(a) General Considerations

I will now discuss the treatment of chronic contracted kidney. I have already discussed the customary dietetic therapy of this form of nephritis, but have not yet touched on other methods of treatment.

As far as I can see a number of methods of treatment have been adopted in this disease that are not really justifiable even though they are commonly employed. The chief error that is made by practising physicians in general is that they apply principles that are correct, or at least permissible in the treatment of acute forms of nephritis, to the treatment of contracted kidney. The latter disease is an essentially chronic condition. In the least favorable cases, provided unforeseen complications do not abbreviate the course of the disease, the condition persists for many years; in favorable cases it persists for many decades; complete recovery is excluded. Our chief aim must therefore be to prolong the course of the disease as much as possible, and to enable the patients to maintain their strength, to continue their work and to enjoy life for years and decades. The essential postulates in the treatment of atrophic nephritis are to protect the kidney from noxious influences, to strengthen the whole organism, to spare the heart on the one hand, and to strengthen the heart muscle on the other. In the first place, then, we must treat the lesion of the kidney itself; in addition every patient with contracted kidney must be treated like a sufferer from heart disease, in some cases like a patient with valvular diseases in which compensation is good, in others like a patient with valvular disease in which compensation is failing. Psychic treatment also plays an important role. Many sufferers from contracted kidney, like patients with diabetes and pulmonary tuberculosis, are fully capable of performing their routine work despite the disease (provided they take care of themselves in certain directions). Many of these patients would be fully justified in taking a hopeful view of the future; nevertheless we find that a majority give up all hope and allow themselves to be depressed by morbid thoughts; as a natural result they do not enjoy life and sacrifice much energy. The chief blame must be attached to the frequency with which these patients have their urine analyzed. Many of them make their mood and their feelings dependent on the results of these tests. Whenever the physician tells the patient perfectly truthfully that the second analysis of the urine revealed the presence of only half as much albumin as the first analysis, the patient may be encouraged and satisfied for the time being, but communications of this kind frequently cause the patient to worry constantly, for the second analysis is followed by a third and a fourth, etc., and every physician must realize that in chronic atrophic nephritis the excretion of albumin is subject to fluctuations, so that each successive analysis cannot possibly furnish more encouraging results than the preceding one. In acute nephritis this is, of course, frequently the case. If only isolated samples of urine are analyzed instead of the whole quantity voided in 24 hours these fluctuations are apt to be particularly marked. The values for albumin vary according to the general condition of the patient, but are in part altogether independent of this factor. The degree of albuminuria, therefore, is no true index of the actual state of the disease, and as we do more harm than good in telling the patient the exact quantity of albumin excreted, I consider it to be an essential feature of the psychic treatment of these cases to divert the patient's attention as much as possible from the analysis of the urine. The physician himself should be careful not to attach too much value to these analyses and not to judge the results from too one-sided a point of view, otherwise his judgment may become biased and he may overlook other indications for treatment.

As in acute nephritis, the chief indication for dietetic treatment is in sparing the kidneys. It is unnecessary, in fact, bad practice to carry the restriction of the diet as far as in acute diseases of the kidneys. This principle is universally recognized in all the text- and hand-books on the subject, and is analogous to similar methods that are vogue in the treatment of other diseases.

In discussing the treatment of contracted kidney we must always remember that this is a protean disease, and that it calls for different methods of therapy in its different stages. Atrophic nephritis is compatible with fairly good health for years and decades. During all this time the patient may be fully capable of performing ordinary physical and mental labor provided he does not over-tax himself. The treatment of this stage is satisfactory. The patient should be carefully advised in regard to the best method of treatment, for the duration of this period of the disease will depend altogether on the persistency with which he carries out the regulations imposed; if he violates them the disease may make a turn for the worse in a very short time and irreparable damage be done in this way. Treatment, in the more extended sense of the word, is of course not the only factor that determines the prognosis, for we occasionally encounter malignant forms of the disease that baffle all treatment. These forms, however, like similar forms of diabetes mellitus, are much less frequent than relatively benign forms.

The therapeutic principles that we will have to study somewhat in detail apply (unless otherwise specified) essentially to the ordinary mild forms of the disease, namely, those forms that can be influenced by treatment. For the treatment of acute exacerbations of the disease I must refer to what has been said in preceding paragraphs. I will refer to the treatment of the later stages that immediately precede the end or determine the fatal issue, wherever it seems necessary, for in stance, in the paragraphs on the administration of water. Generally speaking the dietetic treatment of threatening exacerbations of the disease will vary according to the peculiarities of each individual case. If there is reasonable hope of improving the disease process after it has once taken a turn for the worse, we should immediately institute rigid and persistent measures directed towards sparing the kidney. This protective therapy should be the same as in acute diseases of the kidney. When there is no hope for the patient, the dietary regulations should be very liberal and the desires and tastes of the patient should be met as far as possible. This humane rule is frequently violated, and as I have often seen patients tortured up to the end with a rigorous diet according to the principles in common use in nephritis. In these cases a diet offering much variety and favoring the tastes of the patient is much more appropriate.

From the pathology of metabolism we learn that in that stage of contracted kidney which, as we have seen above, persists for a long time and is not accompanied by serious disturbances in the general health of the patient, the excretion of urinary products is not greatly interfered with. Certain irregularities are of course observed; we may find, for instance, that the excretion of urea, etc., fluctuates considerably fairly early in the disease, so that in this respect the urinary findings differ from those in a normal subject fed on the same diet. At the same time we never encounter a serious retention of excrementitious substances. If a certain proportion of excretory products is retained on one day we will usually find that it is eliminated on the next day or the second day following. Pronounced retention of excretory material is only seen in the later stages of the disease, and must be considered a much more serious prognostic sign in this disease than in acute and subchronic nephritis. For many years I have performed numerous metabolic investigations in my clinic on cases of contracted kidney, and whenever I have found that considerable quantities of urea, phosphoric acid, etc., were retained for long periods of time (not only for one, two or three days), I have always noticed that the disease soon took an unfavorable turn.