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THE TREATMENT OF CHEST INJURIES

MARION A. BLANKENHORN
1919 Journal of the American Medical Association  
prognosis in nephritis and to apply this knowledge in the treatment of our patients. The expectancy of life of the sufferer with chronic nephritis may be regarded as being measured by three possible terminations : First, factors which may be considered to be entirely extrarenai, of which heart failure, apoplexy and intercurrent infections constitute those most constantly met. It is our inability to gage their prog¬ ress satisfactorily that is largely responsible for the uncertain prognosis in
more » ... tain prognosis in chronic nephritis. Second, many patients with chronic nephritis die of uremia before renal function has diminished to such a degree as to render renal insufficiency any more than a contributing factor. Often the phthalein excretion lies between 20 and 30 per cent, and the blood urea nitrogen at a level of from 40 to 50 mg. per hundred cubic centimeters of blood. It is probable that this state of affairs is a toxemia, but from what tissue this poison originates, what its nature is, and what the exact conditions are that call it into action are all open questions. The sudden rise of blood nitrogen seen in one of Dr. O'Hare's cases may pos¬ sibly indicate an excessive protein destruction which I believe is characteristic of certain phases of the toxemia under dis¬ cussion. Third, if all the above vicissitudes leave the sub¬ ject of chronic nephritis alive he finally develops an increas¬ ing renal insufficiency to which he succumbs. This is a very prolonged process and it is almost incredible how low renal function may drop and the patient maintain at least fair health. Dr. O'Hare's report illustrates this very well. I have seen some similar cases though more of them were followed for as long a period. In another condition, polycystic kidney, in which an uncomplicated renal insufficiency develops, the same phenomenon of prolonged life with a maximal impairment of renal function is often found. As far as prognosis is concerned, it becomes· evident that only very few nephritic patients really die as the result of renal insufficiency but that most of them cease to live because of extrarenai influences. Dr. Edward F. Wells, Chicago : Satisfactory management of the patient depends largely on taking him into full con¬ fidence as to the diagnosis, the prognosis, and the general plan of treatment. Chronic interstitial nephritis is not a disease of the kidneys alone, but the blood vessels, heart, lymphatics, and other tissues are so essentially implicated that it is impossible to separate them. It takes a profound clinician to estimate within wide limits, the excretory capac¬ ity, under stress, of the interstitial nephritic kidney; and it requires a wiser physician than most of us to state how long any one of these patients may live. I have seen patients in whom the output of urea was extremely small for many successive months, in whom, when placed on some extra strain the kidneys have passed such quantities of urea as are beyond ordinary credence. Therefore, our prognosis should be extremely circumspect. Our first examination of a chronic interstitial nephritic patient should be made with painstaking care, and accuracy. The renal capacity should be estimated as closely as possible from several points of view, as, e. g., the excretion of water, of salt, the rapidity and completeness of the passage through the circulatory system, including the lymphatic circulation, of titratable solutions, and of the out¬ put of some of the waste products of metabolism. I value highly the measurement of the capacity of the kidneys to excrete urea, and always include this as an important feature of the investigation. The dietetic, regimental and medicinal measures which we employ may, probably, assist the kidney in its functions. However, some adventitious conditions are beyond our control as, e. g., the entrance into the system of an acute infection. In my own experience these most fre¬ quently transform, by disturbing the circulatory balance, a satisfactory progress to a condition from which the patient rarely completely recovers, and is often the beginning of a more or less prolonged downward course, ending fatally. Under these circumstances the patient will become dyspneic, and apneic ; dependent edema will attract attention. It is absolutely necessary for the patient to maintain a posture as nearly horizontal as possible for a prolonged period, at least six weeks. Dr. Lewis A. Conner, New York: The second of Dr. O'Hare's cases illustrates a point which is of great practical importance. That is, that in aged people the usual standards of normal kidney function are not applicable. If we attempt to prognosticate, in the case of people of 70 or 80 years of age, in terms of the standards of renal function which we apply to younger people, we are likely to make embarrassing mistakes. In such patients very low readings of the phthalein test and very high figures for blood nitrogen, creatinin, etc., are compatable with fairly good health and with many years of life. Dr. James P. O'Hare, Boston : This type of case is a rare condition. We do not see it very often but we do see it often enough to warrant hesitancy in making a prognosis in a chronically sclerosed kidney. We have had also a few cases of the edematous chronic glomerular nephritis and the patients have lived for quite a considerable period, that is, for months, with a very low renal function, and then have died from a pneumonia. I was glad to hear Dr. Mosenthal comment on the fact that death in the nephritic is very fre¬ quently due to causes not essentially nephritic but to other conditions like cardiac failure and infection. I have often been very much disappointed in cases that we had studied for a long time to find the patient dying of an acute infection or a cardiac complication when we were looking for a pure nephritis at necropsy. It is important for all of us to make records of our observations on these cases so that if a patient does live for a longer period than we expected, we can analyze the data obtained. Most of us do not do that. In fact, there has been no opportunity to do that until now because the renal tests were unknown until a few years ago. But now we have tests which are easy to make, and it is important to use them and make observations of these patients. Bear in mind, however, that even with our func¬ tional tests we are unable at present to make accurate prog¬ noses. . We make them with a fair degree of accuracy, but that degree of accuracy is often brought about by the fact that the patients die of an intercurrent infection or of cardiac failure rather than from the kidney disease. The treatment of penetrating wounds of the chest early in the war was an unsatisfactory venture offering little prospects of development, but at the end was a very satisfactory procedure promising much in the improvement of its technic and the enlargement of its scope. Methods of examination of a wounded chest are precise; and in contrast to the abdomen or head, the damage done by a foreign body can be estimated and the treatment indicated. Foreign bodies entering the chest usually continue moving in straight lines; they produce discoverable lesions and can be located accurately by the roentgen ray. With proper appliances and training, the surgeon can invade the thorax to make anatomic repairs and remove infecting foreign substances. The effect of various infecting organisms in chest wall, pleura and lungs is still the greatest unknown quantity of the problem and the one that has yielded the least to our efforts. It is with little satisfaction that I review the statistical reports of the various surgeons in France and England, and with even less satisfaction that I inspect my own records during two summers in forward area hospitals and one winter at the base. There were no invariable concomitants-warfare and its wounds,
doi:10.1001/jama.1919.02610300015005 fatcat:rhrk7tynyzgoxd4v7hw5uvnkny