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

by Unknown

9. The patient may first notice that he is passing too much urine. This urine is of low specific gravity, and occasionally contains a little albumen and hyaline casts. Then the health begins to fail: there are dyspeptic symptoms, headache, occasional oedema of the legs. From time to time the patient becomes worse; the urine is diminished in quantity, the headache is more marked; he cannot sleep, he has dyspnoea, he vomits, the muscles of the face twitch, or there may be general convulsions or delirium or partial or complete coma. Such attacks may last for days or weeks, and then either terminate fatally, or the patient gets better and may be able to return to his ordinary business for a time. In this way the same patient may suffer from a number of such attacks.

10. In some cases dropsy is a prominent feature from the very first and goes on to general anasarca.

The following history would answer for many of the cases of atrophied kidneys: A woman, thirty-eight years old, was in good health, fat and robust, until January, 1873. Then she caught cold; her feet became oedematous; she had headache, pain in the back, vomiting; her eyesight was impaired; her urine was increased in amount and passed more frequently. She continued in this condition and losing flesh and strength until June, 1873, when she came into the hospital. At that time the urine was diminished to eighteen ounces in twenty-four hours; it contained a considerable amount of albumen and hyaline and granular casts. Her color was still good. There was moderate oedema of the feet. After this the urine increased in amount to eighty ounces daily—specific gravity 1002, albumen diminished. The dropsy disappeared, and the patient left the hospital feeling very well on September 29, 1873. In December, 1873, she returned to the hospital with nausea and vomiting, dyspnoea, cough, no dropsy; urine 80 to 100 ounces daily. She had become feeble and anæmic, and there was well-marked hypertrophy of the left ventricle of the heart. She again improved, and was discharged after two weeks. In March, 1874, she returned. The urine was now scanty, and she was troubled with vomiting, dyspnoea, cough, sleeplessness, slight convulsive movements of the voluntary muscles, no dropsy. By the end of April she was again feeling well, and left the hospital. In June, 1874, she returned with all the old symptoms and oedema of the legs. On July 20 she had two general convulsions. After this she again improved for a time, but in September all the symptoms returned, and she was delirious a good deal of the time. Urine 40 to 50 ounces daily, specific gravity 1005, moderate amount of albumen, no casts. By the end of September she again was sleepless, had several slight convulsions, and died October 2. The kidneys were a typical picture of the red atrophied kidneys with thickened arteries.

We may say in general that with the atrophied kidneys the so-called uræmic symptoms—headache, sleeplessness, delirium, convulsions, coma, dyspnoea—are very apt to occur, and that early in the disease. The urine is regularly increased in amount and of low specific gravity, except during the uræmic attacks, when it is diminished; but the uræmic attacks may come on while the patient is passing 30 to 40 ounces of urine of a specific gravity of 1020. Albumen is regularly present only in small amounts, and not constantly, but exceptionally there will be a good deal. Casts are hyaline, not constant, but exceptionally in considerable numbers. Dropsy may be absent throughout the disease, or a little oedema of the face and legs may come and go, or there may be marked general anasarca. Not unfrequently during the uræmic attacks the temperature runs up to 99° to 100°. Hypertrophy of the left ventricle of the heart is a frequent complication, but I have not found it in as large a proportion of cases in New York as it is described by English and German writers.

The duration of the disease is very uncertain. In fact, we seldom know what its real duration is, for the reason that there is no necessary relation between the development of the kidney lesions and the appearance of the symptoms. After the appearance of the kidney symptoms some of the patients die in a few days; others go on for months and years with either constant or intermittent symptoms.

The Large White Kidney.—These cases are more readily recognized than the cases of atrophied kidneys, for the reason that dropsy is more constant and occurs earlier in the disease, and that albumen is regularly present in the urine.

In many of the cases oedema of the face or feet is the first symptom. Often the patients will tell you that it is the only symptom, and that they would feel perfectly well if they could only get rid of the swelling. Closer questioning, however, will usually show that the functions of the stomach are disturbed, that there is occasional headache, that the eyesight is impaired, and that the patient has been passing less urine.

In some cases impairment of vision is the first symptom that attracts the attention of the patient. In some cases disturbances of digestion, or neuralgic pains, or gradual loss of health and strength, or a diminished amount of urine, will be the first symptoms, and may last for weeks before other symptoms are developed. Or the patient may be attacked suddenly as if with acute diffuse nephritis. The urine will contain blood and numerous casts; the dropsy and the other symptoms are rapidly developed. In some of the cases complicated with cardiac disease the history will be that of heart disease rather than that of kidney disease.

When the disease is fairly established the dropsy is always a prominent symptom, often very distressing to the patient. In some patients when once developed it continues to increase steadily up to the time of their death; in others the dropsy comes and goes, sometimes disappearing altogether for weeks and months.

The functions of the stomach are usually disturbed, the patients lose appetite, have nausea and vomiting, oppression after eating, etc. But some persons retain a good appetite for a long time, even though they vomit occasionally. Diarrhoea is often developed; sometimes only enough to carry off part of the dropsy, sometimes profuse, persistent, and uncontrollable. The blood becomes thin and watery, and the skin, the mucous membranes, and the sclerotic assume an unnatural white appearance. The patients lose both mental and bodily vigor, and become less and less fit to carry on their ordinary occupations.