A Summary and Comparison of the Facts Involved in Inflammation of the Kidneys, Acute and Chronic
[image:13664 align=left hspace=1]FINLEY ELLINGWOOD, M. D., CHICAGO
I have recently had numerous inquiries concerning the various forms of inflammation of the kidneys. I have thought that it might not be unprofitable to make a summary, and perhaps a comparison, of the important points involved, hoping that this might be of some assistance in the diagnosis and treatment of these conditions.
In acute nephritis, the parenchyma is first involved, and later, usually very soon, the entire structures of the organ. In the chronic parenchymatous form, the disease involves the parenchyma alone, and in the chronic interstitial form, the connective tissue is involved, which results in a degeneration and contraction of the entire organ. In amyloid kidney there is degeneration of the structure of the kidney with deposit of lardacine throughout the structures of the organ.
Etiology. Acute nephritis may develop from primary congestion suddenly, or from direct injury, it may follow excessive drinking, or in childhood it results from autointoxication and from the previous existence of other diseases. It occurs from taking irritating or poisonous agents, and from septic absorption.
Chronic parenchymatous nephritis occurs without explainable cause, or as a result of bad habits of the system—lithemia, persistent gout, rheumatism, chronic malaria, syphilis, and alcoholism, as well as chronic derangement of the stomach. It occurs from the age of thirty-five or forty and runs a course of from two to four years.
Chronic interstitial nephritis results from a prolonged and excessive diet of nitrogenous foods, with chronic gastrointestinal or hepatic disorder; from the absorption of lead, mercury, phosphorus, or other irritating substances, and is common to alcoholics. It occurs after the age of 50.
Amyloid degeneration of the kidney occurs in connection with amyloid degeneration of other organs. It is more common among patients who suffer from bad habits of the body, and changed conditions of the blood. It follows syphilis, tuberculosis, chronic gout, or malaria, leukemia, or cancer, but especially is it likely to occur where there is prolonged suppuration, either of the osseous or other tissues.
Pathology. In acute nephritis engorgement is the first change. The size is increased, the cortex of the kidney is uniformly swollen, and the appearance of the pyramids is like raw beef. The capsule is not adherent.
In the chronic parenchymatous form, the kidney is increased in size, but is of a pale color, and is known as the large, white kidney. The cortex is infiltrated uniformly, is considerably swollen, and the capsule is not adherent.
In the chronic interstitial variety, the organ is contracted to a greater or less degree. It is known as the small red kidney. The cortex is uniformly atrophied, and the capsule is adherent and materially thickened, as the disease pertains to the enveloping structures more than to the organ itself.
In amyloid kidney, the characteristic degeneration produces a large, waxy, or fatty kidney. The cortex is pale, and the capsule is not adherent.
Symptoms. In acute nephritis, there is usually a chill, with a sudden rise of the temperature. In that form which results from cold or injury, the symptoms are in many ways similar to those of acute congestion of the kidney. There is severe aching of the muscles of the back, nausea, vomiting, hot and dry skin, with persistent chilliness, flushed face, contracted pupils, with restlessness and perhaps delirium. The pulse is sharp, hard and think, ultimately small, wiry, and very rapid. Urinary irritation appears early. The urine is scanty, dark, smoky, or wine colored, has a specific gravity of from 1026 to 1034. Uremia appears after two or three days, with edema of the feet and ankles. When this disease appears as the result of other diseases or from septic poisoning, uremia and anasarca may be the first symptoms. The urine is more abundant, pale, has low specific gravity, and there is less urinary irritation. Dropsy advances rapidly, the patient is dull, listless and indifferent, and convulsions are apt to appear.
In chronic parenchymatous nephritis, the condition may exist for some time before albumin is discovered in the urine. The presence of urinary irritation has in several of my cases led to an analysis of the urine, which disclosed the presence of the albumin. If the patient is not alarmed at the condition, some months may elapse before failure of health and strength, failure of appetite, and chronic indigestion appear. Later the gastrointestinal disturbances are marked. Headache and progressive anemia are common, and failing strength is pronounced. Still later the skin is dry, bowels are constipated, there is but a small quantity of urine, dark of color, and of high specific gravity, precipitating on test a large quantity of albumin. Edema is not usually one of the early symptoms, but in the later stages general dropsy with heart complications are the conspicuous conditions, and anemia is extreme. Uremia only occurs in the last stages. At this time the urine is increased in quantity, is of low specific gravity, and pale. There is extreme anorexia, diarrhea, and constant headache.
