TREATMENT - ACUTE PRODUCTIVE OR DIFFUSE NEPHRITIS.
In those cases in which the disease behaves like an acute exuda tive nephritis the indications for treatment are the same as in the latter disease, although the results are not so satisfactory.
The subacute cases have to be managed differently. At first it is wise to keep the patients in bed and on an exclusively milk diet. In some of the patients the daily use of the hot pack seems to be of ser vice, in some nothing is gained by its use, in some it is I think harm ful. I do not know how to distinguish the appropriate cases for the hot pack except by trying its use for a few days.
Digitalis, preferably in the form of digitalin in doses of o 0 of a grain, seems in some of the cases to exert a favorable effect on the nephritis—at all events the quantity of albumin in the urine dimin ishes and the patients improve; but in some other cases it does nothing. In the same way morphine small doses, sometimes not more than ofa grain, relieves the headache, sleeplessness, and nau sea, and the patients are evidently better for it. But there are other patients to whom the morphine is of no service whatever.
The dropsy is always of consequence. It is associated with a soft pulse; a fair heart action, rather feeble than forcible; no great dispo sition to venous congestion. The composition of the blood is pro foundly changed by the diminution in the quantity of haemoglobin and the number of red blood-cells, and probably in other ways which we do not appreciate. The quantity of urine may be either dimin ished or increased. The dropsy, therefore, does not seem to depend on changes in the blood pressure or in the quantity of urine, but rather on changes in the composition of the blood or in the walls of the arteries. It is a dropsy which it is very difficult to treat intel ligently.
There are cases in which the dropsy will disappear simply with the rest in bed and the milk diet.
There are cases in which profuse sweating by the hot-air bath or the hot pack diminishes the dropsy. But some of these patients cannot be made to sweat, some of them are too much depressed by the heat, in some the sweating does not diminish the dropsy.
Hydragogue cathartics, such as jalap and elaterium, will often diminish the dropsy for a time. Their use, however, cannot be con tinued for any length of time without irritating the stomach and in testines.
The daily use of good massage with compression of the legs by bandages is sometimes of real value.
Digitalis, caffeine, and strophauthus in many cases act efficiently, even when they do not increase the quantity of urine. They are the most useful drugs for this particular purpose.
The use of diuretics is limited to the cases in which the quantity of urine is diminished. In a patient with increasing dropsy, who is already passing 90 or 100 ounces of urine 'a day, diuretics are not in dicated. The drugs ordinarily employed to effect diuresis are those which act on the circulation—digitalis, caffeine, strophanthus, and convallaria; and those which are supposed to act on the kidneys— acetate of potash, lactate of strontium, squills, diuretin. Good re sults are reported from the use of those drugs. But experience shows that in some patients the quantity of urine cannot be increased, and in others the increase in the quantity of urine is not followed by diminution of the dropsy.
It would seem as if the disposition to dropsy could be controlled if we could control the composition of the blood, increase the number of the blood-cells, and raise the specific gravity of the blood serum. Unfortunately we do not know how to do this.
When necessary, to make the patient more comfortable, we have to tap the peritoneal and pleural cavities and to puncture the skin of the legs.
If the patients improve, the milk diet is to be gradually replaced by solid food, iron is to be given in fair doses, and the patient gets out of bed and out of the house. At this time climate becomes a matter of much importance. The patient should be sent to a warm, dry, equable climate where lie can lead an out-of-door life.