CHAPTER VI. DISEASES OF THE KIDNEYS AND BLADDER. (Part 2)

of Bright 's disease. Remember that uremic dyspnea may be continu- ous or paroxysmal, and at times Cheyne-Stokes breathing may be observed. The dyspnea is usually nocturnal, and it is very difficult to differentiate from true asthenia without the precaution of urin- ary examination. Remember that cerebral hemorrhage, meningitis, and brain tumors must be excluded in the diagnosis. The hemiplegia is complete and permanent; vomit- ing, tense pulse, and conjugational deviation of the eyes are present. UEEMIA. 85 In brain tumor may have convulsions, vomiting, headache, vertigo, with hemiplegia or monoplegia, but in uremia these are transitory, while in tumor they are chronic and progressive. In meningitis, when headache and vomiting are followed by coma without localizing phenomena, and the urine contains albumin, spinal puncture and examination of some of the spinal fluid is the only means of differentiating from uremia. Remember that uremia may last for several weeks, and patient lie in stupor, with heavily coated, dry tongue, rapid and feeble pulse, and muscular twitchings, suggesting typhoid or miliary tubercu- losis. In miliary tuberculosis the pulmonary signs, with those of associated pleurisy and pericarditis, will differentiate, while Widal reaction of blood, rose spots, enlarged and soft spleen, and peculiar tem- perature range will assist in correct interpretation of the typhoid condition. Remember that in opium poisoning the pupils are contracted equally, while in uremia they are not constant. Examine the eyes for albuminuric retin- itis, and urinalysis should be made. The pulse is slow, and respiration and the stupor are profound. In coma from alcohol the unconsciousness is not so profound, and heavy pressure on the supraorbital nerve at junction of inner and middle third of orbit at the supraorbital notch will always cause a re- sponse. The temperature is subnormal and the 86 DISEASES OF THE KIDNEYS AND BLADDER. pupils usually dilated. Place no value upon the odor of the breath unless you know the history. Remember that uremia occurs most frequently in chronic interstitial nephritis, and that the concomi- tant vascular changes will be of aid in diagnosis. Treatment. In an acute attack of uremia there is nothing com- parable to venesection — withdrawing half a pint of blood and replacing the amount by the saline solution by hypodermoclysis. Never used too early, but often too late. Diaphoretics. Pilocarpin hydrochlorate gr. %- gr. Yi may be given hypodermatically. If heart is weak, give cardiac stimulant. May be used with hot pack. Catharsis. I^ Elaterini gr- ^/^ Sacchari lactis gr. xv Misce et fiant pulveres No. V. Sig. : Powder every three hours until free catharsis, then daily. Or: IJ. Hydrargyri chloridi mitis gr. viij Pulveris jalapse compositse 3 iv Misce et fiant pulveres No. IV. Sig.: Powder hourly. In case of severe vomiting, elaterina hypodermat- ically gr. %0-gr. %o may be given. Cardiac Tonics. With decreased blood pressure and small, thready or irregular pulse, heart stimu- UKEMIA. 87 lants to raise pressure within the kidneys is ad- visable. Digitalis is excellent, but its action is de- layed, so that in acute cases it must be reinforced by quicker-acting stimulants. Camphor is best, and should be given in large doses — 3 ij-3 iij of a 10-per- cent solution in olive oil hypo derma tically during the twenty-four hours should be given with the digi- talis. Convulsions may be treated with hypodermic of morphin or inhalations of chloroform. Venesection is often very beneficial in this condition, or: IJ Chloralis hydrastis 3 ss Potassii bromidi 3 j Tincturae veratri veridi TTL xYTr Syrupi aurantii florum 3 iv Aquae q. s. ad § i j Misce. Sig. : Tablespoonful every hour or two as required. Or: IJ Pilocarpinse hydrochloridi gr. j Tincturae veratri veridi *. TTL xxx Syrupi tolutani 3 iv Aquae anisi q. s. ad § j Misce. Sig.: Teaspoonful in water, repeated in two or three hours, as required. Vomiting. This is frequently persistent and ob- stinate. The following formulae will indicate the best line of treatment: IJ Cerrii oxalitis gr. xv Sacchari lactis 3 ss Misce et divide in pulveres No. VI. Sig.: Powder every three or four hours. 