SECTION FIFTH.

DISEASES AFFECTING THE GENITO-URINARY SYSTEM.

CHAPTER I.

Nephritis and Pyelitis-Anatomical Characters-Clinical History-Pathological CharacterCausation Diagnosis-Prognosis-Treatment-Paroxysms of Pain caused by the Passage of Calculi along the Ureter, or Nephritic Colic, and Lithiasis or Gravel-Acute Desquamative Nephritis, Acute Albuminuria, Acute Bright's Disease, or Acute Inflammatory Dropsy -Anatomical Characters-Clinical History-Pathological Character-Causation-Diagnosis

-Prognosis-Treatment.

A LARGE proportion of the affections of the genito-urinary system do not fall within the scope of this work. Excluding affections peculiar to females, the diseases affecting the male generative organs, and the bladder in either sex, are to be excluded, as belonging to surgical rather than medical practice. The diseases which remain are chiefly those affecting the kidneys. Abnormal changes in the urine are highly important, as denoting morbid conditions relating to the kidneys and the blood. These changes constitute important symptoms in various diseases; they are not to be considered as individual affections, and in general it suffices to notice them in connection with other symptomatic events which make up the clinical history of different diseases. There is, however, one disease which, in the present state of our knowledge respecting its pathological character and seat, it is convenient to consider as a urinary affection, although it is certain that the abnormal change in the urine expressed by the name of the disease is merely a symptom. The disease referred to is glucosuria, or diabetes mellitus. It is common also to apply the term albuminuria to certain affections of the kidneys, characterized by the frequent presence of albumen in the urine.

Proceeding to treat of diseases affecting the kidneys, I shall consider, first, ordinary or simple inflammation of the pelvis and calices, and of the parenchyma of these organs. Inflammation of the renal parenchyma is called nephritis; inflammation of the pelvis and calices is called pyelitis. These are distinct affections, although the former rarely exists without the latter. It will suffice to consider both affections under the one heading.

NEPHRITIS.-PYELITIS.

Acute inflammation of the substance of the kidneys, exclusive of the cases in which it is produced by external wounds or injuries, and of the cases in which the inflammation extends from the pelvis and calices to the parenchyma, is one of the rarest of diseases. Chomel expresses doubt whether a truly spontaneous primary nephritis ever occurs. In respect of its infre

quency, it belongs in the category of other acute inflammations seated in the glandular organs, viz., hepatitis, pancreatitis, and gastritis. Pyelitis is also a rare disease, but it is less infrequent than acute nephritis. The latter occurs without the former, but nephritis is generally consecutive to pyelitis. Both affections, in the majority of cases, arise from the presence of renal calculi, and the terms calculous nephritis and calculous pyelitis have been used to denote the affections as thus produced; in these cases the inflammation is, in fact, traumatic. Next to the local action of calculi, distension of the pelvis and calices from obstruction of the ureter is the most frequent cause of pyelitis and nephritis. It is necessary to premise this statement in order that the morbid anatomy may be understood.

ANATOMICAL CHARACTERS.—Inflammation of the renal parenchyma induces enlargement of the organ, with redness, softening, and suppuration. The pus is sometimes in numerous minute disseminated points, sometimes in distinct abscesses of greater or less size, and sometimes in the form of purulent infiltration. Gangrene of the kidney has been observed. It is to be borne in mind that purulent formations in the kidneys occur, as in other organs, in connection with the morbid condition known as pyæmia. It is rare for a single large abscess to be found in the substance of the kidney, and the inflammation rarely extends to the peritoneum over the kidneywhen the latter event occurs it is called perinephritis.

Inflammation of the pelvis and calices causes redness, thickening, and softening of the lining membrane. If obstruction exist, the cavities contain more or less liquid, which consists of muco-purulent matter and urine. In cases of considerable and long-continued obstruction, the pelvis and calices become greatly dilated, the parenchyma is progressively atrophied by pressure, and at length the whole of the organ may be converted into a sac. Not infrequently the pelvis contains one or more calculi. Perforation may take place in different directions, viz., behind the peritoneum, leading to an abscess which may make its way externally through the integument; into the peritoneal cavity, giving rise to fatal peritonitis; into the colon, stomach, or through the diaphragm. The simple retention of urine, without pyelitis, within the pelvis and calices, from obstruction of the ureter, is called, after Rayer, hydro-nephrosis.

