CHAPTER VI. DISEASES OF THE KIDNEYS AND BLADDER. (Part 1)

CHAPTER VI. DISEASES OF THE KIDNEYS AND BLADDER. Movable Kidney. Remember that this is decidedly more common in women and frequent in hysterical patients. Remember that the di:fference between a palpable, movable, and floating kidney is one of degree. Remember that palpation is the only way a diagnosis can be made. Use the following pro- cedure: Put the patient in the dorsal position, with the head moderately low and the abdominal muscles relaxed. Place the left hand in the lumbar region behind the eleventh and twelfth ribs. Put the right hand in the hypochondriac region in the nipple line, just under the edge of the liver. Gently press the two hands together, when a firm, round body may be detected just below the ribs — this is a palpable kidney. Have the patient take a deep breath, when the fingers may be slipped up over the kidney, but the organ can not be pushed below the level of the navel — a movable kidney. The kidney may be grasped with the hand and moved to any part of the abdomen, or even into the pelvis — a floating kidney. Remember that in a large majority of cases there 71 72 DISEASES OF THE KIDNEYS AND BLADDER. are no sjTnptoms, and the condition is detected acci- d entail}^, but it is well not to inform tlie patient. Eemember that dyspeptic symptoms in a neurotic woman that do not yield to ordinary treatment are probably due to a displaced kidney. Jaundice, slight and of short duration, but recur- ring frequently, is probably due to nephroptosis. In a floating kidney the kinking of the vessels by a twisting of the kidney causes abdominal pain, chills, nausea, vomiting, fever, and collapse. The amount of urine may be decreased, dark, and contain albumin, pus, and blood, and the kidney may be tender and swollen. The skin is moist and cold; at the close of the attack there may be a copious amount of pale urine. Acute hydronephrosis results fi"om strangulation of the ureter. Worry and anx- iety may cause a loss in weight. Treatment. The patient should be confined to bed and forced feeding resorted to. The object of this is twofold — first, it is the best method of treatment for the neuroses coexisting, and, second, by putting on fat the patient furnishes additional support for the dis- placed kidney. The kidney should be held in its normal place by a well-fitting bandage applied to the abdomen, with or without a pad over the dis- placed kidney. The following advice from Dr. Potter should be heeded: "A properly-fitting bandage is not easy MOVABLE KIDXEY ACUTE ]N"EPHEITIS. 73 to secure, especially for very thin patients. I rarely use a pad, but attempt to secure the retention of the kidney by a well-fitting, long, low corset, or, in more difficult cases, by an elastic bandage encircling and sustaining the lower two-thirds of the abdomen. The physician must carefully examine such contri- vances after being applied and worn by the patient. No case should be operated upon, in my judgment, until every possible medical measure has been thor- oughly tried." The only medicine indicated is a tonic when the appetite fails. Acute Nephritis. Remember that this condition may complicate any of the infectious diseases, and frequently follows t}Tphoid and scarlatina. Always inquire about medicinal substances used, as often the use of potassium chlorate tablets, fre- quently used for sore throats, or turpentine, will cause acute nephritis. Remember that there are two classes of cases — one class where the dropsy is extreme, as seen in scarlatinal form, while in the other class there is little or no dropsy. Remember that acute Bright 's disease may exist, the anasarca be extreme, but the urine contain no albumin, or only a trace. Remember uremia may be the first symptom, but it usually occurs later. 