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better in health when he eschews sweets and butchers' meat; feels more
buoyant and in better shape when his meals consist mainly of vegetables,
and particularly rice, and when he eats white meats, fresh fish, and eggs.
On several occasions, I have attended him professionally, when, without
knowledge of the precise cause of his attack, he has had sneezing and
running of the nose ; little or no fever ; slight cough ; no evidences of
stomachal derangement, and yet he was evidently torpid or sluggish
and complained of marked drowsiness. The urine at these times was
dark-colored and loaded with urates. A mercurial, followed by a brisk
saline purge, on two successive days, rest in the house, the free use of
natural Vichy water, and very light diet, cured these manifestations of
disordered function, and in a few days he resumed his occupation and
was as well as previously.

Case II. — A broker ; forty-two years old ; married ; thin and spare ;
of an energetic, resolute character ; states that several years ago he
passed a small mulberry calculus, but previous and subsequent to this
attack has had no disease for many years. His urine is habitually some-
what high-colored, otherwise normal ; his intestinal digestion is imper-
fect ; he is somewhat constipated at times ; again he has two move-
ments in the twenty-four hours, which are formed, but not as large as
would seem to be healthful, due regard being had to the amount he
eats. His diet is varied, abundant, but not excessive. He drinks wine
moderately ; he smokes, but not to excess. He is often annoyed with
vague pains in his abdomen which extend into the lumbar region.
These pains are not severe as a rule, and usually are merely uncomfort-
able sensations. His abdomen is perhaps slightly distended and tense,
but he is scarcely annoyed with flatus. The epigastrium is somewhat
tender on pressure, as also, occasionally, are other regions of the ab-
dominal cavity. There is no manifest stomachal dyspepsia. The vague
abdominal pains come at irregular intervals during the day, last a vari-
able time, and disappear quite suddenly. Patient is rendered irritable
and somewhat morbid by reason of his abdominal condition. He
is also conscious of a slight laryngeal irritation which obliges him to ex-

3



26 TREATMENT OF UREMIC SYMPTOMS.

pectorate a small quantity of viscid phlegm occasionally. His tongue is
broad, slightly coated on the dorsum ; his skin is sallow ; his liver is not
enlarged. Strict regulation of the diet, as in the previous case, the
regular use of euonymin, podophyllin, or cascara, persistent drinking of
Giesshubler or Vals water, have ameliorated but not cured my patient.
Latterly, I have prescribed salicylate of bismuth in addition to what
precedes, with the hope that intestinal antisepsis thus produced would be
effective in controlling the symptoms of functional disturbance which I
have outlined and which I have been led to believe were caused by renal
insufficiency.

Case III. — Only a few weeks sincel was called suddenly to see a near
and dear relative who had been attacked with alarming symptoms of
obstinate nausea and vomiting, marked cardiac weakness, and with but
few or no evidences in the urine, except just before the fatal termina-
tion, of renal complication : at this time a small quantity of albumin
and hyaline casts was discovered. The patient was fifty-eight years
old, the manager of important railroad lines. He had always been re-
markably strong and active. Owing to great irregularity of meals and
the immoderate use of tobacco and whiskey, he was a sufferer frequently
from flatulent dyspepsia, which he relieved with large doses of bicar-
bonate of soda. Some weeks previous to his death he had an attack of
pneumonia, moderate in severity. From this attack he had nearly re-
covered, when, by reason of over-fatigue, anxiety, and exposure, a mild
invasion of acute articular rheumatism developed. The fever had dis-
appeared and he was almost convalescent from this disease, when, owing
to the immediate effects of a cold bath, the final symptoms occurred,
and were regarded by the family physician as evidences of Bright's dis-
ease. When I saw the patient I thought the kidneys were congested,
but secondarily to the action of a weakened heart, and were connected
with engorgement of the other viscera under a similar dependence. This
was eminently true of the lungs and liver. No doubt it was the giving
way, functionally, of several important organs that was the cause
of death. Whilst this is true, it is also highly probable that the con-
dition of the kidneys, which had become more and more insufficient, gave
the terminal features of the combined conditions, to a greater degree
than any other of the organs involved.

