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SCIENTIFIC THERAPEUTICS.
553
Correspondence.
Iaim must, be not to abstract water, but to get rid of the excrementitious substances of which it is the inoffending In clearing the system of these renal exereta, I think it must be admitted that a little urine is worth a great deal of sweat. Sweat, in health, as Dr.ofParkes has nitrogen; recently shown, is nearly or quite destitute and though in uraemia, there is reason to believe that urea may escape by this channel, yet the kidneys afford a much more certain and liberal exit. Uric acid, so far as I am aware, has not been detected in sweat. The sweat, particularly of enforced perspiration, is, compared to urine, an exceedingly poor and watery fluid, and when the renal secretion is already greatly too scanty, it is probable that sweat is seldom worth the urine it costs. I may appeal to Dr. Johnson’s own large experience, and ask him whether he has not observed the oedemataus accumulations of renal disease to obey diuretics more readily than sudorifics. In recent nephritis, whenever the urine from any cause becomes more abundant, then almost certainly will the dropsy proportionally abate; with regard to perspiration the connexion is far less evident. Against active and repeated purging similar objections may be urged, though no one would propose in these cases totally to exclude aperients. The fseces, according to Dr. Parkes, furnishes in health an exit for a quantity of nitrogen equal to about a tenth of that which leaves by the urine, though it is probable that in disease this proportion may be increased. With threatening uræmia, experience has shown that we may advantageously call upon this means of elimination ; but I believe that repeated hydragogues are not beneficial-they should be sharp and seldom. When dropsy causes great distension anything which relieves the pressure may, probably by liberating the organs, help to re-establish secretion. We see something of this kind now and then after tapping for hepatic ascites, and it is quite possible that a diuretic effect may in renal disease now and then follow a drastic purge ; but this is exceptional, and does not invalidate the general rule that hydragogues lessen the urine. I am in the habit of treating acute renal dropsy by careful protection from cold, liquid but not innutritous diet, digitalis (a remedy under these circumstances of unequalled value), iron, and, after a time, in place of the digitalis, a less depressing diuretic, such as acetate of potass. With these measures we may keep drastics and vapour-baths as reserves for uraemia, in the confidence that they will seldom be required. I refer, as Dr. Johnson has done, to results, fully allowing at the same time that I am less entitled than is he to
vehicle.
"Audi alteram partem."
SCIENTIFIC THERAPEUTICS. To the Editor of THE LANCET.
SIR,-A reference by Dr. Wilks to some objections I had expressed to the general treatment of recent nephritis by purging and sweating, has brought from Dr. George Johnson a vigorous defence of those time-honoured measures, as applied to renal dropsy. In the treatment of albuminuria, especially of recent cases associated with dropsy, Dr. Johnson thinks it wise to promote by well-selected meansthe "
free action of the skin and bowels. The well-selected means" include hydragogue purgatives and hot-air baths; and I have no doubt that in certain cases these remedies may be considered as rightly chosen. Dr. Johnson, however, does not solely rely upon these measures, but advises - and in this respect I most heartily concur with him-the free use of diluents, and a scanty diet. The difference of opinion between Dr. Johnson and myself appears to be limited to this. In the treatment of acute renal dropsy he relies mainly upon remedies addressed to the skin and bowels; I rely mainly upon remedies bearing directly upon the kidneys. I wish it to be clearly understood at starting that my objection to repeated purging and sweating relates in particular to remediable or possibly remediable states. With the granular kidney, where the structure of the organ is irretrievably gone, the judicious use of purgatives and hotair baths is often of great and constant service. I believe that in advanced granular degeneration with copious urine, a periodical hot-air bath often does more good than anything else. And when, as the result of simple nephritis or lardaceous change, the kidney has passed redemption, similar measures may be called for. Under any condition of renal disease, should uræmia press, it may be needful to use the most active purgatives, hot-air baths, and evacuants of every class. It is, of course, impossible to make invariable rules for variable cases. Treatment must shift with symptoms, and I am prepared on occasion to take Dr. Lettsom for my guide, and find both rhyme and reason in the practice which is associated with his name. Thus guarded, I still maintain the general principle that recent inflammation of the previously healthy kidney, as manifested by albuminuria and dropsy, is more safely and more rationally treated by unirritating diuretics than by purging and sweating. A hot-air bath every other night, and a dose of compound jalap powder every other morning (extreme practice which I do not for a moment attribute to Dr. Johnson) used to be a not uncommon, but must unsuccessful, routine in renal dropsy. The disease in question consisting essentially of a plugging of the renal tubes by morbid products, it is easy to believe that the mere passage of aqueous fluid may clear the channels and assist in the restoration of the gland-a salutary issue which will be obviously retarded by want of water in the secretion. Besides this, a general rule holds good in this disease that the urinary solids discharged in a given time increase with the quantity of urine. Therefore, whichever way we look at it, what increases the urine will do good; what diminishes it will, so far, do harm. Hydragogues and vapour baths undoubtedly, as a rule, make the urine more scanty. Dr. Johnson urges the evident superabundance of fluid in the tissues in these cases, and infers that the drain by the skin and bowels can be spared; but, on the other hand, it is a matter of common observation that the fluid thus abstracted, especially by sweating, is yielded at the expense of the urine rather than of the effusion. It forestalls the urine instead of draining the dropsy. Dropsical fluid often resists diaphoresis with extreme tenacity. The system is flooded, not by simple water, but by a highly saline and nitrogenised fluid, loaded with urinary elements. I presume that the solid constituents of this fluid play a more important part in the pathology of renal dropsy than the water in which they are dissolved. Our "
from
experience. I, however, have had especial of observing the disease in children, and I have learned to apply the method I have sketched with a general trust in its issue which I have not been able to speak
opportunities
accord to any other method of treatment.
