the same combination of symptoms which I have described in the section
on chronic congestion of the kidneys.
9. The patient may first notice that he is passing too much urine. This
urine is of low specific gravity, and occasionally contains a little
albumen and hyaline casts. Then the health begins to fail: there are
dyspeptic symptoms, headache, occasional oedema of the legs. From time
to time the patient becomes worse; the urine is diminished in quantity,
the headache is more marked; he cannot sleep, he has dyspnoea, he
vomits, the muscles of the face twitch, or there may be general
convulsions or delirium or partial or complete coma. Such attacks may
last for days or weeks, and then either terminate fatally, or the
patient gets better and may be able to return to his ordinary business
for a time. In this way the same patient may suffer from a number of
such attacks.
10. In some cases dropsy is a prominent feature from the very first and
goes on to general anasarca.
The following history would answer for many of the cases of atrophied
kidneys: A woman, thirty-eight years old, was in good health, fat and
robust, until January, 1873. Then she caught cold; her feet became
oedematous; she had headache, pain in the back, vomiting; her eyesight
was impaired; her urine was increased in amount and passed more
frequently. She continued in this condition and losing flesh and
strength until June, 1873, when she came into the hospital. At that
time the urine was diminished to eighteen ounces in twenty-four hours;
it contained a considerable amount of albumen and hyaline and granular
casts. Her color was still good. There was moderate oedema of the feet.
After this the urine increased in amount to eighty ounces
daily--specific gravity 1002, albumen diminished. The dropsy
disappeared, and the patient left the hospital feeling very well on
September 29, 1873. In December, 1873, she returned to the hospital
with nausea and vomiting, dyspnoea, cough, no dropsy; urine 80 to 100
ounces daily. She had become feeble and anæmic, and there was
well-marked hypertrophy of the left ventricle of the heart. She again
improved, and was discharged after two weeks. In March, 1874, she
returned. The urine was now scanty, and she was troubled with vomiting,
dyspnoea, cough, sleeplessness, slight convulsive movements of the
voluntary muscles, no dropsy. By the end of April she was again feeling
well, and left the hospital. In June, 1874, she returned with all the
old symptoms and oedema of the legs. On July 20 she had two general
convulsions. After this she again improved for a time, but in September
all the symptoms returned, and she was delirious a good deal of the
time. Urine 40 to 50 ounces daily, specific gravity 1005, moderate
amount of albumen, no casts. By the end of September she again was
sleepless, had several slight convulsions, and died October 2. The
kidneys were a typical picture of the red atrophied kidneys with
thickened arteries.
We may say in general that with the atrophied kidneys the so-called
uræmic symptoms--headache, sleeplessness, delirium, convulsions, coma,
dyspnoea--are very apt to occur, and that early in the disease. The
urine is regularly increased in amount and of low specific gravity,
except {90} during the uræmic attacks, when it is diminished; but the
uræmic attacks may come on while the patient is passing 30 to 40 ounces
of urine of a specific gravity of 1020. Albumen is regularly present
only in small amounts, and not constantly, but exceptionally there will
be a good deal. Casts are hyaline, not constant, but exceptionally in
considerable numbers. Dropsy may be absent throughout the disease, or a
little oedema of the face and legs may come and go, or there may be
marked general anasarca. Not unfrequently during the uræmic attacks the
temperature runs up to 99° to 100°. Hypertrophy of the left ventricle
of the heart is a frequent complication, but I have not found it in as
large a proportion of cases in New York as it is described by English
and German writers.
The duration of the disease is very uncertain. In fact, we seldom know
what its real duration is, for the reason that there is no necessary
relation between the development of the kidney lesions and the
appearance of the symptoms. After the appearance of the kidney symptoms
some of the patients die in a few days; others go on for months and
years with either constant or intermittent symptoms.
The Large White Kidney.--These cases are more readily recognized than
the cases of atrophied kidneys, for the reason that dropsy is more
constant and occurs earlier in the disease, and that albumen is
regularly present in the urine.
In many of the cases oedema of the face or feet is the first symptom.