74 DISEASES OF THE KIDISTJYS AKD BLADDER. Always examine the nrine. It will be dark and of a smoky color; high specific gravity; small in amount, and contain albumin, tube casts, and often blood cells. Remember that pleural effusions may be large and the lungs edematous, although dropsy is not exten- sive. Remember that anemia is a prominent and early sign, and gives a i^eculiar, pale complexion. Remember that every urine containing abumin is not a case of acute nephritis. A peculiarity of the dropsy in acute nephritis is its irregularity of distribution, and does not always gravitate according to the posture of the patient. Always examine frequently the urine in preg- nancy, especially in cases complaining of occipital headache, or swelling of the ankles, or edema of face. Remember that it is in syphilitic nephritis that large quantities of albumin is found. Teeatmeis't. Often it is easy to discover the etiologic factor, which should then be treated rather than the nephri- tis. In cases due to malaria, quinin is indicated, while in that form occurring in the secondary stage of syphilis, mercury will cause a complete and per- manent subsidence. The iodids are not so bene- ficial as they are in the tertiary stage. In typhoid with nephritis, cold baths should not be given on ACUTE NEPHRITIS. 75 account of the sudden cooling of the skin, but tepid sponging may be substituted. Care as to medica- ments used must be observed, regardless of the cause, in many cases. Drugs causing renal irrita- tion must be abandoned. Some of these are tar, styrax, naphthalin, phenol, oil of turpentine, potas- sic chlorate, and cantharides. While salicylic acid and its derivatives cause renal irritation, they should be used in the treatment of a causative articular rheumatism. Symptomatic Treatment. The patient should be in bed and kept there until all traces of the disease have disappeared. Counterirritation over lumbar area will relieve renal congestion. Cantharides or mustard plaster should not be used because of renal irritation. Cupping, wet or dry, leeches, or the appli- cation of the actual cautery applied to Petit 's tri- angle, as the network of veins here communicate di- rect with the perirenal veins, should be followed. In severe cases of renal congestion, where there is marked diminution of urine, many blood cells, and severe lumbar pain, headache, and vomiting, the ap- plication of leeches every other day and on alternate days, dry cupping morning and night, until the severe symptoms have subsided, afford relief. The quickest and probably the best way of relieving the congestion is by venesection performed on the lower extremity. The vena pediaea may be opened and 10 ounces of blood withdrawn. Diet is of supreme importance. All meats and 76 DISEASES OF THE KIDNEYS AND BLADDER. preparations made from meat must be excluded. Strictly milk diet is best. Buttermilk, gruels made of arrow-root, oatmeal, barley-water, butter, crack- ers, and cream may be allowed. All condiments and alcohol should be forbidden. The diet should be salt (sodium chlorid), free, especially if there be much dropsy. Cases due to bacterial toxin should be given plenty of water to dilute the poison and reduce the renal irritation. Diuretics. Alkaline mineral waters should be used freely. When they fail to increase urinary se- cretion, some of the following may be used to ad- vantage : Caffein is excellent because it is cardiac as well as kidney stimulant. Never give over 10 grains daily, as 15 grains will cause albuminuria. IJ Caff ein, Sodii benzoatis aa gr. iij Misce et fiat eapsula No. I. Dentur tales capsulae No. XV. Sig. : Capsule three times a day. The best form is probably the double salt: B Caffein-sodii salicylatis gi"- "j Sig.: One such dose three times a day. Potassium acetate in large doses is also a good diuretic : TJ Potassii acetatis 3 iv-3 v Syriipi rubi idsei § ss Aquse destillatse q. s. ad 3 vj Misce. Tablespoonful every two hours. ACUTE NEPHRITIS. / / In the early stage the following is a good diu- retic and also equalizes the circulation: B Tincturae aeoniti TTL xij Spiritus setheris nitrosi 3 vj Solutio potassii citratis B i j Syrupi tolutani q. s. ad § iij Misce et flat solutio. Sig. : Teaspoonful every two hours. Or: IJ. Potassii citratis 5 ss Infusi digitalis § j Aquae S j Misee. Sig.: Dessertspoonful every three hours. Where the heart needs stimulating, the following is excellent: IJ. Tincturae digitalis 3 v Vini scillse § iss Spiritus setheris nitrosi 5 ij Misce. Sig. : Teaspoonful every three or four hours. Diaphoretics. To increase the activity of the skin is to lessen the tension on the kidney. Hot baths, and have the patient sleep between blankets dressed in light flannel gown. Pilocarpin can be used with safety only in a selected number of cases. It should never be given to children. It is best administered hypodermatically. It is better always to give minimum dose — say, gr. Ks — and repeat in one hour, than to give one dose of gr. %. Purging should be moderate, but is of great bene- fit. A good rule is, "purge one day and