A system of practical medicine. By American authors. Vol. 4

by Unknown

The urine is bloody or of a brownish smoky color. It is of low specific gravity. It contains a very large amount of albumen, numerous hyaline, granular, epithelial, and blood casts and renal epithelium, and sometimes pus-cells. Later in the disease fatty casts are also present.

The patient soon develops dropsy, the extent of which varies in the different cases. Sometimes it involves only the face, sometimes the hands and feet, or there may be general subcutaneous oedema, serum in the serous cavities, oedema of the lungs and of the glottis. The patients lose their appetite; often there are nausea and vomiting. As a rule, there are cerebral symptoms—headache, drowsiness, stupor, delirium, muscular twitchings, convulsions, and coma. In the milder cases there will be only headache and periods of drowsiness, alternating with periods of irritability. In the severe cases there will be dyspnoea, delirium, repeated convulsions, and coma.

These are the regular symptoms of the disease—symptoms varying in their number and development with the intensity of the nephritis. In the worst cases the cerebral symptoms are developed early and the patients die at the end of a few days. In other cases the symptoms continue for months, and at the end of that time terminate either in the death or recovery of the patient. Albumen and casts in the urine may persist long after all other symptoms have disappeared. In other cases the disease runs a very mild course; the patients are not at any time seriously ill, and they recover completely at the end of two or three weeks. In still other cases the acute inflammation is succeeded by chronic diffuse nephritis. Relapses and repeated attacks of the disease occur in some persons.

The course of the disease may be modified by complicating inflammations. Pericarditis, pleurisy, peritonitis, pneumonia, cystitis, and inflammations of the joints and muscles are not uncommon.

PROGNOSIS.—In the larger number of cases the prognosis is good. The milder cases recover after two or three weeks; more severe cases last for several months. The bad cases die at the end of a few days with cerebral symptoms, or all the symptoms continue and the patient dies at the end of several months, or they pass on to the lesions and symptoms of chronic diffuse nephritis, or they die from some complicating inflammation.

TREATMENT.—In the mild cases but little treatment is required. The patients should be kept in bed, should have a fluid diet, the bowels should be moved, and the restlessness should be quieted by the bromides, chloral hydrate, or opium. If the dropsy is a marked feature, more active purgatives are to be employed, hot-water or hot-air baths are to be used, and jaborandi may be of service. When the urine is very scanty, wet or dry cups over the region of the kidneys and hot fomentation over the same region are of much service. For the more marked cerebral symptoms treatment is not very satisfactory. As the patients get better iron and tonics are usually indicated. Great care must be used to prevent relapses. All exposure to cold must be avoided; the patient is to be kept in the house or sent to a warm climate for some time after he is apparently well. So long as albumen and casts persist in the urine the patients must not be considered well, although they may present no renal symptoms.

(2) In the second set of cases the invasion of the disease is not acute, and the symptoms may at first be so slight that the patient will hardly notice them. Usually the first symptoms are referable to the stomach. The patients lose their appetite, are troubled with nausea, and vomit occasionally. There may be a moderate amount of pain in the back, general languor, and indisposition for mental or physical work. Then they notice a change in the urine; they pass much less than before. The urine remains of its ordinary color or is a little smoky; its specific gravity is less; it contains a good deal of albumen, sometimes a little blood, and large numbers of hyaline, granular, and epithelial casts.

Dropsy makes its appearance at first in the face or feet; it may remain confined to these regions or extend to the rest of the body and become a general dropsy. The cerebral symptoms are slight—headache, irritability, drowsiness. The blood becomes thin and watery and the patients unnaturally pale. There may be dyspnoea either dropsical or nervous. The symptoms continue for weeks or months.

PROGNOSIS.—These cases, as a rule, do well, and recover at the end of a few weeks or months. But in some the symptoms continue and the patients go on to have chronic diffuse nephritis.

TREATMENT.—In the mild cases it is only necessary to keep the patients in the house, put them on a milk diet, keep the bowels open, and after a time give them iron. If the dropsy is more marked, we must try to get rid of it by cathartics, sweating, and diuretics. If the anæmia is marked, inhalations of oxygen must be combined with the administration of iron. In these cases also it is important to guard against relapses.