through the skin; with it an erythema may be present accompanied by a frosty
coating of urea crystals upon the skin.
Numbness and tingling of the extremities and muscular cramps, especially
at night and in the calves of the legs, are less typical symptoms.
Respiratory Symptoms. Uraemic dyspnoea is common. It often appears
suddenly at night, the attack markedly resembhng that of true asthma, respi-
ration being impossible while in the recumbent position. Dyspnoea due to
cardiac dilatation and to pulmonary oedema may be associated with uraemia.
In other instances the dyspnoea is continuous and in still others Cheyne-Stokes
respiration may be present and persistent for considerable periods of time
even when unassociated with coma.
670 DISEASES OF THE URINARY SYSTEM.
Gastro-intestinal symptoms may be the first manifestations of uraemia and
include anorexia, nausea and persistent vomiting; with these diarrhoea may-
be associated or the last may occur independently, being due to catarrhal
or diphtheritic colitis. The tongue is frequently covered with a thick coating,
the breath is foul and a stomatitis with swelling of the buccal, gingival and
lingual mucous membranes may be observed.
Suppression of urine is often the first symptom but is not an essential one.
It may be associated with a urinous odor of the breath, sweat and vomitus,
if emesis i9 present.
A rise of temperature is a frequent symptom but is by no means always
The diagnosis of uraemia by means of the estimation of the amount of urea
in the blood is somewhat uncertain for as previously stated the condition
may not develop when the urea content of the blood is much increased and
it may appear when the urea is present in abnormally small quantity. The
examination of the blood and urine by means of cryoscopic and electric
conductivity tests with the hope of being able to anticipate a uraemic attack
is more or less futile for it has been shown that uraemia often develops
when the salt values in the blood are normal or subnormal and that uraemia
is by no means certain to appear when there is a marked augmentation of
the salts in the blood and corresponding decrease in those of the urine. The
quantitative determination of the urea excretion in the urine is of little value
in predicting a uraemic paroxysm.
With a regard to the differential diagnosis of irraemic coma it may be said
that a sudden attack of coma attended with diminished urine of abnormally
low urea content is likely to be of uraemic origin. The coma of alcoholism
or of opium poisoning may be mistaken for that of uraemia but in the former
the pupils are dilated, in the second they are contracted while in the last con-
dition they may be either the one or the other.
The prognosis. The occiirrence of ursmia is always an unfavorable
manifestation but is by no means always a fatal one.
Treatment. The treatment of the iiraemic seizure will be dealt with in the
sections devoted to the treatment of the nephritides and in addition to the
methods there suggested the injection, after venesection, of a solution of sodium
chloride (o.g percent.) containing sodium bicarbonate or a solution of sodium
citrate or phosphate may be advisable; an important consideration, however,
is the prevention of the development of the acute paroxysm. This is to be
accomplished by giving studious attention to the condition of the functions
of the organs at fault, particularly the liver. Stimulation of this organ is
contraindicated in the pre-uraemic state; on the contrary, rest is a paramount
consideration. The over-worked liver should be spared as much as possible
and likewise the general metabolism of the body should be regulated. The
ACUTE NEPHRITIS. 67 1
liver is given a period of rest by the elimination from the diet of substances
which are in the least irritative or stimulative, that is to say the patient should
be put to bed and upon a regimen chiefly of milk, gruels and easily digesti-
ble semi-solids. This should be continued for a considerable period and at the
same time elimination of the accumulated toxins is assisted by means of high
rectal irrigations of hot normal saline solution. These should be given twice
daily and should consist of two gallons (eight Utres) of the solution at from
116Â° to 120Â° F. (46.5Â° to 49Â° C.) administered by means of a fountain syringe
suspended from three to four feet above the patient and to which a soft rubber
rectal tube is attached. When the liver has been thoroughly rested it should
be stimulated to undertake its work once more by means of moderate doses of
salicylic acid, sodium oleate, or if necessary small doses of calomel. A pill
consisting of 2 grains (0.13) of acid sodium oleate, 2 grains (0.13) of phenol-
phthalein, 5 grains (0.33) of methyl salicylate, and J grain (0.016) of menthol
will be found very useful. Of these four to eight pills may be given during
the twenty-four hours, and through their influence the bile becomes more
fluid, any tendency to hepatic hyperasmia is corrected and intestinal fermen-
tation is to some extent prevented. While this treatment is being carried on
the condition of the liver function as evidenced by the patient's general state,
and the composition of the faeces and lurine, must be watched.
