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will keep every part as clean as he does those parts which are exposed to the light. A pail of cold or tepid water in a common bath is all-sufficient; neither need the washing be a long or formal process. To step into the water ankle deep, with a good glovesponge to wash the surface freely and carefully, and to dry effectually with a rough towel, these are the requirements, and these alone. The whole proceeding is a matter of ten minutes, and, carried out night and morning, is no great encroachment either on time or labour.
Granting, however, that the ablution can be made once only in the day, it had better be conducted at night than in the morning; for during the day a free accumulation of foreign and excreted matters takes place on the skin, to sleep in which is most unwholesome and injurious. During the night this accumulation is trifling in comparison, but still it is better to remove it also in the morning.
Coincidently with free ablution, active exercise of the body is essential; and of all exercise, that on foot is the best. The exercise, in point of duration, may be prolonged, but it should always be so tempered as not to subject the patient to sudden alternations from heat to cold. Nor should the patient, when he has taken a walk or performed any muscular effort to produce a warmth of the surface, linger about in cold, or chilled, or damp air.
In extreme cases, where the suppression of the renal secretion is such as to demand a greater secreting force for the skin, the hot-air bath may
prove very valuable; nay, the immediate risk of an impending comatose attack may be warded off, I believe, by the diaphoresis which the hot-air bath induces. Enthusiastic advocates of the bath, who teach that it is intended to supplant exercise in all who can afford to pay for it, would urge, and do urge, that the said bath is the only remedy in the class of cases now under discussion. I demur to this extreme doctrine; for I know that, in the majority of cases, the simple influences of ablution and exercise constitute the first preventive agencies, and that, so long as the skin maintains a genial function by such agencies, so long all that can be done evenly, and therefore safely, is achieved. But in saying this, I hold no reserve against the bath, in instances where rapid excretion is required. I am not sure, certainly, by what surface the excretion is, in every case, best effected, whether by the alimentary or the cutaneous surface; but in the majority of instances, perhaps cutaneous elimination is the readiest to be excited, the most pleasant, the least irritating, and as a measure for the discharge of urea, the most effective.
The diet of the patient threatened with uræmia should be of the simplest character. Alcoholics in moderate quantities do no harm, but, as it seems to me, good; for they keep the surface of the skin free, and to the circulation supply a gentle stimulus which is much required. All highly seasoned foods should, nevertheless, be avoided, and an excess of nitrogenous foods equally so. Animal food should not be taken
more than once daily. Fruits in their season are useful, and I know of no kind of fruit which may not be taken in the fresh state; preserved fruits appear to derange the digestion, and to be objectionable. · The amount of fluid taken should be moderate; it need not be greatly or ridiculously reduced, but kept within bounds: the adult man, I mean, should not exceed three pints of fluid daily on the average, for to exceed this is to put a strain on the kidneys, the preservation of which from overwork is all-important. And, there is yet another hint of value in reference to diet,—the food taken should always be received in small quantities at a time. This rule, applicable to men and women in all periods of life, is peculiarly forcible in these cases; for the organs of nutrition and excretion have enough to perform when taxed lightly and often ; to overwhelm them with material is to stop their action altogether.
Medicinally, the rule in uræmic cases holds good, " that the least done is soonest mended.”. It may be of service to give a purgative on occasions when there is constipation, and in the absence of a sweating hotair bath, it may be essential to administer a brisk cathartic. Indeed, as a matter of experience derived from common empirical observation for centuries past, in early stages of uræmic coma (apoplexy, according to the vernacular), the treatment by free purgation has been the universal and, on the whole, the successful method. But in the selection of a purgative, great care is necessary. To give, in the cases we are considering, a mercurial purge, is simply and positively to give poison. A saline purgative, therefore, or a simple vegetable pill, such as colocynth, or colocynth with a small proportion of gamboge, is sufficient. In cases where the patient is anæmic and feeble, a chalybeate aperient is often advantageously prescribed, and repeated perhaps daily, if the constipation is obstinate or frequent; such a purgative as the following, for instance, is of great benefit: Saccharine carbonate of iron, ten grains ; carbonate of magnesia, one scruple; sulphate of magnesia, one drachm. This may be given two or three times a week, or even more frequently.
While the bowels and skin are thus led to active performance of their duties, the kidneys should be left to do as little labour as is in any degree possible: these facts being always kept uppermost in the mind of the practitioner, that the cessation of the excreting function of the kidney indicates at once a tendency to congestion of the renal organs; that congestion, once commenced, passes rapidly to suppression of function; and that, to relieve renal congestion, not the kidney, but some other emunctory channel, must be freely opened. Let me dwell on this point with special force; for one of the greatest errors common to the inexperienced, is to give diuretics to a badly working kidney-an error as unphilosophical and injurious as it is unpardonable.
I have shown that, in some cases of chronic renal disease, with tendency to suppression of urine and
accumulation of urea, there is often set up, as though it were a natural means of relief, a frequent action of the bowels. The bowels may act two or three times a day, and the amount of matter passed may be large and fluid. This state may continue for years, and, so far from being hurtful, may be, in truth, the saving clause. During the period while this lasts, the urine, moderately scanty, may be altogether free from albumen, and the progress of renal disorganisation be greatly prevented. I need hardly conjoin to this description the advice, that so long as the elimination by the bowels is moderate it should not be checked ; and, above all, that it should never be checked by opium, i.e. by the administration of one narcotic to check the excretion of another. It is possible, nevertheless, that under some special influence a diarrhæal flux may be set up in an uræmic patient which shall exceed the power of the system, and demand, like an ordinary diarrhea in a healthy individual, the exercise of some means by which it may be checked. In such instances as are now noticed, the use of opium and of grey powder, alone or combined, being carefully avoided, recourse should be had to one of the simple styptic remedies. Tannin and gallic acid are excellent; if they fail, sulphuric acid is the next remedy to resort to: given in free doses with a little ice-water, as in ten-minim doses of the dilute acid of the London Pharmacopoeia, the remedy will require but little repetition to produce an astringent effect as thorough as may be desired, for it is the natural tendency of the flux to