Case IV. — A broker; bachelor; thirty years old; of a nervous,
excitable temperament ; suffers somewhat from symptoms of flatulent
dyspepsia and irritable heart. His bowels are frequently torpid ; his
urine habitually slightly high-colored. Habits are temperate — drinks
little; does not smoke. No gout or rheumatism. After an elaborate
dinner at which he drank different wines — but not to the point of in-
ebriety — he went home and slept. In the early morning he had repeated
attacks of vomiting and diarrhoea. Accompanying these symptoms
there was moderate headache and annoying palpitations. His pulse
was rapid, weak, depressible, and irregular. His heart action was also
much disturbed; it was rapid, irregular, and the pulse weakened.
There was a soft systolic bruit accompanying the second sound over the
pulmonary area. Apparently the cardiac cavities were somewhat dilated.
The tongue was clean, and yet nausea was distressing. No tenderness
over the epigastrium or anywhere in the abdominal cavity. The urine
had been smaller in quantity since the night previous, and instead of
being dark in color, was very light. Under the use, first, of ammonia



TREATMENT OF UREMIC SYMPTOMS. 21

and bismuth, with broths, milk, Vichy, and rest in bed, he improved
rapidly. Plis heart grew stronger ; his urine became more concentrated
and larger in quantity.

When the first symptoms disappeared, strophanthus and nux vomica
were added to the previous treatment.

Such cases as the foregoing may be differently designated, I am quite
aware, and at times are considered of little moment and scarcely worthy
of very careful consideration. I have known many such attacks re-
garded as the usual outcome of excesses of the table, and put down in
doubt, if we mean by that to express the idea that the liver is incident-
ally interfered with as to its physiological function ; but while this may
be true, I claim now that such cases are correctly interrupted in recog-
nizing that the kidneys, by their temporary insufficiency, occasion most
of the symptoms reported, in a very direct manner. It is also evident
that strengthening the cardiac contractions and giving more vascular
tone to the general circulation will be found useful. These indications
may indeed be urgent. Is it not obvious, however, that it is the reten-
tion in the economy of the waste substances, made suddenly enormous
by reason of dietary indiscretion, which brings on the threatening symp-
toms which require relief by all rational methods ? Nature makes every
effort in these cases, by frequently repeated vomiting and purging, to
clear the body, through these natural emunctories, of the poisonous fer-
menting ingesta which enter so largely as a factor in the direct causation
of such explosions. The rest in bed ; the gentle and continuous warmth
to the surface ; the liquid diet, which is the most rational diuretic as
well as food, the quieting effect of the ammonia and bismuth on the
irritated stomachal mucous membrane, and the stimulating influence of
the former in relieving general depression, were rapidly followed by
beneficial effects. As soon as practicable the heart was strengthened
and regulated to overcome the effects of diminished arterial tension
throughout the body, but particularly in the kidneys, whose functions
should be re-established in order to restore equilibrium to the economy.

Case V. — A maiden lady, forty-five years old, thin and spare of body,
passed her menopause without functional disturbances ; she has always
been healthy and vigorous ; has a good appetite and digestion ; bowels
regular ; heart action normal ; no malaria, rheumatism, or gout.
Patient suffers from obstinate, recurrent headaches every morning.
After she awakens, gets her coffee and a light breakfast, they frequently
disappear, or become less intense. At times they continue during many
hours of the day, and only disappear, completely, without apparent
cause, to return again the following morning. The urine is normal in
quantity, rather light in color, containing no abnormal substances. In
this case there was no cardiac hypertrophy and no increased vascular
tension — at least, neither one nor the other could be affirmed after
careful examination. Almost every rational explanation of the head-
aches was attempted, and on each occasion followed up by appropriate



28 TREATMENT OF UREMIC SYMPTOMS.

treatment of the supposed cause, without beneficial effect. Finally, I
thought that imperfect elimination of the products of mal-assimilation
through kidneys functionally insufficient, and which possibly were
affected with the precursory stage of interstitial nephritis, might account
for the headaches. Thereupon I prescribed nitroglycerin in the ordi-
nary dose of one minim of a one per cent, solution every four hours,
and very soon the headaches were relieved, if not cured. I now felt
tolerably sure that my interpretation of the case was correct.