Synonyms. Acute Bright's Disease; Acute Desquamative Nephritis;
Acute Diffuse Nephritis; Acute Catarrhal Nephritis.
Definition. An acute inflammation of the kidneys involving the epithelial,
vascular and connective tissues of these organs. The degree to which these
various structures are affected differs in different instances.
-(Etiology. Acute nephritis occurs most frequently as a result of one of
the acute infectious diseases, scarlatina, diphtheria and smallpox being especi-
ally prone to be followed by this complication. The inflammation is observed
less frequently in measles, enteric fever, cholera, yellow fever and dysentery,
and is still more rare in acute articular rheumatism, tonsillitis, syphilis, acute
tuberculosis and malaria. It may be observed in septicaemia, pyaemia and
purpuric conditions. Exposure to cold and wet is a not uncommon cause ; the
acute congestion caused by the ingestion of chemical poisons such as potassium
chlorate, phenol, mercury, arsenic, creosote, etc., may go on to acute nephritis;
it may also occur secondarily to operations upon the kidney. Chronic skin
diseases and burns, in the latter instance probably as a result of toxins absorbed
through the burned surface or of poisonous substances developed in the organ-
ism, may be accompanied by acute kidney inflammation.
The condition is often seen in pregnancy and is now considered to be a
672 DISEASES OF THE URINARY SYSTEM.
part of a general toxaemia rather than the result of pressure upon the renal
Acute nephritis, since the acute exanthemata and other infectious diseases
are frequent in childhood, often is seen in the young. It is rare after middle
life but may occur in adults before this period has been reached, depending
in its frequency upon the incidence of its various causes.
Pathology. Both organs are equally affected and while in the milder types
of the inflammation they may exhibit no appreciable gross change, in the
severer forms they are more or less enlarged, sometimes even to twice their
normal size and weight. The capsule is easily stripped off, the kidney sub-
stance is less firm than normal and its surface is smooth, mottled and may
present hsemorrhagic spots. Upon section the cortex is swollen and reddish
and the interp}T:amidal portions of the mediilla are also enlarged; from the
cut surface dart blood oozes in considerable amount; this being removed the
blood-vessels are seen to be congested and between them pale areas may be
detected. The Malpighian bodies are swollen, dark and congested; in other
instances they are pale.
Microscopically, changes in the tubules, in the glomeruli and in the inter-
stitial tissue may be found. The tubal epithelium is swollen and may be the
seat of fatty or hyaline degeneration. The convoluted tubules may contain
desquamated epithelial cells, leucocytes and red corpuscles and even hyaline
or blood casts. The epithelium of the straight tubes is not affected but their
lumens may be blocked by cells and degenerated matter which also may
be found in the convoluted tubules.
The toxic cause of the nephritis affects the glomeruli earlier than the other
portions of the kidney struct\u"e; their capillaries are distended with blood and
their walls are often the seat of a hyaline degeneration; the epithelium of the
glomeruli and of Bowman's capsule may be involved and the cavity of the
latter distended with leucocytes and red blood cells. The connective tissue
about the capsule may be increased and this with the other changes may affect
the nutrition of the tubules to a marked extent.
In mild instances of the disease the interstitial tissue is the seat of an exuda-
tion of serum and an extravasation of red and white blood cells; in the more
marked inflammations the cells are greater in number and there is often an
infiltration of small cells between the convoluted tubules and about the cap-
sules. These changes may be localized in certain parts of the organ or gen-
erally scattered through its tissue.
Symptoms. The onset of the disease may be sudden, especially in the type
which follows exposure, or it may be gradual. The first manifestation is a
pufiiness under the eyes or oedema of the ankles. Rarely is the inflammation
ushered in by a chill but its invasion may be marked by a convulsion in children.
Nausea, vomiting and lumbar pain are frequent symptoms. The tempera-
ACUTE NEPHRITIS. 673
ture is seldom high and in certain instances fever may be wholly absent unless
it occurs as a symptom of the causative disease. The pulse may be shghtly
accelerated but an increase in tension is very constantly present and there is
consequent accentuation of the aortic second sound.
