William Henry Porter.

A practical treatise on renal diseases and urinary analysis online

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are less distinct than normal, but to the unaided eye they appear


Fig. 11. — Acute Parenchymatous Metamorphosis of the Kidneys. X 350.
a, Uriniferous tubules showing granular metamorphosis of the epithelial cells; c, c, desqua-
mated epithelial cells lying in intertubular spaces; h, swollen [and cedematous intertubular

more distinct on account of the abnormal pallor of the cortical por-

Microscopic Appearances. — This lesion develops four degrees
of change in the renal epithelium: First, Cloudy Swelling. — This
condition is one in which the elements are swollen by the imbibition
of an albuminous fluid, and in which the protoplasm has become
turbid. Second, Finely Granular Metamorphosis. — Here the epithe-


lium is not only cloudy, but is also infiltrated with fine granular
particles, some of which are oil globules of minute size, and others
granular detritus from the incomplete products of tissue metamor-
phosis which are in part drawn from the blood, and in part from the
further destruction of the epithelial protoplasm itself. Third, Coarse
Granular Change. — This is simply a more advanced degree of the
former, with more abundant and larger fat droplets. Fourth, Fatty
Transformation. — The protoplasm is entirely destroyed and replaced
by fat globules, causing a destruction of its substance and an abolition
of its function.

It seems quite probable that the cloudy and mucoid change is due
to the retention of a small quantity of effete material in the protoplasm
which causes this imbibition and transformation. The fine granular,
too, is a further change, due to the retention of a quanity of these
irritating substances now perceptible in the cell, and a commencing
disintegration of the protoplasm with a development of minute fat
droplets. The retention of a still larger amount of effete material
produces the coarsely granular metamorphosis, or a more advanced
disintegration of the protoplasm, and an increase in the size of the
fat droplets. In the last {fourth), or fatty change, so large a quan-
tity of the products of incomplete tissue metamorphosis, pigments,
etc., remains in the cells that their normal outlines are obliterated, and
the protoplasm is now destroyed by fatty degeneration.

Early in the disease, the cells having swollen rapidly, while the
kidney capsule remains unstretched, the lumen of the tubules is
entirely occluded, and under the microscope they are tortuous instead
of straight. This, of course, refers to the straight tubules, and not
to those normally convoluted; the latter, however, are considerably

In the milder forms, the change in the epithelial cells is confined
principally to those of the cortical layer and those lining the glomeruli.

In more advanced cases, the cells of the pyramidal tubules also be-
come involved. The degree of transformation of the epithelium,
and the extent of territory implicated, will depend wholly upon the
intensity of the cause and its duration.

After the lesion has lasted for some time, what remains of the lumen
of the tubules may be found to contain single, or masses of trans-
formed and desquamated epithelial cells, which appear like the
materials from which casts are made.

Various forms of casts may occasionally be found in the lumen of
the tubules.

The stroma is not involved, and the blood-vessels remain unchanged.


Symptoms. — This lesion occurring, as it does, in connection with
severe diseases, or as the result of some of the acute attacks of metallic
poisoning, the symptoms referable to the nephritic metamorphosis are
not well marked at first. Ordinarily, the symptoms of nephritic dis-
ease may be classified under two headings — rational, and urinary.
The former are divided into cephalic, respiratory, alimentary, and

The cephalic are occipito-f rontal headache, contraction of the pupils,
injected conjunctivae, lesions of the retinae and optic nerves, drowsiness,
convulsions, and coma. The neuro-retinal lesions will be considered
more minutely in studying those lesions of the kidneys in which they
are more frequently met with, for in this form they are rarely seen.

The respiratory symptoms, which are usually asthmatic in character,
are more frequently met with in the chronic forms of the disease than
in the acute parenchymatous variety, and will receive more care-
ful consideration in connection with the affections with which they
are associated.

The alimentary symptoms are dyspeptic in character; they are
nausea, vomiting, loss of appetite, and disgust for food, often asso-
ciated with diarrhoea.

