DISEASES OF THE KIDNEYS, INCLUDING THE PELVIS OF THE KIDNEYS.
BY ROBERT T. EDES, M.D.
Anomalies of Shape, Size, Number, and Position.
The kidneys are two glandular organs, of a concavo-convex shape so characteristic as to be frequently used as a term of comparison, situated on each side of the vertebral column, with the longer diameters nearly parallel thereto, but slightly convergent toward the upper extremity, and extending from about the upper border of the eleventh rib on the left side and the middle of the corresponding rib on the right to the second or third lumbar vertebra. Hence they are somewhat less than half covered by the last two ribs.
The upper extremity is a little the wider and the thinner, and by this peculiarity and a recollection of the position of the vessels (from the front, vein, artery, ureter) the two kidneys may be assigned to their proper sides after removal from the body.
They are behind, and at their upper extremities nearly in contact with, the peritoneum, resting, with their more or less voluminous envelope of adipose tissue, upon the great muscles of the loins. The fat which in the normal condition surrounds the kidneys varies, as might be supposed, within wide limits, and is by no means devoid of importance, since its deficiency is undoubtedly a predisposing cause for some of the displacements hereafter to be described. In this fatty mass may also be situated perinephritic abscesses, and into it spread with considerable facility morbid growths originating in the kidney itself.
At the middle of the inner borders of the kidneys are situated the hiluses into which enter veins, arteries, ureters, nerves, and lymphatics, united by connective tissue and forming a sort of pedicle.
The normal weight of each kidney is to be expressed by a rough average as from four and a quarter avoirdupois ounces, or one hundred and twenty grammes, on the one hand, to seven ounces, or two hundred grammes, on the other; but since a deficiency in the size of one is not unfrequently compensated by an increase in the other, it would be safer to give the weight of the pair as from two hundred and forty to four hundred grammes, the lesser number representing those organs which are not only small but anæmic, and the larger those which are either distinctly hypertrophied or much congested: many diseased kidneys will also be found within these limits.
The size of the kidney is in a general way proportioned to the size of the body: the proportion is stated as 1 to about 240. A disproportionate change in the size of both kidneys without any change in structure is a true hypertrophy, and may be met with in persons whose habits as regards the ingestion of fluids (especially such as are freely secreted by the kidneys—for instance, beer or other forms of dilute alcohol) tend toward excess, or where a disease like diabetes throws a large amount of diuretic material into the circulation.
The deep position of the kidneys makes them usually inaccessible to physical exploration to any practical extent. In stout persons they are so entirely covered by their own immediate envelope of fat, by the adipose tissue of the mesentery, and by the thick abdominal walls as to be completely indistinguishable. In thinner persons deep palpation with both hands may enable us to say that there is a diminished resistance to pressure, as in the case of movable kidney, or that there is or is not any decided enlargement. Slighter changes in size cannot be accurately determined, although Bartels1 states that he was once enabled to detect a considerable enlargement in a case of parenchymatous nephritis by double palpation. In moderately thin persons the lower end of the kidney can be more or less distinctly felt.
1 Ziemssen, vol. xv.
A position upon the hands and knees (not the gynecological semi-prone position), allowing the whole abdomen to gravitate directly away from the backbone, is said to afford, by the varying concavity of the lumbar region on the two sides, information as to the absence of either kidney from its usual place. When the kidney, however, is displaced, and when it comes decidedly forward from increase in its own size or from the pressure of a tumor behind it, it may very often become extremely accessible.
Percussion gives even less information than palpation, since the dulness of the lumbar muscles extends laterally beyond that of the kidneys, and is of itself so complete as to offer no change from the addition or subtraction of the resistance of the underlying organ.2
2 It is probable that Simon's method of thrusting the hand into the rectum and large intestine might be made available by a person with a small hand and arm for diagnosis in doubtful cases where the value of the information to be obtained would be sufficient to compensate for the risk of serious injury.
The removal of the kidneys may be accomplished through the rectum—and has been effected many times by myself and assistants—in cases where a complete autopsy is refused. The manoeuvre is not very difficult through a large and especially a female pelvis, but under other circumstances may be somewhat fatiguing. Considerable post-mortem information in regard to other organs may be obtained in the same way.
The most marked anomaly in the shape of the kidneys when both are present, and the only one which possesses a clinical interest, is that known as the horseshoe kidney, being a more or less complete fusion of the organs of each side in front of the vertebral column and the great vessels. This fusion is usually at the lower end, but may be in the middle or at the upper end. Sometimes there is a portion lying directly in front of the vertebral column so large and thick as to appear almost like a middle lobe or a third kidney. In a few rare instances this portion has formed a pulsating enlargement mistaken for an aortic aneurism or other abdominal tumor. In others compression of the great vessels has given rise to phlebitis, or the abnormal position of the ureters has obstructed the passage of the urine, with the results, as regards the secondary affection of the kidneys, to be described below. These instances are, however, among the curiosities of medicine, and no rule for their diagnosis can be laid down. A horseshoe kidney is usually discovered only after death, and with no special frequency in cases of renal disease.
Variations in the number of the kidneys possess this point of practical interest, that diseases affecting a single organ are more dangerous than if another exists which can take upon itself extra duty. Apparent absence of one kidney may be due to atrophy, attended with very small size of the renal vessels; in which case a small mass of connective tissue is found at the upper end of the ureter, which is usually illy developed. The other kidney is usually hypertrophied.
The kidney may fail to be developed. In this case there are no vessels corresponding to the renal artery and vein, and the ureter is stated to be invariably absent, but the writer has seen a specimen where the left ureter terminated superiorly in a rounded cul-de-sac, no kidney or suprarenal capsule being present. The other kidney was of rather large size in proportion to the size of the patient, but of the usual form. This defect is apt to be associated with some anomaly of the genital organs.
Another condition, apparently similar, but really due to a fusion of the two embryonic kidneys, is sometimes found. In this the single organ, situated upon one side, is irregular in form and in the number and origin of its vessels. There are usually two ureters, arising one above or beside the other, and directed to their proper positions in the floor of the bladder. A single ureter arising from a single kidney has been seen to empty upon the opposite side of the bladder.
Supernumerary kidneys have been noted. In one case an extra pair, situated below the others, were intensely inflamed, while the normal organs were not so.
A position of one kidney has been noticed considerably higher than normal, so as to push the spleen from its place. A more common anomaly, however, is the situation of one kidney at a point much below the usual, most commonly at the brim of the pelvis. When this happens the kidney itself is usually more or less distorted in form, and receives its blood-supply from several small arteries which enter it at irregular points, forming as it were several small hiluses. They may originate from the aorta or from one or both iliacs. The ureter is correspondingly short. This position is of some importance, since a pelvic tumor is formed which has in one instance proved an obstacle in childbirth, while in another the misplaced kidney itself underwent an acute nephritis from the pressure of the foetal head. The kidney tumor has in a few instances been felt in this position during life, but its nature has not been diagnosticated.
Floating Kidney.
The most clinically important change in the position of the kidney is not a permanent one, but varies from time to time with the posture of the patient and the altered conditions of pressure—externally by dress or apparatus, or internally by the other abdominal organs. It is known as floating or wandering kidney. In this affection the kidney ceases to be firmly imbedded in the fat usually found in the lumbar region, constituting a support and packing for these organs as well as for the suprarenal capsules, and is allowed more or less liberty of movement, which is restrained by a pedicle consisting of the ureter, vessels, and nerves, with more or less connective tissue. As it passes downward and forward it comes into more intimate relations with the peritoneum, which usually covers only the anterior surface, often with an intervening layer of fat, so that it may even gain a sort of special investment or meso-nephron.
The extent of the excursions of which the tumor thus formed is capable must naturally vary considerably. Sometimes the organ can be pushed or make its own way forward so as to come into contact with the anterior abdominal wall on the same side, and not much lower than the normal position, or it may pass considerably downward, and thus be confounded with tumors arising from the pelvis.
This affection is much more frequent among women than in men, and the right kidney is more frequently movable than the left: both, however, are sometimes dislocated. It is observed in a much larger proportion of cases in the laboring classes than in those whose work is less severe and carried on in less constrained attitudes. Judging from the relative amount of the literature of the subject, it would appear to be much less frequently observed in this country than among the lower classes of Germany, where so large a proportion of the severest outdoor labor is carried on by women.
Various causes are assigned for this displacement. It is stated to be usually congenital, but is not described as found post-mortem in children with at all the frequency that it occurs in adults; and it is certainly possible in adults to fix in many cases the beginning of the disease with a reasonable degree of certainty. That a certain amount of predisposition, or peculiarly favorable position of the kidney, or an unusual laxity of connective tissue, exists in a certain number of cases is undoubtedly true.
The next most important factor is undoubtedly a laxity of the abdominal walls, affording a less firm and unyielding support to the contained viscera, and a deficiency, usually an acquired one, of the fat surrounding the kidney, which enables it in the normal condition to be supported by the layer of peritoneum passing across its front from the spinal column to the flank. This is seen in a certain set of cases where the trouble dates from an acute disease or a rapid emaciation. The well-known influence of repeated pregnancies is undoubtedly exerted in this way.
Another set, especially those exceptional cases which occur in strongly-built and not thin persons, are referable to severe shocks received in gymnastic exercises, hard riding, or falls from a horse.
One of the most frequent causes, and one which accounts for the fact of the affection being most prevalent among the working classes, is the use of a tight strap or cord to support the garments. Corsets, which exercise a more even pressure over a larger surface, do not have this effect. The right kidney, from the position of its superior extremity in front of the liver and its slightly higher place in the abdomen, appears to be more influenced by this pressure than the left. The movements of respiration, especially when reinforced by the forced inspiration and compression of the abdominal viscera accompanying violent exertion, appear to assist in the dislodgment already favored by the pressure of the girdle.
According to Müller Warnek,3 who has laid especial stress on this method of causation, a slighter degree of displacement is possible in this way without or preceding the full development of wandering kidney. A pressure is exercised upon the descending duodenum with which the right kidney is brought into intimate relations behind, and bound down by, the peritoneum; which leads, as Bartels supposes, to a hindrance in the passage of food from the stomach, and consequent dyspeptic phenomena. In these cases, when the kidney has become a more freely movable one and has dropped farther down in the abdominal cavity, the pressure on the duodenum ceases, the consequent symptoms disappear, and give place to the dragging sensations and severe colicky attacks which are apt to characterize an older case.
3 Berl. klin. Woch., 1877, 38.
SYMPTOMATOLOGY.—There is great variety in the kind and amount of effect which the movable kidney exercises on the general organism and the local effects it produces. Neither the local nor the general symptoms are necessarily proportionate in severity to the amount of the displacement.
It may be said in advance that, contrary to what might be expected, the symptoms are not usually connected with any disturbance in the urinary function, and, although exceptions are not unknown, the rule is for a displaced kidney to be an otherwise healthy one. Cystitis and uterine affections have been observed in this connection, but it is doubtful if any relation other than coincidence or a mutual dependence upon impaired general nutrition and overwork exists between them. The partial stoppages which might be supposed to arise from the twisting of the ureters are not frequently observed.
Hysteria and hypochondriasis have been frequently attributed to this lesion, and might undoubtedly find their exciting cause in anxiety about a tumor of unknown character and origin; but there seems no good reason to connect them in any other relation of causation. It is undoubtedly true that many pains and discomforts exist in these cases which are neither satisfactorily explained nor gotten rid of by being called hysterical. These abdominal pains, especially of a dragging character, and also the sensation as of something falling or moving about in the abdomen, particularly when the patient assumes the upright posture or makes unusual exertions, are very naturally connected with the existence of the actual condition which is likely to give rise to them. Müller Warnek has recorded the frequent coincidence of flatulent dyspepsia and dilatation of the stomach depending on retention, and its consequent fermentation, in connection with the movable kidney and its supposed pressure on the duodenum. It is not probable, however, that all the symptoms are to be explained so simply, but it is quite as likely that the dragging and tension of the pedicle may have a remoter effect through the renal and sympathetic nerves.
Severer attacks occasionally occur with violent colic and inflammatory symptoms, the tumor formed by the misplaced organ becoming exceedingly sensitive to pressure. These have been attributed to some incarceration, but there is no evidence that this accident occurs, and it has not been found after death. They are probably due to a localized peritonitis of the investment of the kidney, or perhaps to simple neuralgia. Icterus and hepatitis, consequent upon a circumscribed peritonitis set up by the pressure of the movable kidney upon the liver, have been observed.
Death is not one of the usual results of this affection, but a recent surgical writer (Keppler4) has called attention to cases where long-continued dyspeptic symptoms, with constant pain and the chagrin and melancholy due to inability to work, have been followed by death from exhaustion, and nothing except a movable kidney has been found at the autopsy.
4 Arch. für Klin. Chirurg., 1879.
There can be no doubt that in many cases the symptoms are more severe than might be supposed from the ordinary descriptions, and are very unfairly characterized as hysterical. On the other hand, many cases are attended with but the mildest form of the symptoms just described, and the patients, ignorant of any tumor either from its discomfort or from having felt it, live in health and comfort for many years.
DIAGNOSIS.—The diagnosis of this condition, if the physician keeps in mind the possibility of its occurrence, is usually not difficult. In many cases a tumor has been felt by the patient which when called to the attention of the physician is recognized by its shape. In some cases in thin persons the form of the kidney, even to its hilus with the strongly-beating artery, can be made out. It glides easily from between the fingers, and can be moved more or less remotely from its normal position, to which, however, it returns without difficulty, especially when the patient assumes the recumbent position. The excursions are of course limited to a certain length of radius, of which the origin of the renal vessels is the centre, and seldom go much beyond the median line toward the side opposite to that on which the movable organ belongs.
The usual statement of text-books, that a depression or lessened resistance is to be felt in the loins of the side from which the kidney is absent, and a diminution of the normal dulness, which returns again when the organ is replaced, rests, as regards the majority of cases, rather upon theoretical considerations than on actual observation. The thickness of the lumbar muscles, upon which the kidney rests, is such that the dulness on percussion is not capable of much change. In most persons the outer limit of dulness in this region is not that of the outer edge of the kidney, but of the extensor dorsi communis. Palpation and percussion therefore in the renal region are not likely to be of much value in diagnosis, although an occasional case appears to justify the ordinary statement. The hand-and-knee position described above would be more likely than any other to show an existing depression.
Palpation for the purpose of finding the tumor, if it be not at once evident, or for examining it after it is found, should be bimanual, one hand being placed in the space between the ribs and the crest of the ilium of the supine patient and pressed strongly upward, while the surface rather than the points of the fingers of the other hand should be carried and pressed with some firmness into the relaxed abdominal parietes. In this way the kidney may be caught between the two hands and examined more or less completely according to the thickness of the abdominal walls. Sometimes the kidney can be partly grasped between the finger and thumb of one hand. In this way the size, shape, and sensitiveness of the tumor can be determined, as well as its position and movability.
A movable kidney may of course present some difficulties of diagnosis from other abdominal tumors. The liver is sometimes, though very rarely, movable, and never to the same extent as a wandering kidney, and as it is pushed downward discloses its much greater bulk. The base of the gall-bladder may occasionally be quite movable, but its excursions are of a more limited radius, being of course executed only by the base and not the whole organ.
The spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. The splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. The left kidney, it should be remembered, is less frequently movable than the right.
A small ovarian tumor might be mistaken for a movable kidney low down in the abdomen, or vice versâ. The latter error has actually been committed, and has led to an attempted removal of the supposed cyst. The more easy movability of the kidney upward and of the ovary downward or laterally, as well as the shape, and in many cases the result of a vaginal examination, should be sufficient to make the distinction, which, if an exact diagnosis be absolutely necessary, may be confirmed by aspiratory puncture.
A malignant omental tumor might at the first examination present points of difficulty in diagnosis, but even if it were single and counterfeited with considerable accuracy the shape of the kidney, neither of these conditions would be likely to continue for any length of time.