Sweating is diminished and the \irine is scant in quantity; entire suppres-
sion may occur as an early symptom. With the diminution of the urine there
is usually dropsy although this symptom may at times be absent. The oedema
begins about the face and in the ankles whence it extends to the trunk and
upper limbs. It often involves the scrotum and prepuce as weU as the peri-
tonseal and pleural cavities. (Edema of the lungs or glottis may occur.
Anaemia is very constant and there may be haemorrhages from the nose and
into the skin during the disease.
The urine is very characteristic; it is scanty, perhaps but a few ounces in
the twenty- four hours, high colored and of high specific gravity; its acidity may
be increased and the sediment is often profuse,.amorphous and reddish brovra
in color. Chemical examination reveals the presence of a considerable quan-
tity of albumin, the urine often becoming almost entirely solid upon boiling;
the albumin may be estimated to be 50 percent, or more by volume; by weight
it is rarely over 2 percent. The albumin is made up of that contained in the
extravasated blood and of the products of the degeneration of the lining of
the tubules. The urea while of high percentage is considerably diminished in
twenty-four hour amount. The microscope shows the sediment to be composed
of blood cells, desquamated epithelium and casts of the uriniferous tubules;
the latter are hyaline and graniilar for the most part, but casts to which
blood cells or epithelium in various stages of degeneration, are attached are
common; these latter are rather characteristic of acute nephritis.
Uraemic symptoms (see p. 669) may appear at any time and add to the
gravity of the disease; they are usually a late manifestation but may occur
with the suppression of urine which marks the onset.
Retinal haemorrhages have been observed but ocular involvement is not
The course of acute nephritis varies; it may last but a few days or be pro-
longed for weeks; the kidneys may return to their normal condition or the
disease may pass into the chronic type of the affection.
Complications are few but among those liable to occur may be mentioned
pneumonia and empyema resulting from an infection of the pleural transudate.
The diagnosis in instances of weU-marked symptoms is easy, especially
if we have the history of a primary disease. Patients who exhibit little dropsy
and few or no other symptoms may possess kidneys which are seriously diseased
as will be shown by urinary examination. The iirine of the acute congestion
of the kidneys may be distinguished from that of acute nephritis by its less
amount of albumin, fewer hyaline and granular casts and the lack of blood
674 DISEASES OF THE URINARY SYSTEM.
and epithelial casts. Sudden uraemic attacks may be the first evidence of
the disease, especially in the type that is due to the toxaemia of pregnancy,
although careful watching of the pulse for an increase of tension and of the
urine for the appearance of albumin, will usually give warning of the impend-
The prognosis is variable. It is unfavorable in the patients whose symp-
toms persist for a month or more; if these gradually diminish after a week or
two, the urine clears and the oedema gradually is lessened, recovery is probable.
The prognosis in children is usually favorable. The occurrence of ursemic
symptoms, of pulmonary oedema and of suppression of urine renders the out-
look grave. In rare instances sudden death may take place.
Treatment. During the course of the disease rest in bed is an absolute
necessity and the patient should be guarded against draughts and chilling
of the body by warm covering; a night gown or pajamas of flannel are to be
preferred to garments of cotton or linen. The ventilation of the room should
be free, an apartment with a fire place being most suitable.
The diet should consist exclusively of milk during the acuity of the disease,
for this substance is usually well borne, is easily digested and assimilated
and is nutritious. It also has the advantage that under its employment the
albumin grows less in quantity and it gives less nitrogen to the blood than does
meat. The quantity should be from 2 to 3 quarts (2 to 3 litres) during the
twenty-four hours, given frequently in small amounts, for instance a glassful
every two hours. It may be more agreeable to the patient when diluted with
lime, carbonic or Vichy water or when it is flavored by the addition of a little
coffee. Its diuretic action may be favored by the addition of 3 to 4 ounces
(90.0-120.0) of lactose to the daily amount. Agreeable substitutes for milk
are kumyss, matzoon, diluted condensed milk, vegetable â€” oatmeal, barley,
arrowroot, etc. â€” gruels and meat broths. The last can hardly take the place
of milk but may now and then be allowed if the patient chafes under a diet
exclusively of milk. When there is clearance of the albuminuria the first addi-
tions to the regimen should be green vegetables, puree soups, bread and butter,
cheese and eggs; later the white meats may be allowed but the red meats should
be delayed for a considerable period. In connection with the discussion of
the diet it would seem well to add a word concerning the management of the
dropsy by means of the dechloridation treatment. There is in oedematious
states a retention of the chlorides in the organism and this results in a transu-
dation from the blood-vessels of serum and a consequent dropsy; if the diet
contains still more chlorides the condition is augmented, consequently it is
wise to eliminate these elements from the food as far as is possible; this is
accomplished by excluding foods containing much salt, and forbidding the
use of this substance in the preparation of the food or as a seasoning. This
subject will be still further considered under the treatment of chronic nephritis.
