(ACUTE BRIGHT’S DISEASE)
=Definition.=—An acute, inflammatory process affecting the epithelium
of the uriniferous tubules and due to the action of cold or toxic
agents upon the kidneys, as well as to injuries to the renal
splanchnics; is characterized by certain nervous symptoms with fever,
dropsy, and scanty and highly colored urine. This inflammation involves
more or less the whole kidney.
=Osteopathic Etiology and Pathology.=—This disease is caused by
exposure to cold and wet while the body is warm and perspiring.
Excessive use of alcohol may be a factor. May be caused also by
infectious diseases, such as scarlet fever, diphtheria, measles,
smallpox, acute tuberculosis and others; also by certain specific
poisons which are eliminated by the kidneys, as turpentine, chlorate
of potash, carbolic acid, phosphorus, ginger, cantharides and oil of
mustard; also by pregnancy, as this is supposed to compress the renal
veins, or through toxic agents. Syphilis may be an underlying cause.
Blows and injuries to the back at the tenth, eleventh and twelfth
dorsals are frequently the cause. Lesions are found from the sixth
dorsal to the fourth lumbar. The lower three ribs may be at fault,
while the innominate and muscular contractions have been found to be
pathological factors. Lordosis may be a contributing cause. Loudon
places considerable importance on cervical lesions and McConnell
believes vasomotor disturbance plays an important causative role in the
disease.
=Pathologically=, at times the kidney alteration may be so slight
as not to be recognizable by the naked eye, the appearance varying
according to the stage and severity of the disease. The kidneys become
enlarged, engorged and of a bright red color, and later have a mottled
appearance; and when the capsule, which is non-adherent, is stripped
off, the kidney is found to be soft and inelastic. In most of the cases
in which the disease is due to toxic agents brought to the kidney
through the blood-vessels, the glomeruli suffer first. The epithelium
of the glomeruli and tubules is the seat of cloudy swelling and, in the
later stages, of fatty change and hyaline degeneration. The tubules
are clogged by altered cells, leucocytes and blood-corpuscles. In mild
cases the interstitial tissue is simply inflamed, but in all cases it
becomes more or less mixed with leucocytes and red blood-corpuscles.
Osteopathic lesions produced upon animals in the region of the ninth to
the twelfth dorsal, resulted in acute nephritis. The autopsy findings
were distinctly typical.
=Symptoms.=—The onset is usually sudden, with moderate fever, pain
in the back in the lumbar region and over the kidneys and following
the ureters. Nausea and vomiting may be present. Dropsy soon appears,
beginning with slight swelling or puffiness in the face below the eyes,
later showing itself in edema of the abdominal walls and extremities.
Uremic symptoms may develop. The urine is characteristic; is diminished
in quantity and of high specific gravity; at first the sediment is
copious and reddish brown in color, becoming less in amount and of
high color. This sediment contains casts of the uriniferous tubules,
free blood, epithelial cells, uric acid and urates. There are large
quantities of albumin in the urine.
The presence of albuminous matter in the urine, even in large
quantities, is not sufficient evidence to warrant a diagnosis of
Bright’s disease nor is the amount a guide as to the severity of the
case, for grave conditions often show a slight amount (Loudon).[98]
=Diagnosis.=—The general symptoms may be very slight, for the most
severe cases may manifest slight edema of the feet, or there may
be only the puffiness under the eyes and of the eyelids. In such
cases the diagnosis must depend upon examination of the urine. With
previous history, suddenness of the attack and character of the urine,
ordinarily the diagnosis will be quite easy.
=Prognosis.=—Although this disease is generally grave, the prognosis is
favorable and the majority of cases recover under judicious treatment.
=Treatment.=—Cases of acute nephritis require rest, quiet and warmth.
Many cases recover under these conditions alone. It is absolutely
necessary, however, that these conditions exist no matter what other
treatment is used. A thorough treatment to the renal splanchnics cannot
be overestimated for it is here (tenth to twelfth dorsal, inclusive)
that a majority of the lesions producing acute nephritis occur. Besides
correcting the vertebral and rib displacements in this region, a very
effective treatment is to have the patient lie flat upon the back and
then the osteopath, reaching around the patient with the fingers of
one hand on either side near the spines of the lower dorsal vertebræ,
raise the patient so that the entire body, except the shoulders and
the feet, are lifted clear of the bed. Thus the treatment springs the
spine anteriorly and produces a marked effect upon the kidneys through
the renal vasomotor nerves. Occasionally lesions in the upper cervical
region interfere with the normal activity of the renal nerve fibers
passing to the kidneys by way of the superior cervical ganglion of the
sympathetics.
Another very effectual treatment for the kidneys is treating them
through the abdomen by a careful pressure upon the kidneys through the
abdomen on either side of the umbilicus, thus lightly working each
kidney outward and upward. This treatment relaxes any tissues about the
blood-vessels, nerves and lymphatics to and from the kidneys that may
be contracted and thus aids in establishing a normal activity of the
involved organs. It also helps in relaxing tissues about the ureters
and prevents the clogging up of the latter with debris. Bandel and
Stearns report cases in which an impacted colon was an important factor
in this particular.
The above means have for their object the direct relief of the
congestion of the kidney. This is further aided by keeping the bowels
active, which supplements the action of the kidneys, and by increasing
the activity of the skin. This also aids in relieving dropsical
effusions. The hot pack, in which the patient is wrapped in a wet sheet
and then covered by a number of blankets, is an exceedingly good method
to relieve the kidneys of some of the work and lessen their congestion,
besides arresting uremic intoxication. This can be repeated daily if
necessary. Where there is dropsy and scanty urine, the indications
are to increase the secreting action of the kidney; besides treatment
through the renal splanchnics, which contain the vasomotor nerves of
the kidneys, stimulating treatment to the vagi will help to increase
the urinary secretion. Hot fomentations, placed directly over the
region of the renal splanchnics, is a valuable aid in cases which do
not respond quickly to osteopathic stimulation. Treatment of the liver
is important. Injections of cold water into the intestines will tend to
stimulate the secretion of the kidneys, but this should be used with
the greatest caution; in some cases tepid water would be better (see
uremia).
The diet of the patient with acute nephritis is important. Give food
that is easy of digestion and which contains a minimum amount of
nitrogen. The stomach is quite likely to be irritable, consequently
food that is adapted to it should be selected. Milk and weak animal
broths are undoubtedly the best foods. The return to a solid diet,
especially of meat, should be very slow. Suitable adjuvants to the
milk diet are rice and farinaceous preparations. Loudon[99] recommends
complete withdrawal of all foods for twenty-four to forty-eight hours
and the reducing of nitrogenous foods to a minimum; a diet of milk and
cream after the fast, followed by cereals and broths, then eggs and
fish until albumin disappears from the urine. Alkaline mineral waters
are useful to help maintain an alkaline urine, thus tending to withdraw
exudates. The patient should be treated daily at first and later on
every other day, for case reports show frequent treatments hasten
recovery.
For treatment of acute uremia in Bright’s disease, see uremia.
Complications should be treated as affections independent of the renal
disorder.