Commentaries on diseases of the kidneys

COMMENTARIES ON DISEASES OF T H E KIDNEYS. ~

PART I I .

By AnTHUR W:~N~E FOOT, M.D., Univ. Dubl. ; Senior Physician, Meath Hospital and County of Dublin Infirmary; Fellow and ex-Censor~ King and Queen's College of Physicians in I re land; Diplomate in State Medicine, Trini ty College, Dubl in ; Lecturer on Practice of Medicine in the Ledwich School of Medicine and Surgery; Fellow, Royal Geological Society of Ireland, &c.

[Continued from page 363, Vol. LXVII.].

IN the treatment of nephritis the double indication is to relieve the kidneys and to promote the action of the other excretory organs. In a case of acute nephritis it is necessary to keep the patient in bed if we wish to render the prospect of a rapid and favourable course more certain. The patient should be at once confined to bed in a room warmed to a temperature of at least 60 ~ F., swathed in flannel, and made to lie between the blankets. By thus maintaining a uniform and constant warmth of the skin, we avoid those fluxions to the kidneys which, as physiological experiments show, are associated with the cooling of the cutaneous surface. Blood may be abstracted from the loins by cups or leeches in proportion to the acuteness and severity of the attack and the age and strength of the patient. After the abstraction of blood, large hot linseed-meal poultices should be applied to the renal regions, and renewed every three hours. In sthenic cases, where the fever runs high, and there is severe headache, venesection may be practised with advantage; it is more likely to be required in such cases as come on from eold~ and attack plethoric persons in their usual health, than if the nephritis be a sequel of some severe febrile affection, as scarlatina. The readiness with which the kidney relieves itself by a copious h~ematuria often makes artificial depletion unnecessary, even where it might other- wise be thought desirable. The method of treatment pursued by Br igh t - - writing in the year 1827, and again in 1836--at the commencement of the disease was "general bleeding, freely practised, and quickly repeated." A study of the cases he reports illustrates the discriminating and cautious manner in which this most eminent physician employed blood-letting. The action of the skin should be promoted by the use of

a The text of the essays of Professor Carl Barrels, of Kiel, and :Professor Wilhelm Ebstein, of Goettingen, in Volume XV. of the "Cyelopeedia of the Practice of ~r cine," edited by Dr. It. Von Ziemssen, has been followed as closely as possible, with additional notes from all the best authorities on the subject.--A. W. Foo~:.

Commentaries on Diseases of tlte Kid~eys. 451

hot-air or hot-water baths. A hot-air bath or a hot-water bath should be administered every evening or every second evening, and followed by envelopment of the body in warm blankets. When no conveniences for a hot-water bath exist~ an excellent substitute is found in the " blanket- bath." A large thick blanket is wrung as dry as possible out of boiling water, and wrapped round the body of the patient ; the bed clothes are then heaped on. In twenty minutes or half an hour, the hot blanket is removed, and the surface of the body quickly dried with a warm soft towel. The production of active diaphoresis (by means of hot baths) in an acute inflammation of the kidneys, which had caused great diminution of the urinary secretion, is followed at once by a marked increase of the m'ine flow. The artificially-produced congestior~ of the cutaneous vessels necessarily helps to bring the stagnant blood in the renal vessels again into circulation, since the natural obstacle to their disgorgement pre- sented by the distension of the general venous system must necessarily have been diminished by the diversion of large quantities of blood to the surface of the body. I t is in this way that the induction of a diaphoresis contributes to the re-establishment of the normal condition of the circulation through the inflamed kidneys, and thereby also to the re-establishment of the normal secretion. A really efficient diaphoresis can be accomplished only by heating the skin through some agency which acts on it from without. The method which is most agreeable to the patient, and at the same time also most effective, is to heat the skin by dry hot air, as is done in the so-called Turkish bath. This plan is greatly to be preferred to vapour and steam-closet baths, since thereby any actual overheating of the body is av.oided, although the atmosphere of the sudatorium is commonly raised to above 50 ~ R. (145 ~ Fahr.) The sweat which pours freely from the whole surface of the body when such a temperature as this is reached rapidly evaporates in the dry hot air, and the heat required to convert the palpable moisture (standing on the body in the form of drops) into vapour is extracted in part from the surface of the body, and in part from the layer of air which lies next against this. In a private house an imperfect substitute for the hot- air chamber may be contrived by seating the patient upon a wooden stool in a well-warmed room, and putting one or two spirit lamps on ~be floor under the stool; after the lamps have been lighted, blankets should be wrapped round the patient in such a manner as to cut off the atmosphere immediately surrounding him from that of the room at large, his head alone being left exposed. An inexpensive and very effective apparatus is now easily obtainable wherewith a very perfect hot-alr bath can be promptly and easily administered.