5b DISEASES OF THE KIDNEYS AND BLADDER. Or: IJ Hydrargyri cliloridi mitis gr. j-gr. ii j Cerrii oxalitis gr. xx Saccliari lactis gr. xxx Misce et divide in pulveres No. X. Sig. : Powder every hour on tongue. Ingliivin gr. v, administered every two hours, is often good. IJ Creosoti gtt. x Emulsio amygdalae B iss Syrupi simplicis 3 iv Misce et fiat emulsio. Sig.: Dessertspoonful every four hours. Lavage of the stomach with water at 105° is ex- cellent and should be tried early. Diarrhea. Don't be too anxious to check it. This is one of nature's methods of ridding the economy of toxic material. Uremic Asthma. Spirits of ether gtt. x-gtt. xxx on sugar several times a day. Or: IJ Extraeti valerianse gr. v-gr. x Dentur tales doses No. XXX. Inclosed in capsule. Sig.: Capsule four or five times daily. Diet. In an acute attack, starvation or Renon's- water diet, one quart to three pints daily, with or without lactose, for two or three days, gives best result. In subacute form a diet similar to that of Bright 's disease is best. In chronic form the diet varies and depends upon the urinary findings. Dilute hydrochloric acid, giving from one to three UEEMIA PYELITIS. 89 teaspoonfuls in the twenty-four hours, is excellent, and probably is indicated, as many cases show hypo- acidity. To be given following meals. Pyelitis. Remember that the great danger in cystitis is pyelitis by extension along the ureters. Remember that pain in the back or tenderness on deep pressure over the affected kidney, with pus in the urine and fever of the septic type, are indicative of pyelitis. The pyuria may be intermittent, due to the plugging of the ureter of the affected side. When this occurs, the intermittency excludes cys- titis. Coincident with the retention, often a tumor mass may be felt on the affected side. Remember that the reaction of the urine is usually acid, unless cystitis coexists. Remember that in cystitis the pain is over the bladder and is made worse in the erect posture. Remember that painful, frequent micturition and an alkaline urine suggest cystitis. Remember that in chronic cases of pyelitis, poly- uria and a low specific gravity are usual. Remember that an infection may extend to the ureter from the bladder. Treatment. Diet. In the acute cases it should be exclusively milk. The chronic cases should have diet used in nephritis. 90 DISEASES OF THE SIDNEYS AJSTD BLADDER. Baths. A warm bath should be given two or three times a week, and the patient should be carefully guarded against catching cold. Congestion is best relieved by applying leeches over Petit 's triangle, as the veins of this region communicate with those of the renal capsule. Free catharsis should be employed, both for the conges- tion and ridding the body of toxins. The vegetable cathartics are best. Pain may be relieved by hot applications over the affected kidney, or, if severe, by atropin and mor- phin. Antiseptics are indicated to combat the infection. Urotropin is best, but benzoic acid or the sodic salt may be used. The action of urotropin is enhanced when it is combined with salol. R Urotropini, Salolis aa 9 iiiss Misce. Dentur tales doses No. XXV. Inclosed in capsule. Sig. : Capsule every three or four hours. A capsule containing gr. iss-gr. iij of methylene blue may be given three times daily. Gastric dis- turbances must be watched for. I^ Acidi benzoic! gr. ij-gr. v Fiat tabella No. I. Dentur tales doses No. XX. Sig.: Tablet every two hours. Or; I^ Sodii benzoatis 3 j Extracti gentianae q. s. Misce et fiant pilulae No. XXX. Sig. : 2 pills every two hours. PYELITIS HYDEONEPHEOSIS. 91 Or: B Sodii benzoatis 5 j Syrupi rubi idsei, Aquae menthaB piperitse aa 3 vj Misce. Sig. : Tablespoonfal two hours after meals. Astringents. Lime water, 2 to 3-ounce doses three or four times a day, diluted with an equal quantity of milk, is excellent. IJ Plumbi acetatiSj Pulveris opii aa gr. xxx Extract! glycyrrhizse q. s. Misce et fiant pilulse No. XXX. Sig.: 1 or 2 pills three or four times daily. Hydronephrosis. Remember that this may be congenital, and either unilateral or bilateral. If bilateral, death results in a short time. Remember that in many cases the obstruction is intermittent, and when the obstruction is relieved there will be a large quantity of urine with the dis- appearance of the renal tumor. Remember that when the tumor is of moderate size it may be palpated in the renal region, but those of extreme size may be mistaken for ascites or ovarian cysts. Aspiration furnishes conclusive evidence. The fluid aspirated