Those classed as general are oedema, commencing first in the sub-
cutaneous connective tissue under and around the inferior eyelids,
oedema of the inferior extremities, watery effusions into all the serous
cavities, oedema of the superior extremities, and general anasarca.
(Edema glottidis may occur. If the disease lasts for any length of time,
a peculiar waxy, almost translucent, pallor of the skin may be de-
veloped. This, however, is seldom seen, except in that form which
follows chronic metallic poisoning.

With this form a large number of the rational symptoms are masked
by the severe symptoms of the disease which it complicates; but those
that do attract attention are usually oedema of the eyelids and feet,
undue severity of the cerebral symptoms of the primary disease, and
a diminution in the quantity of urine passed daily. These symptoms
are followed speedily by those of a more acute character. The patient
complains of a severe headache and drowsiness, rapidly followed by
convulsions and coma. There may be associated with these cerebral
symptoms, or independently, some nausea and irritability of the
stomach, which often usher in severe vomiting and diarrhoea. The
oedema may now become very marked and be followed by dropsy of all
the large serous cavities. Dimness of vision may also occur in some of
these cases, but is due to interference with the optic centres, and not
to any lesion of the optic nerves or retinae. As the disease progresses,


the symptoms become more urgent, the drowsiness is followed by
stupor and delhium, the urine may be entirely suppressed, and the
patient lapses into a state of coma, which is usually followed by con-
vulsions; and death.

During the course of the disease, which seldom lasts more than a
few days, the cephalic, alimentary, and general symptoms may not be
associated as above described. In some cases, especially those which
occur complicating scarlet fever, pneumonia, typhoid fever, and other
acute febrile diseases, only those symptoms referable to the nervous
system appear, and headache, accompanied by dimness of vision,
drowsiness, stupor, delirium, and coma follow each other in rapid
succession; and. if the disease does not take a more favorable course
at this point, convulsions ensue, speedily followed by a fatal result.
In other cases, the alimentary symptoms present themselves, and these
are most apt to terminate in chronic parenchymatous metamorphosis,
resulting, as they do, from the mineral poisons.

Urinary symptoms are always present in all forms of the disease.
The urine is always diminished in quantity, high-colored, and its re-
action acid; the specific gravity ranges between 1.020 and 1.030, but
when the quantity passed is considered as compared with the normal
daily quantity, the specific gravity is found to be below the normal.
Albumin is always present, sometimes in great quantities, sometimes
only a trace, or to the amount of one or two per cent, by volume;
while in the most severe types of the disease it may completely solidify
the urine when boiled, so that, if the test-tube is inverted, no water
flows away.

On microscopical examination early in the disease, small hyaline,
epithelial, nucleated, and fine granular casts and granular debris are
seen, while at a later stage the coarsely granular and fatty casts make
their appearance; and as the disease advances, the casts increase in

The diagnosis is readily made by remembering the causes, and
by a careful examination for casts. The only disease for which
it might be mistaken is acute diffuse nephritis. In the latter
we find blood and blood-casts in the urine; but in this lesion they do
not occur.

The prognosis is always grave, and especially so when the lesion
exists as a complication of acute disease. In scarlet fever, if convul-
sions occur, the patient rarely, if ever, recovers; while in pneumonia,
diphtheria, typhoid fever, etc., the first symptom of acute parenchy-
matous metamorphosis renders a favorable termination very doubtful,


although there are instances in which patients recover even with this
severe complication.

In those cases which result from mineral poisoning, the immediate
danger is not so great; but the disease is very apt to lapse into the
chronic variety, which may end fatally in the course of a few years.

In treating this lesion, its method of production should be kept
constantly in view. It should be remembered that it is not of
an inflammatory nature, but that it results from too much work
being thrown upon the kidneys which undergo this metamorphosis
through their efforts to relieve the system. With this light upon
the subject, the great object in the way of treatment is to prevent an
excessive amount of work being forced upon these glands.