When hot-water baths are employed care should be taken to manage that they arc really hot and not merely warm baths. According to Liebermeister's plan the patient should be placed daily in a hot bath (at

452 Commentarles on Diseases of the Kidneys.

a temperature of 38 ~ Cent. or 100"5 ~ Fahr.), and the temperature of this should then be gradually raised, if the patient can bear it, up to 42 ~ Cent. (107"8 ~ Fahr.) by the addition of hot water. The patient should remain in it as long a time as he comfortably can (not beyond a full hour) ; the room being thoroughly warm, he should then be as quickly as possible packed in previously heated blankets, and be kept wrapped up in these for one or two hours on a couch or convenient lounge; he is then, finally, to be rubbed down quickly, and put into a previously warmed bed.

Of medicinal diaphoretlcs, citrate of potash draughts, given every two hours in effervescence, may be serviceable, or a mixture of the liq. ammon, acct. in two or three drachm doses~ with fifteen drops of tincture of hyoscyamus in an ounce of infusum lini. Stimulating diuretics are to be carefully avoided, as they are liable to exasperate the existing congestion and to produce hmmaturia. Of all diuretics water is the best. Two or three pints of pure or of distilled water mav be taken daily, or sod~ water or any other similar drink may be substituted. The free adminis- tration of water facilitates the elimination of the urinary solids, hence the importance of increasing, if possible, the aqueous part of the urine. An additional reason for the use of so simple and effective a diuretic as pure water is afforded by the character of the disorder, which consists in an exuberant epitheliM growth occurring in the tubes; to prevent dangerous obstruction it is essential that a suflieieney of fluid should wash out the accumulated cells. If the tubes can get rid of their contents, the congestion of the gland will be relieved by secretion, the system cleared of its impurities, the organ gradually restored to its healthy state, and recovery ensue.

Digitalis is a remedy which is often of great value in grown persons or in children when the disease is severe. I t adds to the force of the heart, and increases the vis h J'ronte in the Malpighian filters. The best preparation is the infusion. The doses may vary from one to four drachms, according to the age of the patient, repeated twice or thrice in the day, or in severe eases every three or four hours. Digitalis may also be applied externally in the form of cloths steeped in the infusion and laid over the abdomen. Sir Robert Christison recommends a combination of digitalis and bitartrate of potash as superior to either remedy given singly : - - " The former was usually given in the (lose of one or two grains of the powder, in the form of a pill, three times a day, or in the dose of ten, fifteen, or twenty minims of the tincture, three times daily, in a little distilled water of cinnamon or cassia. The cream of tartar was administered thrice a day in the quantity o f a drachm and a half, or two drachms, with about five ounces of water."

Indiscriminate purging with jalap and elaterium is to be avoided, and it will often be noticed to be followed by a diminution of urine and an

Commentaries on Disei~ses of the K'idJ~ejs. 453

increase of the dropsy~ the result of the misappropriation of the aqueous fluid which is needed to keep the tubes clear.

The obstinate vomiting which occasionally ushers in acute renal dropsy may be combated with creasote or small doses of chloroform given in iced milk or water~ or by two or three drops of hydrocyanic acid in a glass of soda or seltzer water. Severe and intractable vomiting at the commencement of the disease is sometimes due to direct sympathy with the renal irritation, and is probably a reflex symptom provoked by the irritation of the nerves in consequence of the acute swelling of the kidneys. In such cases it is more likety to subside after local depletion of the kidneys than after any medicinal remedies. When it is due to genuine ur~emic poisoning it is rarely amenable to treatment.

The diet to be allowed it, acute nephritis is a matter of very great importance. The physiological repose of the inflamed organs is to be sought for by cutting off the materials which furnish urea and uric acid. Meat and eggs are to be prohibited, also the use of tea and coffee-- substances which are supposed, not without reason~ to exert an irritating action on the kidneys. A milk diet~ with all its possible variations, would be the ideal bill of fare for a patient in acute nephritis~ and to it may be added light farinaceous foods with fruit and vegetables. After the acute stage has passed it is advisable to give iron. If the bematuria be of long duration ergot is a most effective remedy. When a favourable issue has been obtained~ unusual care is required to guard against relapses~ to which the patients continue liable for a considerable period. The slightest exposure is sometimes sufficient to reawaken the pyrexi% and to cause the reappearance of albumen and blood in the urine. A complete suit of flannels is essential, and as a rule the convalescent should not be permitted to leave his room until the albumen has disappeared from the urine. When that comes to pass change of air to a warm~ sheltered locality is likely to be highly beneficial~ and to hasten the restoration of the impoverished blood.