will be clear, of low specific gravity, with urea and urinary salts. Remember that in the history the location of the tumor in the beginning is important, as ovarian 92 DISEASES OF THE KIDNEYS AISTD BLADDER. tumors originate in the pelvis. Ovarian tumors are movable, while hydronephrotic tumors are not, un- less they occur in a movable kidney. Treatment. Cases of intermittent hydronephrosis causing no serious symptoms should be let alone. When the tumor becomes large, aspiration should be done; the needle passed through the flank half way between the crest of the ilium and the last rib. When the tumor recurs, it may be incised and drained. Re- moval of the kidney should be done only as a last resort. Sometimes the wearing of a pad and band- age following aspiration will prevent refilling. Nephrolithiasis. Depending upon the size of the concretion, we have sand, gravel, or stone. Remember that all stones are due to a deposit upon a framework consisting of albuminous sub- stance and at times epithelial cells. Pain. Renal stones cause pain. The character of the pain depends upon the location of the stone." Pain, dull in character, is felt in the loin, frequently associated with local tenderness, with the stone in the renal pelvis. Certain movements which shake the body make it worse. Remember that this dull pain and localized ten- derness may be found without any urinary changes. Remember that renal colic is caused by passing of NEPHROLITHIASIS. 93 stone into the ureter. Pain of renal colic is sharp and lancinating, radiating from the renal region along the nreter to the bladder, testis, labia, or urethra. The testicle is retracted. The kidney is sensitive; there is a continuous desire to urinate, but can pass only a few drops of a concentrated, bloody urine full of sediment. The general symptoms are nausea, vomiting, cold perspiration, chills, weak pulse; the dorsal posture is assumed, legs drawn up, and the abdominal wall rigid. The pain is greatest as the stone passes into the bladder, as the caliber of the ureter is smaller at this point. The attack ceases abruptly on the passing of the stone from the ureter, either into the bladder or back into the renal pelvis. After the passage of the stone a profuse discharge of urine follows. Remember that the absence of hematuria after a renal colic speaks strongly against a diagnosis of renal calculi. Remember in vesical calculi the pain is concen- trated over the bladder, and when it radiates to the flanks it is felt on both, sides. The sudden stoppage of the flow in micturition and the positive informa- tion obtained by examining the bladder with a stone searcher will assist in differentiating. The x-ray in competent hands is of great assistance, but is not to be absolutely relied upon. "While negative find- ing does not absolutely exclude stone, the per- centage of errors is small. 94 diseases of the kidneys and bladder. Treatment. Renal Colic. Prompt immersion in hot bath, 110° to 115°, for half an hour often affords relief, but, if it does not, give while in the bath hypodermic of morphin sulphate gr. ^-gr. ^ with atropin sulphate gr. Mso-gr. Ygo, and, if it fails to relieve the pain, repeat the morphin in one hour; no relief following this, give inhalations of chloroform to slight anes- thesia. It is essential, to further treatment, that careful watch be kept to detect sand or gravel in the urine, so that the kind of stone may be deter- mined— whether uratic, oxalate, or phosphatic. In uratic or oxalate stones the acidity of the urine must be reduced. For this purpose alkalies are given. The following effervescent powder is good: R Lithii carbonatis gr. iv Sodii bicarbonatis gr. v Misce et fiat pulvere No. I. No. 1. R Acidi citrici gr. viij No. 2. Dentur tales doses Nos. 1 and 2 No. X. Sig. : 1 of each powder in half a glass of water three times daily; drink while effervescing. Glycerin in large doses is highly recommended in assisting in passage of the stone. R Glycerini, Succi limonis aa § j Misce. Sig.: 4 tablespoonfuls daily. Or put 1 ounce of glycerin into 1 quart of lemon- ade and give during the day. NEPHEOLITHIASIS. 