I might multiply examples of different kinds pointing to what I
would call insufficiency of renal excretion, with many minute details,
but this narrative would merely prove wearisome.

In many instances of obstinate nasal, naso-pharyngeal, laryngeal, and
tracheal inflammation, chronic in type, I am now firmly convinced that
the inactive functional condition of the kidneys is the primary cause of
these inflammations. An imperfect blood -supply, containing in it many
elements which should be eliminated through the kidneys, is rendered a
source of morbid manifestations in the whole mucous tract — sometimes
of the respiratory organs, sometimes of the organs of digestion and
assimilation. Doubtless, also, the renal congestion which originates, as
it were, this vicious circle is heightened and made more intense by the
blood loaded with excrementitious substances, which come to the kid-
neys continuously, and which, provisionally, they are unable to get rid
of. In such cases I have often found, after the bowels had been freely
moved, and the mucous linings capable of being reached with suitable
topical applications had been treated, that a diuretic solution, such as
the liquor amraonii acetatis, frequently given, produced the happiest
results after it had been taken during several days in a regular manner.

I have noticed the preceding conditions on several occasions follow
bad colds, of the nature of grippe, or attack of influenza, and in these
instances have assumed that the specific nature of the disorder of the
respiratory tract and general system had much to do with the evidences
later on of renal insufficiency. In other cases, in which there could be
no doubt, to my mind, that there were organic changes in the kid-
neys of the nature of chronic parenchymatous or interstitial nephritis,
by reason of the specific gravity of the urine, the deposit of albumin
frequently contained in it, and the frequency with which different kinds
of tube-casts were found on microscopical examination, I have found
the symptoms referred to in the cases reported, but seemingly of graver
significance, because they were united with manifest organic renal
changes. Almost invariably, as we know, all undue fatigue, intense
emotional excitement, errors of diet or drink, cold and exposure, will
aggravate renal disease and bring on, rapidly or slowly, disquieting
symptoms. Knowing the previous condition of the kidneys, we can
never prudently ignore this knowledge when we care for such patients.



TREATMENT OF UREMIC SYMPTOMS. 29

Cask VI. — A distinguished architect Of New York has been one of
my patients, off and on, for at least eighteen years — indeed, during
nearly all my professional life. This gentleman, now over sixty years
of age, is a man of great industry, great talents, and remarkable pro-
fessional success. Once or twice in the course of every year he has an
acute gouty attack affecting the metatarso-phalangeal joint of the big
toe of one or the other foot. Sometimes these gouty attacks in the small
joints of the feet come on without premonition ; sometimes a bronchial
or slightly asthmatic attack precedes them. During the whole period I
have taken care of this patient he has had urine light in color, of low
specific gravity, containing a variable quantity of albumin and some
granular and hyaline casts. Whenever these bronchial, or, frankly
speaking, gouty attacks are upon him, and in view of my knowledge of
the condition of his kidneys, I am always very solicitous in regard to
their outcome. I have seen him when the thoracic oppression was very
intense, the heart beating irregularly, rapidly, and feebly, and the pallor
and pinched expression of the face were striking and alarming. Ac-
companying this condition there were disseminated moist and sonorous
rales in the chest, and the urine looked almost watery, and was dimin-
ished notably in quantity. Under these circumstances I have found
that repeated doses of colchicine and the free use of Fried richshall
water were the most useful medicinal remedies to employ. Rest in bed
and fluid diet were insisted upon, and in some instances counter-irrita-
tion or revulsion to the back was deemed advisable. Subsequent to
such attacks, giving up business affairs and travel were strongly
favored, and when indulged in, rapidly brought about a state of well-
being and the return to usual conditions.

