times useful; among the most effectual of these may be mentioned cerium oxa-
late in 5 to 10 grain (0.33 to 0.66) doses dissolved in milk with double the
amount ot sodium bicarbonate, tincture of iodine or creosote in minim
(0.065) doses and dilute hydrocyanic acid.

Too much stress cannot be laid upon the importance of preventing intes-
tinal fermentation. The occurrence of this is evidenced by the appearance
of indicanuria and for its relief intestinal antiseptics are necessary. An
excellent remedy consists of 5 grains (0.33) of bismuth tetraiodophenol-
phthaleinate combined in a capsule with 2 grains (0.13) of resorcinol. One of
these capsules may be administered three times a day.



678 DISEASES OF THE URINARY SYSTEM.

Hematuria seldom needs treatment by itself but if the renal haemorrhage
is marked we may give calcium lactate in doses of 20 grains (1.33) three times
a day with a view to increasing the coagulability of the blood, and a powder
containing 7^ grains (0.50) each of powdered cinchona and tannic acid has been
suggested.

The complications should be treated as when occurring independently.
The anaemia following the nephritis necessitates the administration of iron, of
which one of the best forms is a solution of iron vitellin; this may be given in
doses of I an ounce (15.0) three times a day to adults and half this quantity to
children. In the latter excellent results are obtained from the ofi&cial syrup
of iron iodide in doses of from 7 to 10 drops (0.5 to 0.66) three times a day. In
cardiac dilatation we may employ the means suggested in the section devoted
to the treatment of this condition.

During convalescence aU exposure should be avoided and a sojourn in a
warmer climate is to be advised.

CHRONIC PARENCHYMATOUS NEPHRITIS.

Synonyms. Chronic Diffuse Nephritis; Chronic Desquamative or Chronic
Tubal Nephritis; Chronic Bright's Disease.

Definition. A chronic diffuse inflammation of the kidneys characterized
by epithelial, glomerular and connective tissue changes with exudation from
the blood-vessels.

.Etiology. This form of chronic neplu-itis may result from the acute des-
quamative nephritis following the acute infectious diseases, exposure to cold,
etc. It may occur as a sequence of chronic malarial poisoning, the abuse of
intoxicating liquors, syphilis, chronic suppuration and tuberculosis, where it
is usually associated with amyloid changes in the kidney. The disease is
observed in children who have suffered from scarlatina but seems more
common in young adult males than in older persons or females.

Pathology. Early in the disease the kidney is of the large white variety;
the organ is considerably enlarged, its consistence is doughy or elastic, the
capsrde is thin and may be easily detached; the denuded siirface is whitish
with yellowish spots and there may be injection of the capillaries bounding the
lobules and of the stellate veins. Section of the kidney reveals a thickening of
the cortex, which is anaemic and white in comparison with that of the con-
gested kidney. The microscope shows the epithelium to be swollen and the
seat of a granular, fatty or hyaline degeneration; the glomeruli are enlarged
and their capillaries and epithelium are degenerated. There is moderate
increase in the connective tissue throughout the kidney; the tubules often
contain granular and hyaline casts.

Later during the course of the affection the kidney becomes secondarily



CHRONIC PARENCHYMATOUS NEPHRITIS. 679

contracted, small and mottled, and is now the seat more especially of a chronic
diffuse inflammation. The capsule is thickened and adherent, the surface
of the organ is granular. Section reveals a firm consistency, a narrowed and
pale cortex and opaque areas of yellowish-white color consisting of fatty epithe-
lium collected in the convoluted tubules. The changes in the interstitial
connective tissue are more marked than in the large white kidney, the walls
of the blood-vessels are thickened, the epithelium of the glomeruli and of the
convoluted tubules is degenerated and the former may be obliterated by inter-
stitial over-growth.

The so-called chronic hcBmorrhagic nephritis is a form of the chronic paren-
chymatous type of the disease. Pathologically the chief distinction of this
variety of the inflammation is the occiirrence of brown foci, due to haemor-
rhage, in the cortex within and about the tubes. Associated with this mani-
festation are the conditions described above.

Hyaline degeneration of the vessels of the kidney is a frequent accompani-
ment of the lesions of chronic diffuse nephritis. Arterial degeneration through-
out the body and cardiac hypertrophy may be mentioned as frequently co-ex-
isting.