sweat the next. ' ' 78 DISEASES OF THE KIDKEYS AND BLADDER. A very excellent cathartic is the following: B Pulveris jalapse compositse, Potassii bitartratis aa 3 ss-3 j Misce et fiat pulvere No. I. Dentur tales No. X. Sig. : 1 powder every other morning. Chronic Parenchymatous Nephritis. Remember that the urine for the twenty-four hours is diminished in quantity, has a dark, smoky color, and is turbid from the presence of urates. The specific gravity is high, and on standing a heavy sediment is deposited. Albumin is always present, and is more abundant in day than night urine. The total amount of solids — as urea, phos- jjhates, and chlorids — is reduced. Hyaline, granu- lar, fatty, and epithelial casts are abundant. Remember that edema is frequent and often the first symptom to attract attention. Occurs first about the eyes, and seen only in the morning, but later it is permanent and becomes general. The patient's appearance is very suggestive — puffy eyes, pale and swollen cheeks, dull expression, distended abdomen, and shapeless wrists and ankles. Remember that anemia is a prominent and pro-, nounced symptom in this form of nephritis. The pulse small, soft, and rapid. The apex beat weak, indicating dilatation. Remember that the first manifestation of long ex- isting trouble may be epileptiform seizures, or an attack of uremic dyspnea simulating asthma. Remember that a general failure of health, CHROlSriC PARENCHYMATOUS NEPHRITIS. 79 shown by loss of energy, easily fatigued, loss of appetite with digestive disturbances, is frequently found early in this condition. Remember that vomiting occurs often in the course of renal trouble, and usually caused at sight of or on taking food. The nausea accompanying the vomiting is intense. Remember the examination of the eyes, as albuminuria retinitis is one of the most character- istic features of this form of renal trouble. Remember that in many asthmatic seizures the trouble is caused by a lesion of the kidney, and the albuminuria is causative and not dependent upon the asthma. Teeat^ient. Rest in bed is best. This should be continued for as long a period of time as possible, as it reduces albuminuria and reduces waste products thrown upon the kidneys for excretion. The patient should be dressed in canton flannel, and lie between blank- ets, so that the skin may be kept active. Diet. Nothing should be allowed that increases the work of the kidneys. Milk diet is excellent, but it is impossible to administer enough to keep up the body nutrition. Two to three pints of milk dur- ing the day, to which cream has been added, is suf- ficient. Calcium carbonate gr. v-gr. x, administered with the milk, precipitates the phosphates and thus prevents their being absorbed and irritating the 80 DISEASES OF THE KIDNEYS AND BLADDER. kidneys. Meat, as veal, mutton (well cooked), and beef, may be allowed restricted. Carbohydrates and sugar must furnish the bulk of nutrition. Potatoes, rice, butter, sugar, eggs (cooked), olive oil, and cod- liver oil are all excellent in varying the diet. A moderate amount of all fresh fruits, except cran- berries, is allowable. Onions, garlic, tomatoes, rad- ishes, asparagus, and celery must be forbidden, while beans, peas, turnips, carrots, lettuce, and cauliflower should be given. Salt. Most nephritics eliminate sodium chloride imperfectly, so that much of it is retained. Sodium chloride controls osmosis in the economy. When retained in the blood, it becomes hypertonic and less water is excreted by the skin, lungs, and kid- neys. Dropsy then begins or increases, as does albuminuria; hence a diet free, or as near that as possible, will lessen both hydrops and the albumin. Water. Care must be exercised in the amount of water taken. An excessive quantity, thus engorg- ing the blood and lymph, and increasing the work of the heart, is just as harmful as too little given. About three pints are an average amount to be given in twenty-four hours. Baths. Lukewarm or hot baths three or four times a week, followed by a light sweat, are advis- able to keep up the activity of the skin. Where atheroma exists, care should be taken. Clothing. The feet must be well protected, and patient should wear woolen underwear. A flannel band over the loins, in addition, is often beneficial. CHROmC INTERSTITIAL I^EPHEITIS. 