years. The cases vary a good deal in the number and severity of the
symptoms. Some cases run their course with nothing but the changes in
the urine, loss of appetite, and a moderate degree of anæmia. In other
cases the dropsy is the most prominent symptom, and in still others the
cerebral symptoms predominate. There may be intervals of weeks and
months during which all the symptoms, except the changes in the urine,
disappear and then come on again.
PROGNOSIS.--The prognosis of chronic parenchymatous nephritis is not
good, but still it is not so bad as that of chronic diffuse nephritis:
some of the cases recover and never have any further indications of
kidney disease.
TREATMENT.--The main indications for treatment are to improve the
digestion, remove the dropsy, and restore the blood to a natural
condition. It is usually necessary for the patient to give up his
ordinary business and if possible to pass the winter months in a warmer
climate.
{82} Acute Diffuse Nephritis.
This form of nephritis has been described under a variety of names. It
has been called acute Bright's disease, acute desquamative nephritis,
acute tubular nephritis, croupous nephritis, acute albuminuria, the
first stage of chronic Bright's disease, acute parenchymatous
nephritis, glomerulo-nephritis, and acute interstitial nephritis.
MORBID ANATOMY.--The kidneys are increased in size, the capsules are
not adherent, the surfaces are smooth. There may be an intense
congestion of the entire kidney, including its pelvis, or the cortex is
of an opaque white color mottled with red spots, and the pyramids are
red. The tissue of the kidney is usually moist and succulent. In the
tubes the epithelial cells are swollen, granular, and detached.
Cast-matter and blood are found in many of the tubes. In the Malpighian
bodies the cells which line the capsules are increased in size and
number, sometimes to such an extent as to compress the tuft of vessels.
The stroma of the kidney is infiltrated with serum, pus-cells, and
blood.
ETIOLOGY.--Most of the cases of acute diffuse nephritis occur after
exposure to cold or as a complication of scarlatina.
SYMPTOMS.--(1) The Idiopathic Cases.--Of these we may distinguish two
sets of cases. In the first set of cases the invasion of the disease is
acute. A person who has previously been usually in good health, after
exposure to cold and wet will be suddenly attacked with rigors, a
febrile movement, and pain in the back. There will be frequent and
painful micturition, the urine being only passed a few drops at a time,
or it is completely suppressed.
The urine is bloody or of a brownish smoky color. It is of low specific
gravity. It contains a very large amount of albumen, numerous hyaline,
granular, epithelial, and blood casts and renal epithelium, and
sometimes pus-cells. Later in the disease fatty casts are also present.
The patient soon develops dropsy, the extent of which varies in the
different cases. Sometimes it involves only the face, sometimes the
hands and feet, or there may be general subcutaneous oedema, serum in
the serous cavities, oedema of the lungs and of the glottis. The
patients lose their appetite; often there are nausea and vomiting. As a
rule, there are cerebral symptoms--headache, drowsiness, stupor,
delirium, muscular twitchings, convulsions, and coma. In the milder
cases there will be only headache and periods of drowsiness,
alternating with periods of irritability. In the severe cases there
will be dyspnoea, delirium, repeated convulsions, and coma.
These are the regular symptoms of the disease--symptoms varying in
their number and development with the intensity of the nephritis. In
the worst cases the cerebral symptoms are developed early and the
patients die at the end of a few days. In other cases the symptoms
continue for months, and at the end of that time terminate either in
the death or recovery of the patient. Albumen and casts in the urine
may persist long after all other symptoms have disappeared. In other
cases the disease runs a very mild course; the patients are not at any
time seriously ill, and they recover completely at the end of two or
three weeks. In still other cases the acute inflammation is succeeded
by {83} chronic diffuse nephritis. Relapses and repeated attacks of the
disease occur in some persons.
The course of the disease may be modified by complicating
inflammations. Pericarditis, pleurisy, peritonitis, pneumonia,
cystitis, and inflammations of the joints and muscles are not uncommon.