Often the patients will tell you that it is the only symptom, and that
they would feel perfectly well if they could only get rid of the
swelling. Closer questioning, however, will usually show that the
functions of the stomach are disturbed, that there is occasional
headache, that the eyesight is impaired, and that the patient has been
passing less urine.
In some cases impairment of vision is the first symptom that attracts
the attention of the patient. In some cases disturbances of digestion,
or neuralgic pains, or gradual loss of health and strength, or a
diminished amount of urine, will be the first symptoms, and may last
for weeks before other symptoms are developed. Or the patient may be
attacked suddenly as if with acute diffuse nephritis. The urine will
contain blood and numerous casts; the dropsy and the other symptoms are
rapidly developed. In some of the cases complicated with cardiac
disease the history will be that of heart disease rather than that of
kidney disease.
When the disease is fairly established the dropsy is always a prominent
symptom, often very distressing to the patient. In some patients when
once developed it continues to increase steadily up to the time of
their death; in others the dropsy comes and goes, sometimes
disappearing altogether for weeks and months.
The functions of the stomach are usually disturbed, the patients lose
appetite, have nausea and vomiting, oppression after eating, etc. But
some persons retain a good appetite for a long time, even though they
vomit occasionally. Diarrhoea is often developed; sometimes only enough
to carry off part of the dropsy, sometimes profuse, persistent, and
uncontrollable. The blood becomes thin and watery, and the skin, the
mucous membranes, and the sclerotic assume an unnatural white
appearance. The patients lose both mental and bodily vigor, and become
less and less fit to carry on their ordinary occupations.
Of the uræmic symptoms, headache and dyspnoea occur at any time in {91}
the course of the disease, but convulsions, delirium, and coma belong
to its later stages.
The urine is regularly first diminished and afterward increased, but
the quantity often varies very much from day to day. The specific
gravity is regularly low, albumen is constant and in large amount;
casts are usually present in considerable numbers, especially during
the exacerbations of the disease, when hyaline, granular, and
epithelial casts are found, but in other cases hardly any casts can be
found. Blood is sometimes present in the urine during the exacerbations
of the nephritis.
The disease varies much in its course and duration. Some cases progress
steadily, getting worse from day to day, and die at the end of a few
months from the time at which the first symptoms appeared. Other
persons go on living for years, the symptoms improving or disappearing
for weeks or months, and then coming again. Finally, the patients
die--some in an exacerbation of the disease with bloody urine and acute
symptoms; some with excessive dropsy; some with delirium, convulsions,
and coma; some suddenly; some with complicating disease.
The following histories may serve to illustrate the course of the
disease:
A male, thirty years old, of intemperate habits, for one year before
his death noticed that his urine was sometimes scanty and high-colored,
sometimes abundant and pale, and that his eyesight became impaired. For
four months there was occasional nausea and vomiting. For six weeks
there was occasional headache, dyspnoea, and oedema of the feet, the
urine more scanty. For nine days before death he passed from one to
four ounces of urine daily, specific gravity 1014, albumen 50 per
cent., numerous hyaline, granular, and epithelial casts. The man was
now feeble and anæmic, had headache, was drowsy, vomited occasionally,
had twitching of muscles of face; continued drowsy, but with his mental
faculties quite clear, so that he was able to transact some business an
hour before he died. Death was sudden while lying quietly in bed. The
kidneys weighed twenty ounces, surfaces smooth, cortex thick and white,
pyramids large and red. The Malpighian bodies showed a marked increase
in the size and number of the capsule cells; the cortex-tubes were
dilated; in some the epithelium was flattened, in others swollen,
granular, and detached; in the pyramid-tubes the epithelium was swollen
and detached; there was cast-matter in some of the tubes, both in the
cortex and pyramids; there was a very extensive new growth of new
connective tissue in the cortex, partly diffuse, partly in patches.
A male, forty-one years old, six years before his death caught cold
while bathing, and suffered with dropsy, a febrile movement,
prostration, scanty urine which contained albumen, blood, and numerous
casts. After a few weeks all the symptoms disappeared and he returned
to his business. He continued to enjoy good health for about eighteen
months; then in the winter the urine became scanty and contained blood,
albumen, and numerous casts. General anasarca was rapidly developed.