Hitherto we have not spoken much of Bright's diseas% at least under that name. We now approach the chronic diseases of the kidney to more or less of which that term is applied. In proportion as increased pattmlogical knowledge has widened the scope of Bright's brilliant generalisation~ in the same proportion has the term become more vague and more difficult of definition. Before Bright's observations it was known that the urine is albuminous in some forms of dropsy~ but he demonstrated that this albuminuria is due to disease of the kidneys. Such kidney diseases as produce albuminuria have ever since been called by the general name of Bright's disease ; and although tim renal changes which agree in producing albuminuria present~ as we shall see~ several distinct varieties, yet the characters which they possess in common unite them into a practically well-rccognised kind. I t is not so very surprising,

454 Commentaries on Diseases of the Kidneys.

as at first might appear, that these states of kidney should have long escaped notice, for the kidney itself gives usually no pain, and the urine is clear, while death occurs under widely various circumstances of dropsy, acute inflammation, apoplexy, &c., not one of which points evidently to the kidney as its source. The discovery and proof of the common cause of the vast number of different disorders produced by this disease will ever make Bright 's name illustrious. Two main divisions of Bright 's diseases, which is a better term than Brlght 's disease, based on clinical characteristics, may be conveniently made--acute and chronic ]~right's disease. The former division embraces a compact and universally recognised group which we have recently been considering, known also as "inflammatory dropsy," " acute renal dropsy," or "acute albuminuria." This typical "acute Bl'ight's disease" occurs, as we have seen, as an independent ailment, associated with albuminuria and dropsy, often caused by cold, and then usually during exposure while the person is hungry or fatigued. We have also considered the similar condition which results from scarlatina, diphtheria, and other severe febrile affections. The latter division, " chronic ]3right's disease," includes the protracted cases which have either passed from the acute form into a chronic state, or, which is far more frequent, have been chronic from the first. The kidneys of persons dying of chronic Bright 's disease present three chief types of alteration. In the first the kidney is smooth, white, and enlarged; in the second it is granular, brownish or red, and contracted (the cirrhotic kidney); in the third the kidney is lardaceous or waxy (the so-called amyloid degeneration). The special clinical history per- taining to each of these anatomical types has not yet been made out with sufficient precision to enable them to be invariably recognised during life. Furthermore, these types are not always found simple and unmixed. Hence it comes to pass that a complex anatomical state is produced which is associated with a complex clinical history. The type (No. 1) of chronic Bright 's disease whose anatomical character is what Samuel Wilks a first described as " t h e large white k idney" is spoken of and writ ten on under different descriptive terms. Thus it forms the second stage of the Bright 's disease of most writers; the non-desquamativc nephritis of Johnson; the chronic parenchymatous nephritis of others. This form of Bright 's disease is, in a few instances, developed from an acute inflammation of the kidneys, the result either of scarlatina or of exposure to cold, but in the great majority of the cases i t progresses in an insidious manner from the very beginning. Among the causes which seem to operate in inducing this form of chronic Bright 's disease are affections which are accompanied by persistent suppuration, malarial poison, or marsh miasm, and the misuse of mercury. ]3ut in a considerable number of cases i t is impossible, from the past history of

a Guy's Hosp. Rep. 1853.

Commentaries on Diseases of the Kid,Legs. 455

the patient, to discover any sufficient cause for the development of the malady. There does not appear to be any good reason for believing that alcoholic excesses, to which the disease is by many attributed, can be fairly charged with being the cause of it. A fact about it which is better known than its etiology is that young persons are decidedly more frequently attacked than those who are advanced in years. The average age of 106 cases of smooth large kidney examined by Dickinson was 28"2 years; whereas in 250 cases of granular kidney the average age was 50"2 years. The disease is very rarely ushered in by an at tack of acute nephritis ; when it is so the concurrent symptoms of acute inflammation of the kidneys are strikingly obvious. When it supervenes in its usual insidious manner, its commencement will only be disclosed by systematic examinations of the urine, which i t should be a standing rule to institute in every suspicious case of disease. Nothing betrays the insidious affection of the kidneys in its earliest stage ; there is no pain or discomfort of any sort in mictur i t ion-- the only signs being a diminution in the quantity of urine passed daily, and the presence of albumen. When the urine is examined a diminution in quantity and a large percentage of albumen may be observed for a long time prior to more obvious symptoms, and the excretion will not revert to its normal con= ditions as long as the disease progresses. In those cases in which no examination of the urine is instituted, and in those in which the disease attacks, without evident cause, persons who were previously in sound health, dropsy is, almost without exception, the first symptom that betrays the malady. When these patients, frightened by the commencing dropsy, seek medical advice, they are generally found to be noticeably pale and anaemic, although they had previously considered themselves perfectly well. They usually state that they have noticed for some time past a diminution of bodily strength, which, however, has not been sufficient to prevent them from pursuing their occupations. As a rule they have experienced no other disturbances of health which would point to any decided organic disease. In a few rare cases they complain of dull pressing pains in the renal region which, masked under the customary cloak of rheumatism, fail to excite the suspicions of the patient or of his medical adviser. Once begun, the dropsy is wont to increase rapidly, and usually attains a high grade in spite of all therapeutic measures. I ts distribution is the same as that of all the other forms of renal dropsy, the subcutaneous areolar tissue being its chief seat. Beginning either in the feet or in the face, it extends, as a rule, over the entire body, and usually holds its ground obstinately in the parts it has once involved. The external genitals, in particular, are constantly swollen, and often remain swollen for months at a time~ so that the foreskin is curled up in front of the penis like a post-horn, and the scrotum presents the appearance of a bladder filled with water~ which may be larger than a child's head~