PROGNOSIS.--In the larger number of cases the prognosis is good. The
milder cases recover after two or three weeks; more severe cases last
for several months. The bad cases die at the end of a few days with
cerebral symptoms, or all the symptoms continue and the patient dies at
the end of several months, or they pass on to the lesions and symptoms
of chronic diffuse nephritis, or they die from some complicating
inflammation.
TREATMENT.--In the mild cases but little treatment is required. The
patients should be kept in bed, should have a fluid diet, the bowels
should be moved, and the restlessness should be quieted by the
bromides, chloral hydrate, or opium. If the dropsy is a marked feature,
more active purgatives are to be employed, hot-water or hot-air baths
are to be used, and jaborandi may be of service. When the urine is very
scanty, wet or dry cups over the region of the kidneys and hot
fomentation over the same region are of much service. For the more
marked cerebral symptoms treatment is not very satisfactory. As the
patients get better iron and tonics are usually indicated. Great care
must be used to prevent relapses. All exposure to cold must be avoided;
the patient is to be kept in the house or sent to a warm climate for
some time after he is apparently well. So long as albumen and casts
persist in the urine the patients must not be considered well, although
they may present no renal symptoms.
(2) In the second set of cases the invasion of the disease is not
acute, and the symptoms may at first be so slight that the patient will
hardly notice them. Usually the first symptoms are referable to the
stomach. The patients lose their appetite, are troubled with nausea,
and vomit occasionally. There may be a moderate amount of pain in the
back, general languor, and indisposition for mental or physical work.
Then they notice a change in the urine; they pass much less than
before. The urine remains of its ordinary color or is a little smoky;
its specific gravity is less; it contains a good deal of albumen,
sometimes a little blood, and large numbers of hyaline, granular, and
epithelial casts.
Dropsy makes its appearance at first in the face or feet; it may remain
confined to these regions or extend to the rest of the body and become
a general dropsy. The cerebral symptoms are slight--headache,
irritability, drowsiness. The blood becomes thin and watery and the
patients unnaturally pale. There may be dyspnoea either dropsical or
nervous. The symptoms continue for weeks or months.
PROGNOSIS.--These cases, as a rule, do well, and recover at the end of
a few weeks or months. But in some the symptoms continue and the
patients go on to have chronic diffuse nephritis.
TREATMENT.--In the mild cases it is only necessary to keep the patients
in the house, put them on a milk diet, keep the bowels open, and after
a time give them iron. If the dropsy is more marked, we must try to get
rid of it by cathartics, sweating, and diuretics. If the anæmia is
marked, inhalations of oxygen must be combined with the {84}
administration of iron. In these cases also it is important to guard
against relapses.
The Acute Diffuse Nephritis of Scarlatina.
Most cases of scarlatina are complicated either by acute parenchymatous
or diffuse nephritis. Some confusion has arisen from the attempt to
describe scarlatinal nephritis as if it was one disease, while really
there are two anatomical forms of nephritis which occur as
complications of scarlatina. When we try to fix the time during the
course of scarlatina when the kidney lesions are developed, we meet
with the same difficulty--that statistics have been compiled on the
supposition that there is only one form of scarlatinal nephritis. If we
take all the cases together, we find that kidney symptoms may be
developed from the very first day of scarlet fever to the end of the
ninth week--that the largest number of cases develop symptoms on the
fourteenth day, the next largest on the twenty-first day, and next to
this on the seventh day (Tripe). It seems probable that parenchymatous
nephritis belongs to the first weeks of the disease, diffuse nephritis
to the later weeks.
SYMPTOMS.--The urine is diminished in amount, and may be suppressed.
Its specific gravity is low, its color is bloody or smoky; it contains
blood, large amounts of albumen, and numerous hyaline, granular, and
epithelial casts.
The patients lose their appetites, and suffer from nausea and
occasional vomiting. There is a febrile movement, usually not very
severe, pain in the back and limbs. They become unnaturally peevish and
irritable and complain of headache, the irritability alternating with
drowsiness. In the more severe cases delirium, convulsions, and coma
are developed. The color of the patients is changed, the skin and
mucous membranes becoming pale. Dropsy is developed--sometimes only a
little puffiness of the face, hands, or feet, sometimes general
anasarca. Synovitis and muscular rheumatism are frequent complications,
while pericarditis, pleurisy, and pneumonia occur less often.
