CASES AND OBSERVATIONS ILLUSTRATIVE OF RENEAL DISEASE ACCOMPANIED WITH By R. The main object of Dr. Bright in writing the present paper is to correct a misconception of which he complains-namely, that he maintains the occurrence. of albuminous urine to be always and necessarily connected with that organic disease which, in various shapes and modifications, has been so fully desscribed. "Now the truth is," he adds, "that I have never written upon the subject without studiously stating the contrary opinion, and declaring that I considered the disease, in its commencement, entirely functional." He quotes passages in corroboration of this statement from his first publication in 1827, from his second in 1831, and from a third memoir in 1836. "After these quotations, I trust I shall be exonerated from the imputation of asserting, that albuminous urine cannot exist without disorganization having taken place in the kidney. At the same time, it must be confessed, that within a very limited time after the occurrence of the morbid condition of the urine the disease has generally proceeded so far as to bid defiance to the best-concerted measures for its removal, and has probably began to produce a scructural change in the organ." In the present communication, Dr. Bright has brought forward a few cases, which, he thinks, may assist us in forming a fair estimate of the degree of success which we may reasonably expect to attain in the treatment of albuminous urine; sometimes effecting complete cures sometimes diminishing the morbid condition of the secretion; but more frequently only rendering the various symptoms less formidable, and the fatal result less immediate. For, noone, he believes he may say, has it in his power to adduce a long series of perfectly successful cases, though relief is frequently afforded, and results produced such as many have considered cures. Although a few of them, says Dr. Bright, deserve that designation, they are calculated to afford some comfort and encouragement while we are engaged in the hitherto discouraging search after efficient remedial agents when the disease has assumed its confirmed form, and to excite a hope of being useful amidst the still more distressing disappointments to which we must submit when the disease has become organic. Dr. Bright details, with considerable circumstantiality, twenty-four cases. These occupy some fifty pages of the "Reports." It would be useless on our part going through each, but their general tenor, the facts they prove, and the conclusions that they point to, may, in some measure, be gleaned from their respective headings, a kind of abstract of their characters. These we shall cite and then notice two or three more fully. CASE 1-Exposure to Cold-Albuminous Urine-Anasarca-strict confinement to bed-diaphoretics-elaterium--permanent cure. CASE 2.-Albuminous Urine-Ascites and Anasarca-warm bath-purgingmineral acids-complete cure. CASE 3.—Albuminous Urine-Anasarca-confinement to bed-simple salines -all symptoms removed. CASE 4.-Albuminous Urine-treated by compound ipecacuanha powder, &c. &c.—great improvement during many years-urine still coagulable. CASE 5.-Anasarca after Scarlatina-urine albuminous-complete cure by confinement to bed. CASE 6.-Albuminous Urine after Scarlatina-strict confinement to bed. CASE 7.--Albuminous Urine-Anasarca-bleeding--gentle purging-light tonics. CASE 8.-Albuminous Urine ufter Scarlatina-excessive anasarca- -deathmottled kidney. CASE 9.-Albuminous Urine, recent Case-strict confinement in bed-purgatives and antimonial diaphoretics-anasara cured-urine still albuminous. CASE 10.-Albuminous Urine, a recent Case-strict confinement to bedantimonials—asasarca cured-urine still slightly albuminous. CASE 11.-Albuminous Urine-general anasarca-bleeding elaterium—anasarca cured-urine remained very slightly albuminous. CASE 12-Albuminous Urine-confinement to bed-bleeding—elaterium— great relief-urine still slightly albuminous. CASE 13.-Albuminous Urine-bleeding-much relief from gentle diuretics and purgatives-urine still slightly albuminous. CASE 14.-Albuminous Urine-anasarca-infus. digitalis, &c. &c.—anasarca cured-urine still coagulable. CASE 15.-Albuminous Urine-elatrium-great improvement. CASE 16.-Albuminous Urine-elaterium-great relief. CASE 18.-Albuminous Urine-severe cramps-serous effusion. CASE 19.