TREATMENT.—The treatment usually suggested for this affection is based partly on the fact that many cases are hysterical, and also on that other more important one, that very little can be done to restrain the vagaries of the offending organ.
A correct diagnosis, it has been frequently remarked, is often sufficient to relieve the patient's mind, and secondarily her body, and may be all that is necessary in cases where the symptoms are all psychical and have arisen from the discovery of a tumor of unknown nature.
As a relief from the more serious annoyances the avoidance of certain disturbing causes may be of value, and such will consist in a proper regulation of the bowels and consequent avoidance of straining, and the choice of an occupation as little laborious and involving as little work in the upright posture as possible. No tight, narrow girdle should be worn about the upper part of the abdomen.
On the other hand, the use of a tight bandage over the whole abdomen is usually recommended, and seems to be useful in a small proportion of cases. It can of course act only by rendering the whole abdomen a little more tightly packed, and cannot exercise much restraint on any special portion of its contents. Pads of various shapes worn under the bandage may bring a little more local pressure to bear. One shaped like a carpenter's square, with an ascending branch to check the lateral movements, and a horizontal one to prevent the descent of the tumor, has been proposed. A truss with pads adapted to the loins and a front pad over the kidney has also been used.
It is impossible to read the history of many cases of this affection without becoming convinced that while the majority need but the mental assurance of the harmlessness of the tumor to restore their mental equilibrium, and others find their troubles bearable or capable of relief by mechanical appliances, no inconsiderable number are incapacitated from labor and the enjoyment of life by the necessity for great care in their movements, or suffer from severe symptoms, as pain and dyspepsia, which demand a more active treatment.
This has been afforded by operative surgery in two ways. Of these the most obvious is removal of the offending organ. It has now been clearly shown, by the number of nephrectomies that have been performed, that one healthy kidney is sufficient to support the function of urinary elimination; and if one kidney can be clearly shown to be healthy, the other can be safely removed. Such an operation undoubtedly adds to a patient's risks, since any subsequent renal affection is likely to prove fatal; but it has been now done a considerable number of times for the relief of the affection in question, and with good results. R. P. Harris5 has collected 16 cases with 10 recoveries, the organ removed in 3 out of the 6 fatal cases being diseased. Only 2 of these operations were by the lumbar incision, both being saved. They have since been reported.
5 Am. Journ. Med. Sci., July, 1882.
The operation has usually been done by the abdominal incision, which offers the advantages of greater accessibility of the pedicle for the purpose of ligating the arteries, and also greater ease in getting at the kidney itself, since it has often formed a partly separate pouch in the peritoneum, from which it would not be so easy to dislodge it by the lumbar incision. The latter operation is, as just stated, by no means impracticable nor specially dangerous. Of course it is desirable to avoid for some time after the operation anything which, like the use of diuretics or the excessive secretion of water, will throw any increased work upon the remaining kidney until it has had time to accommodate itself to them.
A singular case of attempted excision of a tumor supposed to be a wandering kidney, which could not be found after the incision was made, is recorded.6 In this case the symptoms, which, as well as the physical signs, had pointed distinctly to a movable kidney, disappeared after the operation. The author compares this case to another, in which great relief was experienced from a pretended operation for the removal of normal ovaries.
6 Hygeia, 11, 12, 1880, Svensson.
The other operation consists in the fixation of the movable organ. In one case a curved needle bearing a strong tape ligature was passed into the abdominal muscles, through the kidney, and out again. The ligature remained for some time, giving a certain amount of relief from the distressing symptoms, but maintaining a constant discharge until it came away without having accomplished any permanent benefit. The kidney was afterward removed by a lumbar incision, and a deep cicatrix found running longitudinally along the otherwise healthy organ.7
7 A. W. Smyth, New Orleans Med. and Surg. Journal, Aug., 1879.
In other cases8 a dissection has been made until the kidney was reached, which was then, with its adipose capsule, stitched firmly into the wound. In one of these cases the kidney became somewhat loosened again, but it is possible that the risk of this accident might be avoided by some modification in the operative procedure. If this operation can be made a successful one, and generally accepted, of which as yet the paucity of cases hardly permits us to judge, it is manifestly far preferable to removal, since it leaves in its place an organ usually perfectly capable of performing its functions.
8 Hahn, "Fixation of Movable Kidney," Am. Journ. of Med. Sci., April, 1882, from Cbl. für Chirurgie, 1881.
Polyuria; Diabetes Insipidus.
Polyuria is the name of a symptom the presence of which may be easily ascertained beyond a doubt, but which is notwithstanding occasionally overlooked. Its existence is to be determined by measuring the urine. In extreme cases this may be unnecessary, but slighter forms may easily escape notice if this is not done. The quantity of urine normally secreted varies considerably, owing to many causes, of which the principal are—the quantity of fluid ingested, not necessarily in the form of beverages, but of food more or less succulent; the activity of the other secretions, especially those of the skin and the intestines, and the presence of substances which increase the rapidity of its flow through the kidney or stimulate the glandular cells; and, to a certain extent also, individual peculiarities.
The quantity of water furnished by the kidneys depends largely upon the excess of pressure in the vessels, and especially in the Malpighian coils, over that in the interior of the tubes, and is consequently influenced by the general blood-tension.
The second factor of importance is the calibre of the renal vessels, especially the arterioles; and the third, the freedom of exit of the formed secretion from the uriniferous tubes. A certain amount of back pressure, so far from diminishing the amount of urine, seems to increase it, as shown in some of the cases of surgical polyuria, where the normal amount is considerably exceeded, while the renal parenchyma is being gradually destroyed.
The arterioles of the kidney being, like all other arterioles in the body, under the control of the nervous system through the vaso-motor nerves, it is easy to see how the various affections of this controlling element may act upon the secretion of urine; neither is it possible to deny (although by far the most important factor in the rapidity of the urinary secretion has been shown to be the blood-pressure) that the nervous system may have a direct effect upon the secreting renal parenchyma.
The normal quantity of urine for an adult of medium height and weight and ordinary habits as regards the ingestion of liquids may be stated as fifty fluidounces, or a liter and a half, which is of course to be considered as only a very rough approximation. One liter on the one hand, and two liters on the other, can hardly be considered pathological limits, unless the increase or decrease takes place under circumstances which ought to produce the opposite effect.
Frequency of micturition, especially if nocturnal, is often considered almost a proof of polyuria, but can at most only justify a presumption of it, which is to be confirmed or not by exact measurement. Any existing polyuria is likely to be greater during the night. Frequency of micturition may mean polyuria, or, on the contrary, may coexist with a considerably diminished total amount of urine; in which case it means only increased irritability of the bladder, and is then a purely nervous symptom; assuming, of course, the absence of inflammatory trouble. The rapidity with which the secretion accumulates in the bladder has a certain influence in determining the need for micturition; that is, a bladder containing five ounces of urine which has been gradually accumulating for some hours retains it with greater ease than if the same amount had been rapidly secreted, as, for instance, after a full meal with an abundant supply of fluids.
Polyuria is often, or always if persistent, an important symptom, and the suggestions made by it can easily be added to and confirmed by a more minute examination of the urine. Thus we may have the following combinations indicating important diseases:
Polyuria, moderate, with diminished specific gravity, albumen usually in small amount, and some casts; in chronic interstitial nephritis;
Polyuria, with pus and mucus and débris from the urinary passages, usually turbid and often alkaline and offensive; in irritation of the kidneys depending on lesions of the deeper urinary passages, prostate, or bladder (surgical polyuria);
Polyuria, with increase of urea (azoturia);
Polyuria, with increase of phosphates (phosphaturia);
Polyuria, with increased specific gravity and sugar; in diabetes mellitus;
Polyuria, with decreased specific gravity and diminished or normal solids; in diabetes insipidus.
These conditions have many points of mutual contact and resemblance, but the affection which is the subject of the present essay is diabetes insipidus—i.e. that form of polyuria which is accompanied by no abnormal constituents except occasionally inosite, a very little sugar, or a very small amount of albumen. In the cases where these constituents might lead to difficulties in the way of diagnosis the absence of other symptoms of the disease likely to be mistaken will suffice to mark off the affection as entirely distinct.
The normal elements may be decreased, normal, or increased. The disease thus defined includes not only diabetes insipidus, but many cases of so-called phosphaturia and azoturia, which, if not exactly coinciding, have many points in common.
In some cases which, from the character of the urine as well as from the other symptoms, should evidently be classed as diabetes insipidus, the quantity of urine, although somewhat increased, is not very excessive, reaching perhaps two liters, but in the great majority is discharged in much larger quantity. In a case which came under the observation of the writer by the kindness of H. E. Marion the amount of urine gradually rose from two or three gallons to five or six and seven, and on one occasion the patient, a girl of fifteen, after some unusual excitement is supposed to have passed eight gallons in the course of twenty-four hours. Of this eleven quarts was by actual measurement, and passed in the presence of her mother in the course of the afternoon.
The urine in these cases is, as would naturally be supposed, of a very pale color and of low specific gravity, which from 1005 to 1010, representing the usual range, may in extreme cases fall to or even below 1001 as measured by the ordinary urinometer. I have seen no case recorded where the specific gravity of such a urine has been determined by instruments of greater delicacy. Its odor is comparatively faint, but it is somewhat prone to decomposition. The solid constituents are often somewhat increased in the twenty-four hours, especially the urea, which may be present in double the usual amount. This is probably the result of an increased metamorphosis from the passage of so large an amount of water through the tissues.
It is not always true, however, that the solids are increased, and the difference in the amount of destructive metamorphosis taking place in different cases is probably closely connected with the clinical differences which may be observed in regard to the amount of wasting and affection of the general health. The phosphates are frequently increased, as found by Dickenson and Teissier; and such an increase has probably about the same meaning as the increase in urea. In other cases, however, they take part in the general diminution of solids, as in the case of Marion just alluded to, where they were reported as absent, which undoubtedly means simply present in so small amount as to escape the usual clinical tests.
Among the concomitant symptoms the most necessarily and closely connected with the increased discharge of fluid is its increased ingestion, so that the disease has been called polydipsia instead of polyuria, it being assumed that the thirst is the initial and important symptom upon which the diuresis naturally depends. It has been observed in many cases, however, that the quantity of water drunk is very much below that which is passed. In the case last spoken of the water ingested in the form of drink was but a small fraction of the quantity of the urine, so that the patient drank but two or three pints while passing many gallons. In cases where the beginning of the disease has been carefully observed patients have distinctly stated that the increased discharge began before they felt increased thirst. This of course takes no account of the quantity of water contained in solid or semi-solid food. Polyphagia is occasionally seen, as in the oft-quoted case of Trousseau, the terror of restaurant-keepers. So intense is the craving for water that in several instances where attempts have been made to limit its amount the unfortunate patient has drained the chamber-pot. Emaciation is probably connected with increased metamorphosis, as indicated by the increased secretion of urea and phosphates. Dryness of the skin has been frequently noted, and has been said to mark the distinction between polyuria and polydipsia, in the former the skin being dry, and in the latter moist. In one case, however, where copious perspirations were noted, the patient stated positively that the polyuria began a number of days before increased thirst was experienced. In another very extreme case, attended, however, with no wasting, night-sweats occurred. Pruritus has been mentioned as affording another point in the resemblance which undoubtedly exists between the severer cases of this disease and diabetes mellitus. Dyspeptic symptoms have been noted in some cases, and oedema may take place, as in many wasting diseases.
The nervous symptoms are perhaps the most important in the severer cases. In some which have been examined post-mortem distinct nervous lesions have been found, such as the remains of tubercular meningitis, tumors involving the cerebellum, and softening of the floor of the fourth ventricle; in others the patients are known to have been syphilitic.
Severe headache is a symptom of some importance, occurring in a considerable number, but not the majority, of cases. Atrophy of the optic nerve was present in two reported cases, to which the writer can add a third, where failing vision, headache, and emaciation were the principal and earliest phenomena, while at a later period the atrophy was demonstrable by the ophthalmoscope. The polyuria in this case, though marked, was not excessive, and the patient, a young man, after remaining for some years in a condition of chronic invalidism, died. Chronic interstitial nephritis had of course been suspected and sought for, but no evidence of it found beyond the symptoms already stated; neither were there any more definite cerebral symptoms.
Finally, it should be stated that a great many cases of this kind have no marked symptoms at all except the essential one, and so long as they are supplied with a sufficient amount of fluid live in comfort with their single inconvenience.
The diabète phosphatique of Teissier9 should be cited in this connection. In only a small proportion of his cases where an excess of phosphates was noted was the quantity of the urine also increased, and in these the symptoms seem as appropriate to the polyuria as to the phosphaturia. It is worthy of note, however, that one series of his cases is connected with disease of the nervous system; another alternates or coexists, as does also diabetes insipidus, with diabetes mellitus; and his fourth class closely resembles, with the exception of the increase of phosphates (if this can be looked upon, after what has been said above of the increase of solid urinary constituents, as an exception at all), the affection last named—i.e. diabetes mellitus. In fact, many of these cases of Teissier read like what would have evidently been called, without a quantitative analysis, simply polyuria or diabetes insipidus.
9 Du Diabète phosphatique, par L. S. Teissier, Paris, 1877.
According to Teissier, the presence of an excess of phosphates in the blood is sufficient to determine a polyuria. It is possible that in many cases where a polyuria accompanies phthisis, as noted in many of his cases, the symptom may be really due to actual organic (perhaps amyloid) disease of the kidney.
The COURSE AND TERMINATION naturally vary greatly with its etiology and the diseases with which it is associated. In some cases where nutrition is but little affected, and no attempt is made to check the natural appetite for water, the disease may go on for years with no essential change or impairment of the general health, as in the remarkable one quoted by Dickenson, where a French infant had at the age of three impoverished her family by her demand for water, which seems to have been an expensive luxury, and at a later period kept her husband—to whom, however, she bore eleven children—in a constant state of impecuniosity by the same depraved appetite. At the age of forty she drank in the presence of a scientific commission within ten hours fourteen quarts of water, of which she returned through her kidneys ten to their astonished gaze.
When polyuria is merely a symptom of cerebral inflammation, of central tumor, of syphilis, or of phthisis, the course and prognosis will of course be that of the primary disease. It occasionally comes on during pregnancy, and in one such case it is stated to have ceased two days after delivery, and in another the secretion, uninfluenced by parturition, resumed its normal quantity when lactation was fully established.
It is very rare, if indeed it ever happens, for life to be terminated by diabetes insipidus unaccompanied by any other disease, although from its association with many and severe affections, both of the nervous system and of the kidneys, it must of course not unfrequently happen that a patient dies in, though not on account of, the polyuric state. It is strange to observe, however, as has been often before remarked, how thin a shell of renal structure will suffice to carry on not only the usual, but an excessive, flow of water.
The ORIGIN of diabetes insipidus has been found in several conditions. Greater disposition toward it exists in early life, although it is by no means confined to youth. After middle life polyuria is likely to awaken the suspicion either of chronic interstitial nephritis or of prostatic disease, or other affection of the urinary passages setting up a sympathetic irritation of the kidney. It has been found to originate during convalescence from acute diseases, with perhaps preference for meningitis. Syphilis has its share of cases, as in most other organic nervous diseases. Shocks of various kinds, including fright, sudden or prolonged immersion in cold water, the rapid ingestion of large quantities either of water or of alcoholic fluids, are undoubted potent factors. In this respect, again, we may see the resemblance between diabetes without sugar and true or saccharine diabetes. It is favored by the hysterical diathesis. A very interesting case of severe hysteria with hemianæsthesia and hemiplegia and other marked symptoms varied for a time between almost complete anuria and the most profuse discharge of over two hundred ounces per diem.
A most interesting group of cases has been recorded by Weil,10 where out of a family of 91, 28 were polyuric. The head of the family, a polyuric, lived to the age of eighty-three, while his descendants were robust, many of them attaining a good old age. There were no anomalies of the circulation, and the persons affected were not alcoholics. Their only complaint was of a troublesome thirst, and they declined treatment.
