Nephritis

“ 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. ”

“ It is low in chronic interstitial nephritis, diabetes insipidus, and many functional nervous disorders. It is high in fevers and in parenchymatous forms of nephritis. In any form of nephritis a sudden fall without a corresponding increase in quantity of urine may foretell approaching uremia. It is highest in diabetes mellitus. A high specific gravity when the urine is not highly colored should lead one to suspect this disease. A normal specific gravity does not, however, exclude it. ”

“ Rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. Nephritis, if it be moderate, attended by little albuminuria and serous effusion, and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. ”

“ 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. ”

“ Renal Hyperemia.—Active hyperemia is usually an early stage of acute nephritis, but may occur independently as a result of temporary irritation. The urine is generally decreased in quantity, highly colored, and strongly acid. Albumin is always present—usually in traces only, but sometimes in considerable amount for a day or two. The sediment contains a few hyaline and finely granular casts and an occasional red blood-cell. In very severe hyperemia the urine approaches that of acute nephritis.
[p. 133]
Passive hyperemia occurs most commonly in diseases of the heart and liver and in pregnancy. ”

“ Perinephritis and perinephritic cellulitis, i.e., inflammation with or without abscess formation in the connective tissue and adipose layer surrounding the kidney, always occur in cases of suppurative nephritis or pyelo-nephritis. Such inflammations may also, in exceptional cases, follow direct mechanical injury, but they almost invariably represent complications, the organisms infecting the kidney passing through the tissues and the layer of fibrous tissue, or extending by the lymphatic paths, finally attaining the fatty tissue surrounding the kidney and there undergoing multiplication. ”

“ The cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate.
SYMPTOMS.—When the nephritis occurs with cystitis due to stone in the bladder, strictures, or operations on the genito-urinary tract, the [p. 101] symptoms are much the same. The patient has first the symptoms belonging to the cystitis, then he is attacked with rigors, followed by a febrile movement. The rigors are often repeated ”

“ 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. ”

“ Early and correct treatment of the nephritis is attended by much better results than delayed treatment, and many more patients are doubtless now saved than in former times, when little attention was given to the state of the kidneys until dropsy or other prominent symptoms appeared. ”

“ In the severer cases a well-marked parenchymatous nephritis exists; but it should be distinctly borne in mind that if every instance of albuminuria in pregnancy is due to nephritis, it is certainly a form of the disease which may lead neither to severe symptoms nor to chronic disease. On the other hand, the appearance of albumen in the urine of a pregnant woman, though not necessarily calling for active interference of any kind, should always be a danger-signal, and put the physician on the lookout for other indications of actual renal disease. ”

“ Epistaxis is not uncommon. A very unfavorable symptom seems to be hiccough. Another frequent cause of death and the one against which we chiefly direct our therapeutic measures is anuria with subsequent uraemic symptoms, such as coma and convulsions. At times a nephritis may develop in the course of a blackwater attack and the case subsequently run as one of severe nephritis.
Very striking is the rapidly developing anaemia, some cases showing a loss of two million red cells in twenty-four hours. ”

“ On the other hand, when suppurative nephritis tends to develop slowly and assume a chronic form, lesions of pyo-nephrosis gradually develop, and are identical in appearance with those of hydro-nephrosis, except that the ureters, the pelvis and the dilatations corresponding to the lobules, are filled with pus.
Fig. 231.—Leaf lard around kidney of pig.
Diagnosis. The diagnosis is not very difficult. The urinary trouble and the composition of the urine itself always arouse suspicion. ”

“ In chronic nephritis, which may be the result of an acute attack, or as a sequel of other diseases already mentioned, there is seen to be a progressive loss of flesh and strength, marked anemia, gastro-intestinal disturbances, increased blood tension and edema, the latter especially in the face on arising in the morning. Uremia may develop at any time. ”

“ 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 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. ”

“ Problems to Be Considered.—But in nephritis, there are other problems to consider, which make it impossible to institute such a treatment as will effect a perfect rest of the renal organs. The kidneys represent the chief source whereby the waste products of the body are eliminated. This waste consists not only of the end-products of the nitrogenous foods ingested, but also the end-products of tissue metabolism, which is the inevitable result of the wear and tear of life. ”

“ Anaesthetics, that is, chloroform and ether, are not well tolerated when nephritis exists, and this adds to the danger of operation in such patients. No matter how simple or short the operation that is to be performed on a person suffering from kidney disease, if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur.
Kidney disease is often extremely insidious. It may develop absolutely without the patient's knowledge, even though he might be deemed to be in a position to have at least some suspicion of its existence. ”