-Albuminous Urine during at least two or three years-habitual cramps-death, with violent spasm of the muscles-urea in the serous fluids. CASE 20.-Albuminous Urine-severe epileptic fits-death. CASE 21.-Albuminous Urine-very defective vision-spasm—coma, with death. CASE 22.-Albuminous Urine, probably of several years' duration—very defective vision-inflammation of pericardium from exposure-convulsiondeath. CASE 23.-Albuminous Urine-imperfect vision, and other cerebral symptoms -serous inflammation-phosphatic deposits in one kidney. CASE 24.-Albuminous Urine in a case of diabetes mellitus. The title of the preceding cases furnish a sufficient notion of their general character, and present the practitioner with an idea of what he may commonly expect in the treatment of albuminous urine. We shall now take one or two of the more striking, and especially of those which seem to illustrate the beneficial effects of remedies. CASE 1.-Exposure to Cold-Albuminous Urine-Anasarca-Strict confinement to Bed-Diaphoretics-Elaterium—Permanent cure.-Feb. 5, 1837. Dr. Bright saw a gentleman, aged 35, of good constitution, who eight days previously, the weather being very cold, came from Maidstone on the outside of a coach; and on the same evening his wife observed that his face was swollen, and he complained of some pain in the loins. The swelling has since continued and increased, shewing itself in various parts of his body. His skin was dry, except the palms of his hands and soles of the feet: the urine scanty, with lateritious sediment; on the application of heat, it first became clear, and then coagulated freely. A third of a grain of eletarium, given the day before, had somewhat reduced the anasarca. He was ordered to remain strictly confied to bed, in a warm room; to have a light milk diet; and to take a pill composed of three grains of James's powder and two of extract of conium, three times a day; and a draught, containing three drachms of the liquor. ammon. acet. He was also to repeat the elaterium about once a week. Next day he had a profuse perspiration, which was succeeded by a permanent moisture of the skin. On the 8th pulse 80, full; urine, two quarts, of a high brandy colour, and slightly dingy, but free from lateritious deposit; still decidedly coagulable by heat, but in a less degree than before. He was allowed a little vegetables and a small quantity of fish. To take the third of a grain of elaterium the next morning, and continue his other medicines. Feb. 20. The perspiration has been almost constant, and he feels weakened by it. For the last few days, the urine has deposited a slight brown sediment, apparently from the presence of some of the red particles of the blood. To leave off the James's powder, but continue the other medicines. March 6. Up to this time, no alteration has been made in the plan of treatment; except that a little sulphate of magnesia has been added to his draught, and the James's powder has been resumed. He feels and looks quite well; but the urine is too abundant, and he is called upon two or three times each night to pass it It looks pale and watery, and has a slight dingy appearance; but is not the least coagulable by heat. The perspiration is now rather deficient. Twenty minims of the liquor. antim. tart.: to be added to each dose of the mixture, and the pill to be continued. March 13. In appearance, he is now quite well, though the urine has still a slight dinginess. The quantity is natural, and it is not the least coagulable. Skin perspirable Dr. B. now took his leave. The gentleman has remained quite well since. The Second Case was that of a man, aged 56, a coal-whipper, who had always enjoyed good health, and equally enjoyed both gin and porter. The anasarca and ascites had begun eleven days before his admission. The treatment consisted of active purging, which diminished the ascites, but not the anasarca-hot baths which made him sweat, as we may presume only coal-whippers can, for the perspiration is described as "running through the bed, and standing in puddles on the floor," and, lastly, infusion of gentian with the hydrochloric acid. Dr. Bright remarks on the case :-"if it were allowable to speak of our mode of curing the disease from the success of a single case, we should be induced to say, act freely on the skin, lower action by purging, then improve the tone of the kidney by the mineral acid, and the cure is complete: and though I am not, as I have said, sanguine of great success, yet these appear most rational indications, and are, I believe, capable of being frequently carried into effect, if the patient will submit to confinement to bed for many weeks, during the action of remedies." The next case, to which we shall turn is the fourth, because it is, we think, a sample of a class far from uncommon. CASE 4.