Symptoms. The symptoms of an acute nephritis may, without distinct
separation, merge into those of a chronic parenchymatous nephritis, or the
disease may begin gradually with indefinite symptoms of increasing weakness
or indigestion, until the suggestive paleness of the skin and the oedema of the
lower eyelids and of the feet draw the attention to the possibility of renal
disease. The dropsy steadily ascends the legs but in the early stages may be
only slight on rising in the morning. As the day wears on it increases. Ulti-
mately the oedema becomes general, affecting the subcutaneous tissues of the
entire body; it is often especially marked in the penis and scrotum. The
serous sacs may fill with fluid and pulmonary and glottic oedema may appear
with little or no warning and result in death.

Anaemia is constant and characteristic, and results in a pasty color of the
skin which, with the accompanying puffiness of the facies, often gives a very
certain clue to the diagnosis. Accompanying this symptom is a gradually
increasing weakness. Dyspnoea is frequent, resulting from the interference
with respiration due to the presence of pleural transudate, to the general
weakness of the patient or to the cardiac condition. The heart is at first
hypertrophied, more especially its left ventricle; later dilatation may ensue.
There is increase in the tension of the pulse with an accentuation of the aortic
second sound.

Nausea and vomiting with intestinal fermentation due to improper action of
the liver, are common; colonic ulcerations may occur and terminate in death.

Urasmic convulsions are not observed but headache, dizziness, insomnia
and stupor, followed by delirium or coma and ending fatally, are not rare.



68o DISEASES OF THE URINARY SYSTEM.

Retinal changes are less frequent than in chronic arterial nephritis but the
so-called albuminuric neuro-retinitis may be present and cause dimness of
sight and diminution of the visual field.

The urine is diminished in quantity in the earlier stages but later it may be
nearly or quite normal in amount, when scanty it is of high specific gravity
and dark in color and often turbid. On standing an amorphous precipitate
consisting of urates, blood cells, casts, granular detritus, etc., appears. The
albumin content is often large, 3 to 4 percent, by weight, and usually is in
greater (Quantity in the lorine passed during the day. The total content of
urea is diminished. The microscope reveals the presence, first of epitheHal
casts, later granular casts appear and still later those of the fatty and hyahne
types; red blood cells, leucocytes, epithelial and granular debris are often to be
found. Indicanuria is often present and indicates an autointoxication due to
insufficient ehmination on the part of the Uver and intestine. The resulting
toxins act upon the already impaired kidney to its further detriment.

The diagnosis in certain instances is very simple, the pallor and puffi-
ness of the face being characteristic, the saying "large white patient, large
white kidney " proving oftentimes true. When the examination of the urine
shows a diminished amount, increased weight, diminished urea, considerable
quantity of albumin and casts as described above, the problem is not a diffi-
cult one, particularly in connection with a typical history. It is often diffi-
cult to distinguish between the large white and the small white or mottled
kidney; the differentiation is fortunately of no great practical importance.
Points in favor of the small kidney are an increased amount of urine, lower
specific gravity, less albumin and a history of long duration. The kidney
of hyaline degeneration is usually accompanied by enlargement of the other
viscera, there is less oedema, albumin and casts are more scanty and cardiac
h^-pertrophy, retinal involvement and uraemic symptoms are not present.

The prognosis is always unfavorable but life in comparative comfort may
be continued for a number of years, the symptoms disappearing and the
albuminuria clearing to a considerable extent; unfortunately, however, sooner
or later the oedema and other manifestations reappear and the patient finally
dies from uraemia, exhaustion, heart failure, pulmonary oedema or secondary
inflammations of the serous sacs.

It is rare to see recovery take place after the disease has lasted for a year
but this circumstance may occur, particularly in children.

Patients whose urine is markedly diminished, who excrete but little urea and
a persistently large quantity of albumin, and in whom cardiac, arterial and
retinal degenerations are present, have little chance of recovery.

Treatment. With regard to propliylaxis, too great stress cannot be laid
upon the importance of daily qualitative and quantitative examination of
the urine in aU the acute infections; this should be continued until recovery.