81 The Bowels. These must be kept open. If con- stipated, saline cathartics should be used. The compound jalap powder and Eochelle or Epsom salts are probably best. The anemia is to be com- bated by using iron. The syrup of the iodid of iron or the tincture of the chlorid is best; best given half an hour after meals. Diuretics. Most of them should not be used. Cream of tartar 3 j as a refrigerant drink or potas- sium citrate gr. xx-gr. xxv are the only safe ones. Liquoris ferri et ammonii acetatis 3 j-3 ij ( Bash- am 's mixture) may be given for its tonic as well as diuretic effect. Chronic Interstitial Nephritis. Remember that this is the lesion occurring in the aged and is intimately connected with arterio- sclerosis. Remember that the urine is greatly increased in quantity and is voided so often, especially at night, that the patient usually seeks relief of so trouble- some a symptom. Always examine such cases for enlarged prostate. Remember that there are three cardinal findings in this condition — cardiovascular, urinary, and retinal — and he who invariably examines the urine and heart in every instance rarely fails in his diagnosis. Remember that the increased urine is pale in color and low in specific gravity, there is a reduction 82 DISEASES OF THE KIDIS^YS AND BLADDER. of solids, and albumin is found only in trace and may be absent at times. Remember that persistent low specific gravity is one of the constant and important features of this condition; therefore frequent urinary examinations should be made. Remember that the hypertrophy of the heart causes a displacement of the apex beat downward and to the left, and the impulse is forcible and may be heaving. Remember that the pulse is not only hard, but the tension is increased, so that it requires considerable pressure to overcome it, and when abolished the vessel below can be rolled under the finger. Remember that chronic bronchitis, especially in the winter, is common. Remember that trouble in vision may be the first symptom, and caused most frequently by retinal hemorrhage. Remember that edema is not common, and when it appears it is due to cardiac failure. Treatment. Don't advise the use of large amount of liquids, and it is better to restrict them to two pints per day. Milk diet is indicated only when uremia threatens. Remember that in this form of nephritis it is more important to watch the heart than the kidneys. Diuretics should not be used unless there is a chrojs^ic interstitial nephritis. 83 great diminution of quantity of urine or dropsy de- velops, and then only for a short period of time. At first indication of weakening of heart, adminis- ter digitalis, caffein, camphor, or squills until there is cardiac improvement. Drugs should be carefully watched for cumulative action because of slow excretion. lodids are excellent in many cases, and are espe- cially indicated in syphilitic nephritis. Some of the cases of syphilitic origin improve under mer- cury, while others are made worse, but all respond to iodin treatment. The dress should be flannel, and patient must be careful about catching cold. Iron is indicated if anemia is present — shown by marked weakness and pallor. Bowels should be kept open by use of salines, or, perhaps better, by alkaline mineral waters. Calomel purge occasionally is very beneficial. Skin should be kept active, and this is best done by warm baths. When the arterial tension is high, it should be re- lieved because of the danger of hemorrhage. This is best done with nitroglycerin carefully adminis- tered. Begin by giving 1 minim of a 1-percent solution (gr. M.00) three times daily and gradually increase. On the other hand, where the tension is low, as manifested by decreased amount of urine and appearance of dropsy, give strychnin or digitalis. The latter is best given as an infusion. 84 DISEASES OP THE KIDNEYS AND BLADDEE. Worry and anxiety must be forbidden, and patient live a quiet life. Uremia. Remember tliat uremia may exist in a latent form. The mind is clear and pupils are contracted, muscu- lar twitchings and vomiting occur, and tlie tempera- ture is subnormal. Remember that coma always accompanies convul- sions, but it may develop gradually without convul- sions. Remember that all cases of intractable headache, either occipital or low down in back of the neck, call for urinalysis, that threatened uremia may not be overlooked. Remember that muscular cramp, particularly at night in the calves, twitching, monoplegia or hemi- plegia, or tingling sensations in the limbs, call for urinalysis and the elimination