ACUTE NEPHRITIS. 675
With regard to beverages it should be stated that the patient is to be encour-
aged to take plenty of water, unless marked dropsy is present, either plain or
carbonated; it may be flavored with fruit juices if more agreeable. The
so-called cream of tartar lemonade is often well liked. It consists of a
drachm or two (4.0 to 8.0) of potassium bitartrate added to a pint (500.0)
of boiling water and flavored with lemon juice and a bit of lemon peel. It
is most palatable when taken cold.
The lumbar pain at the onset may be relieved by the application of hot
compresses or poultices, a sinapism, or even by wet and dry cupping or the
actual cautery. These measures may, perhaps, have some influence upon
the inflammation of the kidney. Wet cups shoiild not be employed in children
and the dry cups shoifld not be allowed to remain long in one spot since it has
been stated that if they remain too long stagnation of the blood within the
capillaries takes place and consequently circulation in the kidney is delayed
and the congestion augmented rather than relieved.
The suppression of urine and the lack of perspiration which may appear
as an early symptom necessitate the employment of the hot pack. This
procedure is carried out as follows: A large-sized blanket is wrung out in
water as hot as can be borne, wrapped about the patient and outside this a
rubber sheet is applied. The patient is allowed to remain thus enveloped
for from one to two hours during which time hot drinks are given to increase
the diaphoresis. By this means free sweating is induced and much of the toxic
excrementitious matter which should have been passed off through the kidneys
is eliminated. Other methods of producing diaphoresis are by administering
a hot bath for flfteen or twenty minutes after which the patient is wrapped in
blankets; and by the vapor or hot air bath which is given by arranging the
bed clothing so that an apparatus for generating steam or hot air may pass
its product beneath. Any of these measures will cause the patient to per-
spire freely. At the end of the procedure the patient should be rubbed dry
with warm towels, covered warmly and protected from draughts. The free
diaphoresis is also very useful in diminishing the oedema and in warding off
uraemia. Sweating is also to be advised in the treatment of this latter con-
dition. Depletion through the bowels is also important in the management
of the dropsy and the uraemia. Laxatives should be employed from the on-
set of the disease, at first to relieve the congestion of the kidney, later to assist
in removing the dropsical transfusion. The salines are usually preferable to
the vegetable purges; to children we may give the effervescing magnesium
citrate; this is also useful in adults as likewise is the Hay method of administer-
ing magnesium sulphate; here 2 ounces (60.0) of Epsom salts are dissolved in
an equal quantity of boiling water, when cool this is taken during the evening
and by the following morning there will be a noticeable increase in the urine
and several watery stools will have occurred. If acute uraemia is present
676 DISEASES OF THE URINARY SYSTEM.
even more active piirgation is necessary, particularly if the patient is uncon-
scious. Here we may employ elaterium in doses of J of a grain (0.016) in
solution or a drop or two (0.065-0.13) of croton oil diluted with a little olive
oil may be placed upon the back of the tongue. Following this procedure
free catharsis will be established. In the moderately severe instances of the
disease it will suffice to secure a daily free movement of the bowels by means
of moderate doses of any acceptable saline.
