Essays In Pastoral Medicine

by Austin O'Malley; James J. Walsh

When kidney disease exists the individual's resistive vitality is much lowered. The kidneys are the organs which serve to excrete poisons that find their way into the circulation. When the kidneys fail to act, these poisons are retained. As a result other important organs, notably the nervous system and the heart, suffer severely because of the irritating effect of the retained poison. A patient with kidney disease runs a very serious risk in any infectious fever, no matter how mild, and such patients should always be completely prepared for a fatal termination when they acquire any of these diseases.

Nephritic patients bear operations very badly. The shock to the nervous system incident upon operation always throws a certain amount more than usual of excrementitious material into the circulation. Diseased kidneys do not fulfil their function of removing this at once, and the result is an irritated and fatigued nervous system. Anaesthetics, that is, chloroform and ether, are not well tolerated when nephritis exists, and this adds to the danger of operation in such patients. No matter how simple or short the operation that is to be performed on a person suffering from kidney disease, if an anaesthetic is to be administered it would be well to prepare the patient for an untoward event that may occur.

Kidney disease is often extremely insidious. It may develop absolutely without the patient's knowledge, even though he might be deemed to be in a position to have at least some suspicion of its existence. The story is told of more than one professor of medicine who has presented his own urine to his class for examination in order that they might have the opportunity of studying normal urine, only to find to his painful surprise that albumen was present and that he was the subject of latent Bright's disease. In these cases it is [{138}] impossible to foresee results. They constitute a large number of the cases in which patients, seemingly in good health, succumb rather easily and unexpectedly to some simple disease, like grippe or dysentery. It is well to take the precaution, then, to ask the attending physician what the condition of the kidneys is in such cases. If there are anomalous symptoms, this precaution becomes doubly necessary. Even such simple infectious diseases as mumps or chicken-pox may cause a fatal issue where the kidneys are not in a condition to do their normal work of excretion.

An important class of cases for the clergyman are those which are picked up on the street. As a rule, these patients are comatose because of the presence of kidney disease. A certain proportion of them are unconscious because of apoplexy. Very often the patients have had some preliminary symptoms of their approaching collapse, though these were not sufficient to make them think that any serious danger threatened. As a consequence, they will not infrequently have had recourse to some stimulant. It seems unfortunately to be almost a rule, when such cases are picked up, if there is the odour of alcohol on their breath, to consider that the condition is due to alcoholism. Every year, in our large cities, some deaths are reported in the cells of the station houses because a serious illness was mistaken for alcoholism as a result of the odour of the breath. Needless to say, then, the odour of alcohol on the breath of a person in coma should not deter a clergyman from waiting for a time to be sure his ministrations may not be needed for something much more serious than alcoholism.

Patients suffering from kidney disease bear extremes of cold and heat very badly. In cold weather the fact that the blood is driven from the surface of the body lessens the excretory function of the skin, and this throws the work of this important organ, so helpful an auxiliary in excretion, back upon the kidneys. Besides, congestions of internal organs are not infrequent during cold, damp seasons, and these bring on exacerbations of previously existing ailments that may make fatal complications. In summer intense heat leads to many more changes in the tissues, and so provides more material to [{139}] be excreted than in temperate weather. Patients picked up on the street, then, at such time, will usually be found to be suffering from kidney disease. Though in profound coma, such patients seldom die without recovering consciousness. Not infrequently, after the primary stroke of the coma, there is, in an hour or two, a period in which the patient becomes almost completely rational. This period of consciousness does not last long, in many cases, and should be taken immediate advantage of, yet without unduly disturbing the patient.