There is no doubt that elevation of temperature or heat, as the
damaging element in disease, has been much overestimated, and the
cause of the increased heat been too much neglected. The increase
of body-heat should only be looked upon as a symptom, produced in
part by the irritation of the original poison, and in part by the too
abundant and incomplete products of tissue metamorphosis, which
are excited by the poison and which circulate throughout the system.

All we can do in reference to neutralizing the original cause is to
make the hygienic surroundings as perfect as possible, and to supply
the patient with a large quantity of fresh air.

The original poison, in a measure, is probably eliminated from the
system by the kidneys, and also aids in damaging the epithelial pro-

With such a condition as this, the kidneys make an effort to rid the
system of this excessive amount of effete material, while at the same
time they receive less nutriment than in health, and, consequently,
are very likely to suffer irreparable damage.

The application of cold to the body in such conditions as these,
according to well established physiological laws, still further interferes
with tissue metamorphosis and adds new fuel to the fire. Many cases
have undoubtedly developed a fatal renal complication in this way.
It often happens that, following a cold pack or bath, the cerebral
symptoms increase in severity, the temperature rises higher, and
albumin presents itself in the urine for the first time; a speedy and
fatal termination soon following by an induced renal complication. A
striking example of this kind was observed in a case of sunstroke. In
this case, at the commencement of the attack there was a trace of
albumin in the urine; but, following the repeated application of cold
to lower the temperature, the quantity of albumin rose to 50 per cent
by volume, and all the urinary symptoms of acute parenchymatous


metamorphosis presented themselves. Subsequent post-mortem
exam ination confirmed the diagnosis in regard to the renal lesion.
Remembering these facts, the kidneys should demand our first atten-
tion in all these severe diseases and in cases of acute metallic poison-
ing. Every effort should be made to aid the kidneys during this
severe strain and to guard them against this transformation, not
waiting until the metamorphosis has actually developed and then
try to cope with so formidable a malady.

In these cases cur attention should be directed to the other excre-
tory channels — namely, the skin and alimentary tract — and every effort
should be exerted to cause them to perform the largest possible amount
of work. By so doing, we relieve, to a considerable extent, the
increased strain upon these organs.

Cold applications to the skin should be avoided, but it should be
kept moist and active by bathing in tepid water, or with tepid water
to which a little alcohol has been added.

In bathing the sick, one rule should be rigidly enforced. After
sponging a portion of the body, the nurse should rub the skin of that
part perfectly dry with the bare hands before another portion is
bathed. There is nothing more uncomfortable than to be left wet
and clammy. On the other hand, nothing is more refreshing and
soothing to a patient than such a bath, provided the skin is dried
in the way here suggested. The skin is also rendered more active —
one great object to be attained.

Diaphoretics may also be used to advantage; jaborandi, or its
alkaloids, standing first upon the list for promptness and certainty ;
but in these severe forms of disease its use would be contra-indicated,
as it is sometimes said to be depressing in its effects. The liquor
ammoni acetatis, or spiritus aetheris nitrosi, may be found serviceable
in keeping up free activity on the part of the skin.

Alcohol, which is often called for in these febrile diseases, acts as a
diaphoretic and diuretic ; it also retards oxidation, thus being of ser-
vice in three ways.

The bowels should be acted upon as freely as the pre-existing con-
dition will admit. In typhoid fever, little can be accomplished in this
direction; excepting in this fever, yellow fever, and cholera, they
should be moved at least once every day.

Treatment referable to the kidneys is of the greatest importance.
The main object is to increase the watery constituents to the maxi-
mum, so that the effete material necessarily passing through the
renal protoplasm shall be diluted as much as possible.

To accomplish this object, large draughts of water, demulcent


drinks, and various mild mineral waters should be freely adminis-

As medicinal diuretics, tinctura ferri chloridi, digitalis and its
preparations, are the only ones to be used. The tincture of iron is
an invaluable remedy, acting as a non-irritating diuretic, and enabling
the blood to carry more oxygen, thus aiding in bringing about a more
perfect tissue metamorphosis. It is most serviceable as the disease
advances, and tends to assume a more persistent form.