In the evident gouty cases, and particularly in those where the heart-
action is good and the tension in the arteries not excessive, colchicine is
a more valuable remedy than nitroglycerin. In instances, on the con
trary, in which the arterial tension is well marked or excessive and the
heart laboring, whilst the quantity of urine is small and low in specific
gravity, I believe it is wise to begin treatment with nitroglycerin or the
nitrites. In any very alarming expression of this condition, inhalations
of nitrite of amyl should first be employed. We shall sometimes be
disappointed in the efficacy of these agents, and it is, I believe, when-
ever we have been committed to the error of believing that there is
hypertension in the peripheral arterial system, connected or not with
spasm in the vessels of the kidneys, or some other important viscus.
Frequently, the so-called increased arterial tension is merely the conse-
quence of atheromatous thickening of vascular walls, and the blood,
instead of being under too great pressure, requires increase of the vis a
tergo to make it circulate more freely and with greater energy. This
may often be attained by the use of caffein or digitalis, and as a result
of the effective use of one or both of these remedies, we are forced to
conclude that the renal phenomena proceed directly from an enfeebled
heart, and the true way of managing such cases is really not to make



30 TREATMENT OF UKJEMIC SYMPTOMS.

so direct an appeal to the kidneys, in the first place, but rather to the
muscular heart-structure. In strengthening the latter we help the
former in a much more obvious and important manner. When, how-
ever, we are not quite sure to what extent the kidneys originate the
series of pathological events and also tend to keep them up, it is judi-
cious to watch very carefully the administration of digitalis. I am con-
vinced that whenever the renal function is remarkably insufficient and
the urine is greatly diminished, or perhaps wholly suppressed, we are
liable to have those curious phenomena in the heart- beats and in the
pulse, not to speak of nausea and vomiting, which show accumulation
of this drug and its poisonous effects upon the economy. In many
instances it is relatively simple to distinguish, in a differential way, the
part played by the two conditions relative to cause and effect. In
others, we are left in great and reasonable doubt, and our judgment
in the matter remains most uncertain.

In regard to the simple question of the amount of arterial tension in
the radial arteries, I know of nothing more difficult at times than to
accurately estimate it — one reason being, besides the one already given,
the amount of soft tissues about the artery at the wrist. Even with the
use of the sphygmograph we may be unable to decide the matter, for
the simple reason that tracings with this instrument are only valuable
when made by an expert. Otherwise, we are liable to run into very
great errors of interpretation. This is mainly due to the fact that it is
very difficult to fit the instrument on any wrist so that we can form a
perfect estimate of the directness and accuracy of its pressure over the
artery.

Case VII. — A widow, of large, bulky frame, about sixty years of age ;
takes very little exercise, but drives a great deal and lives most of the
time in the open air, in summer at Newport, in winter at Cannes.
She is careful with her diet, as a rule, but commits occasional impru-
dences in eating rich or sweet food ; almost invariably she pays the
penalty of these errors by nausea, stomachal distress, pallor, and a sub-
icteric hue of the skin. The pulse becomes weak, rapid, and depressi-
ble, the heart action fluttering and feeble ; sometimes the bowels are
torpid ; sometimes there is and has been more or less diarrhoea, amount-
ing to several loose movements in the twenty-four hours. I have known
the attacks once or twice to be of a different kind ; instead of the pre-
vious symptoms, the head ached intensely ; there was torpor and somno-
lence ; the speech was thick, the ideas came sluggishly ; the face was
somewhat drawn down on one side ; the pupils were contracted, and there
was more or less nervous irritability, as shown by slight fibrillary muscular
twitchings. Seven or eight years ago, at the period of these latter
symptoms, the urine was ordinarily of low specific gravity, moderate or
abundant in amount, and containing a small quantity of albumin and
granular casts. Although the patient had been told that her condition was
gouty, and this was true in a certain sense, yet she had never had either
a frankly determined attack of gout or rheumatism. Compound cathar-



TREATMENT OF UREMIC SYMPTOMS. 31

tic pills, strophanthus, digitalis, and nitroglycerin have all been useful
at times, and singular to say, the use of Warburg's extract has some-
times enabled me to be of the most manifest benefit, when the other
agents completely failed. I suspected, therefore, very strongly, a malarial
element, without, however, being able confidently to affirm it. Some-
times I have thought it possible that Warburg's extract was useful
simply as an hepatic stimulant, and thus helped notably to relieve
evident ursernic phenomena. Whenever I had gotten rid of the threat-
ening phenomena in this case for a time, I insisted upon a milk diet,
koumyss, matzoon, milk and Vichy, etc.; massage daily, or every other
day ; oxygen inhalations and repeated doses of digitalis in tablet triturate
form. Every winter and spring, for several years, I have sent her to the
south of France, and thus far she has held her own, and, indeed, I
should say, to-day she is in better physical condition than she was
several years ago.