456 Commentaries on Diseases of tlte Kidneys.

and can then no longer be accommodated between the (edematous thighs. Very geaerally the abdominal walls are engaged to an extreme degree in the general swelling even before any perceptible quantity of fluid is collected in the peritoneal cavity. Tile serous cavities do not long remain free from dropsical collections. Large quantities of fluid are found in the pleurm, the pericardium, and the abdominal cavi ty- -more frequently in the chronic than in the acute form of nephritis, and it is not at all rare for death to be caused by them~ when the fluid is not evacuated sufficiently early. The anasarca may attain to such a grade that rupture of the epidermal layer occurs in consequence of the enormous tension of the skin, and the dropsical fluid may trickle out from the small cracks in such quantities as to wet the entire bed of the patient through and through, and collect in pools upon the floor, after filtering through the mattresses. The epidermis over an extensive surface is macerated in this fluid, and thrown off, leaving the corium bare and exposed ; this usually happens on the lower part of the thighs, and in the scrotum. In favourable cases a general diminution of the dropsy follows this enormous discharge of fluid. The bare and relaxed corium in the affected spots is covered with pale, glassy granulations, over which a new layer of epidermis is developed. In other cases, however, the spots in which the corium has been deprived of its epidermis become the start ing- points of superficial or deep gangrene. Another sequel of the loss of the cpidermis~ less common, however, than superficial gangrene of the skin, is a phlegmonous inflammation of the subcutaneous cellular tissue, which, as a rule, proves fatal. The mucous membranes, especially that lining the intestinal tract, are also involved in the dropsical swelling. Vomiting of watery masses and profuse watery diarrhoea are symptoms which indicate this condition of the gastric and intestinal mucous membranes. The mucous membrane of the respiratory organs seems to be less frequently affected than that of the intestines. (Edema of large portions of the pulmonary tissue occurs not infrequently, and, as a rule, proves fatal. Pulmonary (edema is one of the more frequent causes of death in chronic nephritis. Besides the sense of oppression caused by increasing difficulty of respiration, the long agony is preceded by a tormenting cough, accompanied by profuse, watery~ and frothy expectoration, and rMes in the bronchi, which can be heard at a distance ; by a constantly increasing cyanosis of the lips which contrasts strangely with the ash- pale colour of the swollen face, with prominent eyeballs ; by a disappearance of the pulse ; and by a gradually ascending coldness of the extrcmi- ties. As long as the patients remain free from secondary inflammations in other organs, the chronic parenchymatous nephritis runs its course entirely without fever. The disease is of shorter duration than the granular kidney. In fatal cases the ordinary duration of the disease is under six months. Temporary recoveries and relapses are frequent; in

Commentaries on Diseases of tlte Kid~eys. 457

protracted cases the albuminuria may continue long after the dropsical symptoms have passed away ; it may remain copious even for more than a year after all other symptoms of disease have ceased. There is a markedly greater tendency to secondary inflammations and to urmmie accidents than in granular kidney, but less to valvular heart disease and hypertrophy of the left ventricle. As long as the dropsy exists it con- ceals the extreme emaciation which has set in meanwhile. Sometimes it is astonishing how skeleton-like the previously shapeless and swollen limbs become when the dropsy has entirely disappeared--not only the subcutaneous adipose tissue, but also the muscles having been reduced to the merest remnants.

Digestive disturbances set in pretty early in some cases, and a failing or cap~'icious appetite, or slight dyspeptic symptoms may attract notice even before (edema directs attention to the kidneys. The patients~ with especial frequency~ experience a positive repugnance for animal food. When complete recovery takes place, which is rarely the case, the patients slowly improve in condition, and it is a long time before they recover their former healthy aspect. The convalescence is more frequently incomplete. A portion of the renal tissue has been destroyed, and what is left continues to excrete albuminous urine. The patients then remain somewhat emaciated ; the unhealthy colour persists ; the skin is constantly dry; they do not completely recover their strength, and sooner or later death is caused by the consequences of this condition.

_Post Mortem Appearances.--When the disease proves fatal, as usually happens, at its height, we find both kidneys very considerably enlarged, and, as a rule, much larger than they ever are in acute nephritis. When only one kidney is present, or when the other has become incapable of performing its functions~ the diseased kidney~ which may entirely fill the hypochondriac space~ presents rather the appearance of a tumour ; at all events the enlargement is more excessive than it ever is in cases of cyanotic induration (the state of kidney in passive hypera~mia) and simple granular degeneration~ and the organ not infrequently attains double or treble its ordinary volume. The capsule is tightly stretched and gapes widely upon section. These large kidneys are always exceedingly anaemic on the surface; their colour is always strikingly pale, almost white with a strong tinge of yellow. When a vertical section is examined we see that the enlargement of the kidney is principally due to an increase of the cortical substance, which is double or even three times its ordinary thickness. Its colour is ivory white or (in cases of fatty transformation) yellowish. The cones appear conspicuously red from contrast with the abnormal whiteness of the cortex. The microscopic changes are essentially confined to the uriniferous tubes. The epithelial lining of the tubes is enormously increased in quantity, and the tubes are thereby distended and enlarged. The cells are swollen, generally

2 r ~


opaque and granular, and often largely charged with oily particles. The large white kidney is not infrequently greatly infiltrated with fat, and then it constitutes one form of the '~ fatty kidney." F a t t y transformation is much more frequent when the disease has arisen from cold than when it has followed from scarlatina.

