walls of the arteries and capillaries cannot be influenced by any means
at our command. The force and regularity of the contractions of the
heart can, however, be very decidedly modified by drugs. Opium in
moderate doses makes the heart's action slower and stronger; iodide of
potassium makes the heart's action more regular; convallaria makes the
heart's action slower and stronger; digitalis increases the force of
the heart's action, but at the same time contracts the arterioles;
aconite and veratrum viride make the heart's action slower and more
feeble.
The size of the arteries and capillaries can also be altered by drugs.
Nitrite of amyl and nitro-glycerin relax and dilate the whole arterial
and capillary system; chloral hydrate dilates the arterioles
(Fothergill).
The volume of the blood can be diminished by bloodletting and by
eliminating the plasma of the blood indirectly by sweating, purging, or
diuresis.
The symptoms which can be ascribed directly to the presence of the
kidney disease are--(1) The changes in the composition of the blood. We
have still very little exact knowledge of what these changes are, but
we may say generally that there is an increase in the relative quantity
of the watery constituents of the blood and of the excrementitious
products which should be eliminated by the kidneys. (2) The changes in
the quantity of urine probably depend partly on the changes in the
circulation, partly on the composition of the blood, and partly upon
the structural changes in the kidneys. The albumen and casts seem to be
directly due to the kidney lesion. (3) The changes in the nutrition of
the patient, the disturbances of digestion, and some of the headaches,
all seem to belong directly to the kidney disease.
Now let us try to apply these principles to the practical treatment of
the different symptoms.
The Urine.--As regards the presence of albumen and casts, it is
doubtful whether we are able to do anything, although it is customary
to give the tr. ferri chloridi and the bichloride of mercury in order
to diminish the excretion of albumen. As regards the quantity of urine,
we must distinguish whether the patient is in the ordinary course of
the disease, whether he is having an uræmic attack, or whether he is
having an acute exacerbation of the nephritis with congestion of the
kidney and blood in the urine. Under the circumstances last mentioned
the indications are to apply wet or dry cups over the lumbar region, to
use hot fomentations to the back or hot-air baths, to open the bowels
freely, to put the patient on a milk diet, and, if the heart's action
is too strong, to give aconite in small doses.
If during the ordinary course of the disease the urine is constantly
diminished, diuretics are often of good service, although the cases
differ as to the particular drugs which answer best. The preparations
of digitalis, the diuretic pill of digitalis, squills, and bichloride
of mercury, the iodide and acetate of potash, and jaborandi in small
doses, are the most reliable agents of this class. Sometimes the
frequent use of milk or of water in small quantities (half an ounce or
an ounce every half hour) will {97} answer the purpose. There can never
be any use in continuing the employment of diuretics in these cases if
after a fair trial they do not increase the flow of urine.
During the progress of uræmic attacks diuretics do not act, and the
same is often the case with cathartics and diaphoretics. The urine is
only to be increased by the same means which are indicated for the
relief of the whole uræmic condition, and of these we will speak later.
The dropsy in many cases will vary in amount, and even disappear at
times without any treatment. It is regularly most marked with the large
white kidneys and with those kidneys which are neither large white nor
atrophied, especially when there is complicating heart disease and the
patient is anæmic. Generally speaking, it is best to keep dropsical
patients in bed most of the day. We attempt to get rid of the oedema by
the skin, the bowels, and the kidneys, to regulate the heart's action,
and to improve the condition of the blood. Hot-air baths or hot-water
baths repeated every day, the milder hydragogue cathartics, and the
different diuretics may all be used with advantage. If the dropsy is
excessive, it may be necessary to tap the peritoneal or pleural
cavities or to puncture the skin of the legs and scrotum. Sometimes
bandaging the legs so as to exert moderate pressure seems to assist in
getting rid of dropsy. To regulate the heart's action we find that
digitalis, convallaria, and the iodide of potash are often of service.
To improve the condition of the blood the systematic use of iron and
oxygen is indicated. The most hopeless cases are those in which there
is complicating heart disease and those in which the dropsy steadily
increases, although the patient is passing from 60 to 100 ounces of
urine daily.
