Chapter V: Front Matter (5)

TREATMENT.--(1) The Primary Cases.--In the cases characterized by dropsy the first indication is to get rid of the dropsy, and this is to be done by the methodical use of diuretics, cathartics, and diaphoretics. It will be found, however, that there is a great difference in the different cases as regards the precise time when these remedies will take effect and the dropsy decrease. Usually it is the best plan during the first few weeks of the disease to keep the patient confined to bed or to the house, and on a milk diet. From time to time efforts should be made to reduce the dropsy, but if these efforts produce no effect they should be discontinued and then tried again. In addition to the dropsy the condition of the stomach and the anæmia require treatment. For the stomach the milk diet is perhaps the most efficacious treatment. For the anæmia iron given by the mouth, combined with daily inhalations of oxygen gas, is of very great service. It is very important in these cases to guard against relapses. If possible, the patients should not return to their ordinary pursuits for a year after their apparent recovery, but should spend that time in travelling and improving their health in every possible way.

In the cases characterized by cerebral symptoms it must be confessed that treatment is not very efficacious. Diuretics have no effect, cathartics seem to do no good. Systematic sweating, the use of pilocarpine in small doses twice a day, inhalations of nitrite of amyl, the administration of chloral hydrate, caffeine, digitalis, and convallaria, and the use of fluid food in small doses, are indicated.

(2) The Secondary Cases.--While the primary disease, to which the nephritis is secondary, is running its course there is little to be done for renal symptoms. If, however, these symptoms persist after the termination of the primary disease, then the main indication is to improve the general health in every possible way.

Chronic Parenchymatous Nephritis.

A good deal of confusion is connected with this name, for the reason that many authors include in this one class all the large white kidneys except the waxy ones, and such kidneys present a variety of lesions. There are, however, a moderate number of cases in which the morbid changes are confined to the epithelium of the tubes and to the Malpighian bodies. All the kidneys, no matter what their gross appearance may be, which present changes in the stroma and blood-vessels, as well as in the tubes, belong properly to the class of chronic diffuse nephritis. I confine the name of chronic parenchymatous nephritis, therefore, to {81} those kidneys in which the inflammatory process runs a chronic course and is confined to the epithelium of the tubes and the Malpighian bodies.

LESIONS.--The kidneys are regularly increased in size, often weighing sixteen or twenty ounces. The capsules are not adherent, the surface of the kidney is smooth. The cortex of the kidney is thick and white, with white striæ running into the bases of the pyramids; the pyramids are large and red. The epithelium of most of the tubes and of the Malpighian capsules is swollen, granular, and detached. Cast-matter is present in the tubes. There may be an increase in the number of the small cells which cover the tufts of vessels in the Malpighian bodies.

ETIOLOGY.--This form of nephritis is not very common. It may follow acute parenchymatous nephritis and chronic congestion of the kidney; it is one of the complications of chronic pulmonary phthisis, and it occurs as an idiopathic disease.

SYMPTOMS.--There is a good deal of variety in the different cases as to the quantity and specific gravity of the urine. Usually the quantity is somewhat diminished, and the specific gravity is between 1020 and 1030.

Albumen is regularly present in considerable quantity, but it may be scanty, and may even disappear altogether for a time. Hyaline and granular casts are usually present, but in small numbers.

Dropsy is a regular symptom, and often goes on to general anasarca, although the degree of the oedema varies from week to week. Occasionally a case will run its course without any dropsy.

The functions of the stomach are disturbed, and the patients suffer from loss of appetite, nausea, and vomiting.

Muscular twitchings, convulsions, stupor, and coma only occur in the very severe cases.

Dyspnoea is often produced by the dropsy, sometimes is simply a nervous phenomenon.

Bronchitis with cough and expectoration may be a complication.

DURATION.--The course of the disease is slow; it lasts for months and 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.

8. With valvular disease of the heart and atrophied kidneys we may get 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.

Anatomical changes in the valves of the heart, in its walls, and in the walls of the arteries and capillaries cannot be influenced by any means at our command. The force and regularity of the contractions of the heart can, however, be very decidedly modified by drugs. Opium in moderate doses makes the heart's action slower and stronger; iodide of potassium makes the heart's action more regular; convallaria makes the heart's action slower and stronger; digitalis increases the force of the heart's action, but at the same time contracts the arterioles; aconite and veratrum viride make the heart's action slower and more feeble.

The size of the arteries and capillaries can also be altered by drugs. Nitrite of amyl and nitro-glycerin relax and dilate the whole arterial and capillary system; chloral hydrate dilates the arterioles (Fothergill).

The volume of the blood can be diminished by bloodletting and by eliminating the plasma of the blood indirectly by sweating, purging, or diuresis.