The name applied to a series of manifestations resulting from the
retention of poisonous materials in the blood, which should have been
removed by the kidneys. Uremic symptoms may occur any time during an
attack of nephritis. In chronic cases it seems likely that extensive
destruction of renal tissue is the principal factor that leads to the
toxemia. They may also occur when the circulation of the blood in the
kidneys is interfered with or the ureters are obstructed. They are not
due alone to the urea (which is found to be increased in the blood),
but more probably several poisons that are retained in the blood.
Traube’s theory is that acute cerebral edema with anemia accounts for
the symptoms. Halbert says: “A more recent and more plausible claim
is to the effect that a poison is developed in the body as the result
of nephritis,” for retention of effete matter or ligation of renal
arteries and ureters or impaired renal activity does not fully explain
the cause of the stupor, coma, convulsions, sometimes paralysis, and
gastro-intestinal disorders.
=Symptoms.=—Loss of appetite, nausea, vomiting, headache and drowsiness
are the initial symptoms. Headache is usually at the back of the head
and may extend down the neck. The next symptom is coma, alternating
with convulsions which may range from only a slight twitching to
violent epileptiform spasms. These spasms may occur without the
slightest warning and are often followed by blindness which may last
for several days. These attacks of coma and convulsions are sometimes
ascribed to localized edema of the brain.
Transient paralysis is also due to congestion or edema of the brain
and it may be of the cord. There may be mania which comes on abruptly,
although the delirium is not at all violent, while profound melancholia
may be found. There may be nervous symptoms develop, such as numbness
in the hands and fingers, itching of the skin and cramps in the
muscles—especially those of calves of the legs. Pulmonary symptoms are
sometimes continuous—dyspnea, paroxysmal dyspnea and Cheyne-Stokes’
breathing. These attacks of dyspnea may be as distressing as true
asthma. Cheyne-Stokes’ breathing may be present without coma.
Uncontrollable vomiting may set in with great abruptness, followed
by hiccough and purging. There may be a catarrhal or diphtheritic
inflammation of the colon with diarrhea. The breath has a urinous odor
and the tongue is often very foul. The pulse is slow and full, with a
temperature below the normal, although during convulsions the pulse may
become rapid and the temperature rise. Occasionally there are atypical
forms of uremia which may be very confusing and obscure.
=Diagnosis.=—The history, subnormal temperature, the urinous odor of
the breath, high arterial tension and increased second sound of the
heart will distinguish the condition. Feeling of numbness, palpitation,
headache, restlessness, mental wandering are not infrequently early
symptoms. The phenolsulphonephthalein test for the secreting power of
the kidney, and the examination of the urea in the blood are of great
aid in diagnosis.
=Prognosis.=—Extremely grave, but one should always be very careful in
his prognosis, for there is a possibility of recovery, even after the
most serious symptoms have been manifested.
=Treatment.=—As impermeability of the kidneys produces uremia, by not
allowing the various poisons to be eliminated by the renal path as
they should be, the treatment must be applied directly to the kidneys.
Elimination is demanded and if treatment through the abdomen to the
kidneys directly and to the renal splanchnics does not bring about
prompt and thorough elimination of the intoxicating properties, the
bowels and skin must be made active. The vapor or hot air bath or hot
pack should at once be used. An ice-bag to the head will be beneficial.
An increase in the quantity of urine may be brought about by the
displacement of a part of the mass of blood, which is in relative
stagnation in certain parts of the vascular system. Forcing it into the
main circulation in order to increase the pressure within the vessels
of the kidney, is the treatment indicated. This great stagnant mass of
blood is found in the arterial capillaries of the portal system in the
liver and splenic tissues and should be manipulated into the general
circulation in order to increase the arterial tension of the kidneys
and thus favor elimination. The treatment should mainly be applied to
the vasomotor nerves of the portal system, from the fifth to the ninth
dorsal, and directly over the abdomen, liver and spleen.
The introduction of water, from 110 degrees to 120 degrees, or even
150 degrees, into the colon by means of injections, is useful; warm
irrigations increase renal secretion, bowel action and sweating with
a decrease of tension. Cold drinks will stimulate the abdominal
vessels and induce absorption of a certain quantity of water to still
further increase diuresis. Cold irrigation increases blood pressure
temporarily, but later it lessens the pressure; it should be used
only with great caution. Milk is one of the best drinks to be used.
Secretions of the liver must not accumulate. The bile must be expelled
so that its toxicity will not be added to the other poisons.
The food of the patient is an important matter. A milk diet is best;
avoid meat and nitrogenous foods and any food that leaves much residue.
In this way the nutrition of the patient is kept up with a minimum
of urea formation and, besides, there will be very little intestinal
putrefaction. Emergency measures not mentioned above are repeated
high normal salt enemata (two to three pints), the alcohol sweat and
venesection (about one pint). When the attack is broken the condition
resolves itself into the renal disorder, generally acute Bright’s
disease.
This disease illustrates one phase of the uselessness of drugs; for
when the impermeability of the kidney has become such that it ceases to
have the power of eliminating toxic substances formed by the organism,
there is then retained the medicinal substances. The kidney is as
impermeable for therapeutic poisons as for the natural poisons and the
employment of toxic medicines in such cases has often no other effect
than to bring an association of medicinal intoxication with an uremic.