10 Cbl. für die Med. Wiss., 1884, p. 263, from Virch. Arch., xcv.
The PATHOLOGY of diabetes insipidus, so far as is positively known, may be gathered from the previous account of its etiology and symptoms. It is evidently of nervous origin in the great majority if not all cases. It is often connected with distinct lesions of the nervous system, and attended with other nervous symptoms. In some cases it occurs in connection with a well-marked hysterical diathesis. The copious flow of pale urine as a sequel to the hysterical paroxysm is well known, and the same thing often attends a severe nervous headache in either sex. It is probable that the polyuria attending lesions of the urinary passages is a reflex nervous phenomenon, since it may be present when there is no suspicion of organic renal disease.
Guyon11 states that surgical polyuria occurs under three conditions—painful excitation of the sensibility of the deeper portion of the urethra or the vesical mucous membrane; repeated attempts to urinate during the night; retention of urine more or less complete, but especially when there is distension of the bladder. Of the first cause he gives an instance in the case of a young man who had a polyuria whenever a bougie was passed beyond a urethral stricture.
11 Leçons cliniques sur les Maladies des Voies urinaires, Paris, 1881.
Where, however, polyuria, especially chronic, is due to habitual over-distension, it is in the highest degree probable that it is at least partly due to structural alteration of the kidney. The well-known experiment of Bernard, by which an increased flow of urine was induced by a puncture of the floor of the fourth ventricle, and those of Eckhard on section of the splanchnic nerves, show how it is possible for nervous affections to influence the secretion of urine, though the path or paths of the influence are by no means completely made out.
One of the most noticeable points in the pathology of the more excessive cases of polyuria is the disproportion which often exists between the amount of fluid ingested and the amount discharged, the latter often exceeding the former several times. The source of the excess of water has not been satisfactorily determined, but it is evident from a careful experiment of Watson, repeated by Dickenson, that the body has under some circumstances the power of appropriating water from the atmosphere instead of discharging aqueous vapor through the lungs and skin as usual. In the experiments referred to persons affected with extreme polyuria were weighed immediately after passing water, and again after as long an interval as they were able to restrain their thirst, of course being also without food and under observation, when it was found that the weight had been increased by a number of ounces. In Dickenson's case, weighing thirty pounds more or less, where the amount of urine excreted daily was from seven to nine liters, the gain in weight at several observations was as follows: in three hours, 15½ oz.; in five hours twenty minutes, 19¾ oz.; in three and a half hours, 3¾ oz.
The DIAGNOSIS of this affection rests, in the first place, upon the determination of a permanent increase in the quantity of urine passed considerably above the normal, and, as has been already remarked, may require a measurement of the daily amount—a procedure which it is well to make a matter of routine in any cases where urinary trouble may be present. The increase being found, if it be very great it will only remain to determine whether sugar be present, which will be indicated by the specific gravity and the appropriate chemical tests. Traces of sugar are sometimes found in cases of polyuria which do not present the characteristics of saccharine diabetes, and can hardly be considered to materially affect the character of the disease.
A specific gravity decidedly above normal, with an excessive quantity of urine, is not likely to belong to anything but diabetes mellitus, though the chemical tests should never be neglected. If, however, the polyuria be only moderate, it becomes necessary to exclude surgical affections of the urinary passages, especially an enlarged prostate, often attended with retention and distended bladder. Pyelitis and hydro-nephrosis may also give rise to the same condition of over-activity of the kidneys. The appropriate surgical examinations with the sound may be necessary, but the presence of pus, bacteria, and the epithelium of the urinary passages in the surgical urine, as well as its frequent alkalinity, may direct a very strong suspicion before the sound is used. The age of the patient also will be of considerable weight in this connection.
A point of real difficulty of diagnosis, and great importance for treatment and prognosis, is the distinction between simple polyuria not excessive, but attended by constitutional symptoms, such as impaired nutrition, dyspepsia, and severe headache, from chronic interstitial nephritis, which often makes its appearance with similar symptoms. Mistakes between these two affections have undoubtedly occurred, and can in many cases hardly be avoided except by reserving the diagnosis for a time.
The similarity is rendered still more deceptive by the undoubted occurrence of a trace of albumen or a hyaline cast or two in cases of nervous disturbance, without justifying a diagnosis of progressive renal disease. High arterial tension also is likely to be found in both conditions. Nothing but repeated and careful examinations of the urine and of the circulation, especially at times when the nervous symptoms are less marked, and often a considerable amount of time, can fix the diagnosis.
Hypertrophy of the heart, and even slight dropsy, will undoubtedly be extremely decisive symptoms, but are not likely to occur until after a time when the doubt no longer exists. In other cases it may be highly important to carefully exclude organic cerebral disease before making a diagnosis of simple polyuria.
It is hardly appropriate to speak of a diagnosis from azoturia or phosphaturia, since these conditions are extremely likely to exist coincidently with typical polyuria and to make a part of the same disease. It is of much importance, however, to ascertain their presence with reference to the probable effect of the disease on the nutrition.
In regard to the TREATMENT, it may be remarked, to begin with, that restriction of water, although naturally diminishing somewhat the discharge of urine, does not cure the disease, but, on the contrary, in many cases augments not only the discomfort of the patient, but tends to the dryness of the skin, dyspeptic and nervous disturbances, and emaciation. Patients may recover flesh, strength, and spirits on being allowed to drink ad libitum, even although the inconvenience of excessive urination be thereby somewhat increased. Sufficient food and drink should therefore be allowed, although a patient may be ordered to observe such moderation as will not put his powers of endurance to too severe a test.
Of the drugs proposed, nearly all have offered some prospect of success, and have been accordingly reckoned almost specifics. Opium has in some cases been found as useful in these cases as in diabetes mellitus, and probably, as in that disease, by diminishing the sensitiveness of the nervous system. Valerian and valerianate of zinc, recommended by Trousseau and apparently successful in his hands, have reckoned both failures and successes in the hands of others. Nitric acid, in the dose of from 1 to 5 drachms per diem of the dilute in a large quantity of water, is said to have been highly efficacious in one series of cases.12 It is given until aching of the jaws and teeth, with some gingivitis, denoting its constitutional action, is produced. It was more successful than any other drug in Marion's case, although the specific symptoms were not produced, the patient being now in good health or free from her trouble. Atropia from its general action in diminishing secretion has been tried, and with occasional alleged success, but with many more failures. Pilocarpine from its action on the skin might be of value in those cases where the skin is very dry, but has no very general applicability.
12 Kennedy, Practitioner, vol. xx. p. 95.
The drug most frequently employed, and which can claim a larger proportion of successes than any other, is ergot in full doses, half a drachm or a drachm (2 to 4 cubic centimeters of the fluid extract) several times per diem. Its method of action is undoubtedly in the contracting effect which it exercises on the renal arterioles. In many cases it has decidedly diminished the amount of urine, and in some a permanent cure seems to have resulted.
In estimating the value of drugs in certain cases of this affection its not infrequent neurotic origin should be borne in mind, as well as the very capricious effect of supposed remedies in the hysterical diathesis. Unfortunately, many cases remain rebellious to all drugs, and can only be rendered as little uncomfortable as possible.
What has been said of treatment applies only to the well-marked cases of diabetes insipidus. Polyuria, as a symptom of other diseases or of surgical affections, is hardly likely to call for treatment other than that of the disease upon which it depends.
Albuminuria.
Albuminuria signifies a condition in which albumen appears in the urine, and has by some writers been made of equal significance with nephritis or Bright's disease. It is hardly necessary to say that this coincidence is far from being an exact one, and that the symptom may exist without Bright's disease, and also Bright's disease without the symptom. For our present purposes albuminuria will be taken to mean those conditions in which albumen may be found in the urine without the existence of decided diffuse nephritis. As a symptom, and a highly important one, of Bright's disease it will be considered elsewhere.
Albumen is secreted in the kidneys chiefly in the Malpighian capsules, where, if at all abundant, it may be easily demonstrated after death by hardening the kidneys by boiling. This coagulates the albumen in situ, where it may be shown by sections prepared in the usual method. It has been supposed that albumen is normally secreted in the capsules of the healthy kidney, and afterward absorbed by the epithelium lower down; but this view can easily be shown to be erroneous by subjecting a kidney which has not secreted albuminous urine to the process just described, which shows no coagulated albumen in the place where it ought to be most abundant.
The albumen found in the urine is chiefly that which forms the most important portion of the blood-serum, although other albuminoid bodies have from time to time made their appearance and have some diagnostic importance. Semmola13 states that the albumen appearing in the urine in true Bright's disease differs from that found with the cardiac or amyloid kidney. The distinction can, according to him, be shown in the appearance of the precipitate to a practised observer, and also by a more rapid diffusibility through animal membranes. He admits, however, that he has in vain sought for any distinct and clear chemical test by which the difference can be recognized.
13 Archives de Physiologie, 2d Serie, tome ix., and 3d Serie, tome iv.
Fibrin may occur in inflammatory conditions in the form of coagulated masses, and hence cannot affect the question of the presence of albumen. Casein has not been detected with certainty. Various albuminoid bodies, called albuminose, paralbumen, metalbumen, and serum-globulin, are occasionally met with in renal disease, and may give rise to some confusion during an analysis. They are at present, however, more suitable for chemical than for clinical study.
A variety of albumen is said to occur in osteomalacia which is not coagulated by heat alone nor by heat and nitric acid. This has been called Bence Jones's albumen, but has been seen by others. Peptone has been found in urine, but usually in such specimens as have been or which afterward become albuminous. Its exact signification when alone cannot be more exactly stated, as it has appeared in a variety of diseases, though not in perfect health.
Finally, a protein body, a ferment called nephrozymase, may be thrown down from every urine by an excess of alcohol.
Hæmoglobin gives a dark-red color to the urine, which on boiling forms a brown coagulum floating on the surface.
Hæmoglobinuria may be produced in animals by the intravenous injection of large quantities of water, causing a dissolution of the corpuscles, but the degree of hydræmia necessary to produce this condition is much in excess of any met with in diseases of the human being.
Human hæmoglobinuria may be the result of various pathological conditions, among which may be mentioned some infectious diseases, jaundice, burns, and the effects of many poisons, as well as the transfusion of sheep's blood.
Intermittent hæmoglobinuria, which is attended with fever, is usually the result of cold acting upon predisposed persons. The color of the urine and of the coagulum, together with the absence of red corpuscles under the microscope, will distinguish urine of this character from others which are also coagulable by heat.
Several methods are in use for the detection of albumen. Of these, boiling is perhaps the oldest and most generally employed, and if conducted with due care is a very delicate and useful test. The urine to be tested should be clear and slightly acid, when on boiling the albumen, if present, will be precipitated in whitish flocculi, more or less abundant according to the amount, or, if the quantity is very small, as a turbidity. The flocculi soon settle to the bottom of the tube when it cools, and the thickness of the deposit formed gives an approximation to a quantitative estimate. It is to the proportionate thickness of this deposit that the terms 30 or 50 per cent. of albumen are commonly but incorrectly applied. If the quantity is very small, it may not be distinctly perceptible until after cooling.
If alkaline or very slightly acid urine is boiled, a deposit of phosphates will be thrown down which closely resembles that from albumen, while, on the other hand, the albumen remains undissolved unless in large amount. These deposits of phosphates differ a little in appearance from an albuminous one, but in order to be accurate acetic or nitric acid should be added, drop by drop, to the hot urine, when the phosphates will be redissolved and the albumen, if present, precipitated. It is better, however, to add the acid cautiously to the point of slight acidity before boiling. A recent work14 gives the following directions for this reaction, which is then "absolutely conclusive and surpassed in delicacy by no other:" "The urine is first made distinctly acid with some drops of acetic acid, and then about one-sixth of its volume of a concentrated solution of chloride of sodium or sulphate of sodium or magnesium added. If the urine contains albumen, a precipitate of coarser or finer flakes appears on boiling." This reaction may be used as a quantitative test by diluting and acidifying, if necessary, a known quantity of urine, washing the precipitate on a weighed filter, drying, and weighing the whole.
14 Die Lehre vom Harn, Salkowski und Leube.
An exceedingly delicate and convenient test is that by nitric acid. The acid is placed in the bottom of a conical wine-glass, and the urine, filtered if necessary, allowed to flow on top of it from a pipette, so as to disturb the plane of junction of the two fluids as little as possible, and leave a distinct line of demarcation. At this plane of union, if albumen be present, will be formed an opaque white line varying in thickness according to the amount of albumen, so that after some practice and with care an approximate estimate of the percentage may be made. A deposit of urates may sometimes be formed a little above the plane of union, but it may be distinguished by its position, by its less distinct limitation on the upper surface, and also by its disappearance on warming. In a very concentrated urine and in cold weather this error may be conveniently avoided by previous warming of the urine and of the reagent. The same remark applies to the brine test.
A crystalline precipitate of nitrate of urea may give rise to error if the urine be very concentrated or the experiment conducted in the cold. This may be distinguished by its disappearance on warming or by the microscope. The action of the nitric acid on the coloring matter of the urine, forming a dark band at the point of junction, may obscure the reaction, but with care will not give rise to mistakes.
Another test recently introduced, which presents some advantages over the nitric acid, and is certainly quite as delicate, consists in a saturated solution of common salt in water acidulated with about 5 per cent. of the dilute hydrochloric acid of the Pharmacopoeia. This solution should be used exactly in the manner described for nitric acid. There is no change of color at the line of junction, and no precipitate takes place there except albumen or peptone, or resins when they have been administered. The opaque line of precipitate may, if the amount of albumen present be small, require a short time to form, so that in cases of doubt it is well to allow the test-glass to stand for a few minutes. It will, however, show very distinctly in any cases in which nitric acid shows any precipitate. The line does not, however, increase in thickness and density in proportion to the amount of albumen so exactly as that produced by nitric acid, so that the brine test is not so useful for approximately quantitative use as the nitric acid, although fully as delicate. If it be desired to distinguish peptone from albumen, it may be done by a comparison of this test with the nitric acid, which does not throw down peptone. If a deposit occur, which may consist of resin, the addition of more urine will dissolve it if resin, while albumen will not be affected.
Picric acid is a delicate and often a convenient test. The dry acid may be dissolved in the urine, or a saturated solution used into which the urine may be slowly dropped, each drop making a slight whitish cloud as it slowly falls through the yellow solution.
The iodo-hydrargyrate of potassium is perhaps the most delicate test of all: Potassii iodidi, 3.32 gm.; Hydrarg. bichlor., 1.35 gm.; Acidi acetici, 20 c.c.; Aq. destill. q. s. ut fiat 100 c.c.—Tauret's test. It may be used in the same way as the nitric acid or brine, or simply intermixed. Its only disadvantage is that it throws down alkaloids, but as this will not happen unless the alkaloid be taken in large quantity—as might happen, for instance, in the case of quinine—the chances of error from this source are not very great if this peculiarity be borne in mind.
Ferrocyanide of potassium in an acid solution has recently been proposed as a convenient test. It may be made up into pellets with citric acid or used in the same combination in the form of papers.
The phenic-acid test is prepared as follows:
| Ac. phenic. glacial. (95 per cent.), | drachm ij; |
| Ac. acet. puri., | drachm vij; |
| M. Add liq. potassæ, | ounce ij-drachm vj. |
| Millard. |
This is said to be very delicate, but the writer has no experience with it.
Tungstate of sodium is another recent addition to the list, which it is evident is already long enough for practical purposes.
Several of the tests mentioned have recently been prepared in the form of papers saturated with known quantities of the reagent and dried. They may be carried in the pocket-book and applied at the bedside, if desired, in a test-tube small enough to be very conveniently carried in the vest pocket. The iodo-hydrargyrate is perhaps the most useful. It is the most delicate, and a plan has been proposed for making with it a quantitative estimate of considerable accuracy by means of a standard solution or piece of gray glass adjusted by such a solution, with which the precipitate produced can be compared as to its opacity.