In reference to the symptoms of this type of Bright 's disease it cannot be too strongly insisted on that as long as the chronic inflammation of the kidneys continues to advance, or remains at its height, the quantity of urine excreted daily is far below the normal. The complete anuria which is met with in ~ome cases of acute nephritis is, however, not observed in the chronic form. The urine, too, has a peculiar dirty tint~ quite independent of bloody coloration. The dir ty brown colour of the urine is increased by a further clouding which takes place as soon as it cools. When the urine is heavy and viscid from the large amount of albumen it contains, the urates, though no longer held in solution after the fluid cools, instead of falling to the bottom of the vessel, remain suspended in the fluid, and make i t as thick as muddy water. The microscopic examination of the sediment shows that, apart from uric acid and its salts and other crystalline structures, the principal ingredient is urinary casts, the quantity of which in many cases is so great that every drop of the sediment may contain them in dozens. The tube-casts are of various characters--epithelial , fatty, granular, and hyaline. The longer the process has lasted the more numerous become the dark granular casts. The great mass of the casts are produced simply by deposits of spontaneously coagulable albuminoid substances derived from the albuminous urine. The dark granular casts seem to have been developed out of adherent epithelial cells that have undergone inflammatory degeneration. The broad, waxy, yellowish casts are formed principally in the straight robes of the pyramids. The sediment also always contains white blood-corpuscles, often in considerable quantities, and, in addition~ flocculent masses of granular detritus and a quantity of amor- phous renal debris. The chemical analysis of the urine in chronic nephritis invariably reveals the presence of albumen ; this is never absent at any period, and when the disease is at its height the percentage of albumen is greater than it ever is under any other circumstances. In the course of chronic inflammation of the kidneys the appearance and subsidence of dropsy appears to correspond exactly with the diminution and increase of the daily excretion of water through the kidneys ; at the same time it is not to be denied that other factors exert an influence on the development and disappearance of the dropsy ; that, for instance, the impoverishment of the blood caused by the draining away of its albumen promotes the increase of the dropsy, while the intercurrent diarrhoeas and the artificially provoked diaphoresis favour its disappearance.

The kidneys~ when in a state of chronic inflammation~ are on the one

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hand unable to perform properly their natural task-- the removal of the excess of water from the blood ; they are als% on the other hand~ incapable of efficiently performing their other important functions--the depuration of the blood from the specific constituents of the urine. I t is evident from the analysis of the urine passed by patients suffering from chronic inflammation of the kidneys that the amount of urea excreted daily in this disease is far below what may be considered as the normal average excretion in healthy persons. Yet~ nevertheless~ ur~emic attacks are by no means frequent in this disease~ and only in exceedingly rare cases are they the immediate cause of death~ whereas one might expect that~ if retention of urea in the blood and tissues be really the cause of urmmic attacks, such attacks woMd necessarily and invariably occur in the course of chronic nephritis. In solving this problem it is to be borne in mind that all the factors which exert an influence on the production of urea are diminished in chronic inflammation of the kidneys. Tile great mass of the nitrogenous material in the blood has dwindled away~ the quantity of food taken and assimilated is reduced to a minimum~ and the dropsy and the debility of the patients prevent muscular exertion. I t follows of necessity that the production of urea in these patients must be diminished and remain below the normal. Hence, as Bartels remarks~ we should not be justified in concluding that the retention of urea in the blood and tissues does not excite ur~emic attacks~ because these attacks are decidedly rare in chronic nephritis~ in spite of the very scanty excretion of urea through the kidneys. For who can say that even the small amount of this substance excreted with the urine does not represent fully the quantity which is produced in the tissues. But there is another circumstance which may have some influence in preventing the occur- rence of urzemic attacks in chronic nephritis--viz., dropsy. _A certain appreciable quantity of urea is contained in the fluid effused into the subcutaneons cellular tissue~ and this quantity is increased to a very considerable percentage in the fluid effused into the serous cavities of the body. I t is quite reasonable to regard these cavities as constituting a capacious reservoir for the storage of the pernicious material which cannot be excreted. The dropsy~ in this respect~ supplies~ so to speak, a sort of natural compensation for the insufficiency of the renal ftmctions. The importance of the dropsy as a reservoir for the pernicious urinary constituents appears established by a case narrated by ]3artels~ in which the most violent ur~emic convulsions broke out after a profuse perspira- tion had been caused by a hot bath, and in that way a dropsy of considerable extent had been almost entirely reduced in a few hours.