Disturbances of the stomach are of different kinds and dependent upon
different conditions. There may be simply loss of appetite or
discomfort after eating, or nausea, flatulence, and vomiting; and these
symptoms will be associated with chronic catarrhal gastritis or with a
stomach that is anatomically normal. Sometimes, although there is
occasional nausea and vomiting, the appetite continues good, or as part
of an uræmic attack there will be constant vomiting.
The habitual dyspeptic disturbances are to be treated like other cases
of gastric dyspepsia. A regulated diet, the vegetable bitters, the
mineral acids, or the alkalies are sometimes of service. The repeated
and persistent vomiting of uræmic attacks is a most distressing symptom
and one often very difficult to control. The patients must be fed with
small quantities of fluid food or of prepared meat. The most efficient
remedies are those addressed to the condition of the circulation.
Hypodermic injections of morphia, enemata of chloral hydrate,
inhalations of nitrite of amyl, convallaria in small doses by the
mouth, are all of service.
The anæmia from which the patients suffer is to be combated by the
systematic use of iron and oxygen. Any efficient preparation of iron
will answer, but it must often be given in considerable doses.
Sometimes the bichloride of mercury in small doses answers better than
iron. The oxygen should be inhaled for from five to thirty minutes
twice a day.
The so-called uræmic attacks, although they have a general similarity,
yet vary in their manifestations in different cases. In some cases the
{98} patient develops an unnatural restlessness and anxiety, an
inability to sleep, now and then a sudden twitch of one of the facial
muscles, and headache. Or a patient whose color is still good will only
complain of pain in the epigastrium and moderate dyspnoea, and yet will
be in bed and evidently seriously ill. Or a patient who has been
troubled with dyspeptic symptoms and gradual loss of strength suddenly
develops vomiting, intense headache, sleeplessness, a single convulsion
followed by facial paralysis. A man with a previous history of chronic
Bright's disease becomes persistently anæmic and dropsical; he has
constant dyspnoea, cannot lie down, cannot sleep, and yet looks drowsy
and stupid; is mildly delirious and has very little intelligence; then
gradually becomes unconscious, then comatose, and so dies. Or there are
first attacks of dyspnoea, either spasmodic or from exertion, but which
are temporary and can be relieved. Then the dyspnoea becomes more
constant and severe; the patient cannot lie down at all, all remedies
become less and less efficacious, and the dyspnoea only ends with the
life of the sufferer. In other cases a patient will suddenly become
unconscious, although not comatose; he will lie flat in bed, the skin
livid and bathed in perspiration, the respiration labored and rapid,
with coarse râles all over the lungs, the heart's action rapid and
feeble, the temperature perhaps a little elevated; or sudden and
profound coma or noisy delirium or repeated convulsions may be the
prominent features.
There is hardly a limit to the variety of the precise manner in which
all these symptoms--restlessness, sleeplessness, headache, vomiting,
delirium, convulsions, and coma--may present themselves. It is to be
remembered that although all these symptoms are always dangerous, and
often fatal, yet patients may pass through a number of such attacks
before the fatal one arrives.
To relieve these attacks the most effectual remedies are opium, chloral
hydrate, nitrite of amyl, convallaria, digitalis, caffeine,
bloodletting, purging, sweating, and cathartics.
Opium is a very valuable remedy, but great judgment is required in
selecting the preparation and the dose for each case. The old doctrine
that opium is a dangerous drug for patients suffering from Bright's
disease is perfectly true, but it is equally true that it is also a
valuable remedy. Generally speaking, the more marked the uræmic attack
the larger the dose of opium that will be borne. It is always well to
try to obtain a free movement from the bowels, although this is not
always possible.
In the milder cases the fluid extract of convallaria in ten-minim doses
will often diminish the frequency of the heart's action, increase the
production of urine, and improve the general condition of the patient.
In the earlier stages of dyspnoea five-grain doses of the iodide of
potash with a little opium will sometimes keep the patient comfortable
for months. For the severe attacks of dyspnoea dry cups over the chest
and inhalations of oxygen are of service. In the worst and most
uncontrollable dyspnoea it seems justifiable to keep the patient under
the influence of ether or chloroform.