Exact quantitative examinations for albumen may be made by several processes, but that by boiling, if carried out with the precautions described in works on chemistry, is as accurate as any, and probably the best adapted to the needs of the practitioner if he should wish for such results.
For clinical purposes, however, it will rarely if ever be found useful to determine the amount of albumen more accurately than can be done by the various approximations mentioned above.
When even the smallest trace of albumen is discoverable by any of these methods, the question of the integrity of the kidneys at once arises—a question which a few years ago would have been considered as settled in the unfavorable sense by the same occurrence.
It is necessary to distinguish, first of all, between an essential and an accidental albuminuria, the first referring to that condition where the albumen is secreted with the urine and forms an essential part of it, and the other to the accidental admixture from the presence of pus or blood, which may have made its appearance at any point below the secreting tubes. When hemorrhage takes place from the kidney, albumen is of course present in the urine, but its signification under these circumstances is entirely different from that which it bears when unaccompanied by the corpuscular elements of the blood.
No means at present exist for determining whether a small amount of albumen present in the urine is more than enough to be accounted for by the pus or blood known to exist by the presence of its corpuscular elements or of its coloring matter. An approximate estimate may be made by one familiar with such examinations, but no rule can yet be laid down. Such a rule might be approximately established by a succession of counts with the hæmocytometer of the corpuscles found in albuminous urine of known percentage, or estimates of hæmoglobin by color tests.
The exact conditions of the kidney or of the blood which may cause the appearance in the urine of albumen without blood or pus—that is, of true albuminuria—have been the subject of much experiment and argument, which it would be impossible to reproduce, even in outline, within the limits of this article; and this is the less to be regretted since they have as yet led to no practical or generally accepted conclusion. A few of the more important facts bearing on the question may, however, be stated here.
Albumen other than serum-albumen, when introduced into the circulation either by injection into the veins subcutaneously, or if in very large quantity by the mouth, is rapidly excreted by the kidneys. This albumen also, if collected from the urine of the first animal and injected into the vein of a second, again comes through the kidneys. The albumen, however, which is obtained from the urine of an ordinary case of albuminuria—that is, serum-albumen—does not behave in this way, but is not excreted through healthy kidneys. These facts seem to show that the appearance of albumen in the urine in ordinary cases of renal disease is not to be attributed to any change in its quality approximating it to egg-albumen, for instance, but is due to the condition of the kidneys.
Disturbances of the renal circulation, especially those giving rise to venous stasis, are very likely to cause albuminuria; a temporary ligature of the renal vein causes albumen to appear in the urine after its removal, and ligature of the ureter has the same effect.
The albuminuria succeeding the collapse of Asiatic cholera or yellow fever seems to have a somewhat similar origin, being the result of re-establishment of the circulation after extreme anæmia of the kidney. Clinical facts in general seem to point to simple disturbance of the circulation and to alterations in the kidneys themselves as the usual causes of albuminuria, though in many cases the lesion seems to be a slight and temporary one.
Some other conditions under which such disturbances and alterations may arise, exclusive of Bright's disease, are the following:
Munn15 found albumen in small quantities in 11 per cent. of cases presenting themselves for life insurance, supposing themselves healthy and having no lesions of heart or lungs. It is not stated whether casts were found in these cases or not, and their value as representing healthy persons cannot, it is obvious, be correctly estimated until some time has elapsed. It is well known that renal lesions may be exceedingly slow in their progress, and it is by no means improbable that a part of these cases may have been really in the early stages of a chronic form of Bright's disease. Albumen has been found in the urine of boys and adolescents, as well as in that of healthy soldiers, tested immediately after rising: in most of these cases the amount was extremely small. Certain conditions, moreover, may greatly increase the proportion of cases in these same classes in which albumen is present. Thus, fatiguing exercise will bring it on in some persons, and the urine of a body of soldiers if examined late in the day after severe drill shows a much larger proportion of albuminurics than if examined after rising. The urine of the pedestrian Weston is said to have contained not only albumen, but casts. It is certainly not true that fatiguing exercise will cause albuminuria in everybody, and it is not claimed, even by those who report these and similar cases, that they prove albumen to be a normal constituent. Some of the cases are distinctly described as delicate without being actually ill. Cases have been reported where cold bathing has been followed by temporary albuminuria. Here it is in the highest degree probable that a disturbance in the circulation is produced by contraction of the cutaneous arterioles; and it is possible that we may find in this increased sensitiveness of certain persons an explanation of the occurrence of acute dropsy as a sequel to scarlatina or as the result of exposure in only a small proportion of the cases where the exposure takes place. It is hardly necessary to admit, on the basis of these observations, that albumen is a constituent of healthy urine, although this may be shown at some future day by still more delicate tests, but simply that the renal circulation may in certain sensitive persons be sufficiently influenced by slight and transient causes to permit albumen to pass into the urine. It is the almost unanimous conclusion of practical writers, taking fully into the account these recently-ascertained facts of albuminuria in alleged health, that the presence of albumen in the urine in sufficient quantity to be detected by any of the ordinary tests is a decidedly serious symptom.
15 New York Medical Record, xv. 297.
The influence of many well-recognized pathological states in bringing about venous stasis, and that delay of the blood in the renal—and more especially the Malpighian—vessels which seems the most essential factor in the secretion of albumen, is well known, and its recognition is of much importance in diagnosis and prognosis, since the unfavorable signification of albuminuria in certain cases is liable to be overrated, and a diagnosis of chronic renal disease made to depend upon symptoms which really belong to some other affection. How far alteration in the capillaries and epithelium is in each case concerned in the production of albuminuria it is often impossible to say, since any alteration in these elements which can be observed after death is almost certain to be complicated with lesions which can disturb the local circulation.
Cardiac obstructive disease is very likely to be accompanied by albuminuria, and the state of the kidneys by which this condition is brought about is undoubtedly venous congestion. The urine in a case of this kind is usually scanty, of high specific gravity, high colored, often with a deposit of urates, while the albumen appears in small quantity. A few hyaline casts are not infrequently seen, and do not materially increase the gravity of the prognosis so far as renal disease is concerned. The kidney which furnishes this urine is usually a little harder and a little denser than normal, but with a nearly normal microscopic structure, exhibiting but little more than capillaries well filled with blood, and in the interior of some of the tubes casts similar to those found in the urine during life.
Doubt may occasionally arise as to the diagnosis between a congested kidney consequent upon valvular disease of the heart and an interstitial nephritis with hypertrophy of the heart. In the latter case, however, the urine, although containing albumen, is usually much more copious and of low specific gravity. Diminished power of the heart without valvular lesion may have as a consequence albuminuria which disappears if the heart recovers its vigor.
In many of the cases in which albumen appears in the urine temporarily it is not easy to say whether an actual nephritis may not be present, though not sufficiently severe to give rise to other symptoms.
In almost any febrile disease of sufficient intensity albumen is often found, and when such a case terminates fatally without renal symptoms, the condition of the kidneys, consisting in more or less granular degeneration of the epithelium, is often spoken of as parenchymatous nephritis. If it is correctly called so, it is certainly very different from the idiopathic form, whether acute or chronic, since it is very rare for typhoid fever, for example, either to present the symptoms of acute nephritis during life or to terminate in chronic Bright's disease. In scarlatina, and rarely in other fevers, a distinct nephritis is present, but a degeneration of structure sufficient to produce albuminuria is in many instances a result merely of a high temperature.
Many applications to the skin produce albuminuria, but in almost all, if not all, of these an actual nephritis has been found to exist. The same is true of poisoning with strong acids, phosphorus, and arsenic.
A very important form of albuminuria is that found during pregnancy, more frequent with a first child or with twin pregnancy, and often associated with other symptoms of nephritis. It is probable, however, that in many instances it is a result of impeded abdominal circulation, although it is very rarely that the gravid uterus can press directly on the renal veins. In the severer cases a well-marked parenchymatous nephritis exists; but it should be distinctly borne in mind that if every instance of albuminuria in pregnancy is due to nephritis, it is certainly a form of the disease which may lead neither to severe symptoms nor to chronic disease. On the other hand, the appearance of albumen in the urine of a pregnant woman, though not necessarily calling for active interference of any kind, should always be a danger-signal, and put the physician on the lookout for other indications of actual renal disease.
In many nervous affections albumen may be found in the urine. It can be produced, as was shown long ago by Bernard, by a puncture in the floor of the fourth ventricle near to the point where a similar puncture gives rise to diabetes. Lesion of the cerebral peduncles, section, destruction, or irritation of the spinal cord, and irritation of the renal nerves are also causes of this symptom. It is by no means difficult to account for this phenomenon by the changes which take place in the renal circulation under influence of the vaso-motor nerves which originate or pass through the peduncles, pons, and spinal cord, although it is highly probable that similar results might follow irritation transmitted from a distance. These facts are not without practical importance, for they give rise to very considerable chances of error in diagnosis; as, for instance, where a patient suffering from severe headache, with possibly gastric symptoms, is found to have albumen and casts in his urine, which is also copious and of low specific gravity. It might not be easy to decide that such a case was not one of interstitial nephritis with symptoms far from unusual, and yet it might perfectly well be a cerebral tumor. The diagnosis would demand a thorough search for other symptoms, such as double optic neuritis on the one hand, as indicating cerebral disease and cardiac hypertrophy, with high arterial tension on the other, as connected with nephritis. A careful consideration of the order of their occurrence is also desirable.
After an epileptic attack albumen may appear in the urine for a short time, disappearing within a few hours. This occurrence might lead to an erroneous diagnosis of uræmic convulsions if the examination happened to be made shortly after a fit and not repeated at a later period. Transitory mania may perhaps be placed in the same category.
Chronic mental disease, like general paralysis of the insane, is frequently accompanied by albuminuria, and even temporary mental disturbance in a sensitive person has been known to excite the symptom.
In narcotic poisoning both by alcohol and by opium a similar state of things sometimes occurs. With alcohol, however, distinction is to be made between chronic cases, where a suspicion of parenchymatous nephritis may be fairly entertained, and acute alcoholism or delirium tremens, where the albumen appears and disappears within a few days. In a patient profoundly under the influence of opium the urine may contain not only albumen, but casts, and the diagnosis of uræmic coma is very likely to be made if nothing is known about the history—an error which might be of great consequence, as tending to discourage the efficient treatment necessary in opium-poisoning or causing the waste of time on inefficient measures.
It is obvious from what has been said that the diagnosis of albuminuria as a symptom is sufficiently simple with a little care in chemical manipulation, but that its significance is not so easy to determine in every case, since it is found in so many cases unconnected with chronic or progressive renal disease, and on the other hand may be absent while serious nephritis is going on.
Albuminuria, as defined at the beginning of this article—that is, occurring in the absence of chronic and serious renal disease—is only to be diagnosticated by the exclusion of such diseases, by careful consideration of all the symptoms present, such as changes in the quantity and specific gravity of the urine, in the force, rhythm, and size of the heart, and of the arterial tension, as well as the relation of the amount of albumen to the amount of urine and character of the sediment as indicating one or the other form of nephritis. Thus a very small amount of albumen with a highly concentrated urine is not likely to be met with in the usual forms of nephritis, but is often found in connection with valvular disease of the heart.
Treatment is but rarely directed to this symptom, since, when albumen is present in but small quantity, as usually happens, it is of little or no consequence except as an important element in diagnosis, while the few cases in which the amount is large enough to constitute a serious drain upon the system are almost exclusively cases of actual Bright's disease, and hence do not come under this head. The administration of astringents, especially tannic and gallic acids, has been found to diminish the quantity of albumen in the urine.
(A copious bibliography of this subject will be found in an article by Ellis in the Boston Medical and Surgical Journal, vol. i., 1880.)
Renal Colic; Renal Calculus.
Renal colic is the appellation of a group of symptoms caused, in by far the greater proportion of cases, by the passage of a renal calculus through the ureter, or sometimes merely its engagement in the upper extremity and impaction or subsequent falling back. Other foreign bodies large enough to cause distension and obstruction, such as clots of fibrin or portions of hydatid cysts, may give rise to the same phenomena. Most physicians, however, have seen cases where the same set of symptoms have not been followed either by the discharge of the stone per urethram or by evidence of its continued sojourn anywhere in the urinary organs. They may occur in persons of a neuralgic tendency in connection with the uric or oxalic diathesis. The conclusiveness of such cases, as proving the possibility of a purely neuralgic or spasmodic attack, must of course depend upon the carefulness and intelligence of the patient and the opportunities of the physician for observation extending over years. As it is admitted, however, that these symptoms may occur without the demonstrated presence of a calculus, it would be perhaps better nomenclature to apply the term renal colic to painful and spasmodic affections of the kidney and ureter, however caused, and to describe the passage of a calculus or other obstruction under its own name.
Calculi of various kinds, sizes, and shapes may be found in the pelvis of the kidney. They are most frequently composed of uric acid, which may exist alone or with layers of phosphates superimposed. They are usually in concentric layers, more or less irregular in shape, and of a reddish-brown color of various shades. Soft concretions of urates are occasionally noted. Oxalate of lime is the material of many small calculi, and may be the nucleus of a larger one or occur in alternate layers with uric acid. These stones are of a dark grayish-brown and are exceedingly rough and irritating. Among the most frequent constituents of renal calculi are to be found phosphates, either of lime or the triple salt of ammonia and magnesia. They may form layers with other material, or constitute alone the largest and most curiously shaped of all the renal calculi. Their surface may be smooth and almost polished, or roughened, eroded, and almost crystalline in texture.
Cystine rarely forms a renal calculus, and xanthic oxide still more rarely. Masses of fibrin resulting from renal hemorrhage are described. They are said to be of the consistency of wax, tough and elastic. Coagula of the ordinary form may also give rise to the same set of symptoms. On one occasion the writer saw the dilated pelvis of the kidney filled with hundreds of spherical brownish soft masses from the size of a mustard-seed to that of a pea, easily crushed in the fingers, burning with the smell of albumen, and leaving but a small amount of ash.
The size of renal calculi may vary from almost microscopic grains, which then usually take the collective name of sand or gravel, and are most commonly composed of uric acid, up to masses of some ounces in weight, completely filling a dilated pelvis.
It is doubtful in what way renal calculi originate, their constituents being always present in the urine, but rarely crystallizing out. The uric-acid infarction of new-born children can hardly be considered as accounting for any large number of cases, although it might be the basis of calculi in young children. The uric and phosphatic deposits sometimes found in the tubes of the more mature kidney may possibly, when dislodged, be a point upon which additional quantities of the same substances are deposited, but anything which delays in the pelvis or in some of its calices a concentrated urine, especially if much mucus be present, may be regarded as favoring the agglomeration of deposits. A previous pyelitis is perhaps the usual cause of phosphatic deposits. Small uric-acid calculi may sometimes be found in considerable numbers in the sulcus surrounding some of the papillæ, and of a size which could hardly afford any marked symptoms in passing down the ureter. These, if any inflammation were to arise, would form a mass with pus or mucus which might serve as a nucleus for a phosphatic calculus. These suppositions are, however, rather theoretical and fragmentary, and do not cover all the cases. Constitutional predisposition has been much discussed, though not a great deal is known about it. A gouty tendency, however, undoubtedly favors the production of uric-acid calculi.