Treatment.--Intimately connected with the treatment of ]3right's disease is the question of Prognosis, because if the prognosis is hopelessly unfavourable there is little probability of any line of treatment being carried out with the diligence and perseverance which alone can invite

460 Commentaries on Diseases o f the Kidneys.

success. In Bright 's first publications on the diseased conditions of the kidneys, which have since been called after him, the ques t ion-- Is this disease really curable or not ? was answered pretty decidedly in the negative. The great confusion which exists on the subject of renal diseases attended with albuminuria is a cause of the very contradictory opinions which are put forward with regard to both prognosis and treatment. He who calls every case of albuminuria that he encounters " Bright 's disease," and who speaks of chronic Bright's disease or chronic nephritis when the albuminuria has lasted for more than a few weeks, may pride himself upon the number of cures he has effected. Those, on the other hand~ who confine the term Bright 's disease, or chronic nephritis, to the more distinctly marked cases that pursue a truly chronic course, attended by great anasarca, will scarcely give a more favourable prognosis for them than did Bright himself. Bartels' opinion is that all hope of the possibility of complete recovery must be surrendered after the affection has lasted for a certain time.

Although clinical experience certainly confirms tile generally bad prognosis for these cases, yet it would be decidedly a mistake to state to patients affected with chronic parenchymatous nephritis that the disease invariably terminated fatally. For in certain of the more fortunate cases the structural changes in the kidney cease to advance, the dropsical effusions (if any existed) are absorbed~ and the condition of the patient remains stationary, perhaps for months~ perhaps for years ; and he may be able, with proper precautions, to prolong existence in fair comfort, and even to pursue light avocations, for very considerable periods of time. The tenure of life under these circumstances is exceedingly precarious, and any imprudence in indulgence or exposure may bring life, in a few hours or days~ to the verge of destruction. The protracted survivorship of some cases of chronic Bright 's disease is very remarkable, and is possibly due to the circumstance that in such cases only one kidney is affected; anatomical examinations of the kidneys have also taught that although a very large part of the secreting renal structure has been destroyed, yet those portions which remained had recovered perfectly their normal microscopical features. There is also reason to believe that all the urinary tubules of the cortical substance are not affected in the same degree by the chronic inflammatory process. In judging of the possible amount of damage the kidneys may have sustained in chronic nephritis, it is well to bear in mind the fact that Nature, in constructing the body of man, has supplied with lavish hand the apparatus destined to excrete the ur ine--so that, even though one entire half of it be destroyed, the half that remains is capable of fulfilling the task of both. Even in the more severe cases of parenchymatous nephritis it is injudicious to give up the hope of a possibility of recovery. At the same time the prognosis of this complaint would be far more favourable if it were

Commentaries on Diseases of t],e Kidneys. 461

recognised earlier than is, unfortunately, invariably the case. As a rule, attention is not drawn to the kidneys until the tell-tale dropsy has indicated the threatening danger- -only then does the physician deem it necessary to make an examination of the urine, and he is apt to give his patient up for lost when he finds that the fluid, on the application of heat, coagulates in the test-tube to a stiff jelly. Inasmuch as the albuminuria may precede the dropsy by many months, much time may be gained for treatment by an early recognition of the nephritis before the anasarca sets in. I t was before observed that among the causes which seem to operate in inducing the form of Bright 's disease which we are discussing, and whose anatomical expression is the large white kidney, are affections which are accompanied by persistent suppurations and malarial poison, or marsh miasm. Hence, in undertaking the treatment of chronic parenchymatous nephritis the physician must endeavour to obviate any existing injurious influences which are capable of causing the disease of the kidneys or of favouring its prolongation. Examples are not wanting of the good results which have followed the cure of chronic suppurative processes by operative treatment. When the nephritis is a consequence of intermittent fever, the latter must be checked rapidly and thoroughly, and the patient, if possible, withdrawn from the influence of the malaria by removal from the miasmatic district. Complete arrest of the paroxysms of fever by sufficiently large doses of quinine is here the first requisite for the cure of renal malady. Where syphilis exists we should try to eradicate it from the system by the energetic employment of such remedies as the particular case appears to indicate.

Although the final prognosis in chronic and confirmed cases is most unfavourable, nevertheless, even in full developed cases in which the dropsy has existed for months, as long as the renal affection is not com- plicated by some incurable constitutional or organic disease, treatment is to be by no means regarded as impotent, provided only that both the patient and tile physician employ the means at their command with sufficient patience and persistence. The expectant treatment holds out no hopes of success, as it may be positively stated that such cases never get well spontaneously. The favourable and unfavourable signs in Bright 's disease have relation to the state of the skin, the duration of the disease, the degree of deviation of the urine from its normal characters, and the existence of complications. An obstinate and unvarying dryness of the skin is an unfavourable sign. The longer the disease has lasted the less is the prospect of the treatment being successful. The degree in which the urine deviates from the normal furnishes a gauge not only for the imminence of the immediate danger to llfe, but also for the extent of the anatomical changes which htive taken place in the kidneys. Speedy death is indicated by the breaking out of pneumonia or pericarditis, by the suppression of urine, uncontrollable vomiting, or diarrhoea. Tim