{99} SUPPURATIVE NEPHRITIS AND PYELO-NEPHRITIS.
Suppurative inflammation of the tissue of the kidney and of its pelvis
and calices occurs under several different conditions: It is the result
of injuries; it is due to emboli; it occurs without discoverable
causes; it is secondary to cystitis, the cystitis being due to
strictures of the urethra, to stone in the bladder, to paraplegia, to
operations on the urethra, bladder, and uterus, to gonorrhoea, to
enlarged prostate.
Chronic suppurative pyelo-nephritis is often caused by the presence of
calculi in the pelvis of the kidney.
1. Suppurative Nephritis from Injury.--Gunshot wounds, incised or
punctured wounds, falls, blows, and kicks are the ordinary traumatic
causes. If the injury is a very severe one, it causes the death of the
patient in a short time; if it is less severe, suppurative inflammation
may be developed.
The inflammatory process may be diffuse, so that the whole of one or
both kidneys is converted into a soft mass composed of pus, blood, and
broken-down tissue, or it is circumscribed, and one or more abscesses
are found in the kidney which may communicate with the pelvis.
SYMPTOMS.--Rigors mark the beginning of the suppuration, and are often
repeated through its course. A febrile movement is developed which is
apt to assume the hectic character with sweatings. There is often
vomiting. There may be very severe pain, referred to the region of the
inflamed kidneys. The urine is diminished or suppressed; it contains
blood alone or blood and pus.
In the bad cases the patients pass into the typhoid condition, become
delirious, and die comatose or with a very rapid or febrile pulse. Or
the disease is protracted, the patients become more and more emaciated,
and finally die exhausted.
In other cases the symptoms abate, the urine returns to its natural
condition, and the patients recover.
TREATMENT.--The management of these cases is rather surgical than
medical. The external wound is to be treated antiseptically, and the
general condition of the patient to be looked after in the ordinary
way.
Such traumatic abscesses are of infrequent occurrence. I have no
personal knowledge of them.
2. Abscesses produced by Emboli.--In ordinary endocarditis with
vegetations on the valves it often happens that fragments of the
vegetations become fixed in the branches of the renal arteries. When
this is the case infarctions are produced, usually of the white
variety.
With malignant endocarditis, with surgical pyæmia, and with the curious
cases called idiopathic pyæmia, small emboli seem to find their way
into the smallest branches of the renal artery. They do not produce
infarctions, but small abscesses. In these cases the kidneys are
increased in size and dotted with little white points surrounded by a
red zone. These little white points are formed by an infiltration of
pus-cells between the tubes, and in the larger foci by a breaking down
of the kidney-tissue. Colonies of micrococci are sometimes, but not
always, found in the Malpighian tufts, the veins, and the abscesses.
{100} SYMPTOMS.--These embolic abscesses can hardly be said to have any
clinical history. Whatever symptoms may belong to them are lost in
those of the general disease from which the patient is suffering.
3. Idiopathic Abscesses.--Occasionally cases of abscesses of one of the
kidneys are met with. They last a long time, and when the patient dies
both the kidney tissue and the pelvis are involved to such an extent as
to render the anatomical diagnosis difficult. The greater part of the
kidney-tissue is destroyed and replaced by sacs full of pus; the pelvis
is dilated and its walls thickened. The surrounding connective tissue
is thickened; perforations and sinuses may extend into the surrounding
connective tissue, into the large intestine, and through the diaphragm
into the lung.
SYMPTOMS.--At first these cases are apt to be very obscure. An
irregular febrile movement accompanied with rigors comes and goes,
lasting for shorter or longer periods. The patients lose appetite,
vomit occasionally, and become emaciated and anæmic. With this there
may be pain over the region of one of the kidneys.
After a time a tumor may make its appearance in the position of one
kidney--a tumor which can be felt through the anterior abdominal wall.