A small renal calculus, when formed, may be the beginning of several quite different sets of phenomena. Of these, the simplest and most favorable event is its descent through the ureter into the bladder, with its subsequent expulsion with the jet of urine from the urethra. If the calculus be small and smooth, the passage through the ureter may be attended with little or no uneasiness, but if it is large enough to fill or distend the tube, and especially if the stone be irregular and rough, its descent gives rise to excessively severe symptoms. These are pain in the back at the level of the kidney, in the side and groin corresponding to the ureter affected, sometimes shooting down the thigh; with retraction of the testicle; usually no fever, but much general depression; feeble pulse, coldness and paleness of the surface, fainting, and vomiting. The beginning of the attack is usually sudden, corresponding to the entrance of the calculus into the ureter, and the pain continues without intermission, though with some remissions, until its discharge into the bladder. The pain is usually of the severest, and is described as cutting or tearing in character. It is probable that an attack may sometimes end by the calculus, which has become engaged in the ureter, falling back into the pelvis instead of advancing through the ureter. In this case the pain ceases for the time, to be perhaps subsequently renewed, or, if the stone grow larger, so that it cannot re-enter the ureter, giving place to the symptoms due to irritation of the pelvis.
The urine is usually diminished in amount until the arrival of the calculus at the bladder, when the fluid that has been retained is suddenly discharged with the stone. Constant attempts to pass water during the passage downward of the calculus are the consequence of sympathetic irritation of the bladder, and not of accumulation of urine therein. The urine is likely to be bloody, but is not necessarily so. The smoothness or roughness of the surface of the stone is of much importance as determining the presence of this symptom.
The DIAGNOSIS of renal colic is usually not difficult, but it may not always be readily distinguished from hepatic or intestinal colic. The suddenness of the attack and intensity of the pain, its location in the side and downward to the groin, will in most cases make the condition very characteristic.
From hepatic colic or the passage of a gall-stone the situation of the pain, which is in the latter affection naturally somewhat farther forward, the tenderness on pressure in the same region, and often the whitish color of the stools or the presence of jaundice, as well as the history of former attacks, will usually make the distinction a matter of a high degree of probability.
Intestinal colic is usually referred to the middle of the abdomen, is accompanied by constipation, while the movements of the intestines and of flatus are often distinctly perceived by the sensation of the patient or the ears of the bystanders, and on the whole the attack is less severe and the pain less intense.
As has already been stated, it is probable that symptoms closely resembling if not identical with those of the passage of a calculus may occur when the substantial cause of them does not make its appearance; and although many of these may perhaps be accounted for by the ill-success of the search or by the calculus having ceased to pursue its downward course and having become quiescent in the kidney, yet it is well for the practitioner to be prepared for an occasional disappointment in obtaining tangible proof of the nature of the attack. Time may be required to decide whether an attack is due to calculus, or is simply one of the spasmodic or neuralgic paroxysms mentioned above.
If after careful watching no stone makes its appearance, and on the other hand the pain does not continue and no pus gives evidence of pyelitis, it is highly probable that no stone is or has been present.
A true neuralgia of the kidney may undoubtedly exist. Lumbago and lumbar neuralgia may simulate renal colic, but are almost always much less severe, the pain less sharp and more dull and aching, aggravated by movement, while the sympathetic phenomena, especially those connected with the urinary apparatus, are wanting.
The diagnosis of the character of the calculus can sometimes be made with a reasonable degree of probability. If crystals of uric acid or of oxalate of lime have been or are present in considerable quantity, it is highly probable that a possible stone may consist of those substances. These crystals, however, are of little value in proving the presence of a stone.
The important diagnosis of the occlusion of a ureter by a calculus, and at the same time that of the soundness of the opposite kidney, may be made with great certainty if the urine, which has previously been purulent, bloody, or containing renal epithelium or casts, suddenly becomes clear coincidently with the occurrence of symptoms of the impaction of a stone.
It is not of course necessary that in every case of impaction the flow of urine from the affected side should be entirely stopped, since the calculus may be of such a shape as to permit the passage of urine past it.
The PROGNOSIS in this affection is extremely favorable, so far as the recovery from the individual attack is concerned, since if the stone is small enough to enter the ureter it will probably be successful in forcing its way through sooner or later. It is of course possible that this pain, like any other of excessive severity, might cause death, but such an occurrence must be extremely rare.
Perforation of the ureter may occur, with consequent peritonitis. A permanent plugging of the ureter from failure of the calculus to pass will give rise to changes in the kidney to be subsequently described.
In cases where only a single kidney exists, and this becomes obstructed, the symptoms of suppression of the urine may come on, including death by coma if the obstruction is not relieved. Ten days is the limit assigned by Ebstein beyond which recovery is not to be expected, but he mentions a case in which it took place after thirteen days of anuria. It must be remembered that a painful obstruction, or in fact any severe shock to one kidney, may produce a very great diminution in the amount of urine even when the other is sound. This is undoubtedly the result of nervous sympathy.
One attack of renal colic renders another very probable, either immediately or after months or years. Several hundred small calculi may follow each other in rapid succession, or, on the other hand, a single one may leave the patient in peace for a long time. Much depends on the character of the calculus, the diathesis and habits of the patient, and upon the treatment.
The subsequent history of the renal calculus belongs to surgery. After it has reached the bladder and failed to be discharged, it increases in size and is removed by lithotomy or lithotrity. The urethra, however, will usually permit to pass any stone which has come through the ureter. The patient who has just experienced relief from renal colic should be instructed to pass his water into a vessel which can be examined, and if the calculus do not soon make its appearance he should void the urine when stooping forward or even lying on his face, so as to bring the stone to the orifice of the urethra. It may catch in the urethra and demand surgical interference.
The TREATMENT of the paroxysm consists chiefly in relieving the pain, which may be partly done by the hot bath or hot applications. Opium, or preferably morphine subcutaneously, is likely to be called for in large doses. Attention has been called to the danger of morphine in sufficient dose to relieve severe pain in cases where, as in renal colic, the pain is likely to be suddenly terminated by the natural progress of the affection, thus destroying the physiological antagonism which exists between pain and morphine, and allowing the drug to exercise its full power to an extent which may be over-narcotic. The use of atropine with the morphine will mitigate to some extent its danger, without interfering with its analgesic effects.
In the milder cases ether and chloroform may be of value given by the mouth, while in excessively severe ones anæsthetics by inhalation may be called for, and their use continued for hours. This course also is not without its inconveniences. The writer has seen a case where a somewhat prolonged maniacal attack, with delusions lasting several days, came on after the long-continued use of chloroform to relieve the pain incident to the passage of a multitude of small uric-acid calculi.
The use of diluents has been suggested as hastening the passage, but there is no reason to doubt that the pressure upon the calculus is always sufficient to move it forward as rapidly as its shape and size will permit. The relaxation of the spasmodically contracted ureter is of much more importance than an excessive vis-a-tergo applied to the calculus.
The treatment of the incipient calculus in the kidney or of the condition which gives rise to it must naturally vary according to its chemical constitution, which can only be certainly determined after its discharge, but as to which an approximate opinion can be formed from a knowledge of the tendencies and diseases of the patient and from an examination of the urine.
The use of a largely-diluted solution of citrate of lithia or of acetate, citrate, or tartrate of potassium will probably prevent the deposition of uric-acid sand, and might even dissolve a small calculus, although the proofs of this having actually been done are not conclusive. If the urine be largely diluted the risk of the formation of a calculus of another kind—i.e. phosphatic—is not great. Simple water would be of great value in many cases, both as dissolving uric acid and as promoting the metamorphosis of tissue, upon some abnormality of which the accumulation of uric acid is supposed to depend. The benzoate of lithia, by the destructive action which Garrod has shown benzoic acid or its derivative hippuric acid to have upon uric acid and the solvent action of the lithia, may be of value. The phosphatic deposit, on the other hand, although beneficially influenced by a sufficient supply of water, is not so amenable to chemical influence as the other form, because it is much easier to render the urine alkaline than acid when any irritation of the urinary passages is present.
The vegetable acids, however, pass into the urine, and may render it acid if in sufficient quantity. Benzoic acid becomes hippuric acid, and can be used to make the urine more acid, as it causes very little gastric irritation even in considerable doses. Boric acid also passes into the urine, and acidifies as well as disinfects it, and might perhaps be used to promote the solution of a phosphatic stone, though the writer is unaware of any instance in which this has actually been done. It does much toward diminishing suppuration in the urinary passages, upon which phosphatic urine largely depends.
The conditions which lead to the deposit of oxalate of lime are not sufficiently well known to make the prophylaxis of this calculus easy by any chemical means, except by dilution of the urine and by a general tonic regimen with abundant exercise.
Although it is not usual for a calculus to be arrested in the ureter after having once fairly entered, this sometimes occurs, and the result is stoppage of the flow of urine upon that side, dilatation of the ureter, followed in turn by dilatation of the pelvis, and finally atrophy of the renal substance. This does not happen suddenly, however. The urinary passages do not rapidly dilate to any considerable extent, and their increase in calibre under pressure from within has been considered a growth rather than a distension. This condition will be treated under the head of Hydro-nephrosis.
Calculous Pyelitis.
When a calculus remains in the pelvis of the kidney without completely obstructing the flow of urine, it usually increases in size, while the resulting irritation may be the cause of fresh deposits either upon the surface of the original calculus or in the form of new concretions. In this way immense deposits of urinary salts may be formed. Thus, in a case given in detail in the second series of Boston City Hospital Reports there was found upon the one side a calculus which when perfectly clean and dry weighed 204 grammes, filling the whole dilated pelvis and sending prolongations into the calices, so that its shape was compared to that of a hippopotamus. The resemblance was made more complete by the wrinkling and roughness of the exterior. In the other kidney were several hundred calculi, from the size (and shape) of a large almond down to that of white mustard-seed. The latter were composed of two apparently distinct substances—one a reddish-brown, looking like uric acid, and the other of the color and polish of white marble; both, however, were phosphates.
The amount of local disturbance produced in the pelvis of the kidney by the presence of a foreign body seems to depend somewhat upon the character of its surface. Rough and uneven calculi, such as oxalate of lime, are apt to produce inflammation much more rapidly than smooth and polished ones, but it is seldom that any calculus remains without some pyelitis. At first only a loss of polish of the mucous membrane, with a little increase of mucus, may be observed, to which succeed roughening and suppuration with occasional fibrinous deposit. The pelvis, more or less dilated, may then contain a quantity of mucopurulent urine, with perhaps some blood, in which are concealed the stones which have given rise to this condition, and often phosphatic deposits not converted into calculi.
Pyelitis is divided by some foreign writers into catarrhal and diphtheritic—a distinction rather of degree than of kind. The mucous membrane of the pelvis may, like other mucous membranes rarely, and like serous membranes often, throw out a fibrinous exudation which takes the form of false membrane. This indicates intensity of inflammation, but has no necessary connection with diphtheria. A true diphtheritic pyelitis, that is, connected with the general disease known as diphtheria, is of course a conceivable lesion, but certainly not a common one.
The renal symptoms—especially true albuminuria, so common and of such grave import in this disease—are due to lesions of the secreting substance, and not of the pelvis. It is important, but not always easy, to decide whether there is more albumen present than is to be accounted for by the pus. The pyelitis may be acute or chronic, being characterized by the intensity of the attack and the rapidity with which the symptoms subside. The prospect of a given attack being acute is decided largely by the supposed cause: a small calculus passing into the ureter undoubtedly gives rise in most instances to a localized pyelitis, which subsides after the cause of irritation has disappeared. An inflammation from a larger one remaining is naturally of slower development, but may be more acute while the calculus remains rough and irritating, and partially subside when it becomes covered with a smoother coating of phosphates. The mucous membrane, however, is not likely to regain a completely healthy condition.
The mucous membrane in severe pyelitis may be deeply eroded, and even perforated, so that the contents of the pelvis escape and give rise to abscess in the perinephritic or prevertebral cellular tissue, which may be discharged through the loins with resulting cure, or the establishment of a fistula, from which issues pus and at times calculi. Among the rarer results of perforation may be mentioned gastro-nephric and duodeno-nephric fistulæ. These might be diagnosticated by the presence of food and other intestinal contents in the urine, provided that the ureter were still pervious. Vomiting of calculi and urine has been reported by the older writers.
The writer is indebted to J. R. Chadwick for references to two modern cases—one where such a fistula was diagnosticated during life;16 and another where a gastro-nephric fistula was found after death.17 In the latter case a diagnosis would have been impossible, as the kidney was disorganized and the ureter occluded. The extent to which the renal secreting substance suffers in calculous pyelitis varies considerably, and is very probably connected with the amount of pressure exercised either by the calculus itself when it attains a large size or by the urine in cases of obstruction. It is rare for either pyelitis or hydro-nephrosis to exist entirely independently.
16 Giornale di Anat. e Fis. path., iii. p. 370.
17 Marquezy, Thèse de Paris, 1856.
The changes which take place are those of atrophy. Interstitial suppurative nephritis seems to follow this form of pyelitis much less frequently than that which is due to extension upward of disease in the lower urinary passages.
Corresponding to the pressure of solid or fluid, the papillæ are eroded and the straight tubes shortened. In the cortical substance, which soon becomes diminished in thickness, the interstitial tissue is hypertrophied, dense, and hard, while the tubes become smaller or in time disappear. The Malpighian bodies are changed to dense masses of connective tissue, but are still plainly recognizable, irregularly crowded together instead of being arranged as usual in more or less symmetrical double rows. The cortex of the kidney may thus become but little more than a mere skin stretched over a large stone, with perhaps here and there a piece of renal structure recognizable and in a comparatively normal condition.
The extremer grades of hydro-nephrosis do not seem to be met with in this form of atrophy, but the pelvis is considerably dilated, while its internal capacity is also added to by the atrophy of the renal substance. The interior of the cyst thus formed usually retains distinct traces of its original division into infundibula, and may be, as already stated, almost filled by the calculus. Kidneys undergoing this process of degeneration often furnish up to a short time before death a normal, or even more than normal, amount of urine, and one is often astonished to find how little disturbance of elimination has been caused in cases where the true kidney-structure seems to the naked eye to have been almost entirely destroyed.
The DIAGNOSIS of a calculus remaining in the pelvis of the kidney depends chiefly on the determination of hæmaturia and pyelitis for which no other cause can be found, and upon the presence of pain in one loin. It is naturally greatly assisted by the presence or history of renal colic. An aching pain in the loins, more or less permanent, is a frequent but not invariable symptom. It may be such as to prevent the patient from standing upright, and cause him to assume an habitually stooping posture in standing or walking. A careful examination of the urine in conjunction with this symptom, especially if an unusually abnormal condition has been preceded by an exacerbation of the pain, may make the diagnosis almost certain. In the beginning of a case occasional not severe hæmaturia, with some increase of mucus or a little pus, may be all that can lead to the suspicion of calculus as the cause of pain. At a later period an increase of these symptoms, with a considerable quantity of the peculiar irregular epithelium lining the pelvis, may be observed. The latter constituent, however, can hardly be looked upon as entirely conclusive of pyelitis, since the lower urinary passages may give rise to cells of about the same form and size, and the irregularity is likely to be increased beyond recognition by the presence of inflammation. They may also undergo change of form in the urine. The presence of transparent or other casts denotes the irritation of the renal parenchyma.
The point of chief difficulty in the diagnosis of pyelitis is the determination of the origin of the pus, whether from the kidney or the bladder. Cystitis may be only partly excluded by the absence of dysuria. A point of considerable weight is the reaction of the urine, that from the kidneys being usually acid, while that from the bladder, when cystitis of much severity exists, is alkaline or rapidly becomes so. The pus coming from the kidneys is more intimately mixed with the often profuse urine than when formed in the bladder. The whole of it does not in the former case completely subside, but remains in sufficient quantity to form a turbid or opalescent mixture—the polyuric trouble of Felix Guyon, according to whom this condition in an acid urine is strongly indicative of renal as distinguished from vesical lesion. In cystitis the pus subsides in more or less distinct masses, but if the urine is alkaline, or when it becomes so, is altered to a ropy consistency usually spoken of as muco-purulent.
The procedure recommended by Thompson may be resorted to in order to determine whether the urine comes from the kidneys loaded with cellular detritus, or whether the addition is made in the bladder. This consists in washing out thoroughly the bladder with several successive quantities of water through a single catheter, until the water comes away clear and the bladder has contracted itself around the instrument, when the urine from the kidneys will for a time come through direct and comparatively uncontaminated.
