that the tubes were blocked up to an extent very unusual with the granular disease. The duration of the denia (12 months) was sufficient to suggest that it was connected with the more chronic type of disease. There never was any doubt in this case as to the nature of his disorder. The age of the patient, the concurrence of gout, the early increase of the urine and the chronic character of the dropsy, led to an easy and certain conclusion. It was thought worth while to give iodide of potassium, with a vain hope that some such remedy might be found to remove or arrest the intertubular growth. It need not be said that all such views must be abandoned as chimerical. The new growth is a homogeneous addition to the fibrous tissue already existing, and is probably equally out of the reach of removal, by 'sorbifacient,' as by medicines of any other denomination. CHAPTER X. Essentially incurable, but admits of TREATMENT OF GRANULAR DEGENERATION. In the treatment of this disorder it is necessary to have regard to the fact that it is essentially incurable. The kidney has undergone changes from which there is no return. Tubes palliation. have been destroyed, and others that remain are interfered with by the presence of fibrous tissue, which is as far beyond the power of medicine to remove as fibrous tissue which belongs to the original structure of the body. We are therefore unable to touch the disease in its organic seat. can hope to do is to modify its progress and delay its consequences; and in this way much may be done. Life may be prolonged, in some cases almost indefinitely, while the bodily and mental powers are retained with so little loss that the patient, though a valetudinarian, may be equal to many of the duties and pleasures of life. General All we There is much less diversity of opinion as to the treatment agreement of the chronic forms of Bright's disease than of the acute. as to treatment. Patient seldom applies until disease advanced. General principles of treatment. It is but seldom that a patient comes under treatment until the disease has caused such injury to the gland as is sufficient to disturb the health in some obvious manner. There has been a gradual access of dropsy, there is troublesome dyspepsia or vomiting, the sight has become impaired, some cerebral disturbance has occurred, there is an indefinite failure of health which renders the patient unable to follow his usual avocations, or perhaps some conspicuous change in the urine has arrested his attention. The irremediable state of the kidneys compels us to direct our attention not to the disease but to its consequences. We may do something to cleanse the system from the contami nation of excrementitious matter, and we may meet, with more or less success, the symptoms which arise in the course of the complaint. There is probably no part of our surroundings which has Climate. so great an effect on the promotion or arrest of granular degeneration as climate, but it will be better to devote a separate chapter to this important branch of the inquiry, and to consider at present only such measures as do not involve change of habitation. active. If the patient be in a quiescent state, not pressed by any Skin to be kept urgent disturbance, much may be done to keep him in comparative health. The secretions, particularly that of the skin, should be kept in an active state. The patient should be completely clothed in flannel, and should take regular exercise such as to produce perspiration. The greatest benefit may be Vapour derived from the use, at regular intervals, of a hot air or a Turkish bath. Patients sometimes complain at first that such baths exhaust them, but they generally soon learn to like them for the sake of their obvious benefit. baths They may be given twice a week in an urgent case, once a week if there are no pressing symptoms, while in a patient who has been restored to some degree of health by their action, once a fortnight may suffice. Under their influence the general health improves and the complexion becomes brighter and clearer. The muddy tint of the face may be often seen to be visibly different on the day following the bath. The vapour or hot air bath is of most service in cases where the urine is copious, or at least not scanty; and is more effective copious. as a means of improving the general health than as a cure for dropsy. By the periodic use of this evacuation we prevent the accumulation of the mischievous substances which the kidneys have failed to remove. Most useful where urine Beside such measures, it will generally be necessary to give Iron. iron. The citrate or acetate answers the purpose. The acetate * may be mixed with liquor ammoniæ acetatis, * Dr. Basham advises the mixture of tinct. ferri perchloridi with liquor ammoniæ acetatis and acetic acid. This is an indirect method of giving the acetate of iron, which must result from the decomposition of the salts. Diet. Alcoholic liquors. Dropsy treated by diuretics. should it be thought well to give acetate of ammonia for the sake of its effect upon the skin, or with acetate of potass if a diuretic be needed. The sulphate or perchloride may be used if the urine contain blood, or there be any other indication for an astringent. As to diet, it is necessary to pursue a judicious and medium course. Nitrogenous or animal food increases the formation of urea, while non-nitrogenous or vegetable food diminishes it. Urea is probably formed from the excess of animal food, as well as from the waste of tissue. A meal of animal food has an immediate effect in increasing this element of the urine, while vegetable food has been shown not to have the same action.* The food therefore should be as non-nitrogenous as is onsistent with the proper nutrition of the patient. A purely vegetable diet has been tried, and found not to succeed, and the anæmic tendencies of the complaint forbid the use of a non-nutritious regimen. At the same time it is obvious that the patient should be kept upon the smallest amount of animal food upon which he can thrive. It does not appear that harm is done by the moderate use of alcohol; indeed it often has a most beneficial diuretic action. In gouty cases beer should be avoided, while gin or other spirit, in a diluted form, often agrees well. Among wines, claret appears suitable. Dr. Prout advises sherry or hock. In the choice of alcoholic beverages much may be left to the circumstances and peculiarities of the individual. With such a basis of treatment in quiescent cases, complications must be met as they arise. The dropsy may be treated by diuretics, mixed and varied until an effective remedy is hit. Most uncertain where they are most needed, it is not possible to lay down rules of any general application, as to the selection of these medicines. Perhaps the most effective is scoparium, used as decoction, three or four ounces for a dose. Small doses of digitalis, squills, or juniper, may be given with one or other of the saline diuretics, nitre or acetate, or bitartrate of potass. Nitric * See Parkes on the Urine, p. 50. ether may take a place in any mixture, and cantharides may be used as a last resource. Dr. Christison,* in speaking of remedies of this character, gives preference to digitalis squills and bitartrate of potass taken together. Dr. Burrows, speaking of the good effect of diuretics in chronic Bright's disease, advises a mixture containing tartrate of potash and nitric ether. The inhalation of the oil of juniper has been advocated of late, but in a few cases in which I have seen it tried no effect has been observed. tives. Should oedema resist the action of such medicines, purging Purgaand diaphoresis must be enforced. Hydragogue purgatives, as jalap or cream of tartar, may be given occasionally or at regular, but not too frequent, intervals. A compound jalap powder may serve twice a week, or a senna draught as often, to which one or two drachms of bitartrate of potass have been added. Elaterium is a resort for emergencies. Vapour baths Vapour are better borne in this disease than in any other renal affec- baths. tion, and though too often ineffective, may be used as a means of keeping down oedema. Acupuncture may be necessary in Acupuncrare cases; it must be used with the precautions already urged.‡ But such measures which have for their object the removal of dropsical effusion are not needed in a large proportion of cases. Many patients die without having had dropsy in any form, and others have it only for a short time. ture. symptoms. A careful regulation of the diet is of course necessary, Treatment in all cases of dyspepsia, whether associated with albuminuria of stomach or with any other condition. In the dyspepsia which belongs to this form of renal disease much may be done by medicine. The remedies which appear most useful are nitric and hydrochloric acids, and strychnia. These may be given with calumba or some other mild bitter. Acids appear to be sometimes indicated by the presence of alkaline or ammoniacal secretion in the stomach. When vomiting becomes frequent it is a very intractable symptom. After mineral acids and strychnia, hydrocyanic acid, creosote, brandy and soda water, and ice, may *Clinical Lecture, Ranking's Abstract, 1852, p. 85, vol. xv. See p. 89. M |