Digitalis and its preparations as diuretics are serviceable remedies
during the early stages of this lesion. They are non-irritating,
and act principally by contracting the arterioles and increasing the
general blood-pressure; in this way increasing the pressure upon the
glomeruli. They probably have less effect upon the renal arterioles
than on the rest of the circulatory system, otherwise they would
diminish instead of increase the flow of urine. Further investigation
will probably show that they only act when there is venous congestion
of the intertubular plexus of veins. Some have advanced the idea that
this drug has a specific, and as yet unexplained, action directly upon
the kidneys, especially upon the Malpighian tufts. The condition of
the intertubular plexus may be the cause of the so-called specific

The potassium salts are contra-indicated as diuretics, as they
depress the heart's action and relax the arterioles. Their action as
diuretics is ascribed to their power to increase oxidation and tissue
metamorphosis, and in this way force more work upon the renal
epithelial cells. They are therefore injurious for three reasons r
First, they weaken the heart ; second, they relax the whole arterial
system ; and, third, they increase the effete material to be thrown
off by the epithelial protoplasm.

When opiates are used as nerve-sedatives, in this form of renal
lesion, a fatal termination often results, if it is not the rule. In
some forms of acute urasmia, morphine, hypodermatically adminis-
tered, may be efficacious, but is not considered safe.

The application of dry cups to the loins, followed by warm poul-
tices, will be found very serviceable, especially if the renal symptoms
become at all severe.

The functional derangement of the liver, with its inability to pro-
duce a sufficient quantity and quality of bile to prevent the de-
composition in the alimentary tract, and assist in perfecting the
intestinal and hepatic digestion, requires a word in connection with
the treatment.

Recent experiments go to show that all infectious diseases produce


as tlieir first effect a disturbance in the bile-producing power of the


With this condition the intestinal and hepatic digestion is very im-
perfectly performed and its products are quite incomplete and irritat-
ing, which, together with the constantly absorbed decomposing ma-
terials from the intestine, are the chief causes of the increased bodily
heat, and of the overworking of the kidneys.

This condition may be overcome in a large measure by using the
pure or inspissated ox bile, either alone or in combination, as in the
following formula :

I£ Fellis Bovis Inspissati, . . 3 ss. 3.7 grams.

Quinina? Sulphatis, ... gr. xv. 0.9 grams.

Extract] Taraxaci, . . . 3 ss. 3.7 grams.

M. et fiat massa las in capsulas no. xv. dividenda.

Sig. One ter in die, or every three hours, as the case may require.

The ordinary pure ox bile may be given in drachm doses, or the in-
spissated in doses of two or three grains.

By either method, the decomposition going on in the intestinal
tract is overcome, and digestion, absorption, and assimilation become
more perfect, while the liver is supplied with new bile with which to
do its work.

As a result the temperature falls, the products of tissue metamor-
phosis to be eliminated are diminished in quantity and rendered
more perfect and less irritating to the excretory organs; consequently
the work to be accomplished by the renal epithelium is decreased
and it is enabled to maintain its integrity and repair the damage it
has received.



Ohkonic Parenchymatous Metamokphosis of the Kidneys.

first form of large white kidneys.

Definition. — Chronic parenchymatous metamorphosis of the kidneys
is a transformation in which the irritation of the epithelial cells
lining the uriniferous tubules has continued for a considerable
length of time, and caused a progressive granular and fatty change.
The slight alteration in the intertubular tissue is cedematous in
character and not inflammatory.

Etiology. — A large number of the cases appear to result from
a previous acute attack which has passed without being recognized,
and it is often associated with cirrhosis of the liver and with all forms
of chronic hepatic disease which disturb the functions of the liver
so that the transformed proteids are less perfectly formed and pro-
duced in abnormally large quantities. As a result of this condition,
the kidneys attempt to rid the system of the effete material, and
the substances which have now to be eliminated by the special renal
epithelial cells are not only more abundant, but unduly irritating.
For a time, however, the kidneys may succeed in performing this
extra work, much of which should have been accomplished by the
liver, without suffering any material change, but, ultimately, the
cells give way and the abnormal condition is fully established.