In the preceding case and the one narrated before it I have more
than once seen what I believed to be evident and pernicious effects
resulting from the use of even small doses of opium or morphine in
some form — given by the mouth, for I have never had occasion to resort
to the use of morphine hypodermatically in either of the preceding cases.
One of the interesting features in my last case is this : During the past
two years the character of the urine has changed in a remarkable
manner ; as a rule, this is no longer light-colored, of low specific gravity,
containing albumin and granular casts; on the contrary, it is of a fairly
deep color, does not generally contain any albumin, and on several
occasions has shown no casts when examined very carefully and by
expert microscopists. What is my conclusion ? Have I cured a case of
interstitial nephritis or not ? I will not pretend to solve this difficult
question. I would simply report a very interesting clinical fact in my
own private experience, of which there may be many in that of my
listeners, so far as I know.

I now wish to speak of the use of opiates, and more particularly of
morphine in these latter cases, whenever respiratory or other symptoms,
such as obstinate or distressing insomnia, seem to require their employ-
ment. Personally, I am and always have been much opposed to the use
of opiates, and especially of morphine hypodermatically, whenever used in
cases of chronic Bright's disease, except in very minute doses. I believe
I have seen it do harm so often in locking up the secretions, when just
the contrary was imperatively required — in bringing out further symp-
toms of uraemia, acute or chronic — that it appears to me reasonable to
abstain from this medication as long as possible. If its use is forced
upon me by symptoms that I have vainly endeavored to relieve by other
drugs which are more innocent in their effects, I always make use of it
with great care and watchfulness.

There are times, however, when I do not feel in this way, and where
ursernic symptoms are unquestionably manifest. In general terms, these



32 TREATMENT OF UREMIC SYMPTOMS.

are the cases in which the heart is the weak organ primarily, and in which
the kidneys will be greatly helped by .cardiac stimulation of an active
kind. Of the numerous drugs which strengthen, quiet, and regulate a
weakened, dilated heart, none at times is comparable to the hypodermatic
use of morphine in small or moderate doses. Therefore, when this condition
is obviously the cause of the distressiug or threatening symptoms, I am
not unwilling to recur to its use. If blood pressure is low, as shown by
slight, imperfect arterial tension in the radials, and if the pupils are
normal or somewhat dilated, with the previous condition also clearly
denned, I am not averse to morphine medication in the manner I have
mentioned. Unquestionably, when thus employed, I have had no good
reason myself to regret making use of it. When, however, with the
weak, irregular, or failing heart, are also present the pulse of lowered
tension and the contracted pupil, then I would cry halt ! because I
believe these conditions often mean poisoning from retention in the
system of excrementitious substances of different sorts and more or less
poisonous, which may rapidly overwhelm the economy in their disas-
trous effects unless the clear indications of treatment are distinctly made
out and followed by the practitioner. Again, in cases where we are in
great and legitimate doubt — as we frequently are — despite our most
careful scrutiny of a given case, as to which organ, the heart or the
kidneys, most evidently needs immediate help — in these cases I advise
against morphine hypodermatically as long as possible, on account of the
possible immediate and great harm which may follow its use.

Alongside of these cases, and as a further development of similar
underlying conditions, is what we often see, i. e., ursemic convulsions
actually take place. The quite general teaching of more than twenty
years in New York City, owing perhaps more to Prof. Loomis's influence
as a very prominent clinician than to anyone else, has been to the effect
that morphine hypodermatically in large and repeated doses in acute
uraemia has done what no other drug with which we are familiar will do
It will bring the convulsive seizure to a rapid termination ; it will at
times prevent the recurrence of it ; it will break up arterial spasm, it
will thus lessen arterial pressure ; it will promote diaphoresis ; it will
greatly increase the bulk of the urine when this secretion is diminished
or almost suppressed ; it will bring back to life when hope seems almost
lost.

In view of the facts so graphically and forcibly brought to our atten-


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Online LibraryBeverley RobinsonEssays on clinical medicine → online text (page 3 of 20)