absence of the signs just indicated may be construed as negative evidence of a favourable tendency~ pointing to a stationary state, and to the probability that the final issue may be yet far distant. When we are unable to fulfil the etiological indication--the removal of the cause--the pros- pects of a successful result to the treatment are but poor. These are just the cases in which the disease is often not discovered until it has made considerable progress, and which are often enough only brought to the attention of the physician after dropsy has been in existence for some length of time. The search after a satisfactory means of directly treating the disease has had the result of bringing us back almost to the identical point on which Bright stood at the time of his first publication, when he regarded all chronic renal diseases that are accompanied by albuminuria as incurable. These experiments hay% at least~ brought us a negative profit, inasmuch as they warn us against the useless employment of all medicines and modes of treatment that are directly weakening, or that derange the digestive organs of the patients~ who are usually already anmmic. I t is important to get patients with chronic Bright's disease to take iron in some form, as the best safeguard against the profound anmmia, which is a fertile source of danger to sufferers from chronic renal degeneration. The non-astringent salts of iron, administered in infusion of calumba, are occasionally useful--from three to five grains in an ounce of the infusion being taken three times daily, an hour after food. In cases where severe headache seems to result from the adminis- tration of this form of the drug, it may be given as a citrat% in combination with free citric acid and citrate of ammonia. The following is recommended by Dr. Carter a as a very nice form :--Citrate of iron, gr. 5; citric acid~ gr. 5; liq. ammonite citratis, 4 oz. ; syrupi aurantii, 3 iv. ; and either water or infusion of calumba to 8 oz.--one ounce three times a day, an hour after meals; or the same prepa'ration~ the citrate, may be given in the effervescing form. Forty grains of it and 80 grains of citric acid dissolved in 8 oz. of water, sweetened with syrup of oranges or other flavouring ingredient, make a palatable mixture, of which an ounce may be given three times daily, with 15 grains of bicarbonate of potash in a state of effervescence. I t is best to drop the powder--the fifteen grains of the bicarbonate--into the mixture.

With the view of controlling the quantity of albumen lost in the urine, the drugs which contain tannic acid were tried by Bright, and, especially since Frerichs recommended them, have been very generally employed. The opinion of most observers is that they exercise no influence upon the excretion of albumen, while in some cases they excite serious gastric dis- turbance. The treatment of chronic nephritis by drastic purgatives is found to have nothing to recommend i t ; any reduction of the dropsy thus effected is far outweighed by the injurious influence they exert on

a Clinical Reports on Renal and Urinary Diseases. 1878. P. 189.

Commentaries on Diseases of tl, e Kidlteys. 463

the already anaemic patients. The methodical employment of di.tphoresis seems to offer the only expectation of curative results on the processes of the disease, but to justify such expectation it must be carried out systematically and with obstinate pertinacity. The patient should be habitually clothed in flannel, both limbs and trunk, diligent frictions of the surface of the body ; and the other measures for procuring diaphoresis which were alluded to in the treatment of acute nephritis must be continued without interruption until the urine shows signs of abatement of the inflammatory process in the kidneys. Bright held strict confinement to bed to be the most reliable of all the methods at our command for the maintenance of the proper degree of activity of the skin, and without this he thought there was no prospect of curing the disease in our climate. Should opportunity offer, a voyage to the West Indies and a residence on one of the healthier islands there would be likely to effect a great change in the constitution, principally on account of the action upon the pores of the skin. The effect of jaborandi and piloearpine as diaphoretics deserve more extensive trials than they have yet obtained. In established cases of Bright's disease the diuretic salts have been found to do little or no good. Immermann has recently strongly advised the acetate of potash in large doses (five to ten grammes a day). The diet should be regulated so as to suit the particular state of the digestive organs. The consump- tion of milk or buttermilk should be as large as the person can tolerate ; both of these substances have undoubtedly a beneficial diuretic action. Care must be taken to provide the patient with the most abundant practicable compensation for the loss of albuminous matter to which he is subjected. This is a problem often rendered most difficult to solve by the dislike the patients themselves so often evince for a meat diet or animal food in any shape. With the assistance of hydrochloric acid and pepsin, some amount of the concentrated meat essences may be managed to be assimilated with care and patience. The stronger wines and all spirits agree, as a rule, badly, and should be prohibited, unless under special circumstances.

The dropsy of the limbs and genitals sometimes requires mechanical relief in order to prevent rupture of the skin. In no other renal affection does it attain to such a grade. Bartels observes that in no other disease of the kidneys has he so often observed extreme anasarca as in the chronic parenchymatous inflammation. Niemeyer mentions the case of a patient who doubled his weight in eight weeks from this cause. The extreme dropsical swelling, from the strain which it exerts, may, as was before mentioned, be the cause of inflammation and superficial gangrene of the skin, especially of the scrotum and labia majora. The time, the place, and the means of affording exit to the accumulating serum are all subjects of anxious consideration. 5~any do not look with favour upon the practice of making scarifications for the relief of the anasarca. Thus