In connection with acute diseases there is a similar transformation,
only of a more acute nature, which results in an arrest of the meta-
morphosis, and a restoration of the renal cells to a fairly normal
condition upon the removal of the cause, that is to say, upon recovery
from the condition which gave rise to the morbid phenomeua. The
kidneys, however, remain somewhat damaged and consequently more
susceptible to a second attack, or later on in life to a spontaneous de-


velopment, as it were, of this metamorphotic change, which then
assumes a chronic type. It is in this way that many of the chronic
cases have their origin.

Bepeated attacks of acute diseases, witli their accompanying changes
in the overworked renal organs, must in time impair the renal cells
to such an extent as to place them beyond hope of repair. These
attacks decidedly damage the excretory function of the glands, aud
as a person advances in years this form of chronic renal lesion is more
likely to be developed. These mild, but many times repeated and
often unnoticed attacks of acute metamorphosis are the most potent
predisposing causes for all forms of chronic nephritic diseases com-
monly classed as Bright's.

Until this fact is more fully appreciated, and the renal cells more
carefully guarded, when subjected to such extra strains, chronic
renal lesions will remain common.

By carefully considering the way in which these lesions originate,
most of the so-called idiopathic cases can be traced to some definite
origin. Overcrowding patients with food and stimulants beyond
the capacity of the liver undoubtedly is a very common cause of this
chronic type. In the early stage of either form, if the cause can be
removed, it would seem reasonable to suppose that here, as elsewhere
in the body, the epithelial cells would proliferate and fill up the
gaps left by those that have already fallen from their places.

In many instances this is the case, especially in the acute variety;
but in some, another influence appears in the form of an unob-
served irritant, which, by being continually applied to already
weakened cells, prevents their complete regeneration and causes a
subacute which finally develops into the chronic condition. Be-
fore the attack of the originating disease, the epithelial cells
of the kidneys have no difficulty in removing from the circulation
those effete materials which it is their function to excrete ; but
the acute attack of parenchymatous metamorphosis lessens their
number and quality to a very great extent, so that even where the
general system has returned to its original state, the remaining cells,
already in a damaged condition, are called upon to perform the work
which was previously accomplished by a much larger number. An
important question now arises: will this small number of weak cells
be capable of removing the products of normal tissue change which
are circulating in the blood, and at the same time regain their own
normal condition ? If so, they will proliferate and renew the epithe-
lial lining of the tubules, and the kidney will be restored to a perfect
physiological state; if not, they will tend to undergo further retrograde


chauge, and as healthy tissue cannot be built from unhealthy, no new
cells capable of performing the functions of the old will be produced,
and the remaining corpuscles will be more and more transformed.
These in turn finally degenerate, drop from their places, and leave the
kidneys wholly unable to perform their task, even though they are
aided in every way possible, by increased action of the skin and bowels.
In continued and often repeated exposure to cold, and in fail-
ure in the functional activity of the liver, the effete material in
the circulation is considerably increased and less completely trans-
formed, although not to so great an extent as to produce an acute
parenchymatous change in the kidneys, but still sufficient to bring
about a subacute condition; and, now, if the over-worked cells are
not quickly relieved from this extra strain, they undergo the fur-
ther retrograde change, and the patient eventually succumbs.

Renal lesions dependent upon the excessive use of alcohol as their
etiological factor are produced in like manner, instead of depending
for their cause upon any direct irritation of the renal tissue per se,
and when the trouble dates from the ingestion of a metallic poison,
it takes first the acute and subsequently the chronic form.

Pathological Anatomy. — The kidneys are always enlarged, and their
capsules are normal in thickness, and non-adherent to the underlying
renal tissue, wh'.ch is usually smooth after enucleation. If the disease

Online LibraryWilliam Henry PorterA practical treatise on renal diseases and urinary analysis → online text (page 3 of 32)