Chronic Parenchymatous Nephritis.
Synonyms:—Chronic desquamative nephritis; chronic diffused nephritis (exudative); large, white kidney; chronic tubular nephritis; chronic glomerulonephritis.
Definition:—A chronic inflammation of the structure of the kidney, diffuse in character, attended with exudation from the blood vessels, degeneration of the epithelium, and important structural changes in the glomeruli.
Etiology:—The condition may follow acute nephritis, or it may develop insidiously without a discoverable cause. It occurs with those who indulge in alcohol and tobacco and those who are irregular and dissipated in their habits. It occurs also among painters and those who are brought constantly into contact with lead or other mineral poisons. Syphilis, chronic gonorrhea, gout, rheumatism and other diatheses will lead to it. It results also from chronic indigestion and abuse of the stomach by overfeeding, bolting of food or irregularity of eating. It occurs from conditions which impair the integrity of the heart or of the circulation of the blood, or of the respiratory organs. It may develop slowly and insidiously, following an attack of measles, scarlet fever or diphtheria, without the characteristic phenomena of acute nephritis.
The condition also depends upon chronic infection or malarial poisoning which results in chronic disease of the liver or spleen. It occurs during the course of the pregnant term. Many cases of nephritis of pregnancy are not completely cured at the first attack, but lie dormant until a subsequent pregnancy, when they recur in a much more active form. They may then result fatally, or they may be in part controlled and continue as a chronic disorder after the confinement. I am convinced that various forms of autointoxication also lead to this disease.
It is most common in young males, occurring from twenty-five to forty-five years of age, especially with those who indulge in beer drinking.
Symptomatology:—In a large number of cases, the discovery, either accidentally or otherwise, of albumin in the urine is the first suggestion of this disease. One of my patients had a marked urinary irritation, almost as soon as albumin appeared, which persisted throughout the entire two and a half years of the course of the disease. When albuminuria with tube casts is pronounced and progressive, there is a gradual failure of strength and health, the patient becomes irritable, and, if aware of the presence of the disease, becomes morose and despondent. The appetite fails, there are some nausea and irregular attacks of indigestion, or the stomach disorder may assume a chronic form and be more or less intractable to treatment. There is some headache and progressive anemia. Usually the patient will persist in his customary employment as long as his failing strength will permit. When the disease occurs in younger people, or in children, it is a condition of rather slow development from previous acute disease, most often following scarlet fever or diphtheria. Following scarlet fever, the patient continues for some time in poor health, emaciated, weak, disinclined to physical or mental effort. The appetite is very poor, bowels constipated, skin dry and harsh. For quite a period there may be little if any albumin in the urine. The urine slowly decreases in quantity, the specific gravity increases, but there is deficient urea, and mild dropsical symptoms occur.
Later, as the disease progresses, there is a dragging sensation in the loins, the skin is pallid or of a dusky hue, and mild eruptions may occur. Occasionally the patient will improve under treatment and become more hopeful, to subsequently, from some indiscretion or from undiscover-able causes, relapse into the original condition, or grow rapidly worse, with the manifestation of new symptoms. The latter stages of the disease are marked by conspicuous, persistent dropsy, great debility, extreme anemia, and general uremic symptoms, such as muscular twitchings, mental aberration, faults of vision, albuminuric retinitis, mental dulness, or insomnia, with the persistent but irregular occurrence of more or less severe distressing headache. It is seldom that convulsions occur in this form of the disease. It is quite tommon for the heart to become involved and circulatory changes to become conspicuous. On the other hand, heart disease may be the cause of this form of nephritis.
The condition of the urine is in many particulars quite diametrically the opposite of that found in the chronic interstitial forms of Bright's disease, although there is considerable variation. The urine is at first deficient in quantity, and continues to grow more and more scanty; the specific gravity is high—from 1,020 to 1,035—and the color is usually dark. As in chronic congestion, there may be a heavy deposit of the urates or brickdust sediment upon cooling, or there may be some blood present. In most cases, however, especially those of men in early middle life, I have not found blood, but I have found a small quantity of clear, acid urine, of high specific gravity, which deposits upon the use of the heat and nitric acid test a very large quantity of flaky white albumin, amounting to one-fourth or one-third of the bulk of the urine.