The dropsy lasted for six months, and then disappeared, but the urine
from that time always contained varying amounts of albumen and casts.
For nearly two years after this time the man continued to feel well,
was actively engaged in business, had no dropsy, but the urine still
contained {92} casts and albumen. Then the dropsy returned again, and
was very considerable. But the appetite and digestion continued good,
there was no headache, the patient was intelligent and cheerful. The
dropsy, a moderate diarrhoea, and the change in the urine were the only
symptoms. In two months the dropsy had again disappeared and the
patient returned to his work. After this time, however, the patient was
never as well: a little oedema of the legs was present much of the
time; he became gradually more and more anæmic and feeble, and finally
died with marked dropsy and anæmia about six years from the time of the
first appearance of kidney symptoms.
The Large White Kidneys with Waxy Infiltration.--It is well known that
in certain persons a peculiar morbid change takes place in the viscera.
The walls of the blood-vessels and some of the glandular cells become
infiltrated with a peculiar translucent substance. This morbid change
is commonly known by the name of waxy or amyloid infiltration. It is
known that such an infiltration occurs regularly in persons who have
chronic inflammations of the bones and joints, constitutional syphilis,
and pulmonary phthisis. It is also known that this new substance is
colored in a special way by iodine and some of the aniline colors.
Beyond this we have no real knowledge of what the substance is or how
it is produced.
In other parts of the body the waxy infiltration can hardly be said to
produce any local symptoms. If one has a waxy liver or spleen, these
organs may give the physical evidences of their enlargement, but that
is all. We look upon such patients as suffering from some general
changes concerning the nature of which we are ignorant, but not as
suffering simply from disease of the liver or spleen.
It seems at first sight natural to think of waxy kidneys in the same
way--not as examples of kidney disease, but as parts of a general
morbid condition. This view has been adopted by most authors. They
describe the waxy kidneys as something different from the other forms
of nephritis. But really this is an error. In the vast majority of
cases the waxy kidneys are simply a variety of chronic diffuse
nephritis. It is possible (Cohnheim) to have waxy infiltration of the
Malpighian bodies without other lesion of the kidney, but this is a
rare exception. The rule is that we find the ordinary lesions of
chronic diffuse nephritis; and, more than this, we often find the
nephritic lesions very much farther advanced than the waxy
infiltration. The association of the lesions is not at all such as to
give the idea that the waxy infiltration is produced first and the
other lesions afterward. It is also not uncommon to find waxy
infiltration of the Malpighian tufts without similar changes in any
other part of the body.
The type of the nephritis varies in different cases. Most of the
kidneys resemble the large white kidneys, some the atrophied, some
those which are neither large white nor atrophied. The clinical history
varies in the same way, and is that of a large white or atrophied
kidney, as the case may be. The only difference is that in some
patients (not in the majority) there is a very large amount of urine
passed of low specific gravity.
As a matter of fact, in most cases of waxy kidneys we simply make the
diagnosis of chronic diffuse nephritis, and if we add to this that of
{93} waxy infiltration it is because the patients have had syphilis or
bone or joint disease. Even in this way we are often enough deceived,
as in the following case:
A woman, twenty-six years old, came into the hospital on January 25,
1876. She had contracted syphilis five years before. For two years she
had suffered from dyspnoea and frontal headache. For seven months there
was occasional oedema of the face and feet. At the time of her
admission to the hospital she was very pale and anæmic; the urine was
of a specific gravity of 1008, abundant, and contained no albumen or
casts. The liver was very large and smooth. It was supposed that she
had waxy liver and kidneys. She grew steadily weaker, continued to have
a little oedema, vomited occasionally, developed the physical signs of
bronchitis, with a temperature of 104° Fahr., and died on April 3,
1876. At the autopsy the aortic valves were found thin and
insufficient. There was muco-pus in both the large and small bronchi,
with irregular spots of red hepatization in the lung. The liver and
spleen were large and waxy. The kidneys weighed together four ounces,
and presented the ordinary lesions of atrophied kidneys, with only
commencing waxy infiltrations of a few of the Malpighian tufts.