The disease runs its course within a moderate length of time, although
the changes in the urine often persist long after all the other
symptoms have disappeared. The ordinary cases recover after from one to
three weeks; the very bad cases die at the end of a few days. In a few
cases the symptoms continue and the patient develops chronic diffuse
nephritis.
PROGNOSIS.--The prognosis is quite good. The larger number of the cases
recover completely. In the more severe cases, however, the patients may
die with cerebral symptoms, or all the symptoms will continue and the
patient die after several weeks.
TREATMENT.--The indications for treatment are the same as in the
idiopathic form of acute diffuse nephritis.
Chronic Diffuse Nephritis.
This is the most common and the most important form of kidney disease.
It has been described under a variety of names--chronic Bright's {85}
disease, croupous, catarrhal, interstitial, tubal, and parenchymatous
nephritis; fatty, granular, atrophied, cirrhotic, and large white
kidney.
Although all patients with chronic diffuse nephritis suffer from
essentially the same symptoms, yet there is a good deal of difference
as to the way in which these symptoms are developed and as to the
predominance of some symptoms over others. Although the minute lesions
of the kidneys are essentially the same in all cases, yet the gross
appearance varies a good deal. There is, therefore, a practical
convenience in distinguishing certain varieties of chronic diffuse
nephritis. Of late years, however, the tendency to do this has been
carried very far, especially as regards the atrophic form of chronic
diffuse nephritis. Writers speak as if there were only two forms of
chronic diffuse nephritis--the large white kidneys and the atrophied
kidneys--and as if each of these had a distinct clinical history. More
than this, the changes in the blood-vessels and in the circulation
which so often complicate chronic Bright's disease have attracted so
much attention that the arterial changes have been regarded as the most
important part of the disease, so that we even hear of Bright's disease
without any lesion of the kidneys. It is also customary to describe
separately those kidneys of which the arteries have undergone waxy
infiltrations.
I do not think that either the lesions or the symptoms are such as to
justify such views. After separating the true cases of chronic
parenchymatous nephritis--cases in which only the epithelium of the
tubes and of the Malpighian capsules is changed--all the other kidneys
of chronic Bright's disease present essentially the same lesions and
give rise to the same symptoms.
We can indeed often tell during the life of the patient whether he has
large white or atrophied or waxy kidneys, but in many cases such a
diagnosis is impossible.
MORBID ANATOMY.--There is good deal of variety in the gross appearances
and size of the kidneys. Most numerous are the so-called atrophied
kidneys. These kidneys are usually diminished in weight, the kidneys
weighing together three or four ounces, but often they weigh up to ten
or twelve ounces. The capsules are adherent, and when they are stripped
off portions of the kidney-tissue adhere to them. After stripping off
the capsules the surface of the kidney is left finely or coarsely
nodular. The cortex is thinned and of a red or grayish mottled color;
the pyramids are small or of normal size, sometimes studded with small
white concretions of urate of soda. There are often small cysts both in
the cortex and pyramids.
Next in frequency come the so-called large white kidneys. Of these a
certain number are not examples of chronic diffuse nephritis at all,
but of acute or chronic parenchymatous nephritis. Of the large white
kidneys which belong to chronic diffuse nephritis we can distinguish
three varieties--the simple large white, the waxy large white, and the
large white of cardiac disease.
The gross appearance of the kidneys is very much the same whether they
are or are not the seat of waxy infiltrations. They are increased in
size, weighing together from sixteen to twenty ounces. The capsules are
not adherent; the surfaces of the kidneys are smooth and pale, often
mottled by large stellate veins. The cortex is thickened, of white or
{86} white mottled with red, or yellow or grayish color. In the very
waxy kidneys the gray or white color has a semi-translucent appearance.
The pyramids are large and red, contrasting with the cortex. We find
some kidneys of the same color and general appearance as large white
kidneys, but with atrophied cortex and adherent capsules.