-A.buminous Urine-treated by Compound Ipecacuanha Powder, &c. &c.-Great Improvement during many years—Urine still coagulable.—“ March 9, 1835. A man, aged about 25, pale and scrofulous in appearance, and deeply pitted with the small-pox, came to me, labouring under anasarca, and having albuminous urine. His illness commenced, as far as he knew, eight months before, with a diarrhoea, which lasted three weeks; and, when getting better, he went into the country for a month; but there his legs began to swell, and anasarca proceeded up the thighs and abdomen. He had been taking various remedies for the last four or five months, without deriving material benefit. I found the urine of a pale straw-colour, exceedingly coagulable by heat and by nitric acid it became frothy on agitation, and remained so. The whole quantity he passed was very considerable, and he suffered much from irritation of the bladder, so that he was always obliged to rise three or four times during the night." Extracti Humuli. Extracti Uvæ Ursi āā gr. xv. contunde et in pilulas decem divide, e quibus sumat unam ter quotidie. Milk diet. Flannel. On the 23rd, the urine less coagulable-only one call at night-cough, and relaxed bowels. R. Soda Subcarbonat. 3ij. Pulv. Uvæ Ursi 3ij. Pulv. Ipecac. Comp. 3ss. in pulveres xij. divide, e quibus sumat unum ter quotidie. Habeat Mistura m Creta aromat. pro re natâ. On the 17th of April, the skin being dry, he was ordered 4 grs. of Dover's No. 81. 22 powder twice or thrice daily, which was soon increased to five grains thrice daily. In June, he had improved, but a slight periosteal enlargement had appeared on his left shin; he had taken much mercury. The iodide of potassium in infusion of cascarilla was added to the Dover's powder. On the 9th July, he was ordered Pulv. Ipecac. Comp. j. Soda Carbonat. 3ij. Pulv. Uva Ursi zij. In pulv. duodecim divide, e quibus sumat unum omni nocte. Infus. Gentian. C. zv. Potassæ Hydriod at. 3iss. Tinct. Aurant. 3iij. Tinct. Card. Comp. 3iij. Syrup. Aurant. 3ij. Sumat cochl. mag. i. ex cyatho aquæ semel vel bis quotidie. Passing over some intermediate reports we may cite the concluding ones. “Oct. 30, 1839. Nearly four years had elapsed since I last saw this patient; and he now came to me, telling me that he had continued in good health till within the last two or three months; but when he had occasionally felt some of his old symptoms, he had recurred to the mixture. He had passed his time in the comfortable discharge of his business; had experienced no swelling; his skin natural, and his urine not more frequent nor in larger quantities than usual: at present, however, he suffered from frequent calls to pass it after going to bed; and on rising in the morning he had headache, with frequent nausea, proceeding often to vomiting. I had no opportunity of seeing his urine at that time.— I ordered an effervescing draught occasionally. Nov. 3. I examined his urine; it was not acid, and became very faintly opaque by heat; it coagulated freely with nitric acid: specific gravity 1012. He passed a large quantity of urine at night, but little in the day: his ankles had swollen slightly of late." We give this case, as we before observed, because it may be loosely said to represent a class. It is by no means rare to see persons go on for year after year with albumen in the urine, more or less irritability of the bladder, a tendency to anasarca, and indifferent, rather than positively bad health. We fancy that it is the quantum of disease in the kidney, rather than the influence of particular medicines, that enables the patient to creep on thus little better or worse for an almost indefinite time. We have, at all events, seen this occur under very different remedies, and regimen and the avoidance of the causes of disease have, perhaps, had as much to say to it as physic. Albuminous Urine in connexion with Scarlatina. Dr. Bright remarks : "During the autumn and winter which have just passed (1839-40), we have experienced an almost epidemic prevalence, in London