The Large White Kidney of Heart Disease.--This variety of chronic
diffuse nephritis seems to be secondary to organic disease of the
heart, and, less frequently, to emphysema of the lungs. The urine is
diminished in amount, sometimes suppressed; it is dark-colored, the
specific gravity varies between 1010 and 1030; albumen is absent
altogether or present in small amount; hyaline and granular casts may
be present, but are not constant. Dropsy may be absent or moderate or
excessive. Cerebral symptoms--vomiting, cough, dyspnoea, anæmia--are
usually present. Some of the patients die suddenly, some with dropsy,
some with urgent dyspnoea.
The examples of chronic diffuse nephritis which are neither atrophied
kidneys nor large white kidneys are numerous. Some of them give the
clinical history of the large white kidneys, some that of the atrophied
kidneys, some do not correspond to that of either; but they all exhibit
some of the characteristic symptoms of chronic nephritis--changes in
the urine, dyspnoea, vomiting, cerebral symptoms, dropsy, anæmia.
The following histories will show the course of the disease in some of
these cases:
Case 1.--A male, forty years old, came into hospital on October 9,
1881. The patient was a beer-drinker, but denied rheumatism and
syphilis. He said that he had been perfectly well until fourteen months
before; then he had an attack of lobar pneumonia which confined him to
the house for four weeks. Since that time he has never felt as well and
has had occasional dyspnoea. Nine months ago the dyspnoea became so
troublesome that he had to give up work, and he also began to suffer
from severe headaches. Three weeks ago the urine became scanty and
dropsy appeared in the legs and scrotum. When admitted to the hospital
the patient was large and fat. There was dropsy of the legs and of the
scrotum, marked dyspnoea, sibillant râles over both lungs; 10 ounces of
urine in twenty-four hours, specific gravity 1023, albumen 10 per
cent., hyaline and epithelial casts. The urine on Oct. 12 was 13
ounces; on Oct. 14, 42 ounces; on Oct. 18, 54 ounces. On this last day
he had {94} several convulsions, became comatose, and died October 19.
At the autopsy the pia mater was thickened and there was an increase of
serum beneath it. The heart weighed fourteen ounces, the aortic and
mitral valves were a little thickened, the walls of the ventricles were
unnaturally hard. In the lungs there were a few old hard miliary
tubercles. The kidneys weighed sixteen ounces, surfaces smooth,
capsules not adherent, cortex and pyramids of red color, urates in the
pyramids. The cortex-tubes showed marked changes in their epithelium,
but the Malpighian bodies, stroma, and arteries were nearly normal.
Case 2.--A female, forty-five years old, was admitted to the hospital
December 5, 1881. Denied rheumatism, syphilis, and intemperance. She
had considered herself strong and well until two months before. Then
she had a sudden attack of dyspnoea, dizziness, faintness, and cardiac
palpitation. After this she was never well, complained of pain about
the heart, headache, attacks of dyspnoea, dropsy of the face, hands,
and feet. The urine was scanty and dark-colored. She is now emaciated
and anæmic, has moderate oedema of the legs, complains of dyspnoea,
headache, and nausea. The heart's action is feeble and irregular, and
there is a presystolic murmur. On December 19 she vomited blood. On
January 2 she had a chill, followed by a temperature of 102°. On
January 5 she became drowsy, then had twitchings of the muscles of the
face; became semi-comatose, and died January 11. While she was in the
hospital the urine varied in amount from 1 to 6 ounces daily; it
contained a very large amount of albumen and a few hyaline casts. After
death the pia mater looked sodden and finely granular. The walls of its
arteries were a little thickened, and there were little clumps of
endothelial cells on its outer surface. The mitral valve of the heart
was thickened and stenosed. The kidneys were of medium size, their
capsules slightly adherent, their surfaces finely nodular, the cortex
of normal thickness, red mottled with yellow spots. There was an
extensive growth of diffuse connective tissue separating the tubes both
in the cortex and pyramids. The tubes were large and contained much
cast-matter. Most of the Malpighian bodies were normal.