The administration of diuretics should be confined to cases in which the
urine is diminished and oedema is present, and attempts to increase the urine
by means of drugs should be deferred until it is certain that this excretion
cannot be sufficiently augmented by means of packs, hot baths and especially
by copious high rectal irrigations of hot normal saline solution. The latter
are among our chief reliances in uraemic and toxaemic states resulting from
inflammations of the kidneys, they are stimulating, diuretic and greatly facili-
tate the elimination of poisonous substances from the system. They may be
given two or three times daily or oftener if necessary. The quantity of saline
should be 2 to 3 gallons (8 to 12 litres), the temperature should be from 116Â° to
120Â° F. (46.5Â° to 49Â° C), the tube (a soft rubber rectal tube is essential) should
be introduced as far as possible and the force of the flow should be gentle, the
bag being elevated but three or four feet above the patient. This measure is
usually superior to the administration of diuretic drugs, the latter often being
irritant to the aheady impaired kidneys and possibly causative of anuria.
Even water, which is an excellent diuretic, will tend to increase the dropsy, and
consequently when we are desirous of diminishing the latter, shoiild be taken
in small quantities only. If absolutely necessary the alkaline diuretic drugs
may be employed and the same is true of digitalis and strophanthus, the last
two being admissible only when the blood pressure is low and there is tendency
to cardiac weakness. Of digitalis the infusion is probably the most effective
preparation, the dose being 2 drachms to ^ an ounce (8.0 to 15.0); diuresis
has been brought about by merely laying compresses wet in the hot infusion
upon the abdomen of the patient. Caffeine and theobromine are useful at
It is probable that we have no means of directly causing a diminution in the
albuminuria although we may give sodium tannate in daily doses of 40 to 60
grains (2.66 to 4.0) with this purpose in view. Quinine tannate â€” 30 to 40
grains (2.0 to 2.66) daily â€” and tannalbin â€” 30 to 45 grains (2.0 to 3.0) daily â€”
have also been recommended. Strontium lactate which will in certain
conditions bring about a considerable diminution in the albumin content of
the lurine is contraindicated in acute inflammations of the kidneys.
Excessive arterial tension which may be a precursor of a convulsive seizure,
especially in the nephritis of pregnancy, should be controlled by erythrol
tetranitrate, gr. y^ to ^ (0.006 to 0.032) three to four times daily or glyceryl ni-
ACUTE NEPHRITIS. ' 677
trate, gr. y-g-g- to -g-^ (0.0006 to 0.0012) at similar intervals. Threatened uraemic
seizures also may be warded off by the administration of hydrated chloral,
gr. 3 to 5 (0.2 to 0.33) three times a day; this drug is especially useful in the al-
buminuria of pregnancy where there are restlessness, sleeplessness and other
nervous symptoms and is also efficacious in the uraemic convulsion. Here it
is best given by rectal injection, the dose for an adult being a drachm (4.0),
and that for a child 10 to 30 grains (0.66 to 2.0). The heart should always
be carefully watched for signs of weakness whenever chloral is given.
The treatment of a uramic attack consists first in the control of the convul-
sion, if this is present. Chloroform should usually be given by inhalation
to a degree sufficient to cause a cessation of the movements while the action
of other measures has not yet begun. Chloral is also useful is suggested above.
In order to strike at the cause of the seizure it is necessary to undertake meas-
ures with a view to bringing about an elimination of the toxic substances in the
blood, the presence of which has resulted in the paroxysm, consequently
all the channels of elimination should be opened by purges, diuretics and
diaphoretics as suggested in preceding paragraphs. Pilocarpine is sometimes
useful as an adjunct to other diaphoretic measures but should not be given
if pulmonary complications or advanced degeneration of the heart muscle are
present. Pilocarpine hydrochloride may be administered hypodermatically
in doses of J of a grain (0.02) and repeated in half to one hour if perspira-
tion is not induced, or a fresh infusion made from a drachm (4.0) of jaborandi
leaves and 4 ounces (120.0) of water may be injected â– per rectum.
In case of obstinate convulsions venesection may be practiced. If weakness
supervenes hot normal saline solution should be given by hypodermatoclysis
or by rectal injection. The latter is indicated in all cases as an aid to elimi-
nation of toxins and as a stimulant. Heart weakness and pulmonary oedema
should be combated by means of cardiac stimulants, particularly strychnine,
and in the latter condition oxygen inhalations may be employed.
The nausea and vomiting of acute nephritis may be controlled by restricting
the diet temporarily, by the administration of cracked ice and if necessary
gastric lavage may be employed. The ordinary antiemetics also are some-