We must call attention to the cardiac symptoms which always accompany interstitial nephritis.
We have already referred to arterial tension. We must add to it hypertrophy of the heart and the “bruit de gallop,” which is often so diagnostic of this disease.
We must not forget, moreover, that interstitial nephritis is only an affection of arterio-sclerosis, and consequently that it may be accompanied by the cardiac, pulmonary, hepatic, and cerebral symptoms peculiar to this lesion of the arteries.
Interstitial nephritis progresses slowly, and is prolonged for years. It shows, from one time to another, periods of aggravation, characterized either by bloody and scanty urine or by the appearance of oedema, or, above all, by manifestations of uraemic symptoms, of which we shall speak in a moment. These aggravations are always due to errors of diet or to failure to observe the rules of health; subsequently, an amelioration, more or less complete, takes place, and thus the disease is prolonged through many years.
Almost always death comes from uraemic accidents, which may assume two principal forms, pulmonary and cerebral.
In the pulmonary form the patient is seized by paroxysmal dyspnoea, which comes especially at night, and which may be accompanied by pulmonary congestion, with expectoration of rust- colored sputum. This dyspnoea may lead to the death of the patient.
The cerebral form is much more frequent. A number of patients show symptoms of cerebral apoplexy, together with hemiplegia, and die comatose.
Others have veritable attacks of eclampsia, more or less intense and more or less lasting, taking, in severe cases, a subintrant course, such that the patient are in a veritable “etat de mal,” and die comatose.
Other patients resist uraemic eclampsia. Some gain their health completely, at least in appearance, and my yet live for a long time after having experienced its attack.
Uraemic accidents are always ushered in by a considerable diminutions in the quantity of urine, just as amelioration is accompanied by abundant diuresis. Dimness of vision, increase in headaches, slight twitching of the limbs often precede and usher in serious uraemic accidents.
Aetiology.-The causes of interstitial nephritis are first and foremost the causes of arterio-sclerosis. Abuse of strong liquors, life in a damp locality, and chilling of the body are circumstances which favor localization of arterio-sclerosis in the kidney.
Pathological Anatomy.-In interstitial nephritis the two kidneys are invaded almost equally. In the first stage the lesion is characterized by congestion and increase in the volume of the kidney; the capsule is easily detached form the organ; the parenchyma, slightly soft and pale, varies in color from red to gray, and is sown with capillary dilatation. On section, the cortical substance is brownish, with gray or white stains, the medullary substance of a violet hue. Histological examination shows a more or less abundant proliferation of embryonic elements spread unequally throughout the cortical substance, and seizing upon the connective and vascular tissue of the region of the convoluted canaliculi and of the corpuscles of Malpighi. Sometimes the Malpighian glomeruli are the seat of a haemorrhage which becomes mixed with the urine.
The kidney diminishes gradually in volume, its tissue is retracted, and its surface becomes roughened in all its extent. The kidney takes on a solid and coriaceous consistency; its capsule becomes adherent and is removed with difficulty. More or less numerous cysts are formed. Atrophy of the kidney takes place upon the cortical substance, which is sometimes reduced to a millimetre. The round cells, of which we have already spoken, stretch out and form fusiform bodies soon to be transformed into cicatricial tissue.
Next retraction supervenes, with atrophy of the convoluted tubes and of the glomeruli.
The epithelia of the tubes undergo a granulo-fatty degeneration, and end by disappearing.
The lesion, having arrived at its last stage, shows the kidneys reduced to the size of large chestnut, and in weight 190 grammes, [About six ounces Troy.] partly transformed into fibrous tissue, and then constituting that which is called the small red kidney.
The renal artery is, like most of the arteries of the body, attacked by arterio-sclerosis.
It is useless to describe here the lesions common to arterio-sclerosis and to gout, of which interstitial nephritis constitutes only an affection.