95 IJ Potassii acetatis 3 iij Aquse cinnamomi q. s. ad 5 ij Misce. Sig. : Teaspoonful every two or three hours until urine is only slightly acid. Or: IJ Lithii citratis gr. xx Sodii citratis 3 ij Aquae q. s. ad § ij Misce. Sig.: Teaspoonful in carbonated water every two or three hours until urine is only slightly acid. Or: IJ Sodii benzoatis 3 iss Syrupi tolutani 3 v Aquse destillatse q. s. ad § vj Misce. Sig.: Tablespoonful every two hours. As a preventive of urate deposit the following may be used: IJ Magnesii carbonatis 3 j Acidi citrici 3 ij Sodii biboratis 3 ij Aquae q. s. ad B vii j Misce. Sig.: Teaspoonful three times daily. Calcium carbonate influences the monosodium and disodium phosphates in such a way that the urine can hold a greater quantity of uric acid in solution without losing its acid reaction. IJ Calcii carbonatis gr. x Lithii carbonatis gr. j-gr. ij Misce et fiat pulvere No. I. Dentur tales doses iSTo. XX. Sig.: Powder every three hours with glass of water until urine only slightly acid; then three or four times a day. 96 DISEASES OP THE KIDNEYS AND BLADDER. Or: IJ. Urotropini 3 j Misce et fiant pulveres No. X. Sig. : Powder three times daily. Or: R Magnesii borocitrici 3 iss Sacchari lactis 3 iiss Olei limonis TTL xv Misce et fiat pulvere No. I. Dentur tales doses No. X. Sig.: Powder three times daily in a glass of sweetened water. Diet. The diet for uric acid stones is very im- portant. A mixed diet, with a preponderance of vegetables, fats, and carbohydrates, and occasion- ally a period of absolutely no meat, is indicated. Meats. Avoid all kinds of meats that are rich in cell nuclei, such as liver, brain, sweetbreads, and kidneys. The best method of preparation is by boiling, especially by putting the meat into cold water first. Fruits. Are exceedingly good for patients suf- fering with uric acid excess. The vegetable acids are changed to carbonates and combine with uric acid, forming urates, and these are much more solu- ble in the urine. The therapy of phosphatic deposits differs con- siderably from the foregoing. The urine is usually alkaline, and contains abundant crystals of triple phosphates. Mineral acids are indicated unless there is a co- existing hyperacidity of the stomach. NEPHEOLITHIASIS. 97 IJ Acidi phosphorici or hydrochloric! diluti 3 iss Syrupi rubi idaei 3 iv Aquae destillatse q. s. ad g vj Misce. Sig. : Teaspoonful in a glass of water often enough to use the whole amount during the day. Where fermentation occurs in the digestive tract we must use the antifermentatives. IJ Sodii boratis gr. xx-gr. xxx Syrupi althaeae 3 v Aquas destillatse q. s. ad 5 vj Misce. Sig.: Tablespoonful every two hours. Or: 3 Urotropini 3 iiss Aquae destillatse 5 v Misce. Sig. : Tablespoonful in a glass of water to be taken gradu- ally during the day. Or: 3 Resorcinolis ( Merck ) gr- x Saechari gr. x Olei menthsc piperitse gtt. i j Misce et flat cachet No. I. Dentur tales cachets amylaceae No. XX. Sig.: Cachet three times daily. Always treat the faulty condition back of the calculus formation, such as dypepsia, hyperacidity, neurasthenia, etc. Have patient use large quan- tity of water to keep the kidneys flushed out. Surgery. Where a stone becomes lodged in the ureters and can not be passed either into the blad- der or back into the renal pelvis, or where a large stone forms in the pelvis too large to embark upon 98 DISEASES OF THE KIDNEYS AND BLADDEK. the journey to the bladder, surgery offers the only relief, and such cases should be turned over to a competent surgeon. Cystitis. Remember that cystitis is probably in all in- stances due to bacteria. The alkalinity of the urine is due to the power of many of the bacteria to break up urea into ammonia compound. Urinalysis shows alkaline urine as a rule; mucus, pus, and leucocytes more or less abundant; and crystals of the trijole phosphates. Remember that the walls of the urinary bladder may become so thickened that it can be felt as a globular, hard tumor, and hypertrophied, muscular bands detected by the sound. Remember that when a stone is the cause of the cystitis, hematuria is more common; sudden, fre- quent interruption of the stream in micturition, due to obstruction of neck of bladder, and pain and strangury at the close of micturition. The explo- ration of the bladder with a sound will confirm the presence of the stones. Remember that the examination of the bladder with the cysto scope is important — not only in the diagnosis of cystitis, but the cause is frequently re- vealed. Remember that in tubercular cystitis without the presence of other organisms the urine is acid in re- action, as the tubercle bacilli do not decompose urea.