Barrels observes that the dropsy may be subdued by other means with more durable results; cuts made into (edematous skin readily become starting-points for erysipelas and phlegmonous inflammations, and besides they are open to the objectibn of wetting the bed, and thus causing all kinds of inconvenience and harm. Sir W. Gull 's ~ experience, as expressed in the Clinical Society of London, is that in the (edema of heart disease puncture answers admirably, but in that due to renal disease it is of less benefit, if it does not positively do harm. Murchison b observes that there is this objection to acupuncture in renal d r o p s y - - namely, that the serum being loaded with urea or other impurities is apt to excite inflammation and abscesses at the seats of puncture, which are often followed by erysipelas and sloughing. Under such circumstances he thinks preferable the operation originally recommended many years ago by Dr. Mead. This consists in making an incision about an inch in length in either leg, two finger-breadths above and behind the inner ankle, through the true skin into the subjacent areolar tissue. The incision of Mead is approved of by Dr. George Johnson, c who writes as follows : - - " W h e n other means fail to remove the dropsy, when the anasarcous distension of the legs is increasing and causing pain and incipient erythematous inflammation~ or when the breathing is becoming impeded by the accumulation of water within the abdomen or the chest, or by an (edematous condition of the lungs, prompt, decided, and sometimes permanent relief may be afforded by allowing the water to escape through an incision in the skin about half an inch long, just above either the outer or the inner ankle of each leg; the incision must be deep enough to enter the are01ar tissue beneath the skin."

The operation of puncturing the skin is sometimes painful enough to particular patients, and it is well to bear in mind that this annoyance may be got rid of by using a small spring searifier such as that with a single row of lancets used for cupping the temporal region. Dr. Johnson gives an illustration of this fact : - - A dropsical patient had his legs acupunctured by the house physician, and cried out with the pain caused by the needle punctures. A few days afterwards, the punctures having ceased to discharge, while the dropsical swelling was but little reduced, an incision was made into each leg with a spring lancet. He declared that he scarcely felt the cuts ; and the incisions discharged so freely that the dropsy was for a time completely removed. After the dropsical legs have been punctured, the folded sheet and mackintosh, placed beneath to receive the serous discharge, should be frequently renewed and kept clean. The liquid quickly decomposes and becomes ammoniaeal, and in this state it may irritate and inflame the skin. Cleanliness is as essential

Bri~. Med. Jour. l l t h 1VIarch, 1871. t ). 254. b Op. cit. 25th May, 1872. P. 548. c Lectures on Bright's Disease. 1873. P. 143.

Commentaries on Diseases of the Kidneys. 465

for safety as for comfort. Any inflammatory redness about the wounds may usually be removed quickly by the application of a lead lotion. I t is true that severe inflammation and sloughing have sometimes followed incisions or punctures in anasarcous legs, but this may, and often does, occur from over-distension of the skin, or from the mere pressure of the heavy dropsical limbs upon the bed. The result of Dr. George Johnson's ~ experience is that inflammation of anasarcous legs has been as often subdued as provoked by acupuncture or incision; that inflammation is much less likely to follow incisions in cases of renal than of cardiac dropsy, when the circulation is much impeded by valvular disease; and that incisions made with the spring scarifier are as safe as acupuncture, and much less painful. The capillary trocars invented by Dr. Southey form a convenient mode of withdrawing the anasarcous fluid. By using these instruments the fluid is kept from contact with the skin ; one may be introduced into each leg, and as much as over 140 oz. may be drained away by a single trocar in twenty-four hours3

A U S C U L T A T I O N O F T H E S K I N F O R C H I R U R G I C A L P U R P O S E S . - - D E R . , ~ A T O -

P H O N Y .

C. HUETER (Centralblatt f. die medicinische Wissenschaflen, 1878. Nos. 51 and 52), having found that the vascular bruit of the pulp of the finger was clearly audible upon a microphone, constructed a cheap and efficient "dermatophonc," by stretching a piece of gutta-percha over the open end of a binaural stethoscope (Voltolini's, but Camman's might do). On placing this plate over certain vascular parts, such as the finger- tips, malar eminence, eyeball~ &c., a peculiar sound, varying somewhat in pitch in different parts, is heard. This sound is the normalbru i t of the subcutaneous capillaries and smaller vessels. I f the hand be rendered bloodless by means of an Esmarch's band, the vascular bruit can no longer be heard in the finger-tips. In acute cutaneous inflammation (furuncle, paronychia), a louder but deeper note is heard. In a case of part ial stasis of blood in the foot, caused by a too tightly applied dressing for fracture of the thigh, the toes being dusky and cool, the vascular sound was weaker and hardly perceptible; but after loosening of the bandage, and a restoration of heat to the foot, i t became louder, then normal. The instrument is also applicable to the muscles and t e n d o n s ~ myophony and tendophony. Applied to superficial bones while they are percussed (with a hammer or whalebone), according to Liicke's method, a distinct sound is heard. The author anticipates that these applications of auscultation will prove of help in medical and surgical diagnosis .-- Archives of Medicine, Vol. I. , ,No. 2, April , 1879.

a Lectures on Brlght's Disease. 1873. P. 145. Carter. Urinary and Renal Diseases. 1878. P. 87.

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Commentaries on diseases of the kidneys