CHRONIC PARENCHYMATOUS NEPHRITIS. 68l

If the -kidney is damaged the urine should be watched with particular care
for the occurrence of indican which by its presence shows that there is an
auto-toxsemia due to the non-elimination of intestinal poisons through the
liver. These toxic substances are most deleterious to the kidneys and should
be gotten rid of as quickly as possible by hastening their elimination by purging
and the process of high intestinal irrigation with normal (0.9 percent.) salt
solution. Their further formation should be prevented by regulation of the
diet — cutting off the carbohydrates — and the administration of intestinal
antifermentives such as bismuth naphtholate (orphol) or tetraiodophenol-
phthaleinate, 5 grains (0.33) of either of which may be given three or four
times daily.

The treatment of chronic parenchymatous nephritis is fh-st of all dietetic.
While a strict milk diet formerly was considered an essential, the work of
von Noorden and others seems to prove that a mixed regimen may be
allowed, at least in certain instances, without detriment and certainly to the
great comfort of the patient. The diet should be regulated upon the data
obtained upon the examination of the urine and upon the amount of oedema.
An abnormal quantity of urates in the urine indicates too much proteid;
indicanuria shows that intestinal fermentation is present as a result of too
free ingestion of starch and sugar; consequently the feeding should be arranged
with a view toward maintaining a proper balance between the intake and the
output. When the dropsy and albuminuria are marked the diet should be
limited to milk or buttermilk, preferably diluted with carbonic, lime or
Vichy water (fermented milks such as kumyss or matzoon are usually
better borne than plain milk if the period of administration is long), dry toast,
zwieback or biscuits; if the oedema and albuminuria are but slight we may
be more liberal, allowing in addition to the above, vegetables, especially those
whose iron content is small, cereals, fruits and small amounts of meat, white
or red. Irritating condiments must be forbidden; asparagus, which for-
merly was considered as something to be totally excluded from the diet of the
nephritic, has been proven to be harmless.

While dealing with the question of diet the important subject of the treat-
ment of dropsical conditions by means of dechloridation or the restriction of
salt from the food should be considered. In chronic parenchymatous neph-
ritis the kidneys excrete but a small amount of chlorides and consequently
these substances, being taken into the organism in greater quantity than
they are eliminated, accumulate within the system. This retention results
in dropsical conditions.

Chloride retention in nephritic patients varies greatly in different instances,
but whether transient or permanent, slight or intense, it is governed by the
impermeability of the kidneys to sodium chloride; therefore, the indications
as to duration and strictness of the limitation of the chloride intake depend



682 DISEASES OF THE URINARY SYSTEM.

upon the condition of the patient in hand. Fortunately we have a very simple
means of estimating these indications, namely, by daily weighing of the
patient. By carrying out this procedure the physician possesses a method of
following step by step the effect of the prescribed diet. Loss of weight signi-
fies diminution of the oedema. A sample diet containing but a small amount
of chloride is appended. Bread made without salt, lo ounces (300.0), beef, 10
ounces (300.0), potatoes, 10 ounces (300.0), cooked in about 2 ounces (60.0) of
unsalted butter. For drink, a quart (i litre) of water with 6 ounces (180.0)
of coffee and, if desirable, 10 ounces (300.0) of wine, may be allowed. Daily
weighing of the patient enables us to follow from day to day the progress of
the chloride elimination and to regulate the rigorousness of the treatment
in accordance with the chloride retention, and in the intervals of marked
chloridaemia we have a means of testing the impermeability of the kidneys
to sodium chloride. Thus we can avoid unnecessarily depriving the patient
of salt and we are able to detect at once any threatened retention of chlorides
which we may avert, or at least moderate, by insistence upon a regimen lack-
ing in salt.

The administration of theobromine in doses of 10 grains (0.66) three times
daily in connection with the dechloridation treatment is an important adju-
vant. This drug increases the effect of the restricted diet but cannot replace
it; by prescribing throbromine together with a diet low in chlorides it is possible
to free a nephritic from the distressing dropsy so often observed in kidney
lesions.

The albuminuria of chronic parenchymatous nepliritis may be greatly
reduced by putting the patient to bed and at the beginning of treatment this
measure is always advisable; later when the more distressing symptoms have
become ameliorated the sufferer may be allowed up and may even take modei*-
ate exercise. Fresh air and outdoor life are particularly necessary in this
disease. The clothing should be of linen mesh or wool next the skin for it is
most essential that chilling of the surface shaU be prevented, since cold inter-
feres with the eliminatory action of the skin and may produce an acute exac-
erbation of the chronic renal inflammation; even suppression of urine has
been known to follow exposure to cold and wet.