The large white kidneys due to cardiac disease are increased in size
and weight. The capsules are not adherent, the surfaces are smooth. The
cortex is thickened and of a peculiar pinkish-white color; the cortical
striæ may still be visible. The pyramids are of a somewhat darker red
than the cortex. The whole coloring is entirely different from that of
chronic congestion of the kidneys, and the texture, although firm, is
not of the stony hardness of that lesion.
Besides the atrophied and the large white kidneys, there are a large
number of kidneys which are not diminished in weight and which do not
resemble either the large white or the atrophied kidneys. These kidneys
weigh together from nine to twenty ounces. The capsules are sometimes
adherent, sometimes not. The surface of the cortex may look like that
of a normal kidney or be finely or coarsely nodular. The cortex is of
normal thickness or thickened; it is of a variety of colors. Sometimes
it is not to be distinguished from a normal kidney, or it may be gray
or gray mottled with yellow or red or white, or of a diffuse red color.
The pyramids are of natural size or large, of red or pale color. I do
not know a good name for these kidneys, but their appearance differs
altogether from that of the large white or atrophied kidneys.
Still another class may be made of those kidneys which pass from the
condition of chronic congestion into that of chronic diffuse nephritis.
These kidneys retain the color and the hardness of chronic congestion,
but the capsules are adherent, the surfaces finely nodular, and the
cortex irregular.
Minute Lesions.--Nearly all the component parts of the kidneys undergo
morbid changes. In the tubes the epithelial cells undergo marked
changes, especially in the cortex. The epithelial cells are swollen,
finely or coarsely granular, or fatty or completely disintegrated, or
the seat of hyaline degeneration. They may be detached from the walls
of the tubes, or sometimes they are in place, but flattened. The tubes
may contain cast-matter, blood, pus-cells, small polygonal cells. The
calibre of the tubes is often changed. The tubes may be dilated either
in the form of cylindrical or sacculated dilatations; the latter often
form cysts of considerable size. Such dilatations regularly affect
groups of tubes, as if they were due to obstruction of the large tubes
in the pyramids. In other cases the tubes are denuded of epithelium,
become smaller, fall together, and look like connective tissue. The
membranous wall of the tubules may be thickened or it may undergo waxy
degeneration.
The Malpighian bodies are changed. Their capsules may be thickened,
contracted, or dilated. The flat cells which line the capsules are
increased in size, sometimes in number. The capillary tuft may be
dilated or its walls may be thickened; it may be completely obliterated
and changed into a ball of fibrous tissue, or it may be the seat of
waxy infiltration. Often the Malpighian bodies are much closer together
than they are in a normal kidney.
{87} In the stroma, especially in the cortex, there is a new growth of
connective tissue. This new connective tissue is in patches of varying
size, surrounds Malpighian bodies and blood-vessels, and may be
continuous with the capsule of the kidneys.
The arteries are frequently changed. There is a general thickening of
all their coats, usually a simple sclerotic thickening.
All these changes, when they have once begun in the kidneys, have a
natural tendency to go on and become more and more marked. There is
much difference in different kidneys in the predominance of one or more
of these changes over others. In one kidney the changes in the tubes
will be most marked, in another those in the Malpighian bodies, in
another those in the stroma. But there seems no good reason for
believing that these changes are developed successively--that there is
first a lesion of the stroma, then a lesion of the tubes, or first a
lesion of the tubes, and then of the stroma. The earliest examples of
chronic diffuse nephritis, obtained from persons dying accidentally of
other diseases, show that the lesions are diffuse at the very outset.
In the atrophied kidneys the new connective tissue is in patches. In
the earliest stages of the lesion these patches are confined to the
region close to the capsule; later in the disease the whole thickness
of the cortex is involved. The tubes embraced within these areas of new
connective tissue are atrophied and collapsed. The rest of the
cortex-tubes exhibit marked degenerative changes in the epithelium, and
often cast-matter. Dilatation of the tubes is very common. The
Malpighian bodies are usually much altered--the capsules thickened, the
tufts atrophied. Occasionally there is waxy degeneration of the
Malpighian tufts. There are some atrophied kidneys in which the changes
in the stroma are very slight.