Differential Diagnosis Between the Two Nephritis.-This paragraph is perhaps superfluous. We wish, however, to call to mind that true bright’s disease is distinguished form interstitial nephritis by the intensity of the anasarca and by urine so well marked in character, namely, scanty and loaded with albumin; while in interstitial nephritis the urine is exceedingly abundant, with albumin scanty, or but a trace. Cardiac symptoms; hypertrophy of the heart, the “bruit de gallop;” Cardiac symptoms of aortitis; arterial tension, and more or less general arterio- sclerosis serve to distinguish interstitial nephritis and permit us to recognize it.
Prognosis in Bright’s Disease.-The prognosis of Bright’s disease is always grave. This disease is terminated usually by death in the first days of the malady, or by passage into the chronic state, the termination of which is always fatal. However, it is necessary to remember that complete recovery from Bright’s disease may take place. I have records of recovery in cases dating back more than thirty years.
Sings Pointing to Recovery in Bright’s Disease.-Diminution of the fever and of the anasarca, but, above all, increase in the quantity. All the same time strength and appetite return, but recovery is not assured until albumin has completely disappeared, and until the urine has resumed its ordinary color, density and chemical composition.
We should not forget that, if recovery is possible, this possibility exists only in the first period of the disease and before the lesions of interstitial nephritis are produced.
Sings of death are, in the first days, an increase in the febrile movement, diminution in the quantity of urine and, most commonly, the appearance of uraemic symptoms; convulsions or coma.
Sometimes erysipelas supervenes as a complication, or some other inflammation, as bronchitis, pneumonia, pleurisy or pericarditis.
The signs of passage into the chronic condition, and change form parenchymatous to interstitial nephritis, are as follows: profound anaemia and lack of color in the integuments; sometimes the urine remains scanty and contains much albumin, with persistence of the anasarca; gastric symptoms appear (anorexia, vomiting, which is often obstinate, frequent and continual diarrhoea); often oedema of the lung and hydrothorax complicate the condition of the patient. Death comes from exhaustion, asphyxia or inflammation of the lungs.
In other cases the progress is slower. The patient may return to a condition of health, doubtless incomplete, but which permits a fairly long survival. The urine becomes more abundant and clearer, always remaining albuminous; anasarca diminishes, and the disease takes upon itself, more or less, the pace and termination of interstitial nephritis.
Prognosis in Interstitial Nephritis.-The prognosis is that of a disease of very long duration, but absolutely incurable. If the patient is subjected to the proper diet, he may live for many years, with every appearance of health. We have already said that he usually falls a victim to uraemic accidents, and the prognostic sign which cases us to fear these accidents is drawn absolutely from the quantity and the quality of the urine. As long as the urine is abundant and not too poor in urea, as long as its density reaches 1012, the physician may rest easy; but as soon as the urine diminishes in quantity, while at the same time urea falls to very small quantities, we must expect to see uraemic symptoms burst forth.
Treatment of Acute Bright’s Disease.-In the beginning, when the urine is scanty, bloody and albuminous, when there is pain in the region of the kidneys and general anasarca, the indicated remedies are: Belladonna, Cantharides, Apium virus, Koch’s lymph, Iodium.
1. Belladonna.-This is the remedy in the beginning. We should give it preference over the other three when fever is present, with headache and vomiting; scanty urine colored red b haemato-globulin (haemoglobin) confirms us in its choice.
Does and method of Administration: The first three dilutions: Six drops in 200 grammes of water (about seven fluid ounces). A teaspoonful every two hours.
2. Cantharides.-The symptoms and lesions of acute Bright’s disease correspond exactly to the symptoms and lesions produced by poisoning with Cantharides. The experiments of Galippe put this fact beyond doubt, and in later days Lancereau has held, before the Academy of Medicine, that the best remedy for albuminuria is Cantharides. This is truly scandalous, and reply has been made that Cantharides may be very dangerous in the treatment of albuminuria, since it causes nephritis. It goes without saying that this objection is of no consequence to the disciples of Hahnemann.