If the abscess communicates with the pelvis of the kidney and the
ureter remains pervious, pus and fragments of kidney-tissue are
discharged with the urine. The pus is usually discharged at intervals,
and at such times the size of the tumor diminishes. In other cases the
pus burrows in other directions--into the retro-peritoneal connective
tissue, the peritoneal cavity, the colon, or through the diaphragm into
the lung. These cases are apt to run a protracted course and terminate
fatally.
TREATMENT.--The only plan of treatment likely to cure the patient is a
surgical one--either to extirpate the diseased kidney, or to cut down
on the abscess and treat it on the antiseptic plan like any deep
abscess.
4. Suppurative Pyelo-Nephritis with Cystitis.--LESIONS.--Usually both
kidneys are affected. They are increased in size, and both the kidneys
and their pelvis are congested. The mucous membrane of the pelvis is
thickened and coated with pus or patches of fibrin. Scattered through
the kidneys are abscesses and purulent foci of different sizes. The
smallest foci are not visible to the naked eye, but with the microscope
we find collections of pus-globules between the tubes, with swelling
and degeneration of the epithelium within the tubes. The larger
purulent foci look like white streaks or wedges running parallel to the
tubes and surrounded by zones of congestion. The larger abscesses
replace considerable portions of the kidney.
The ureters in some cases are inflamed, their walls thickened, their
inner surface coated with pus or fibrin. The bladder presents regularly
the lesions of acute or chronic cystitis.
ETIOLOGY.--For the production of this form of nephritis inflammation of
the bladder seems to be necessary. How the inflammatory process is
transmitted from the bladder to the kidneys is still uncertain, but it
seems probable that it is effected by bacteria. The cases of cystitis
in which a suppurative nephritis is likely to be developed are those
due to strictures of the urethra, stone in the bladder, operations on
the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged
prostate.
SYMPTOMS.--When the nephritis occurs with cystitis due to stone in the
bladder, strictures, or operations on the genito-urinary tract, the
{101} symptoms are much the same. The patient has first the symptoms
belonging to the cystitis, then he is attacked with rigors, followed by
a febrile movement. The rigors are often repeated; the febrile movement
is very irregular and often accompanied by profuse sweating. There is a
rapid change in the general condition of the patient. He becomes much
prostrated and emaciated from day to day. The face is drawn and
anxious, the tongue dry and brown, the pulse rapid and feeble, and
delirium is developed, and the patient finally dies in a condition
resembling that of typhoid fever or of pyæmia. The urine is diminished
in amount; it may be suppressed. It contains blood, pus, and mucus. The
pus and mucus belong to the cystitis; the blood seems to be derived
both from the kidneys and the bladder.
Cases of suppurative nephritis complicating gonorrhoea are fortunately
not common, but several of them have been observed. Murchison[2]
describes two cases, in both of which the cerebral symptoms were very
marked--delirium, convulsions, and coma. I have seen one such case. The
patient was a prostitute who came into the hospital with a specific
vaginitis. After a few days she developed symptoms of an acute
cystitis; then after a few more days she was attacked with rigors and a
febrile movement, passed rapidly into the typhoid condition, and died.
At the autopsy there were found acute cystitis, pyelitis, and numerous
small abscesses in both kidneys.
[Footnote 2: _Lancet_, 1875, p. 80.]
When suppurative nephritis complicates the cystitis due to enlarged
prostate, the clinical symptoms are somewhat different. The patients
are usually men over fifty. They have generally suffered from the
symptoms of enlarged prostate--retention of urine, either constant or
intermittent, and more or less cystitis, with pus and mucus in the
urine in varying amount. Sometimes, however, no such history is
obtained; the patients assert that they have had no previous bladder
trouble. The first symptom is diminution in the amount of urine passed
and the appearance of blood. The quantity of urine is only a few ounces
or it is completely suppressed. The blood is present in considerable
amount; often the patients seem to pass pure blood instead of urine.
The patients rapidly become prostrated and very anxious. There are
usually no rigors, and there may be no febrile movement. After this the
prostration becomes more marked, the pulse is rapid and feeble, the
skin cold and bathed in perspiration, and the patients die in collapse
at the end of a few days.