Other distinctive points which will be considered in the diagnosis are that this form of the disease occurs before the age of forty-five, runs its full course in about two and half years, and is marked by the appearance of dropsy in the later stages. With children the course is much more rapid, and dropsy is usually present during its entire course. There are usually no convulsions.
The tube casts found in this form of the disease are fatty, granular, hyaline and epithelial casts, with blood casts if there is hemorrhage. The dropsy extends to all the subcutaneous tissues, especially those of the pendent portions of the body. It shows itself in the early stage, in the feet at night, and disappearing there during sleep, appears in the morning in the face and eyelids. The exudation may fill the pleural sac or the pericardium, inducing great difficulty of breathing, or it may involve the larynx and the epiglottis, inducing sudden or immediate suffocation. There may be difficult breathing from failure of the heart's action without the dropsy, apparent upon lying down, and depending upon the influence of the uremia upon the central nervous system.
As the end approaches, the sufferings of the patient becomes extreme. There is the loss of hope of recovery, the general dropsy, the severe muscular pains, the difficulty of breathing, and the almost constant headaches. The fact that sleep is almost impossible, because of the inability to lie down, renders the patient very greatly exhausted. There is no desire for food, often a repulsion, and diarrhea is common at this period, with severe, colicky pains. The urine now decreases yet more in quantity, and the specific gravity falls to from 1,008 to 1,004.
Diagnosis:—The diagnosis of parenchymatous nephritis depends upon the presence of a large quantity of albumin with tube casts, and a small quantity of urine, dark colored and of high specific gravity, in a patient young or usualty less than forty years old. The course of the disease is not above two and a half years in adults, but may be somewhat longer in children, having been of slower development. The tendency to dropsy is a diagnostic feature.
Prognosis:—The prognosis is usually unfavorable when the disease is fully established. Carefully selected treatment, with the perfect co-operation of the patient, may retard the development of the disease and prolong life for a number of years. Following the infectious or exudative diseases of childhood it is more amenable to treatment, and a favorable termination may be anticipated. However, the sudden occurrence of uremia or dropsy, or the presence of serious organic complications, may cause a fatal termination within a short time.
Treatment:—Medicinal treatment is not as satisfactory in this form of the disease as in the acute form. The general condition of the patient's health, the improvement of nutrition, favorable surroundings and restored tone of the nervous system are all essential in the absence of severe complicating disease. The general measures will be similar to those adopted in the cure of acute cases. The patient should have frequent salt water baths, with massage, and occasional rubbing of the skin, to produce considerable friction; he should wear flannels the year around, in order to keep the skin warm and to promote a steady, free excretion through the skin. The patient must avoid exposure to draughts or sudden cold or chilling of the skin. Sudden changes of the temperature are very undesirable. Our own locality, in the region of the lakes, is especially unfavorable. I invariably advise these patients to spend their winters in a milder climate and. to place themselves in a condition in which there is at no time any occasion to resist cold.
The use of alcoholics and tobacco is invariably proscribed. I refuse to treat patients who will persist in their use. Tea and coffee should also be greatly restricted if not entirely excluded. The drinking of large quantities of skimmed milk, either hot (not boiled) or cold, which contains a trace of salt; or whey, buttermilk or malted milk is desirable with children, and in cases where the digestion is imperfectly performed predigested milk is given to advantage. The patient may have stale bread, toasted bread, zwieback and crackers. He may also partake occasionally of a piece of rare, juicy broiled beefsteak. Beef juice or scraped beef will be found serviceable also, but cured meats and meats fried in fat must be avoided. At other times prepared foods, cereal foods or light cereals, as rice, sago and tapioca, may be eaten with fruits in season. The patient may drink abundantly of water, and should adopt a regular habit of flushing the intestinal canal at least once each week. The introduction of a quart of the normal salt solution as hot as could be borne, the last thing before retiring, after having thoroughly flushed the bowels, will be of much benefit. It will strengthen the patient, will exercise a restorative influence, and conduce to profound natural sleep.