The administration of strontium lactate is often an efl&cient measure in re-
ducing the quantity of albumin excreted in the urine but this drug should
not be employed when any acute process, as evidenced by the presence of
epithelial or blood casts or of red blood cells, is present. The proper dosage
of this agent is from 30 to 40 grains (2.0 to 2.66) daily, well diluted.

The anaemia which may be less extreme than the paleness of the skin would
lead one to suspect, necessitates the exhibition of iron. The dropsy may be
diminished, in addition to its treatment by regulation of the diet as dis-
cussed in a previous paragraph, by the means suggested under the treat-



CHRONIC ARTERIAL NEPHRITIS. 683

ment of acute nephritis. Aspiration of the pleural and peritonaeal cavities
is often necessary. The extreme tension of the skin of the lower limbs result-
ing from marked cedema may be relieved by making numerous punctures
with a needle or by incisions of considerable size in the region of the ankles.
The so-called Southey's tubes may also be used. The tube consists of a
fine trocar and canula, the former being withdrawn after the puncture is
made and the latter left in situ. To its outer extremity a fine rubber tube
mav be attached and led to a vessel which will collect the serum. All the
surgical procedures mentioned above should be carried out with the utmost
precautions as to asepsis for septic infection added to the primary condition
is a serious matter.

The cedema of the glottis which sometimes appears should be promptly
scarified or if this fails intubation or tracheotomy should be practiced.

The uraemic, cardiac and other symptoms and complications should be
treated as when occurring in acute nephritis.

Surgical treatment by means of decapsulation of the kidney if applicable
in any form of chronic nephritis, may possibly benefit the patient's condition
in this type of the disease by establishing a collateral circulation which will
relieve the kidney of its accumulated toxic substances.

The operation consists in exposing the organ and peeling off the capsule
in its entirety to within a short distance of its junction with the renal pelvis.
It is a useless procedure except in rare instances of chronic parenchymatous
nephritis.

CHRONIC ARTERIAL NEPHRITIS.

Synonyms. Chronic Interstitial Nephritis; Contracted Kidney; Cirrhosis
of the Kidney; Renal Sclerosis; Gouty Kidney.

Definition. A chronic sclerosis of the blood-vessels of the kidney occur-
ring as a part of a general arteriosclerosis and connective tissue inflamma-
tion of the viscera. It is not properly an inflammation of the kidneys
but a part of a generalized sclerotic process.

etiology. Being merely a localized manifestation of a sclerosis affect-
ing aU the arteries of the body, the causation of chronic arterial nephritis,
perhaps more properly denominated chronic arterial degeneration of the
kidneys, is identical with that of arteriosclerosis in general. It is rarely seen
in individuals under forty years of age and is more common in males, be-
cause of their more frequent exposure to the direct astiological factors of the
degeneration.

Gout, syphilis and chronic plumbism are important causes and a history
of excessive use of alcohol and over-eating, especially when associated with
life at high mental and physical tension, is very frequently met in patients
with this affection. It is probable that the disordered metabolism from which



684 DISEASES OF THE URINARY SYSTEM.

such individuals suffer is responsible for the occurrence in the circulation of
certain toxic substances which by their action cause an over-growth of the
arterial connective tissue.

Certain families possess a tendency to early arterial degeneration and this
hereditary influence may be set down as one of the factors which produce
this form of kidney lesion.

The chronic passive congestion of the kidneys which occurs in cardiac
lesions predisposes to arterial degeneration in the organ, as also does renal
lithiasis, and arterial nephritis occurs as a part of the ordinary senile connective
tissue changes.