In the interstitial form, the first symptoms are those of fatigue, a lack of energy and vivacity, headaches, defective action of the stomach and bowels, and slowly increasing polyuria with corresponding increase in the amount of water drunk. The urine is pale, greatly increased in quantity, specific gravity from 1008 to 1012 at first, later 1002 to 1006 At no time is there any great quantity of albumin in the urine. The condition may exist for from three to five years, before its real character is known, lasting sometimes as long as fifteen years. At its termination, there is a complete abatement of vital force, usually preceded by failure of the stomach and digestive functions; the urine becomes suddenly scanty and dropsy, diarrhea and heart symptoms are apparent at the last.
Differential Diagnosis. Acute nephritis is common to all ages up to middle life. The symptoms are of sudden occurrence, run a rapid course, terminating within a few days, or at the farthest a few weeks. In the parenchymatous form, the condition does not occur till after forty, runs a course of from one and a half to two and a half or three years; there is but little urine, dark colored, with high specific gravity; there is an abundance of albumin in the urine, and there is uremic intoxication and dropsy. The interstitial form does not occur before the age of 50 and is more common in men. The condition may last for many years; the first symptoms are often entirely overlooked. There is a polyuria, the urine is almost colorless, and of low specific gravity. There is but a trace of albumin, and no uremia or dropsy until the end. In amyloid kidney anemia, derangement of the stomach, permanent and increasing debility, and diarrhea with chronic enlargement of the liver and spleen are the distinguishing points. This condition is diagnosed by the large proportion of globulin present in comparison with the amount of serum albumin.
Prognosis. In acute cases, if taken early, the prognosis is good, in the parenchymatous form, a few cases recover. In the interstitial form, the disease is not cured, but may be prolonged until the patient reaches old age. In amyloid degeneration the prognosis is fatal.
Treatment. But little can be said of the treatment in a summary of this character. In the acute form, the first essential is hot applications to the back, persisted in, until the urine passes more freely, and with reduced specific gravity. Free transpiration from the skin must be obtained and continued, gelsemium, macrotys and aconite are the most serviceable remedies at the onset; jaborandi and apocynum will encourage transpiration. Magnesium sulphate and elaterium with an infusion of digitalis will sometimes be of service in removing the effusion. Hyoscyamus will control the delirium, veratrum and chloral will control the convulsions. Echinacea should be given to antagonize toxemia. In children, following diphtheria or scarlet fever, small doses of belladonna and santonin are sometimes immediately efficacious. The food must be selected with much care.
In the treatment of chronic parenchymatous nephritis, alcoholics and tobacco must be excluded positively, tea and coffee must be greatly restricted, skimmed milk may be drunk freely. The introduction of a quart of the normal salt solution into the rectum each night is of service. Internally the etherial tincture of the perchloride of iron is the best single remedy I have used.
Nux vomica in full doses, with the tincture of the chloride of iron, are beneficial. The chloride of gold, and sodium given early, and in full doses, is an excellent remedy. The bromide of arsenic, or the arsenite of copper are strongly recommended. The heart must be supported, and dropsy antagonized. Apocynum, magnesium sulphate, hair cap moss, and small doses of elaterium, are serviceable for this purpose. The general nutrition of the patient must be sustained by close attention to the condition of the stomach.
In the treatment of the chronic interstitial form, hygienic measures are applicable from the first to the last. A cachexia must be guarded against. The integrity and full quantity of the red blood corpuscles must be retained. The most essential condition to sustain, never forgetting its importance, is the condition of the stomach and the digestion. I have seen very many cases of this disease, and I am convinced that if this function alone was kept in an absolutely correct condition, year after year, the disease would not materially shorten the patient's life. On the other hand I have seen several cases where everything was favorable to a prolongation of life, until some indiscretion produced a marked derangement of the stomach, with sudden failure of the vital forces, and in a few cases, death. Selection of remedies must be made with reference to existing specific condition and they must be changed as the conditions change.
In amyloid degeneration, when once fully established, treatment is of but little benefit. If diagnosed early, the blood should be promptly restored, every dyscrasia eliminated, and echinacea or calcium sulphid should be given to correct any tendency toward suppuration. Syrups of the hypophosphites, or the glycerophosphates; syrups of the iodid or oxide of iron, should be given, or the etherial tincture of the perchlorid. Other tonics should be adapted to the condition of the individual patient. Hygienic and dietary measures advised for chronic parenchymatous nephritis are usually applicable here.
Ellingwood's Therapeutist, Vol. 2, 1908, was edited by Finley Ellingwood M.D.