The ureters in some cases are inflamed, their walls thickened, their inner surface coated with pus or fibrin. The bladder presents regularly the lesions of acute or chronic cystitis.
ETIOLOGY.—For the production of this form of nephritis inflammation of the bladder seems to be necessary. How the inflammatory process is transmitted from the bladder to the kidneys is still uncertain, but it seems probable that it is effected by bacteria. The cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate.
SYMPTOMS.—When the nephritis occurs with cystitis due to stone in the bladder, strictures, or operations on the genito-urinary tract, the symptoms are much the same. The patient has first the symptoms belonging to the cystitis, then he is attacked with rigors, followed by a febrile movement. The rigors are often repeated; the febrile movement is very irregular and often accompanied by profuse sweating. There is a rapid change in the general condition of the patient. He becomes much prostrated and emaciated from day to day. The face is drawn and anxious, the tongue dry and brown, the pulse rapid and feeble, and delirium is developed, and the patient finally dies in a condition resembling that of typhoid fever or of pyæmia. The urine is diminished in amount; it may be suppressed. It contains blood, pus, and mucus. The pus and mucus belong to the cystitis; the blood seems to be derived both from the kidneys and the bladder.
Cases of suppurative nephritis complicating gonorrhoea are fortunately not common, but several of them have been observed. Murchison2 describes two cases, in both of which the cerebral symptoms were very marked—delirium, convulsions, and coma. I have seen one such case. The patient was a prostitute who came into the hospital with a specific vaginitis. After a few days she developed symptoms of an acute cystitis; then after a few more days she was attacked with rigors and a febrile movement, passed rapidly into the typhoid condition, and died. At the autopsy there were found acute cystitis, pyelitis, and numerous small abscesses in both kidneys.
2 Lancet, 1875, p. 80.
When suppurative nephritis complicates the cystitis due to enlarged prostate, the clinical symptoms are somewhat different. The patients are usually men over fifty. They have generally suffered from the symptoms of enlarged prostate—retention of urine, either constant or intermittent, and more or less cystitis, with pus and mucus in the urine in varying amount. Sometimes, however, no such history is obtained; the patients assert that they have had no previous bladder trouble. The first symptom is diminution in the amount of urine passed and the appearance of blood. The quantity of urine is only a few ounces or it is completely suppressed. The blood is present in considerable amount; often the patients seem to pass pure blood instead of urine. The patients rapidly become prostrated and very anxious. There are usually no rigors, and there may be no febrile movement. After this the prostration becomes more marked, the pulse is rapid and feeble, the skin cold and bathed in perspiration, and the patients die in collapse at the end of a few days.
PROGNOSIS.—Suppurative nephritis secondary to cystitis is a very fatal disease; so far as I know, all the cases die.
TREATMENT.—The treatment for these cases is altogether a preventive one directed to the cystitis. In the cases of paraplegia, stone in the bladder, stricture, and enlarged prostate constant care must be used to prevent the accumulation of urine in the bladder and the development of cystitis.
In all cases of operation on the genito-urinary tract the supervention of cystitis is to be guarded against.