In cases where the urine is alkaline in the kidney, which may happen, distinctions founded on the reaction cannot be of value, and the same may be said of cases where cystitis is known to exist, but where there is in addition a possibility of a renal calculus. In these some such mechanical procedure as that just described must be resorted to.
The presence of a calculus as a cause of pyelitis cannot always be demonstrated, but may be more or less strongly suspected according to the conclusiveness with which any other cause can be excluded, by the definiteness and character of the local pain, the history of renal colic, the presence of uric-acid crystals in the urine, and perhaps in some cases the results of palpation. The exploring-needle may be used, and may of course, if reaching the calculus and giving a characteristic grating feeling and sound, give absolutely positive results; but a failure to strike a stone could hardly be regarded as proof positive of its absence.
The diagnosis of renal calculus from lumbago or neuralgia should rest, in case the pain is severe enough or long-continued enough to really cause the question to arise, upon an examination of the urine.
A very important point in diagnosis, especially when the question of operative procedure arises, is that of the soundness of the other kidney. Accidental circumstances will sometimes permit this to be determined; as, for instance, when one ureter is suddenly blocked by a calculus, and at the same time the urine, which has previously been found purulent, bloody, and containing renal cells and casts, becomes clear and normal until the obstruction is removed and the abnormal ingredients reappear. Cases of exstrophied bladder, where of course it is possible easily to separate the urine of the two kidneys, may be, from their rarity, practically left out of the account. Various proposals for obtaining the separate urine of the two kidneys have been made. A small catheter has been passed into the female ureter through the dilated urethra. In the female also a finger in the vagina may succeed in temporarily blocking one ureter, while the secretion of the other alone is filling the bladder, a catheter with a bent portion at the end being used for making counter-pressure from the inside. It would probably remain doubtful in most cases how successful this manoeuvre had been in completely stopping the flow of urine, although experiments upon the dead body have been made by Polk,18 who proposes the method, with entire success. The male bladder offers greater difficulties, which are at present insurmountable. A point opposite the lower end of the ureter can, it is true, be reached with some difficulty in the rectum, and it is possible that a catheter might be so adjusted as to make counter-pressure to the finger in this position, but there could be no certainty that the occlusion was complete.
18 New York Med. Journ., Feb. 17, 1883.
The whole hand in the rectum, after Simon's method, would enable the object to be accomplished with more certainty, but this procedure has risks of its own. A staff with flattened extremity, as suggested by Weir,19 may more conveniently, though with somewhat less certainty, be used for pressing from within the rectum on the ureter where it passes over the brim of the pelvis. A compressorium consisting of an empty and folded bag, to be introduced into the bladder and there expanded by the introduction of metallic mercury, has been described and used, with the result of partly checking the flow of urine.20 The proposition to pinch up the extremity of one ureter in the bladder by means of the lithotrite is still more open to the objection of great uncertainty, and would, to say the least, demand very special skill to obtain even a chance of success.
19 Ibid., Dec. 27, 1884.
20 See Weir's article, just quoted.
None of these procedures have as yet been put to practical use, and it is doubtful whether any of them, unless we except perhaps the use of a staff in the rectum, would be justified for purely diagnostic purposes, considering the great risks involved. For the present, at least, the possibility of separating the secretion of one kidney from that of the other must be looked upon as depending chiefly upon accident, and in case of contemplated operation it is not possible to assure one's self of the integrity of the other kidney before the abdomen is opened. In many cases after opening the abdomen both kidneys may be examined before deciding upon further steps. Lawson Tait considers an exploratory incision distinctly indicated whenever abdominal disease not malignant threatens the life of the patient. The soundness of the other kidney, however, may be considered highly probable if in spite of demonstrated extensive disease of one kidney a sufficient quantity of urine with a normal amount of urea and salts continues to be formed.
The SYMPTOMS arising from a large calculus producing destruction of the renal substance, when both kidneys are affected or one is insufficient to supplement the partial or total loss of the other, may closely resemble those of diffuse nephritis, either interstitial or parenchymatous, or perhaps it would be more correct to say that these forms of nephritis are the symptoms of such a change. Thus we may have polyuria, albumen, and casts, dyspnoea, dropsy, and uræmia. The enormous calculus described above as resembling a hippopotamus had given rise to no marked symptoms until palpitation, dyspnoea, and oedema were complained of; the heart was hypertrophied.
The TREATMENT of calculi remaining in the kidney is, so far as medical means are concerned, that which has been already described, and, to say the least, is not a high degree of efficiency. Rest, diuretics, and solvents of the kind already spoken of, and narcotics, may afford relief, and in the case of quite small calculi, such as sometimes remain in the kidney even when not too large to pass through the ureter, solution is possible; but there is even less reason to suppose that large calculi can be dissolved in the kidney than that the tendency to their formation can be counteracted.
Surgery, however, offers in some cases complete relief. Two operations have been undertaken for this purpose, of which the surgical details are here inappropriate, but the indications for which may very properly be discussed from a medical point of view. These are nephrotomy or nephro-lithotomy, the removal of the stone through an incision in the pelvis or secreting substance of the kidney; and nephrectomy, or the removal of the whole gland with its contents. It is obvious that the indications for these two operations are quite different, although cases are likely to arise where it will be well to change the plan from the former to the latter during the operation.
When a sinus exists from the inflamed and perforated pelvis, or an abscess connected with the kidney has been recently opened, it may be dilated or enlarged by incision sufficiently to allow the passage of an exploring finger and forceps. The large arterial and venous branches which surround the pelvis make it safer to trust rather to dilatation or tearing to get through to its interior than to incision, which must, if necessary, be practised with great care. Experience has shown that an incision can be made through the renal substance without great danger, the hemorrhage being chiefly venous. This incision has been made in several cases, and where the secreting portion is much atrophied is obviously of still less consequence than in the healthy kidney. After the removal of the calculus, drainage may be established for a time until the pelvis has resumed its normal condition or the purulent discharge has diminished.
If no sinus exists, but a diagnosis has been clearly made, or even if symptoms of sufficient severity exist to justify a strong suspicion and decisive treatment, an incision may be made along the edge of the erector spinæ or the great mass of muscle attached to the spinal column and passing through the quadratus lumborum. An incision outside of the quadratus lumborum will come upon the kidney, but too far outside to make a direct access to the pelvis practicable. If it be known, however, that the cut must be made through the kidney itself, then the primary incision through the skin may be made in the exterior line, and will be less deep. Measuring along the last rib two inches from its extremity, and then at right angles an inch and a half downward and inward, will indicate a point at which a puncture will reach the renal pelvis. This may be made the central point of an incision, though it is often necessary to utilize the whole space from the last rib to the crest of the ilium. After reaching and exploring the kidney with the finger, the incision may be carried cautiously through the pelvis and enlarged by dilatation or tearing.
In order to feel the calculus it may be necessary to have counter-pressure made from the front of the abdomen in order to lift or fix the kidney, and a case has been mentioned where the finger, having failed to reach a calculus behind, was carried around and in front of the kidney with success. If the calculus is too large or too irregular to be removed whole, it may be broken and extracted piecemeal.
This lumbar method is undoubtedly to be preferred when it is known that a simple nephrotomy will be sufficient or when the more or less diseased kidney is to be treated as a cyst or abscess by drainage. It is open to the objection that if it be found desirable to change the operation into an nephrectomy, it is not quite so easy to remove a large mass in this way as by laparotomy, and the pedicle is much less accessible. The objection is not sufficient, however, to contraindicate it in many cases, for additional room can be obtained by resection of the last rib. So far as the writer is aware, laparotomy has never been performed for the simple removal of a calculus.
Nephrectomy, or removal of the kidney, may be required for various conditions, among which is to be reckoned a renal calculus with pyelitis of sufficient severity to threaten life or give rise to constant suffering; but as it is often indicated for other reasons, its consideration will be deferred.
Pyelitis may be excited by the presence of other foreign bodies, among which are coagula and parasites. An acute pyelitis may accompany an acute nephritis. Occasionally also an idiopathic pyelitis is said to be met with, but it must be difficult in such a case to exclude the presence of some irritant which has escaped observation.
Secondary Pyelitis.
Pyelitis is most frequently excited by the propagation of an inflammatory process upward from the bladder, and hence it is, with its resulting effects upon the renal structure, one of the most important complications of chronic cystitis and of surgical affections in the lower urinary passages. Anatomically, a pyelitis of this character differs but little from that of local origin described above, except that the contents of the inflamed cavity do not include deposits of urinary salts unless such have been formed secondarily. It is, however, more likely to be severe, and especially to affect the true renal substance more rapidly and more seriously, and consequently to be attended with constitutional symptoms in an acute form.
Two factors are of especial importance in determining the rate of development and severity of pyelitis supervening on affections of the urinary passages: First, the amount of obstruction which exists to the exit of the urine; and, secondly, the character of the cystitis as regards decomposition of the urine. It is obvious that whatever sends urine back into the ureters, or, what is the same thing, prevents its passage downward, will by keeping it longer in contact with the mucous membrane intensify whatever morbid action such an irritant would have, and of course a putrid or ammoniacal urine will induce inflammatory action, while a normal secretion might remain for a long time innocuous. Hence it is that we may have hydro-nephrosis and pyelitis entirely distinct from each other, but are very likely to have both combined in most cases.
It is especially in surgical affections of the urinary passages, involving, as many of them do, considerable obstruction with a more or less intense cystitis, that we meet with the combination of the two conditions. Such are enlarged prostate with its usual obstruction and frequent chronically-distended bladder, with ammoniacal, purulent, and decomposing urine, or stricture with frequent over-contraction of the bladder, forcing the urine backward as well as forward. In diseases of the female generative organs we are more likely to have the hydro-nephrosis and pyelitis as separate affections, since the compression which so frequently arises in cases of cancer or of pelvic inflammation is likely to be above the bladder, thus preventing the regurgitation of urine as well as its passage downward.
Two conditions of the renal substance seem to result from pyelitis of this kind: one, a chronic nephritis already described, with increased formation of connective tissue, atrophy of the tubes and the Malpighian bodies (the latter, however, remaining recognizable, although crowded together), and a general, and at times extreme, shrinking of the whole organ. The other is more acute, and consists in the formation of abscesses of small size, which in the medullary portion are somewhat elongated and arranged parallel to the tubes, and in the cortical portion preserve a less degree of regularity, though still having some reference to the columnar arrangement of the masses of convoluted tubes. The intervening structure is usually in a marked condition of parenchymatous degeneration. This is the so-called surgical kidney.
Whether the one or the other of these processes shall take place probably depends chiefly on the infectiousness of the cystitis or of the urine contained in the bladder and backing up into the kidneys, although it is not necessary that any degree of dilatation should be present for this condition to arise. Sometimes also the surgical kidney may be found when the original cystitis is not at all severe.
The DIAGNOSIS of a pyelitis supervening on a cystitis is not always easy, but may frequently be inferred, and it is possible that by careful treatment of the cystitis it may be reduced to a very low grade of severity, while the pyelitis still remains, which will permit the diagnosis to be somewhat more conclusive.
If the urine comes acid, but pus-laden, from the kidney, it will soon assume the contrary reaction in the bladder, and the pus will be changed by the ammonia into so-called muco-pus; the cells supposed to be characteristic of the pelvis of the kidney will, like the pus-cells, be so altered by the same causes, and so intermixed with similar cells from the bladder, that the distinction will be difficult or impossible. The presence of a few hyaline casts is very likely to be noticed, and indicates irritation, or perhaps a more decided implication, of the renal substance. Nothing, however, can be inferred from failure to find them. Hæmaturia is not so necessary an accompaniment of this form of pyelitis as of that arising from a mechanical irritant in the kidney. If, however, the urine does not become rapidly altered in the bladder, or if by any of the processes mentioned above the kidney urine can be obtained in a condition of comparative purity, the microscopic indications become more precise.
A dull pain and tenderness in the loins and along the course of the ureters is a symptom of value, though by no mean conclusive, and should lead to a suspicion of pyelitis. A polyuria of short duration may be a purely nervous symptom, but a persistent flow of pale urine, which fails to settle clear, and of which the turbidity is caused by pus, is due in great probability to renal disease, and if it could be shown to come in this condition from the kidney would almost certainly denote pyelitis.
The rational SYMPTOMS are of the greatest value as determining the extent and severity of the disease, although it may be impossible to distribute them with absolute exactness between the various organs involved—that is, bladder, pelvis, and renal substance.
The occurrence of a single chill, or even of several, with rapid subsidence of the fever, is not conclusive, since the ordinary urinary fever supervening on surgical operations, even so slight as passing the catheter, is not necessarily connected with renal disease.
A long-continued fever, not especially intense and of a more or less distinctly intermittent type, especially if becoming at some definite period decidedly more intense, is likely to mean the invasion of a new tract of mucous membrane, such as that of the renal pelves or even of the kidney-substance itself. Continued or remittent urinary fever is of very grave import. With this fever will appear the dry red tongue and the distressing anorexia, nausea, and vomiting, with either constipation or diarrhoea.
The TREATMENT of this form of pyelitis, so far as it differs from that of the calculous variety, depends largely upon that of the causative cystitis, though not entirely, since if it has once assumed the chronic condition it does not necessarily subside even if the cystitis be cured. The essentials of treatment may be said to be drainage from below and washing from below and from above. The measures for carrying the first of these indications are those which are also required for the causative cystitis, and, being chiefly surgical, a minute description of them does not come within the scope of this article. They may be simply catheterization, dilatation, divulsion or section of a stricture of the urethra, drainage of the bladder through the rectum or through the perineum.
It is not out of place, however, even in a strictly medical essay, to point out the extreme importance, not only in the way of treatment, but of prophylaxis, of securing a free exit for the urine. Even that small degree of obstruction or hindrance which leads a person to habitually put a little extra strain upon the bladder in order to expel its contents, especially if it be allowed occasionally to become dilated, may gradually lead to dilatation of the ureters, and thus make an easy passage upward for inflammatory and decomposed urine if such should afterward be formed as a consequence of cystitis by retention. The washing of the bladder from the urethra may be done with a great variety of antiseptics and acids: nitric acid in the proportion of 1 per mille may be used to change the reaction of the urine. Carbolic acid should be carefully used, from the danger of its absorption in poisonous amounts. Boric acid is a safe and quite efficient antiseptic.
Washing from above, which is evidently that which alone can directly affect the renal pelvis, must be done with such drugs as can be safely given internally, so that carbolic acid cannot be of much use in this way. Salicylic acid loses a part, but not all, of its antiseptic properties in its passage through the blood and kidneys. Boric acid passes readily into the urine, alters its reaction, and seems to have some antiseptic action. It is unirritating in the stomach, and may be given in doses of 30 centigrammes or 5 grains to the extent of 1 or 2 grammes per diem. Benzoic acid and the benzoate of sodium, ammonium, or lithium have been found to be of value in cystitis, and as they can only reach the bladder by previously passing over the pelvic mucous membrane, they should also have a good effect here. It is obvious that constitutional symptoms arising from cystitis and its consequent nephritis may demand the most attention, and should evidently be of a decidedly supporting character, the details of which have no special reference to the disease, but to the general condition. Quinine may be called for as an antipyretic.
The question of removal of a kidney for pyo-nephrosis is less likely to arise in this form than the other, since from its causation it is much more likely to be bilateral; but if under any peculiarity of anatomical arrangement, such as greater dilatation of the one ureter, it should be found that one kidney was nearly healthy while the other was in a state of pyelitis, and purulent inflammation was giving rise to serious constitutional disturbance, such an operation might be undertaken.