COMPLICATIONS.--The most frequent complication of chronic diffuse
nephritis is disease of the heart. We find cardiac lesions and renal
lesions associated in three different ways:
1. Valvular lesions or dilatation of the ventricles produce chronic
congestion of the kidney, with its changes into parenchymatous or
diffuse nephritis or the large white kidney of cardiac disease.
2. Chronic diffuse nephritis is followed by the development of
hypertrophy of the left ventricle. This may occur with all the
varieties of chronic diffuse nephritis, but is most common with the
atrophied kidneys.
3. Valvular lesions and chronic nephritis occur in the same persons,
but neither can be said to depend upon the other.
The arteries are often diseased, the aorta and the arteries throughout
the body. There may be a simple sclerosis and thickening of the wall of
an artery, or endarteritis deformans, or obliterating arteritis.
Cerebral apoplexy may occur with all the varieties of chronic diffuse
nephritis, but much more frequently with atrophied kidneys.
Thickening of the pia mater, with increase of serum beneath it, is
often seen.
{95} Dilatation of the lateral ventricles of the brain sometimes
occurs, and may give rise to cerebral symptoms.
Pericarditis is seen more frequently with the atrophied kidneys.
Pneumonia is especially apt to be fatal when it occurs in persons
already suffering from chronic diffuse nephritis.
Emphysema and chronic bronchitis are often associated with the
atrophied kidneys.
Phthisis is found with all the varieties of chronic nephritis.
Peritonitis occurs in a few cases as a complicating inflammation.
Cirrhosis of the liver is found quite frequently.
PROGNOSIS.--In every case of chronic diffuse nephritis the natural
course of the morbid changes in the kidney tissue is to become more
marked and involve more and more of the kidney. The effect upon the
general health of the patient is not in any exact relation to the
degree of the kidney lesion. These two facts render the prognosis of
chronic diffuse nephritis very uncertain. The disease is always a very
serious one, and terminates regularly in destroying life, but the
length of time that will elapse before this fatal termination, and the
precise way in which death will take place, are difficult to determine
beforehand.
TREATMENT.--There seems no good reason for believing that we can
directly influence the development of the lesions in the kidneys. It is
possible that such a development may be indirectly delayed by improving
the general health of the patient.
There is good reason to believe that some of the symptoms which occur
regularly in patients who have chronic diffuse nephritis are dependent
not upon the nephritis, but upon other causes. We may therefore look
for indications for treatment in three different directions:
1. To delay the development of the disease by improving the general
health of the patient.
2. To treat those symptoms which are not produced by the kidney
disease.
3. To treat those symptoms which are produced by the kidney lesions.
To fulfil the first indication the most potent influences that we have
are the giving up of business and of vicious habits and causing the
patient to live year after year in the most suitable climates.
Generally speaking, warm climates are to be preferred, but the
individual disposition of each patient must always be consulted.
Of less efficacy, but still of importance, are the improvement of the
digestion by means of drugs and the feeding of the patient.
In every patient suffering from chronic diffuse nephritis there are a
number of symptoms which seem to depend directly upon other conditions,
and not upon the kidney lesions; for if these conditions are removed
the symptoms disappear, although the kidney lesions continue. To this
category of symptoms seem to belong the headache, delirium, stupor,
coma, and convulsions, the nervous dyspnoea, the vomiting in part, the
dropsy in part, the diminution of urine in part. All these symptoms are
due to disturbances of the circulation, and the disturbances of the
circulation are produced by a number of causes which may act separately
or together. Changes in the valves and walls of the heart, in the force
and regularity of the heart's contraction, in the walls and size of the
arteries and capillaries, and in the volume and composition of the {96}
blood, each, separately or associated, may interfere with the proper
circulation of the blood, and this interference usually takes the form
of too much blood in the veins and too little blood in the arteries.