“ Unsuspected cases of nephritis showing only gastric symptoms clinically have been detected by blood chemistry. The significance of albumin in traces and occasional casts in urine has been more definitely established by examination for increase of uric acid in the blood—an increase arguing for an organic lesion. Values of over 4 for creatinine do not occur without great impairment of renal function, and findings of more than 5 have practically uniformly foretold a fatal termination in less than six months, except in acute nephritis and mild bichloride of mercury poisoning. ”

“ Chronic nephritis is certainly met with much oftener than formerly, and I know that many a death certificate ought to bear the inscription of nephritis instead of meningitis, convulsions or acute pulmonary œdema. ”

“ When taking various drugs, we must always remember that they must pass through our kidneys. The drug habit, especially when irritating drugs are taken, can have a ruinous effect on these vital organs and surely diminish our prospects for a long life. Day by day many of the epithelial cells will be desquamated, slowly but surely, and inflammatory conditions of the kidneys will eventually appear. There is nothing in this world without a cause, and if a chronic parenchymatous or interstitial nephritis suddenly appear, it must have a pre-existing cause. ”

“ Even more important for the sake of the individual himself than for those he is in contact with is the recognition of his pathological condition. Nothing is more likely to cause kidney disease to grow rapidly worse than responsibilities heavier than the individual is accustomed to. When, then, there are symptoms of nephritis it is inadvisable for the patient to be made Superior, and if the symptoms develop after his appointment or election he should be relieved of his responsibilities, at least to a considerable degree. ”

“ The chief symptoms may be grouped as follows:—
Salivation, indigestion and tympanites, nausea, vomiting, diarrhœa, and (especially) intense polyuria: the kidney may be irritated to such a degree as to produce albuminuria and hæmaturia. Intense dulness and general weakness precede death, which sometimes occurs in four to twelve hours after the poison has been taken.
The lesions are to be found in the digestive and urinary apparatus. The kidneys are congested and hypertrophied, or present changes indicating epithelial nephritis. The ureters and the bladder may show similar lesions. ”

“ Squamous epithelium points to the cystic mucosa and is not increased in nephritis.
Mucus in cylindroid form may point to nephritic congestion or inflammation, but this may be present in health, and may show in irregular masses derived from the renal pelvis or the bladder. Mucous casts are always extremely elastic and mobile, and lack the even clear cut margins of the casts of nephritis. They are much more common in horses urine than in that of other animals. ”

“ Hyaline casts are the least significant of all the casts, [p. 115] and occur in many slight and transitory conditions. Small numbers are common following ether anesthesia, in fevers, after excessive exercise, and in congestions and irritations of the kidney. They are always present, and are usually stained yellow when the urine contains much bile. While they are found in all organic diseases of the kidney, they [p. 116] are most important in chronic interstitial nephritis. Here they are seldom abundant, but their constant presence is the most reliable urinary sign of the disease. ”

“ In some patients that die of scarlatinous nephritis, death occurring in convulsions or coma, no appreciable lesions are observed within the cranium, unless more or less congestion, the fatal ending being attributable to the uræmia. In other instances we find an effusion of serum within the ventricles or upon the surface of the brain. Although the symptoms in scarlatinous nephritis and uræmia may appear very unfavorable, the prognosis is usually good under prompt and appropriate treatment. ”

“ Infectious diseases, such as gangrenous coryza, hæmoglobinuria, tuberculosis and post-partum infections, also play an important part, whether the nephritis be direct, that is to say, the result of the infecting agent itself, or indirect, i.e., produced by toxins generated in the body. In female animals gestation is an often unsuspected cause. Moussu believes that albuminuria is frequent during gestation, and although in most cases it is only of moderate degree, he thinks it is often associated with subacute nephritis, which might be aggravated by an accidental cause. ”

“ Palpation, more especially palpation of the right flank, percussion over the region of the loins, and examination of the kidneys through the rectum are painful. Wasting is rapid.
If the suppurative nephritis develops rapidly, and particularly if it be accompanied by perinephritis, the patients refuse to rise and appear to be suffering from paraplegia, although not really so, both sensation and motor power persisting in a greater or less degree. Probably the condition is accompanied by reflex pain and irritation of the nerve trunks of the lumbo-pubic plexus. ”