PROGNOSIS.--Suppurative nephritis secondary to cystitis is a very fatal
disease; so far as I know, all the cases die.
TREATMENT.--The treatment for these cases is altogether a preventive
one directed to the cystitis. In the cases of paraplegia, stone in the
bladder, stricture, and enlarged prostate constant care must be used to
prevent the accumulation of urine in the bladder and the development of
cystitis.
In all cases of operation on the genito-urinary tract the supervention
of cystitis is to be guarded against.
{102} PERINEPHRITIS.
The loose connective tissue which is situated around and beneath the
kidney may become the seat of suppurative inflammation, and in this way
abscesses of considerable size are formed.
LESIONS.--The connective tissue behind the kidney seems to be the usual
point of origin of the inflammatory process, and it is here that the
pus first collects. After the abscess has reached a certain size the
suppuration seems to have a natural tendency to spread and the pus
burrows in different directions--backward through the muscles; downward
along the iliac fossa, even as far as the perineum and scrotum or
vagina; forward into the peritoneal cavity, the colon, or the bladder;
upward through the diaphragm. The kidney is either compressed by the
abscess or its tissue also becomes involved in the suppurative process.
The soft parts around the abscess become thickened.
ETIOLOGY.--Perinephritis is either secondary or primary. The secondary
cases are due to extension of the inflammation from abscesses in the
vicinity, such as are formed with caries of the spine, pelvic
cellulitis, puerperal parametritis, perityphlitis, suppuration of the
kidneys, and pyelo-nephritis. The primary cases occur after exposure to
cold, after contusions over the lumbar region, great muscular exertion,
and without discoverable cause. The lesion is said to complicate typhus
and typhoid fever and smallpox. The disease occurs both in children and
adults, most of the cases reported having been between the ages of
twenty and forty years.
SYMPTOMS.--The disease begins regularly with pain and tenderness
referred to the lumbar region on one side between the lower border of
the ribs and the crest of the ilium, sometimes to a point above or
below this. At about the same time are developed repeated rigors, a
febrile movement with evening exacerbations, sweating, loss of
appetite, vomiting, and prostration. These are all the symptoms for
from one to two weeks. Then the skin over the lumbar region on one side
becomes red and oedematous; the corresponding thigh is kept flexed and
rigid, for any movement of it gives pain. Then the lumbar region
becomes more and more swollen until fluctuation can be made out, and
finally the abscess breaks through the skin. If such cases are left to
run their course the abscess may reach a very large size. If the pus
does not extend backward, but in some other direction, the symptoms are
more obscure, for the local symptoms of an abscess in the back are
absent.
If the abscess ruptures into the peritoneal cavity, the symptoms of
acute general peritonitis are suddenly developed. If it perforates into
the colon or bladder, the pus is discharged with the feces or the
urine. If the perforation is through the diaphragm, there will be
empyema, or the lung becomes adherent and pus is coughed up from the
bronchi. As soon as the abscess is opened and the pus escapes the acute
constitutional symptoms subside.
Trousseau believes that the inflammatory process sometimes stops short
of the production of pus. In such cases of course there are no
evidences of the formation of an abscess.
The disease may terminate in different ways: {103}
1. The inflammation may terminate in resolution (Trousseau).
2. The abscess is opened by operation or spontaneously and the patient
recovers.
3. Although the abscess is opened either by the surgeon or
spontaneously, the suppurative process continues and the patient dies
exhausted, usually with waxy viscera.
4. Perforation into the peritoneum, the pleura, or the lung causes
death.
TREATMENT.--The main point in treatment is to discover the abscess and
to open it. The longer the suppurative process goes on and the larger
the abscess, so much the worse is the prognosis. It is proper to
explore with the aspirator after the disease has lasted for a few days,
even if no fluctuation can be made out. The abscess is to be opened and
treated on antiseptic principles.
{104}
HÆMATURIA AND HÆMOGLOBINURIA OR HÆMATINURIA.
BY JAMES TYSON, A.M., M.D.