and its neighbourhood, of that anasarca with albuminous urine, which has been long known to accompany or follow scarlatina. The attack of the original disease has often been slight; the rash sometimes scarcely perceived; the sore-throat often mild; and the affection of the urine has frequently shewn itself while the rash or sore-throat has still existed. Hæmaturia has occasianaily occurred during the severity of the attack; but more commonly this symptom, with or without anasarca, has followed on the subsidence of the fever, or during the early convalescence. The number who have offered themselves as out-patients, or have been admitted into the wards of Guy's Hospital, under such circumstances, as well as the cases which have occurred in private practice in other parts of London, have been quite unprecedented, within the limits of my experience. This I consider one very important form of the disease, and one which very generally admits of cure; but I have seen and heard of several fatal cases, and have had the opportunity afforded me of examining the kidneys of some who have died. In some instances, there has been obvious irregular congestion, with out apparent lesion of structure; but in one or two, where there was reason to believe that a foundation had been previously laid, the more usual appearances of advanced structural derangement have been ascertained. With regard to the occurrence of albuminous urine after scarlatina, I have already said, in a former paper in these Reports,* that I consider it as often laying the foundation for the future disease, or as an evidence of the strong tendency existing in the constitution, even when the cure has been apparently complete." Four cases are detailed. The three first terminated favourably, and as there was nothing particular in the treatment, nor indeed in the circumstances, we may dismiss them. The fourth, however, has pathological interest at all events. CASE.-Albuminous Urine after Scarlatina-Excessive Anasarca-DeathMottled Kidney.-John Wiseman, aged 16, admitted November 16, 1839. He has always enjoyed a good state of health till about a month ago, when an eruption of scarlet-fever made its appearance on the body. During the attack he continued to be engaged in the discharge of his duty, frequently exposing himself to damp and cold by going into the cellar. A medical gentleman, who attended, said he had scarlatina. A fortnight ago, he perceived a swelling about the eyelids, which increased considerably towards evening, attended by pain and giddiness in the head: the next morning, the swelling had extended to the face, and in three days more, to the upper and lower extremities, scrotum, penis and abdomen. At this time he complained of sickness and trembling of the limbs, accompanied by coldness of the feet; his urine was small in quantity. Present Symptoms.-Has a general edema over the body, with great tension of the skin, more strikingly marked in the abdomen, scrotum, eyelids, face, and lower extremities: great thirst: pain in the loins on pressure: skin dry and hot tongue furred and injected: respiration hurried and laborious: urine of a dingy orange colour, small in quantity, very coagulable by heat and nitric acid. He was ordered to be freely purged by elaterium and supertartrate of potash; but this produced great sickness, without better action on the bowels. Nov. 17. Has had no sleep: constant vomiting: pulse 114, small and sharp: skin dry: respiration hurried and laborious: tongue somewhat brown: pain in the head: has passed six ounces of urine, the same in character: great thirst, and pain in the loins: cannot lie down. Baln. tepid. Hydr, è Cret. gr. v. t. d. Acid. Hydrogen. ex M. Mag. t. d. 18. Has passed a very restless night: pain in the loins undiminished: great pain and tension in the scrotum: the skin burning: oedema remains the same: urine very scanty, and coagulable. Incidatur scrotum. V.S. ad 3x. Fot. Papav. lumbis. Only ziv. of blood could be obtained; which was buffed, and of a light colour. 19. Died. SECTIO CADAVERIS.-The whole body much swollen, and anasarcous. right ventricle contained a small quantity of fluid. The Chest.-The right pleura contained about a pint of clear serum; the left about eight ounces of dark-coloured serum. The lungs were only compressed from fluid. The cavity of the pericardium contained three ounces of straw-coloured * Vol. I. p. 339, |