CHAPTER V. CAUSES OF TUBAL NEPHRITIS CONSIDERED IN DETAIL. Cold. More fre quent cause COLD AS A CAUSE OF TUBAL NEPHRITIS. WITH adults exposure to cold is the most frequent cause of tubal nephritis. During childhood it is comparatively seldom that the symptoms can be traced to this cause. In a series of 16 fatal cases in adults, where I had the opportunity of examining the patients during life, and their kidneys after death, the disease was traced to cold in 8; not vaguely, but to a definite exposure of which the date could be fixed, and which in most instances had given rise to other catarrhal symptoms. Of 43 fatal cases in children, some of which were under of nephri- my own notice, others contributed by my colleagues at the Children's Hospital, the disease was traced to wet or cold in but 2. tis with grown people than children. It would be easy to collect from various sources a vast number of cases where renal disease has been attributed to this cause. Dr. Wilks, in his valuable paper on Bright's disease,* gives a short history, as ascertained by himself, of 22 cases; in which, either from post-mortem evidence or from the no less conclusive fact of recovery having taken place, the disease was ascertained to be of the kind under consideration. In 10 it was traced to a definite exposure to cold or wet. Thus both from Dr. Wilks's histories and my own, it * Guy's Hospital Reports, 1853. appears that in about half the cases of tubal nephritis which are met with in general hospitals, cold or wet, or both to gether, are the source of the complaint. It will be instructive to look more particularly into the Examples. circumstances under which these often harmless agencies have become so mischievous. Here are some of the more definite instances. A gentleman rode from Maidstone to London outside a coach in very cold weather. The same evening his wife observed that his face was flabby, and a well-marked attack of renal dropsy followed, from which he eventually recovered.* A bricklayer, very much heated by carrying a great weight, drank some beer and lay down on the damp grass. Next day he was anasarcous, and three months later he died in Guy's Hospital, where he afforded Dr. Bright one of the earliest cases of the disease which bears his name (case 4). The kidneys were enlarged, soft, pale, and apparently fatty. A journeyman currier, who was of temperate habits, was often exposed to cold in his occupation while in a state of profuse perspiration. One day he was employed in washing skins, his feet being very wet. At six o'clock the same evening he became dropsical; he died in a month, and the kidneys were found to be greatly enlarged, and congested to the colour of chocolate.† A labourer drank a large quantity of cold water when heated and fatigued by labour in the harvest-field. He had an attack of jaundice with 'coagulable urine,' and eventually recovered.‡ A house-painter was exposed to weather and had no food for the whole of one very cold day. In the evening he was œdematous. He died after an illness of eight months, with the large white fatty kidney. A lamplighter was wet through for a whole week, during one or two nights of which he sat up as watchman. He Bright. Guy's Hosp. Reports, 1840. + Bright's Med. Rep., case 14. Dr. Blackall, 4th edit. p. 122. 'took a violent cold,' and had an attack of dropsy, from which he never recovered. Five months afterwards the kidneys were found to be double their natural size, white, smooth, and fatty.* Dr. Wilks gives four cases, in all of which the disease had precisely the same origin; the patients were shipwrights, who were working over-hours, day and night, by the river side. They came into Guy's Hospital with renal dropsy. The overwork, and the subsequent exposure to the cold winds from the river, probably during profuse perspiration, set up the same symptoms in all.† A coachman, in the habit of drinking to excess, walked eight and a half miles in the snow; next morning he was dropsical, and in a month he was dead. The kidneys were enlarged, smooth, and greatly congested.‡ A drunken shoemaker got wet through, and sat in his wet clothes; this was immediately followed by an attack of rheumatism, and in a fortnight by renal dropsy, which ended fatally. The kidneys were greatly enlarged, white and smooth. A man of dissolute habits, but in perfect health, being hot and greatly excited by drink, jumped into the Thames and swam about for some time. He immediately felt ill, and next day dropsy set in. He died fourteen weeks afterwards in Guy's Hospital, and his kidneys were found to be large, white, and smooth.