The operation of nephrectomy, or removal of the kidney, may be required for various lesions, most of which include more or less pyelitis, and it may be considered once for all in this place. It has now been practised more than one hundred times. A table including 100 cases is given by R. P. Harris in the American Journal of the Medical Sciences for July, 1882, and many have been recorded since.21 It can, of course, hardly be expected that the removal of one of a pair of vital organs, under circumstances where it is often the case that the other is not completely capable of carrying on the additional work, should present the same favorable array of statistics as ovariotomy; but it gives no small number of recoveries in cases which without it would undoubtedly have proved fatal, and it must be considered as having a legitimate and well-defined place among the major operations.
21 Weir, New York Med. Journ., Dec. 27, 1884.
There are two distinct methods, besides, of course, all the minor differences of detail called for in the individual case. The kidney may be reached from the loin by an incision along the outer edge of the erector spinæ, as already described for nephrotomy. It is to be enucleated from its capsule of fat by the fingers, and a ligature or ligatures passed around the pedicle consisting of the veins, arteries, and ureter. The kidney is then cut off, possibly leaving a little renal substance if the pedicle be short and accessible with difficulty. The wound is left partly open for drainage. This method has the advantage of avoiding the peritoneum and the handling of other abdominal organs. Its disadvantages are, in some cases, the want of room, and when undertaken for the relief of floating kidney the difficulty of finding the organ, which is likely to be at the end of a pouch formed of peritoneum. In cases of calculous pyelitis, where it may be at the beginning of the operation uncertain whether merely an incision for the removal of a stone or a total removal of a kidney of normal size may be necessary, this line of approach presents decided advantages.
The other method is by abdominal incision or laparotomy, which is usually made through the linea alba, though in a number of cases the outer edge of the rectus abdominis on the side corresponding to the organ to be removed has been taken as the guide. The steps of the operation are similar to those of ovariotomy where the pedicle is tied and returned to the abdominal cavity. This operation may be one of choice, from the greater ease with which the pedicle can be reached and the possibility of increasing the length of the incision in case of necessity for the removal of a very large tumor. In one case a crucial incision was made. When the kidney to be removed is a wandering one, and especially when a kidney has become fixed in an anomalous position, this is by far the easiest, and sometimes the only practicable, method.
Antiseptic precautions are of course to be used.
Hydro-nephrosis.
Obstruction to the discharge of urine from the body naturally produces special disorders in the secreting and discharging organs. If the obstruction exist below the neck of the bladder, as in stricture of the urethra or enlarged prostate, then the bladder is the organ primarily affected, and it may become distended, sacculated, its muscular coat hypertrophied, its mucous membrane affected with catarrhal inflammation, and its contents changed from the normal by the addition of mucus, of pus, of bacteria, or a deposit of earthy phosphates from the ammoniacal reaction produced by decomposition of the urea.
The effects of distension of the bladder will sooner or later make themselves felt in the upper urinary passages, and will then give rise to the same dilatation of the ureters and the renal pelvis as occurs when the obstruction is higher up. As regards the rapidity with which such changes progress, much depends upon the degree of obstruction as well as upon the amount of urine secreted. It probably, however, never takes place suddenly.
In a case which came under the observation of the writer a partial paralysis of the bladder, probably existing from infancy, had in the course of three or four years, during which large quantities of light urine were passed, given rise to dilatation of the ureters, slight dilatation of the pelvis of the kidneys, atrophy of the parenchyma, and hypertrophy of the left ventricle.
Obstructions in the course of the ureters may exist at their opening into the bladder, which may be contracted by chronic cystitis; at a point immediately above this from compression by morbid growths, especially of the uterus, one of the most common causes of hydro-nephrosis, or even from retroflexion of the uterus when pregnant; at any point in its course by a twisting or sharp angle, as in movable kidney, although this is a much rarer accident than might be supposed; or at the brim of the pelvis, where it may be bound down by old peritoneal adhesions, and at its junction with the renal pelvis, which may be formed in such a manner as to constitute a valve, so that the urine escapes slowly or with great difficulty; or where it may be blocked by a calculus or other deposit in the cavity of the pelvis.
Obstructions by a twist or angle or by a valvular opening may, it is obvious, be temporary or intermittent in their action, and probably some arrangement of this kind was present in the cases which have been reported of relief of hydro-nephrosis by gentle massage of the abdomen.
Above the point of obstruction the ureter and pelvis are found dilated and the walls somewhat thinned. The kidney and its pelvis form a more or less irregular rounded pouch, with the tense cylindrical tube of the ureter attached to it below. The kidney itself becomes in various degrees atrophied. In some cases it retains nearly all its secreting structure, and is merely spread out upon the surface of the sac; in others, while the pelvis is but little dilated, the true kidney substance atrophies almost completely, and becomes a mere shell enclosing a cavity continuous with the pelvis and broken up by fibrous septa into subordinate cavities representing the original calices. A partial hydro-nephrosis is sometimes observed affecting only the calices.
Whether the one or the other of these conditions shall result depends, as has already been remarked, upon the completeness and suddenness of the obstruction. If the ureter of a rabbit is ligatured, the second condition—that is, atrophy of the kidney with but little dilatation—is observed. The pressure of urine soon puts a stop to further secretion, and there is no time for a slow and gradual dilatation of the pelvis and ureter. When, as is much more frequently the case in the human subject, the obstruction is more gradual or incomplete, the back pressure is for a long time insufficient to completely stop the passage of fluid through the renal capillaries, so that the pelvis and ureter, though allowing their contents to pass out only under a considerable vis-a-tergo, have time to accommodate themselves to the change, and dilate gradually, attaining sometimes enormous dimensions. The size of a hydro-nephrotic sac varies greatly: 60 liters of contents is certainly a very extreme case.
The sac is usually white and glistening, thinner at some places than at others, and lined with a smooth, pale, and atrophied mucous membrane. The muscular layer has degenerated, and perhaps partly disappeared. The liquid contained in the sac, supposing no inflammatory products to have been mingled therewith, is at first nearly identical with urine, and always contains urea. Afterward its character changes from the absorption of the urinary salts and the secretion of mucus. The contents may be dark-colored from hemorrhage or somewhat gelatinous. At a later period again they become serous and may contain cholesterin.
The description just given, as well as that of the symptoms, applies to simple hydro-nephrosis. When the sac has become inflamed we have the very common combination with pyelitis, and the affection is called pyo-nephrosis. The progress of a case of hydro-nephrosis may be in rare cases to recovery by spontaneous re-establishment of the permeability of the ureter. In others it persists a long time without giving rise to trouble. If inflammation supervene, it is obvious that fever, either simply irritative or of pyæmic character, may be a severe or even a fatal concomitant, or that in this condition a perforation may take place. When the tumor is large it may from its bulk alone produce disturbance of the circulation, dyspnoea, palpitation, and oedema of the lower limbs.
As regards the influence of this lesion on the secretion of urine, everything must depend on the amount of renal atrophy. A single kidney may undoubtedly be completely atrophied by this as by any other lesion without producing serious symptoms, since, as has been repeatedly demonstrated, the other is sufficient to carry on the work under ordinary circumstances; but if, as very frequently happens, both kidneys are involved, there must come a time when the renal substance no longer suffices, and the usual results of suppression of urine follow. It is possible, however, for extensive changes to take place in both kidneys before symptoms of insufficient secretion arise.
Hydro-nephrosis, in the entire absence of inflammatory symptoms and in the presence of conditions likely to cause it known to exist in the lower urinary passages, may be rather suspected than diagnosticated until the appearance of a tumor. Some dull pain in the loins without irradiations in any direction may exist, but so common a symptom can have but little weight in diagnosis. For an early recognition of swelling in suspected cases where nothing can be felt anteriorly, it has been recommended that the patient be placed upon the hands and knees, when the flank upon the affected side, instead of falling slightly forward and leaving a shallow depression outside of the erector spinæ, will remain full or protuberant. When an enlargement evidently connected with the kidney makes its appearance after obstruction to the passage of urine is known to exist, the diagnosis may often be very simple; but if the tumor be the first phenomenon observed, as may easily happen when the obstruction is situated high up or even at the commencement of the ureter, it may require to be distinguished from several other kinds of tumor occupying the lumbar region, or, since hydro-nephrosis of a movable or misplaced kidney sometimes takes place, from tumors of the abdomen in general. From solid malignant tumors of the kidney the feeling of comparative elasticity and fluctuation will in most cases distinguish it, though an encephaloid kidney may be so soft as to render the second of these points of comparatively little value. Absence of hæmaturia and of the cancerous cachexia, though not conclusive, would have much weight.
A hydatid cyst might counterfeit a hydro-nephrosis, but instances of this affection having its primary seat in the kidney are of extreme rarity. An ordinary cystic kidney is most likely to be connected with chronic diffuse interstitial nephritis, which will have made itself manifest by the usual symptoms, and is moreover unlikely to attain the dimensions of a large or even moderate hydro-nephrosis. In a thin person the ureter might, if felt dilated through the abdominal walls, clear up the diagnosis. Extreme cases of cystic kidney with comparatively little nephritis may, however, present great similarity and cause difficulty in diagnosis.
From most other tumors of the abdominal cavity those of the kidney present the important distinction that they are situated behind the peritoneum, and consequently behind the intestines, so that the surface of a renal tumor is likely to be crossed by a more or less extensive area of percussion resonance, representing usually the large intestine. This criterion is, however, not absolute, since a renal tumor may push the colon completely to one side, or, on the other hand, tumors not connected with the kidney may allow the intestine to come between themselves and the abdominal wall.
An ovarian cyst is more manifestly attached to the pelvis, and its history will disclose the fact of its having arisen from below. A gravid uterus should also, when small, be manifestly connected with the pelvis, and when larger be accompanied by the usual symptoms of pregnancy. The same may be said of extra-uterine pregnancy, which may be mentioned as among the conditions possibly giving rise to difficulties in diagnosis.
The most efficient aid to diagnosis, when it is of importance that such should be accurately made, is the aspirator-needle, which will procure a fluid more or less characteristic of the tumor into which it is thrust. In hydro-nephrosis the contents are a somewhat dilute urine, with perhaps mucus; in a solid tumor, blood, with pieces of tissue recognizable by the microscope; in a cystic tumor, fluid which is perhaps somewhat urinous, but much more changed than in simple hydro-nephrosis, and perhaps containing solid-looking bodies with concentric and radiating striation; in hydatid cysts, hooks and fragments of scolices; in ovarian cysts, the various contents, fluid and semi-fluid, but not urinous, generally found therein.
With all these means, however, cases will occasionally arise in which expert diagnosticians may be lead astray, and the difficulties become considerably greater when the dilated pelvis is that of a displaced or unusually-placed kidney. Such cases have been subjected to operation under the impression that an ovarian cyst was present.
The medical TREATMENT of hydro-nephrosis is nil. In many cases nothing is demanded by the immediate necessities of the case, and atrophy, if it be probable that only one kidney is involved, may be allowed to take place without interference. It is possible that in some instances manipulation of the tumor might relieve the obstruction and allow the tumor to subside when a slight twist or angle in the ureter is the cause. The fact of an occasional spontaneous subsidence of such a tumor shows that something of this kind has taken place.
The surgical treatment of affections of the lower urinary passages, as both a prophylactic and therapeutic measure, has already been spoken of under the head of Pyelitis. It would, however, be only in a minority of cases of pure hydro-nephrosis that the seat of obstruction could be efficiently reached by surgery.
Puncture and aspiration of the sac may very properly be resorted to, and may prove of value—in the first place, as a more or less temporary relief; and secondly, as a means of re-establishing the flow through the natural passages by the relief of pressure and consequent opening of the valvular fold, which has occasionally been observed at the junction of the ureter with the pelvis.
In a case where the obstruction is known to be irremediable, and where the hydro-nephrosis, if existing only on one side, is likely to increase, it is not desirable to make the puncture too early or to repeat it too frequently, since by allowing the pressure to increase the atrophy of the kidney will be more rapidly accomplished, and the need of frequently emptying the sac will not arise so often in the future. On the other hand, if there is a prospect of a restoration, if both kidneys are affected, or if the kidney not involved in the hydro-nephrosis is known to be seriously impaired in function, and it is desirable to preserve the secreting structure as long as possible, the punctures should be so arranged as to keep the pressure at its minimum. This must, however, be regarded as a temporary expedient. The puncture may be made either from the back or front, though in most cases the latter position, if the puncture be made with a small clean needle, would be the more convenient, and equally safe notwithstanding its traversing the peritoneum.
A hydro-nephrosis may be treated either by removal or by drainage. Both of these methods have been resorted to, and are to be employed according to the circumstances of the individual case. A pyo-nephrosis naturally demands interference more peremptorily and more promptly than a simple hydro-nephrosis, because it exposes the patient to the dangers not only of its pressure and of its tendency to destruction of the renal substance, but to those more urgent ones of purulent infection or of perforation and perinephritic abscess. Removal is to be undertaken by the ordinary rules of laparotomy. Drainage has been arranged in cases where removal was impossible or unadvisable by stitching the edges of an opened sac to the external wound. It is possible that the choice between the two operations can be made only after the primary incisions and explorations have advanced sufficiently to enable the extent of adhesions and the amount of healthy renal substance to be approximately determined.
Staples of Dubuque states, on the basis of 71 cases collected by him, that "63 per cent. of patients operated on are cured by lumbar nephrectomy, 68 per cent. by open methods in general, and up to date 100 per cent. by either lumbar incision and drainage or the creation of a fistula."
Malignant Growths.
As pathological rarities only, and having but little clinical interest, may be mentioned, as occurring in the kidneys, fibroma, lipoma, myxoma, anginoma, and adenoma. Malignant growths originating in or involving the kidneys, sarcoma or carcinoma, are, however, more frequent and more important.
Sarcoma, primitive or secondary, of the kidney is a somewhat rare occurrence, but most frequent in children. The whole kidney may be transformed into a mass occupying its place and somewhat resembling it in form, but many times exceeding it in bulk and weight. Such a tumor may largely distend the abdominal cavity and compress its contents. Upon section we often find a substance varying greatly in consistence, from almost fibrous hardness to cavities filled with grumous material broken down by fatty degeneration and often colored by hemorrhage. In the interior may be found remains of the pyramids and cortical substance occupying their usual relative positions, but as it were distended, these portions being surrounded by a much thicker layer of purely abnormal neoplasm, probably connected with the capsule and its surrounding fat. In other cases all traces of normal form and structure may have disappeared. The microscopic structure of such a growth presents no peculiarity except so far as the arrangement of cells in the normal gland may be followed to a certain extent in the less-altered portions of the tumor. Besides this total destruction of the kidney, it is not uncommon to find nodules involving a part of one or both the organs, and more or less distinctly marked off from the healthy portion.
The origin of sarcomata involving the kidneys may be the subperitoneal cellular tissue or the neighboring organs. As a primary disease sarcoma of the kidneys is very rare.
True cancer or carcinoma of the kidney is not a common disease, and is said to have been found 12 times in 447 cases of cancer of various organs. It may be primary or secondary, and a description of the gross appearances would be essentially the same as that of the sarcoma. The tumor does not, however, usually attain so large a size, and the amount of degeneration of neighboring organs and of ulceration is greater. Calculi are often found in cancerous kidneys.
The SYMPTOMS produced by either sarcoma or carcinoma may be none at all for a time. Dull pains in the loins or referred to the hypochondrium—which, however, from their indefiniteness can have but little diagnostic importance—are among the early phenomena. Pains like nephritic colic may appear. The urine usually shows little of importance. There may be sympathetic disturbance of micturition, but unless hemorrhage occurs there is not likely to be anything in the urine discoverable by the microscope to fix the nature of the trouble. Fragments of cancer-structure in the very rare cases in which they are said to have been found would of course be conclusive, but evidence based on the alleged discovery of cancer-cells in the urine must be received with the utmost caution, recollecting the great variety of shapes and sizes assumed by the epithelium of the urinary passages. Hæmaturia is a symptom occurring in only a portion of the cases, its appearance in a given case evidently depending on the way in which the tumor invades the kidney and increases in size. If growing in such a way as to compress the ureter at an early stage before any erosion of the mucous membrane has taken place, blood, even if set free in the pelvis, cannot reach the bladder. If hæmaturia is present before any tumor can be felt, it has only a subordinate value, but if occurring after the discovery of such a tumor, the combination is of the highest significance. At a later period all the symptoms of compression of other abdominal viscera arise—anorexia, vomiting, jaundice, oedema, ascites, emaciation, and death.
