TREATMENT - CHRONIC PRODUCTIVE OR DIFFUSE NEPHRITIS WITH In the second and third group of cases just described the attacks are of acute or subacute character. The conditions calling for treat ment are: The nephritis; The albuminuria; The dropsy; The headache and sleeplessness; The nausea and vomiting; The contraction of the arteries ; The anemia; The dyspncea.
For the nephritis the patient should be kept in bed and placed on a fluid diet. He should have a hot pack twice a day, once a day, or every other day, as he will bear it. The most useful drugs are: mor phine in very small doses, digitalin gr. 1+5, and aconite Tri i.—iij.
The quantity of albumin in the urine can be diminished by the hot pack and by the use of digitalin gr. four times a day.
The dropsy is favorably affected by the hot pack. It can be sen sibly diminished by cathartics, of which elaterium is perhaps the best. But the effect of cathartics is temporary, and their administra tion cannot often be repeated.
For many patients digitalis in some form is the most useful drug for the dropsy, and it can be continued without injury for weeks and months. Favorable results are reported from the use of lactate of strontium in 30-grain closes four times a clay, and from diuretin in 5-grain doses three times a day. In some patients caffeine, conval laria, or strophanthus will answer better than digitalis.
If there is much fluid in the serous cavities it should be drawn off with the aspirator. If the dropsy of the subcutaneous connective tissue is excessive the skin is to be pricked and the fluid allowed to drain off.
The headache and sleeplessness may exist with or without tion of the arteries. If the arteries are not contracted, morphine in very small closes, codeine, or the bromides can be used. If the arteries are contracted morphine in larger doses and chloral are the best drugs. The nausea and vomiting are controlled by the milk diet, or it may be necessary to add an alkali to the milk, or to use peptonized milk or ku my ss Contraction of the character of the radial pulse and the heart's action are to be constantly watched. We do not wait for the dyspncea, or vomiting, or convulsions to make their appear ance, but as soon as the pulse shows an increased tension we begin with nitroglycerin, chloral hydrate, morphine, or potassium iodide. It is to be remembered that morphine iu considerable doses can only be given to patients with this form of nephritis when the arteries are contracted. At all other times it is very easy to have dangerous and even fatal results with any preparation of opium.
The ancernia of chronic nephritis does not behave like simple anaemia. Iron is not a specific for it, although it may be of service. The greatest improvement in the anaemia is effected by the subsidence of the nephritis.
The dyspncea is dependent either upon contraction of the arteries or upon dropsy. The treatment for it, therefore, is either the treat ment of dropsy or the treatment of contraction of the arteries.
In these two groups of cases treatment carried on in these ways is often very satisfactory. All the symptoms subside and disappear. But it must be remembered that the kidneys have become changed in their structure, that a chronic productive nephritis still continues, that relapses and exacerbations are to be expected.
As the symptoms subside the patient gets back to a solid diet, is out of bed and then out of doors. If it is possible for him to spend the next two years in a warm climate where he can lead an out-of door life, the probabilities of permanent improvement will be much greater.
In the first set of cases, those in which the symptoms continue and get steadily worse, treatment is very unsatisfactory. We try the measures that have just been described, but they are of no avail. We cannot even alleviate symptoms, the drugs do not help at all. After a time it becomes evident that there is no use in continuing plans of treatment which do nothing, and we employ very little treat ment.
The fourth set of cases have no acute attacks, no great change in the general health, nothing but the anaemia and the changes in the urine. The management of these cases requires much judgment.
The patients should have a liberal and varied diet and yet every form of indigestion is to be guarded against. They do best if they can live in a warm climate all the year round. But even in an unfa vorable climate they need out-of-door exercise. The drugs indicated are those for the relief of indigestion, and the preparations of iron.
The patients who begin with attacks of dyspncea, without other renal symptoms, can often be relieved and enabled to work for a number of years. The dyspncea is associated with a pulse of high tension; if we can relieve this the dyspncea disappears. The best drugs for this purpose are nitroglycerin, chloral hydrate, and po tassium iodide.
In the cases with chronic endocarditis, myocarditis, or dilatation of the ventricles, the management of the heart's action becomes a matter of great importance.