There is a well-known tendency in kidney disease to the production of oedema, that is, to the outflow of the watery constituents of the blood into certain loose tissues of the body. This is easily recognised, and constitutes a valuable sign of kidney disease in the swelling of the eyelids and of the feet, that occurs so often in patients suffering from kidney trouble. The usual rule is, if the oedema begins in the face, it is due to the kidneys; if in the feet, to the heart. The cause in the latter case is the sluggish circulation due to the weakness of the heart muscle, which delays the blood so long in the extremities that its watery elements find their way out into the tissues. In kidney disease this tendency to oedema constitutes a distinct danger that may involve sudden death in certain affections. In patients suffering from kidney disease any acute sore throat involving the larynx and causing hoarseness may be followed by what is called oedema of the glottis. This is often fatal in a very short time. The glottis is the opening between the vocal cords through which respiration is carried on. This opening is but small, and swelling of the surrounding tissues readily encroaches upon it, and soon causes difficulty of breathing. If the swelling is not relieved without delay, death takes place from asphyxiation. This was probably the cause of death in George Washington. In almost the same way any acute affection of the lungs that occurs in a patient suffering from kidney disease may be followed by oedema of the lungs. The outflow of serum from the blood vessels into the loose tissues of the lungs so encroaches upon the space available for breathing, and at the same time so reduces the elasticity of lung tissue, that [{140}] respiration becomes impossible, and death takes place in a few hours. This is often the cause of unexpected death after operations. The kidney affection in the patient is so slight as to have been unsuspected, or to have been considered of not sufficient importance to render the operation especially dangerous.

After kidney disease the most important factor in the production of unexpected death is heart disease. In about 60 per centum of the patients who die suddenly, in the midst of seemingly good-health, death is due to heart disease. All forms of heart disease may be considered under two heads—the congenital and the acquired. The congenital form of heart disease usually causes death in early years. If such patients survive the fourth or fifth year, they are usually carried off by some slight intercurrent disease shortly after puberty. A few cases of congenital heart disease, however, live on to a good old age and seem not to be seriously inconvenienced by their heart trouble. Most of the acquired heart disease, that is, at least 65 per centum of it, is due to rheumatism. All of the infectious fevers, however, may cause heart disease, and scarlet fever especially is prone to do so; heart complications occurring in about one out of every ten cases. The probabilities of sudden death in a case of heart disease depend on what valve is affected and what the condition of the heart muscle is. Most of the cases of sudden death occur in disease of the aortic valves, that is, of the valves that prevent the blood from flowing back from the heart after it has been pumped out. Diseases of the other side of the heart, the mitral valve, cause lingering illness until the heart muscle becomes diseased, when sudden death usually closes the scene.

Diseases of the aortic valves of the heart cause visible pulsations of the arteries, especially of those in the neck. This readily attracts attention if one is on the lookout for it. Deaths in heart disease, whether sudden or in the midst of apparent health, or as the terminal stage after confinement to bed because of weak heart, are apt to occur particularly during continued cold or hot spells. Each of the blizzards that we have had in recent years has been the occasion for a [{141}] markedly increased mortality in all forms of heart disease. The cold itself is exhaustive, and the heavy fall of snow, by delaying cars and modes of conveyance generally, is very apt to give occasion for considerably more exertion than usual. Besides, cold closes up the peripheral capillaries and makes the pumping work of the heart much harder than before. At times of continued cold, in our large cities particularly, the ordinary arrangements for heating the house fail to keep it at a constant temperature, and this proves a source of exhaustion to cardiac patients.

Heated spells, if prolonged, always cause an increased mortality in such patients, because heat is relaxant and this leads to exhaustion. Patients who have been nursed faithfully through a severe winter will sometimes succumb to the first few successive days of hot weather that are likely to come at the end of May or the beginning of June. The deaths that occur during the hot spells of July and August are more looked for and accordingly prove not so unexpected.

The warning symptom in heart disease that the patient is giving out is the development of irregularity and rapidity of the pulse. On the other hand, when a pulse has been running rapidly for weeks and then drops to below the regular rate, to 50 or 60, a fatal termination may be looked for at almost any time, though, of course, the patient may rally. The prognosis of heart cases is extremely difficult. Confined to bed and evidently seriously ill, they may continue in reasonably good condition for months, and then some indiscretion in diet, which causes a dilation of the stomach with gas, pushes the diaphragm up against the heart, adds a mechanical impediment to the physical difficulties the organ is already labouring under, and a sudden termination may ensue. As a rule, lingering heart cases terminate suddenly and often with little warning of the approach of death.