Obediently Chesterfield-street, April 17th.
yours,
W. HOWSHIP DICKINSON.
ON THE TEMPERATURE OF THE BODY IN TETANUS. To the Editor of THE LANCET. SIR,—When bringing before the Clinical Society, in October last, a case of recovery from tetanus (see THE LANCET of Oct. 22nd), I drew attention to the fact that during a considerable period, and at a certain stage of the attack, the temperature of the patient, in addition to its being unusually high, was found to be augmented in the evening. I was thus led to offer the suggestion that possibly this thermal variation of temperature might be found to obtain generally or even universally in true tetanus. Since then I have had no opportunity of making further research as to temperature in this disease, but Dr. W. W. Keen, of Philadelphia, has sent me an account of a case of tetanus which was under his care* in St. Mary’s Hospital in that city, in which, for several days during a portion of the illness, the evening temperature was markedly higher than Dr. Keen gives a table showing thLin the morning. diurnal state of the pulse, respiration, and temperature, *
The Medical 2’imea
(Philadelphia), March lst.
Correspondence.
Iaim must, be not to abstract water, but to get rid of the excrementitious substances of which it is the inoffending In clearing the system of these renal exereta, I think it must be admitted that a little urine is worth a great deal of sweat. Sweat, in health, as Dr.ofParkes has nitrogen; recently shown, is nearly or quite destitute and though in uraemia, there is reason to believe that urea may escape by this channel, yet the kidneys afford a much more certain and liberal exit. Uric acid, so far as I am aware, has not been detected in sweat. The sweat, particularly of enforced perspiration, is, compared to urine, an exceedingly poor and watery fluid, and when the renal secretion is already greatly too scanty, it is probable that sweat is seldom worth the urine it costs. I may appeal to Dr. Johnson’s own large experience, and ask him whether he has not observed the oedemataus accumulations of renal disease to obey diuretics more readily than sudorifics. In recent nephritis, whenever the urine from any cause becomes more abundant, then almost certainly will the dropsy proportionally abate; with regard to perspiration the connexion is far less evident. Against active and repeated purging similar objections may be urged, though no one would propose in these cases totally to exclude aperients. The fseces, according to Dr. Parkes, furnishes in health an exit for a quantity of nitrogen equal to about a tenth of that which leaves by the urine, though it is probable that in disease this proportion may be increased. With threatening uræmia, experience has shown that we may advantageously call upon this means of elimination ; but I believe that repeated hydragogues are not beneficial-they should be sharp and seldom. When dropsy causes great distension anything which relieves the pressure may, probably by liberating the organs, help to re-establish secretion. We see something of this kind now and then after tapping for hepatic ascites, and it is quite possible that a diuretic effect may in renal disease now and then follow a drastic purge ; but this is exceptional, and does not invalidate the general rule that hydragogues lessen the urine. I am in the habit of treating acute renal dropsy by careful protection from cold, liquid but not innutritous diet, digitalis (a remedy under these circumstances of unequalled value), iron, and, after a time, in place of the digitalis, a less depressing diuretic, such as acetate of potass. With these measures we may keep drastics and vapour-baths as reserves for uraemia, in the confidence that they will seldom be required. I refer, as Dr. Johnson has done, to results, fully allowing at the same time that I am less entitled than is he to
vehicle.
