BRIGHT'S DISEASE OF THE KIDNEYS.
After considering separately the condition of chronic congestion of the
kidney, we find that there are a group of kidney diseases characterized
by certain rational symptoms, changes in the urine, and alterations in
the structure of the kidneys which are popularly known by the name of
Bright's disease.
Various attempts have been made to classify these cases.
1. All the kidney lesions have been supposed to correspond to the
stages of an inflammatory process--a stage of congestion, a second
stage of exudation, and a third stage of contraction.
2. The disease has been divided, according to its clinical symptoms,
simply into acute and chronic Bright's disease.
3. The gross appearances have been taken as a standard, and the cases
are classed as examples of large white kidney, atrophied kidney, waxy
kidney, etc.
4. The kidneys have been compared to mucous membranes, and authors
speak of catarrhal and croupous nephritis.
5. The disease has been classified, according to the particular part of
the kidney affected, into parenchymatous, tubular, glomerular,
interstitial, and diffuse nephritis.
With our present knowledge of the subject it seems to me most
convenient to speak of acute and chronic parenchymatous nephritis and
acute and chronic diffuse nephritis. I include under the head of
parenchymatous nephritis all those kidneys in which the lesions are
strictly confined to the epithelial cells lining the tubules and the
capsules of the {73} glomeruli; under the head of diffuse nephritis,
those kidneys in which the lesions involve the tubes, stroma,
glomeruli, and arteries; under the head of interstitial nephritis,
those kidneys in which the essential morbid changes are in the stroma.
This classification seems to me to be theoretically correct, but yet I
must admit that from a clinical standpoint nearly all the cases may be
conveniently arranged into the two classes of acute and chronic
Bright's disease.
GENERAL SYMPTOMS OF BRIGHT'S DISEASE.--There are a certain number of
symptoms common to all the varieties of Bright's disease, and it is
convenient to consider them before going on to the special description
of each of these varieties. These symptoms are--
Changes in the Urine.--Healthy adults usually secrete during the
twenty-four hours from 40 to 50 ounces of urine of a light-yellow
color, of acid reaction, of a specific gravity of 1015 to 1025, and
holding in solution a number of excrementitious substances. Small
amounts of albumen and of sugar seem to be, in some persons,
physiological ingredients of the urine.
In most cases of Bright's disease the quantity of the urine at some
time in the course of the disease deviates from the normal standard.
Either the urine is increased in amount or diminished or suppressed,
and in the course of the same case the urine may be at one time
increased, at another diminished.
We find in healthy persons that the quantity of urine varies with the
amount of fluids that are imbibed and with the condition of the skin
and the bowels--that nervous influences and certain drugs will increase
or diminish the amount of urine. Physiologists teach us that the amount
of urine excreted varies with the degree of the blood-pressure in the
renal arteries or with the rapidity with which the blood circulates
through these arteries.
The urine may be very much increased or diminished in amount as the
result of various morbid conditions. Scanty urine or suppression of
urine is observed in the course of acute parenchymatous and acute
diffuse nephritis and in the early stages of the development of the
large white kidney. During the course of any case of chronic Bright's
disease there are usually periods during which the urine is scanty or
suppressed, especially toward the close of the disease. The kidney
lesions which complicate scarlet fever, yellow fever, and cholera are
often attended with suppression of urine. Any diseases accompanied by a
well-marked rise of temperature are apt to be associated with a
diminution in the amount of urine. Injuries to the urethra, even very
slight ones, may be followed by complete suppression of urine, without
any changes in the kidneys except congestion.
Marked diminution in the amount of urine occurring in the course of
acute and chronic Bright's disease is usually associated with the
development of cerebral symptoms--headache, restlessness, delirium,
muscular twitchings, convulsions, stupor, and coma. Such a change in
the amount of the urine usually lasts only a few days and may terminate
fatally, or the quantity of urine will increase and the patient get
better. There are, however, cases in which the suppression of urine
lasts for several days without the development of uræmic symptoms.
Whitelaw[1] relates a {74} case of suppression of urine lasting for
twenty-five days in a boy eight years old. The suppression began twelve
weeks after an attack of scarlatina. There were no uræmic symptoms, and
the child recovered completely.
[Footnote 1: _Lancet_, September, 1877.]
The suppression of urine due to injuries of the urethra gives rise to
symptoms of great prostration--rigors, vomiting, and collapse--rather
than to uræmic symptoms.
Suppression of urine is also produced by occlusion of the ureters by
calculi, new growths, etc. It is a curious fact that in these cases the
patients continue to live for a number of days (9 to 11, Roberts), and
no uræmic symptoms are developed until a few hours before death.