In the large white kidneys there is much variety. In some of them one
is surprised to find how slight the minute lesions are. In others the
principal changes are in the epithelium of the tubes, so that it may be
difficult to tell whether they are examples of parenchymatous or of
diffuse nephritis. In many others there is a very marked production of
new connective tissue either in patches or diffuse. The large white
kidneys which are waxy differ from the others only in the addition of
the waxy degeneration of the Malpighian tufts and arteries to the other
lesions. I have no knowledge of any kidneys in which waxy degeneration
exists without the presence of the regular lesions of diffuse
nephritis.
In the large white kidneys of cardiac disease the large thickened
arteries are a prominent feature.
ETIOLOGY.--Chronic diffuse nephritis is more common in males than in
females. It is said to occur at nearly all ages; the maximum liability
is in persons between the ages of forty-five and fifty-five years. The
disease prevails principally in temperate climates; in New York it is
of very common occurrence. Persons who are habitually intemperate, who
have constitutional syphilis, who suffer from privation, are very
liable to the disease. There is a disposition in certain families to
the development of the disease. Not that it is, strictly speaking,
hereditary, but there will be a number of examples of it in the same
family. A number of brothers and sisters or of more distant relatives
in the same family will {88} at different times suffer from the
disease. There seems also to be some sort of relationship between
chronic diffuse nephritis and pulmonary phthisis. Not only does
nephritis complicate phthisis, but in the same family some members have
phthisis, others nephritis.
Acute diffuse nephritis and chronic congestion of the kidney may be
followed by chronic diffuse nephritis.
Heart disease, emphysema, phthisis, cirrhosis of the liver, chronic
inflammation of the bones and joints, gout, rheumatism, and chronic
arteritis, are often complicated by the disease.
SYMPTOMS.--It is sometimes impossible to tell which of the varieties of
chronic nephritis exists in a given patient, but in other cases the
diagnosis can be made. If, however, we correct our clinical diagnosis
by post-mortem observations, we find that we may be mistaken about even
the (apparently) most characteristic cases. There is more difference in
the earlier stages of these cases than in the later ones. In hospitals,
where the patients come to die, all the cases of chronic diffuse
nephritis are a good deal alike.
The atrophied kidneys present us with a very great variety of clinical
histories. It is impossible to describe all the different ways in which
the disease may begin and run its course, but we may enumerate some of
them:
1. Persons may have atrophied kidneys for a number of years without any
renal symptoms; they die from accident or from some other disease, and
at the autopsy the kidneys are found to be far advanced in disease.
2. The disease of the kidneys exists, but it gives no symptoms until
the patient suffers from some severe accident or is attacked by some
acute disease, and then the renal symptoms are suddenly developed.
3. The patient will very slowly lose flesh and strength, the appetite
will be capricious, either mental or bodily exertion is an effort, but
there are no positive symptoms, except that the urine is of rather low
specific gravity, and in the evening urine there will be occasionally a
trace of albumen. In this condition these patients may continue for
years. They may improve very much under treatment, and finally die from
some other disease without ever developing any renal symptoms. Other
cases, however, do after a time develop all the characteristic
symptoms.
4. For several months the patients do not feel well: the appetite is
lost, there is nausea and occasional vomiting, they become pale and
anæmic, do not sleep well at night, are irritable and easily worried,
are troubled with headache. The urine continues normal or is of low
specific gravity or contains a little albumen. Then they suddenly
become worse and the regular symptoms are developed.
5. In other cases headache or sleeplessness or dyspnoea or loss of
vision may precede all the other symptoms by several weeks.
6. Severe neuralgic pains in different parts of the body, coming on in
attacks and very rebellious to treatment, may precede the other
symptoms for months.
7. The very first symptoms may be an attack of convulsions. The patient
may have been apparently in good health, and while sitting quietly in a
room or lying in bed will be seized with a general convulsion. In some
of these cases the convulsions are repeated; between them the patient
remains partly or completely unconscious, and dies in {89} a few days.
In other cases one or two convulsions are followed by the development
of the other symptoms of the disease.