When there is a large quantity of free white albumin, or when albumin is present in abundance with blood cells, or when the tendency to hemorrhage is marked, I have obtained excellent results from the administration of ten grains of gallic acid every two hours. Where anemia is present, I alternate this remedy with the tincture of the chlorid of iron every two hours, giving about four doses of each daily. Where the nervous system is at fault, I am in favor of giving large doses of nux vomica. I believe there is a class of cases, especially those who have indulged in alcohol in excess, who may take as high as one grain of the extract four or five times a day for two or three weeks with only beneficial results. This is the maximum dose, and if I had not prescribed it with good results I should not now advise it. From one-sixth to one-third of a grain every three hours will suit the condition of most of the patients.
Where it is desirable to continue a treatment similar to the above for a long time, it is a good plan to break in once in a while upon the regular course for six or eight days, and give the patient hydrastis, quinin and capsicum, or other tonic or restorative treatment. Instead of the tincture of the chlorid of iron I have used the ethereal tincture of the perchlorid of iron, official in the German Pharmacopeia, and have found it to be a superior remedy. It is given in from five to ten minim doses. Another excellent tonic is a phosphorized elixir of calisaya bark and pyrophosphate of iron. This may be given where the nervous system is involved, especially where nervous debility is present.
The chlorid of gold and sodium has been given, in the early stage of chronic Bright's disease, with good results. It may be given in one-eighth grain doses three or four times each day. It should be given in conjunction with or alternately with iron. Before the occurrence of dropsy the use of arsenic or the arsenite of copper will materially benefit some cases. Five drops of Fowler's solution may be given three times a day, or one-fiftieth of a grain of the arsenite of copper may be given every three hours. For the dropsy I have obtained good results from the use of haircap moss. An infusion of beech leaves has been advised by a number of my friends, who claim it to be very reliable. Our main dependence has been upon apocynum, and I should give it as I have advised in the acute form of the disease. Any active eliminant that induces rapid excretion of water is apt to produce weakness of the heart, which must be met with some sufficient remedy. The citrate of caffeine may be used regularly to prevent such weakness or to sustain the influence of the organ. Professor Whitford's method of administering full doses of iron with the sulphate of magnesium will be found of much service in emergency cases. When danger from extreme dropsical accumulation seems imminent, relief may be obtained within a few hours, often rendering tapping unnecessary.
I believe that a better understanding of the agents which act upon dropsical accumulations should be had in order to obtain the best results from our remedies. Cathartics are administered to reduce the quantity of fluids within the tissues, carrying them off through the intestinal tract. I believe that apocynum, elaterium, haircap moss, magnesium sulphate and some other remedies of this class will so influence the process of absorption that the diffused serum will be resorted through the capillaries, and dropsy will disappear without hydragog, or diuretic action. Whether these remedies act directly upon the heart, or upon the secretory or excretory glands of the intestinal tract, as elaterium is supposed to act, or upon both of these processes, as apocynum acts, there is no doubt that they exercise an influence upon the blood pressure, upon arterial tension, and perhaps also upon the specific gravity of the blood, which influences the osmotic processes, thus promoting the re-absorption of the diffused serum with no loss of the fluids of the body from increased eliminative action. This is certainly of much importance in the ultimate restoration of the patient. For the accomplishment of this result the patient should have small doses of the remedies, frequently repeated.
There is a class of these cases in which there is extreme arterial tension. These are influenced favorably with nitroglycerin in 1/100 grain doses three times each day. This controls heart action to a degree and reduces the loss of albumin through the kidneys.