When a tumor has become evident, it is to be diagnosticated from cystic disease and from hydro-nephrosis, with which it agrees in position and possibly in form. From the former of these its hardness and rapid growth, the invasion of other organs, and the cachexia will serve to distinguish it. Hæmaturia is not present in cystic disease. From hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated. On the right side it might not in every case be easy to distinguish a morbid growth of the kidney from one affecting the liver, and a similar difficulty might arise on the other side with the spleen. The diagnosis is to be made by a careful location of the tumor by palpation and percussion and the absence of symptoms likely to occur in connection with affections of the organs named. In children psoas abscess and degeneration of the lumbar lymphatic glands should also be considered.
A sarcoma of the kidney has been mistaken and punctured for an empyema. A sarcoma behind the kidney, pushing it forward, is very difficult to distinguish from a similar growth affecting the organ itself, especially as it is likely to give rise to signs of renal irritation discoverable by the microscope. A slight pyelitis, distinguished by pus and the absence of any cellular elements to indicate an origin at a lower point, has been observed in such a case.
The results of exploratory puncture have been before alluded to. If a piece can be brought away large enough to be examined microscopically, it may settle the diagnosis, not only as to a malignant growth, but also as to its kind.
The distinction between carcinoma and sarcoma cannot always be made during life, nor indeed, without a microscopical examination, after death. It is of importance chiefly with reference to prognosis after operation for removal of the organ. A more rapid growth, a greater tendency to invade other organs, and a more marked cachexia would speak in favor of carcinoma, while a tumor gradually attaining a very large size, and not spreading beyond the kidney and its immediate envelopes, is more likely to be a sarcoma.
There is no TREATMENT known to be of value in cancer or sarcoma of the kidney, except so far as it may diminish pain or regulate the secretions. Surgically, removal of the diseased organ is the only expedient to be thought of. Although nephrectomy has been shown to be a perfectly practicable operation, and one that is usually well borne when the other kidney is sound, it has not proved very successful with malignant growths, even as a temporary expedient. This is partly at least to be accounted for by the difficulties lying in the way of diagnosis in the earlier stages, and the reluctance with which so serious an operation would naturally be resorted to until hopes based either on the uncertainties of diagnosis or mistaken reliance on medical treatment have been given up. Cases, however, have been reported where patients have recovered from the operation, and the disease has not returned for some months. When an operation has been resorted to, the tumor has usually become too large to be extracted through the loin, and laparotomy has been the course pursued. According to Billroth,22 out of 33 operations for tumors of the kidney, 13 have been cured.
22 Mittheil. der Aerzte in Nieder Oesterreich, Bd. x. p. 161 et seq.
Cysts.
Three kinds of cysts are met with in the kidney besides those connected with the growth of parasites.
Kidneys congenitally affected with cystic degeneration contain a large number of sacs lined with a vascular membrane, among the partitions of which are found the remains of secreting structure. Both kidneys are equally affected, and are enlarged and more or less lobulated. They are occasionally so large as to constitute an obstacle to labor, and various operative procedures, even evisceration, have been required to accomplish the delivery of the foetus affected. The cysts are filled with fluid of various degrees of darkness of color from almost perfect limpidity to almost black. The fluid in the smaller cysts, at least, contains some of the urinary solids. The slighter degrees of this affection do not render a child necessarily non-viable, but with the larger some accident is likely to happen.
The formation of these cysts has been referred to an intra-uterine chronic nephritis, but another theory accounts for them by a vice of development. The fact that when the lesion is unilateral, as sometimes happens, there is apt to be a deficiency of some other part of the genito-urinary apparatus on the same side, and that several infants with cystic degeneration have been born of the same mother, speaks strongly in favor of the latter theory.
Serous cysts of later origin do not usually attain so large a size, or rather the kidney does not, on account of their smaller number. They are lined with a thinner membrane, and their contents are nearly clear, but coagulable, comprising uric acid, carbonate of lime, and cholesterin. Occasionally a single cyst attains considerable dimensions and produces by its pressure atrophy of part of the kidney. These cysts are supposed to arise in consequence of the blocking of a tube.
The third class of cysts closely resemble the first in appearance and in form, and contain more or less serous or gelatinous fluid, with albumen, blood-corpuscles, and pus, as well as the peculiar colloid bodies previously mentioned. They undoubtedly arise from the distension of tubes and of Malpighian bodies. These cysts are usually associated with chronic interstitial nephritis, and in fact they are rarely absent in cases of this kind, although the extreme degree—that is, where the cysts assume the most prominent position while the contracting nephritis falls into the background—are less common. In these latter cases the organ may be almost transformed into a mass of rounded bodies somewhat resembling a bunch of grapes.
The SYMPTOMS of the first two of these conditions—that is, of the cysts which are not connected with an active nephritis and attract attention simply as tumors—depend on the pressure they exert; and a diagnosis is to be made by a knowledge of their history and by the rules already given. The symptoms and diagnosis of the third variety are involved in those of chronic interstitial nephritis.
There is no reason to suppose that any drug has any therapeutic action on such kidneys, so far as the cysts are concerned. It should always be remembered that a kidney may contain a large number of cysts, and yet scattered portions of secreting substance enough be left to carry on the function indefinitely.
It might under some circumstances be justifiable to remove a cystic kidney on account of the pressure exercised on other organs, but as the cysts do not increase rapidly in size, punctures several times repeated, so as to empty a number of them, would in most cases prove as effectual an operation, and, what is of greater importance, would not involve the loss of any portion, even if small, of secreting structure which may be left.
Tuberculosis.
The tubercles which are found in the kidney in cases of general miliary tuberculosis have usually no clinical interest, since the kidney is not, even in children, one of the points where tubercular localization is most intense, and renal tubercles are consequently but little advanced when death takes place from the extension of the disease in other organs. They present no symptoms which are perceptible among the much graver ones attending the progress of the disease elsewhere.
In the disease known as tubercle of the kidney, caseous nephritis, or nephro-phthisis, masses of caseous material are deposited in the renal parenchyma which may soften, break down, and communicate with each other and with the calices and pelvis. In some cases it is probable that the disease originates in or immediately underneath the mucous membrane of the urinary passages. This process of breaking down continues much in the same way as that of a phthisical lung, until the kidney becomes little more than a hardened, irregular, knobby shell enclosing a ragged, ulcerated cavity with thickened, pus-secreting walls and filled with pus, more or less blood, and débris of kidney-structure and tubercle. In such portions of renal substance as may remain it is not unusual to find miliary tubercle. If obstruction of the ureter exists, a pyo-nephrosis may exist in addition. Rupture into the peritoneal cavity or into the intestine has occurred.
It is probable that in this affection are included two processes, differing in pathology and etiology and to some extent in clinical history. It is probable that true tubercle may originate in the kidney as a result of either tubercle or cheesy inflammation elsewhere, as in the lungs, bodies of the vertebræ, or scrofulous glands. In this case there are no marked symptoms until the process of softening and breaking down has reached the mucous membrane of the pelvis. Besides this, renal phthisis sometimes succeeds, as a more local invasion, to tubercle or cheesy inflammation of the urinary passages, and in this case the symptoms appear simply as aggravations of those already present and depending upon ureteritis and pyelitis. Renal phthisis is seldom if ever an independent disease. It is often associated, besides the affections already named as standing in etiological relationship with it, with cheesy inflammation of the testicle, vesiculæ seminales, and much less frequently of the ovaries and Fallopian tubes.
The DIAGNOSIS of tubercle in the kidney before it has reached the pelvis is probably impossible. Pain in the back or slight albuminuria, as has been already stated, is of no diagnostic value except as pointing to some renal irritation, as to the cause of which it tells nothing. In the presence of tubercle elsewhere it might be regarded as suspicious.
After cavities have become connected with the pelvis or have extended from it, the symptoms become more marked. In the urine are to be found pus, some blood, epithelium of the urinary passages and often of the kidneys, in many cases in the form of casts; and it is claimed that masses of caseous matter as large perhaps as the head of a pin may be found, which will of course make the diagnosis almost a matter of certainty. If the urine containing such a deposit is acid, it is almost certain that the lesion is mainly in the kidney and that the bladder is but slightly if at all affected. It is also stated that the bacillus of tubercle has been found. The presence of this parasite will not only testify as to the presence of the clinical condition known as phthisis of the kidney, but will also make it sure that the affection depends upon tubercle in the strictest pathological sense, and will influence the prognosis accordingly. Inoculation of purulent sediment from the urine of a patient suffering from tuberculosis of the urinary passages has produced tubercle in the iris of the rabbit. This procedure has been suggested as a means of diagnosis as to the character of a chronic catarrh of these passages before the appearance of tubercle elsewhere.23
23 Ebstein, Centralblatt für die Med. Wiss., 1882, p. 918, from Deutsch. Arch. f. klin. Med., xxxi. S. 63.
If pyelitis have already been present, the change in the appearance of the urine will be less characteristic, but there may be a marked aggravation of symptoms when the contents of softened masses are added to the secretions of the mucous surface. There is likely to be much fluctuation in the quantity of débris present from day to day. Urinary fever of the hectic or subcontinued type, with anorexia, nausea, dry tongue, and diarrhoea, is present. In some cases the enlarged and irregular kidney may be felt.
The PROGNOSIS of this condition is in the highest degree unfavorable, although the finding of cicatrices in kidneys where symptoms of renal phthisis have been present suggests that it is possible for caseous masses in these organs, as well as in the lungs, to undergo absorption and healing.
The TREATMENT must be, in the first place, constitutional by tonics and reconstituents, and local by the use of such antiseptics as are eliminated through the kidney, as boric or benzoic acid or the benzoates. But little, however, is to be expected from it.
Parasites.
The most important parasite which is known to inhabit the kidney is the immature tapeworm of the dog, or Tænia echinococcus. It is decidedly rare in this country to meet with this affection in any part of the body, and as the kidney is not one of the organs most likely to be chosen as its habitat, the condition is not one which comes often under the observation of physicians.
It is hardly necessary to describe here the structure or contents of the hydatid cyst which forms the home of the parasite, nor its etiology, since these topics belong to general pathology, and the cyst is the same in whatever organ it may be seated. When it affects the kidney, it is usually the left—more frequently that of a man between thirty and forty years of age.
A hydatid cyst may be situated upon any part of the kidney. If small, it may never make its presence known. A larger one may give rise to those vague pains in the back found with so many diseases of the kidney and characteristic of none of them. A cyst may open in any direction, but is more likely to empty into the pelvis of the kidney. When this happens, the smaller cysts or pieces of the larger ones often enter the ureter and give rise to renal colic, and possibly, later, to a pyelitis. Other points of discharge are the intestines, the lungs, or the abdominal walls.
After a hydatid cyst has reached a certain size its presence may be recognized by palpation, but the diagnosis between it and other tumors of the kidney must be very difficult unless characteristic fragments make their appearance in the urine at the same time that the tumor diminishes in size, or unless they can be obtained by puncture. The hydatid thrill, if it can be obtained, will be an important factor in diagnosis.
The TREATMENT of this affection in the kidney presents no special points of difference from that of similar cysts in the liver; with this important exception, that besides punctures with large and small trocars, incisions, electrolysis, etc., the resource of complete extirpation still remains. Cures have been obtained by repeated punctures and subsequent suppuration, and by partial removal through the abdominal walls and subsequent drainage.
Among the parasites of the kidney it is customary to mention the Strongylus gigas, which is a worm somewhat resembling the ascaris and inhabiting the pelvis. It is not very infrequent among the Carnivora, but since only seven cases have been described in the human subject since the seventeenth century, and only a part of these are admitted as genuine by certain authors, its diagnosis, prognosis, and treatment must depend more upon theory than upon experience. The diagnosis is to be made, if at all, on the basis of a pyelitis and the discovery of the eggs of the parasite in the urine.
The Distoma hæmatobium is a parasite found chiefly in the blood-vessels, and especially those of the portal system. It is occasionally, however, met with in the veins of the kidney and also in the urinary passages. Its eggs pass into the pelvis and ureters, and there begin their development, which, however, is soon arrested, as they rapidly perish in the urine.
These parasites appear to produce either by a direct action or by the occlusion of vessels, ulceration, and hemorrhages from the urinary mucous membrane, including that of the bladder. These effects are supposed to be due to the blocking of the smaller vessels by the worms themselves. An adherent deposit consisting of masses of distoma eggs and grains of uric acid sometimes forms in grayish-yellow patches within the ureter, and gives rise to stricture, with dilatation and hydro-nephrosis above. This parasite has been considered the cause of the endemic hæmaturia of hot countries, but as cases of this affection have been carefully examined for the distoma with negative results, it must be considered as only one among several causes. Strongyli are said to have been found in some of the cases.
Nothing is known of an appropriate TREATMENT for the distoma. An abundant flow of urine might perhaps carry off more rapidly such individuals as have found their way into the urinary passages, and, considering the character of the deposit described above as causing stoppage of the ureter, treatment directed against the uric-acid diathesis might diminish the risk of this particular form of trouble.
Diseases of the Ureters.
Absence of the ureter may take place when one kidney is congenitally absent, though this is not an absolute rule, since the ureter may terminate above in a rounded sac. When a single kidney exists, consisting of the fusion of two, there are usually two ureters opening in the usual position. In one instance, in which only one kidney and one ureter were present, the ureter opened into the bladder on the side opposite to that upon which the kidney was situated.
Not very infrequently two ureters exist in connection with a normal kidney, remaining separate for the whole or a part of their course to the bladder. This condition is merely a sort of exaggeration of the separation between the two branches of the renal pelvis.
A few instances have been noted where a ureter or a fistula connected therewith has opened outside of the bladder at a point near the urethra. This malformation gave rise to symptoms of incontinence of urine, and in one case was remedied by operation.
Abnormal openings of the ureter into the uterus and vagina as the results of pelvic inflammations, and upon the external surface as the result of wounds, have occurred. They are more or less amenable to surgical treatment, and belong to the domain of surgery and gynecology rather than to medicine.
Occlusion of the ureter has already been spoken of in connection with the hydro-nephrosis and pyelitis to which it gives rise. This occlusion results from pressure exerted either at the vesical orifice from cystitis; a little higher up from malignant disease connected with the uterus or a fibroma surrounding the ureter; from contracting adhesions resulting from pelvic inflammation; or from sharp flexions of the tube itself, perhaps also from valvular folds of the mucous membrane. Sometimes its obliteration seems to be the result of old inflammation of the mucous membrane of the ureter itself in connection with that of the renal pelvis. In the latter case the occlusion may be complete at several points, while at others a collection of dry, cheesy, or putty-like material occupies the cavity of the ureter as well as the pelvis of the atrophied kidney.
Cancer is not known primarily to invade the ureter.
Tubercle is not infrequently found in the form of small granulations in cases of general tuberculosis, and it is possible that this deposit may be among the earlier ones; hence a chronic catarrh of the urinary passages without some known cause should be looked upon with suspicion, and the development of phthisis as far as possible guarded against. The presence of these small tubercles in the ureter, if none are present or no ulceration exists in the kidney, are of little or no local importance.
Inflammation of the ureter often exists in connection with cystitis and pyelitis, and in fact constitutes the means by which the higher urinary passages become gradually involved in the diseases below.
The DIAGNOSIS of this condition as a distinct disease is hardly possible, and is besides unnecessary, as the treatment to be directed thereto would be included in that called for by the more extensive and obvious inflammation of the kidney and bladder.