Pathology. The morbid changes occurring in this affection are not confined
to the kidneys, and the involvement of these organs usually does not take place
until a considerable period after the pathological process has begun in the
general arterial system. The essential lesion is a thickening and connective
tissue degeneration of the intima of the arteries throughout the body, associated
with increase in the connective tissue of the viscera. The kidney of chronic
arterial degeneration is the small, red granular kidney with thickened and
adherent capsule. The organ may be shrunken to only half its normal size,
its surface, especially after removal of the capsule, is uneven, granular, dense
and tough, and its color is often red in contradistinction to the yellowish- white
tinge of the kidney of the stage of contraction of chronic parenchymatous
nephritis. Cysts containing watery or viscid fluid are often observed at the
surface; these vary in size from that of a pin-head to that of a good-sized
marble.

The kidney substance is dense and resistant to the knife. Section reveals
a great decrease in the width of the cortex and a less marked shrinkage of the
medullary substance; the walls of the arteries are much thickened and the
Malpighian bodies shrunken; cysts may be present. The pelvis may be
normal in size, enlarged or decreased. The surrounding fatty tissue is often
much increased in amount.

Microscopic examination shows an increase in the connective tissue of the
walls of the blood-vessels and an over-development of the interstitial connective
tissue of the organ itself; this tissue is increased at the expense of the tubules
and blood-vessels which it tends to obliterate. Certain parts of the organ
may show marked changes such as those described above, while in others
there is but little interstitial over-growth. Certain of the tubiiles appear to be
normal while others may be dilated, shrunken and obliterated or even entirely
replaced by new connective tissue. The epithelial lining of those which
remain may be in normal conditioner granular; the tubes may contain hyaline
casts. The Malpighian tufts are enclosed by connective tissue and often are
shrunken and atrophic. The walls of the arteries are in a condition of marked
sclerosis, the intima is thickened and the media is also affected, its muscular



CHRONIC ARTERIAL NEPHRITIS. 685

tissue being encroached upon by the increase in its connective tissue elements.
There is also over-growth of the interstitial tissue of the adventitia. As a
consequence of these changes the arteries become dilated and twisted and
the hyperplasia of the connective tissue of the organ itself may result in their
final obliteration.

Associated with the changes in the kidneys are those of general arterio-
sclerosis, sclerotic changes in the liver, spleen, lung, heart etc., and as a result
of the heightened blood presstire and increased difficulty in forcing the blood
through the diseased arteries, h}^ertrophy of the last organ, especially of its
left ventricle, is frequent.

The retinal abnormalities which are often associated with arterial nephritis
are merely a part of the general arterial degeneration, as a result of which
haemorrhages due to rupture of the degenerated arterial walls may occur.

Symptoms. The diagnosis of this condition is often unsuspected until the
appearance of a terminal ursemic attack, but the careful and thorough clinician
may make frequent early diagnoses upon the occurrence of an accentuated
aortic second sound; in other instances the condition of the retina (see p. 778)
as revealed by ophthalmoscopic examination leads to the first suspicion of the
presence of arterial nephritis. Urinary examination, suggested by the auscul-
tation of the heart and inspection of the retina, reveals the following changes :
In quantity this excretion is increased, the polyuria being due to the damaging
effect of the inflammation upon the epithelial cells of the tubules which nor-
mally absorb water from the urine which has passed from the glomeruli.
The acidity is low as is also the specific gravity as a result of the low excretion
of total solids; the color is light. The constant low specific gravity is an impor-
tant feature and tuines so characterized are always to be considered suspicious.
The albumin content is small, often merely a trace, and even this may be
absent in specimens passed in the early morning. Casts, chiefly hyaline,
sometimes granular, are usuaUy present but thorough sedimentation of the
urine is often necessary for their demonstration. The urea excretion is dimin-
ished; the total quantity passed in twenty-four hours may be as small as 20
or 30 grains (1.33 to 2.0) — the normal amount being about 500 grains (33.0)
— just before an attack of uraemia. The urea content as well as the amount
of albumin present varies with the patient's diet and the amount of exercise
taken.

The patient often complains of a progressive physical weakness and various
casual disorders may occur early in the disease. Retinal haemorrhages are
not infrequent and retinitis or papiUitis may be observed. The resulting
impairment of sight is permanent but the amblyopia and amaurosis which
sometimes appear may be merely temporary. Tinnitus, impairment of hearing
and vertigo are not uncommon.

Dropsy is rare in this form of nephritis but slight oedema of the ankles may



686 DISEASES OF THE URINARY SYSTEM.

be observed, and the pasty pallor of the skin so characteristic of chronic paren-