§ A child was put to bed in a newly-finished house, and had an attack of renal dropsy afterwards. The same result followed in the case of a woman from a similar cause. Looking generally at the circumstances under which cold has given rise to renal dropsy, it appears that in the first place there is frequently some preceding cause of exhaustion. The patient is fatigued by bodily toil, or weakened by want Where no reference is given, the case occurred at St. George's Hospital. Dr. Wilks' cases of Bright's disease, Guy's Hosp. Reports, 2nd series, vol. viii. Case of Benj. Patrick, p. 60. § Reported by Dr. Wilks. of food, or he is a drunkard, perhaps under the influence of liquor at the time of the exposure. In many cases the disease has come on under circumstances of exhaustion where the exciting cause has been so trifling as to escape notice altogether. I may instance the case of a medical student (related p. 38), who had a most serious attack of what must have been tubal nephritis, after a course of very close labour as demonstrator of anatomy, while at the same time he lived in a very abstemious manner. rare most mis haustion or sleep; tracted, In the same category must be placed those cases-not Cold where the disease has arisen from cold and damp chievous affecting the body during sleep. Sleep appears to bring with during exit a lowering of the nervous force, which, like exhaustion or depression, allows the body to become an easy prey to influences which produce disease. Next, there are two conditions of which both are usually when The cold is protracted, and it is ap- and when present, always one. plied during free perspiration. Cold, acting under these suddenly succeeding circumstances upon a person who has been exhausted or de- perspirapressed, is likely enough in our climate to be followed by tion. renal anasarca. It appears, however, that this statement does not hold good, or holds good only in a modified degree in climates either much warmer or much colder than our own. In the account of Arctic expeditions, though the most intense cold was often endured, under circumstances of great fatigue, by men previously weakened by disease and hardship, renal anasarca is not among the diseases from which they suffered. Dr. Kane's men, though enduring extreme cold, exposed on one occasion for seventy-two hours at a mean temperature of 41° below zero, suffered fearfully from frost-bite and scurvy, but not from any renal affection. Other travellers within the Arctic circle bear the same testimony as to the nature of the diseases which the climate produces. I have been informed by those familiar with the cold districts of North America, that there renal dropsy is rare or unknown. * Kane's Arctic Exploration, ch. xvi. Nephritis belongs to temperate climates. Arctic cold The companions of Franklin in his earlier expedition suffered from œdematous swellings of the limbs, but this occurred after unparalleled hardships from starvation, to which some of the party succumbed. Their chief food for some time consisted of hides, and an acrid soup made from bones. It is clear that the dropsy was not of renal origin, but depended upon the extreme state of anæmia and prostration to which they were reduced. The urine is mentioned as unnaturally copious. * Renal anasarca is not a disease of the frigid zone. The travellers in that region are exposed to far greater and more sudden transitions of temperature than are ever felt in our changeable but temperate climate. Captain Parry states that his men often underwent a sudden change of 100° or even 120°, in passing from the cabin of their vessel to the outer air, and yet none but the most trifling complaints resulted. Here we have all the circumstances from which experience would lead us to anticipate renal disease: great preceding depression, intense and protracted cold suddenly applied. From these facts we may be guided as to the way in which cold acts as a source of renal inflammation. Extreme cold, though does not it produce it. may stop cutaneous exhalation, probably does not allow the material to accumulate. Cold increases the action of oxygen, and gives rise to increased combustion of the solids and fluids of the body. By cold the respiratory function is exalted, and the excretion of urea is diminished. With the intense cold of the North Pole, the introduction of oxygen by the lungs is probably so great, and oxydation in the body so active, that all material susceptible of such action becomes oxydized, as much of it as can be converted into carbonic acid and water passing out with the breath. The kidneys, therefore, are not liable as in temperate climates, to be irritated by excrementitious matter, for the stress of excretion falls upon the lungs.† Kidneys saved by the lungs. Journey to the Shores of the Polar Sea.' By Captain Franklin. Vol. iv. †The importance of the skin as an organ of excretion, and the amount of resemblance between the secretion of the skin and that of the kidneys, may be learned from the following details :— Urea is known to be constantly present in the cutaneous secretions. It has |