"Audi alteram partem."
SCIENTIFIC THERAPEUTICS. To the Editor of THE LANCET.
SIR,-A reference by Dr. Wilks to some objections I had expressed to the general treatment of recent nephritis by purging and sweating, has brought from Dr. George Johnson a vigorous defence of those time-honoured measures, as applied to renal dropsy. In the treatment of albuminuria, especially of recent cases associated with dropsy, Dr. Johnson thinks it wise to promote by well-selected meansthe "
free action of the skin and bowels. The well-selected means" include hydragogue purgatives and hot-air baths; and I have no doubt that in certain cases these remedies may be considered as rightly chosen. Dr. Johnson, however, does not solely rely upon these measures, but advises - and in this respect I most heartily concur with him-the free use of diluents, and a scanty diet. The difference of opinion between Dr. Johnson and myself appears to be limited to this. In the treatment of acute renal dropsy he relies mainly upon remedies addressed to the skin and bowels; I rely mainly upon remedies bearing directly upon the kidneys. I wish it to be clearly understood at starting that my objection to repeated purging and sweating relates in particular to remediable or possibly remediable states. With the granular kidney, where the structure of the organ is irretrievably gone, the judicious use of purgatives and hotair baths is often of great and constant service. I believe that in advanced granular degeneration with copious urine, a periodical hot-air bath often does more good than anything else. And when, as the result of simple nephritis or lardaceous change, the kidney has passed redemption, similar measures may be called for. Under any condition of renal disease, should uræmia press, it may be needful to use the most active purgatives, hot-air baths, and evacuants of every class. It is, of course, impossible to make invariable rules for variable cases. Treatment must shift with symptoms, and I am prepared on occasion to take Dr. Lettsom for my guide, and find both rhyme and reason in the practice which is associated with his name. Thus guarded, I still maintain the general principle that recent inflammation of the previously healthy kidney, as manifested by albuminuria and dropsy, is more safely and more rationally treated by unirritating diuretics than by purging and sweating. A hot-air bath every other night, and a dose of compound jalap powder every other morning (extreme practice which I do not for a moment attribute to Dr. Johnson) used to be a not uncommon, but must unsuccessful, routine in renal dropsy. The disease in question consisting essentially of a plugging of the renal tubes by morbid products, it is easy to believe that the mere passage of aqueous fluid may clear the channels and assist in the restoration of the gland-a salutary issue which will be obviously retarded by want of water in the secretion. Besides this, a general rule holds good in this disease that the urinary solids discharged in a given time increase with the quantity of urine. Therefore, whichever way we look at it, what increases the urine will do good; what diminishes it will, so far, do harm. Hydragogues and vapour baths undoubtedly, as a rule, make the urine more scanty. Dr. Johnson urges the evident superabundance of fluid in the tissues in these cases, and infers that the drain by the skin and bowels can be spared; but, on the other hand, it is a matter of common observation that the fluid thus abstracted, especially by sweating, is yielded at the expense of the urine rather than of the effusion. It forestalls the urine instead of draining the dropsy. Dropsical fluid often resists diaphoresis with extreme tenacity. The system is flooded, not by simple water, but by a highly saline and nitrogenised fluid, loaded with urinary elements. I presume that the solid constituents of this fluid play a more important part in the pathology of renal dropsy than the water in which they are dissolved. Our "
from
experience. I, however, have had especial of observing the disease in children, and I have learned to apply the method I have sketched with a general trust in its issue which I have not been able to speak
opportunities
accord to any other method of treatment.
Obediently Chesterfield-street, April 17th.
yours,
W. HOWSHIP DICKINSON.
ON THE TEMPERATURE OF THE BODY IN TETANUS. To the Editor of THE LANCET. SIR,—When bringing before the Clinical Society, in October last, a case of recovery from tetanus (see THE LANCET of Oct. 22nd), I drew attention to the fact that during a considerable period, and at a certain stage of the attack, the temperature of the patient, in addition to its being unusually high, was found to be augmented in the evening. I was thus led to offer the suggestion that possibly this thermal variation of temperature might be found to obtain generally or even universally in true tetanus. Since then I have had no opportunity of making further research as to temperature in this disease, but Dr. W. W. Keen, of Philadelphia, has sent me an account of a case of tetanus which was under his care* in St. Mary’s Hospital in that city, in which, for several days during a portion of the illness, the evening temperature was markedly higher than Dr. Keen gives a table showing thLin the morning. diurnal state of the pulse, respiration, and temperature, *
The Medical 2’imea
(Philadelphia), March lst.