CLINICAL HISTORY.-The symptoms of inflammation of the renal parenchyma and those of pyelitis have, heretofore, been confounded, both affections having been embraced under the name nephritis. Cases of the former affection, disconnected from the latter, are so rare that its symptomatic characters have been imperfectly studied. Moreover, the term nephritis has been sometimes applied to an inflammation of the membrane lining the tubuli uriniferi, which will be considered as a separate affection, now commonly known as acute albuminuria, acute Bright's disease, or acute desquamative nephritis. The local symptoms of simple, acute nephritis, according to Rayer and others, are as follows: Dull pain and a sense of tension in the region of the kidneys, or on one side only if but one kiduey be inflamed; tenderness on deep pressure; blood in the urine, or hæmaturia, if the nephritis be due to a wound or injury, and also sometimes when the inflammation is spontaneous; albumen in the urine, or albuminuria, in some of the cases in which hæmaturia is wanting; diminution and even suppression of urine if both kidneys be affected; absence of pus in the urine if pyelitis do not coexist. With these local symptoms are associated more or less febrile movement and general disturbance. The pain and other symptoms are stated to be sometimes intermittent.

In acute pyelitis, with or without an extension of the inflammation to the renal parenchyma, the local symptoms are better known and more distinctive. There is more or less pain in the lumbar region, but the pain is not usually severe, and may be but slight. The pain produced by the presence of calculi, and especially by their passage along the ureter, is to be distinguished from the pain incident to inflammation. Distension of the pelvis and calices, if the ureter be obstructed, occasions an obscure, dull pain in addition to the pain due to the inflammation. The urine, in cases of pyelitis, contains muco-pus or pus in more or less abundance, provided there be not complete occlusion of the ureter. In determining that the muco-purulent or purulent matter comes from the kidney, inflammation of the bladder, or cystitis, is to be excluded. With these local symptoms are associated more or less febrile movement and other symptoms denoting constitutional disturbance. The pyelitis may succeed an attack of pain caused by the passage of a calculus along the ureter, called nephritic colic, or the latter may occur during the continuance of the pyelitis.

Pyelitis may be acute, and, running its course, end in recovery, or the inflammation may continue and become chronic. In chronic pyelitis, the local symptoms persist, leading to progressive emaciation and debility with hectic fever.

In cases of nephritic abscess, the primary affection is generally pyelitis ; pus and urine accumulate within the pelvis and calices, leading, in some cases, to destruction of the kidney from extension of the inflammation to the parenchyma and from pressure. The accumulation of pus and urine gives rise to a tumor which may be felt through the abdominal walls. This accumulation involves either occlusion or great obstruction of the ureter. If the obstruction be removed, a sudden and copious discharge of purulent matter with the urine takes place. If the obstruction continue, the contents of the abscess may be discharged in various directions, as already stated. The symptoms may show the pyelitis to be single or double.

PATHOLOGICAL CHARACTER.-The inflammation, in nephritis and pyelitis, is seated in different structures. In nephritis, the parenchyma, or substance of the kidney, especially the cortical portion, is the seat of the affection. In pyelitis, the mucous membrane lining the pelvis and calices is the structure affected. As already stated, they are different affections, and either may exist without the other; but, almost invariably, nephritis is secondary to, and dependent upon, pyelitis, excluding cases in which nephritis follows an external wound or injury.

CAUSATION. The causation of nephritis, in the great majority of cases, has just been stated; it is dependent on pyelitis. The affection, therefore, may be produced, secondarily, by the causes which give rise to pyelitis. As a primary affection, it may be caused by wounds and contusions. Possibly it may arise from excessive doses of certain remedies which act directly upon the kidneys, such as the nitrate of potassa, turpentine, and cantharides.

Pyelitis may be produced by wounds penetrating the pelvis of the kidney, but rarely, if ever, by contusions. The most frequent cause of this affection is the local action of calculi. In may arise from the presence of the entozoon of the kidneys, the strongylus gigas, and from a hydatid production. Next to renal calculi, the most frequent cause is obstruction, leading to distension of the pelvis and calices from an accumulation of urine. The obstruction may be due to the impaction of a calculus in the ureter, a morbid growth within the canal, a tumor pressing upon it, or to retention of urine within the bladder from stricture of the urethra, enlarged prostate, or paralysis of

the bladder in cases of paraplegia. In a case which came under my observation at Bellevue Hospital, the patient passed a very large quantity of limpid urine of a very low specific gravity, and the case was supposed to be one of polyuria, or diabetes insipidus. Uræmic coma and convulsions became developed, and the case terminated fatally. On examination after death, the bladder was found to be contracted and the muscular coat enormously hypertrophied; both ureters were greatly dilated; the pelvis and calices of the kidneys were much enlarged, and the parenchyma nearly destroyed by atrophy. In some cases of cystitis the inflammation extends along the ureters to the pelvis of the kidneys. Rayer has observed this to follow suppression of gonorrheal urethritis.

DIAGNOSIS.-Lumbar pain, more or less constitutional disturbance, and bloody urine, after a wound or injury has been received in the region of one of the kidneys, render the diagnosis of nephritis quite positive. Except in traumatic cases, it is probable that primary nephritis affects usually both kidneys. And the diagnosis is to be based on the existence of lumbar pain and general symptoms, together with notable diminution or suppression of urine. The urine in these cases may be bloody and albuminous. An examination of the sediment of the urine with the microscope may show bloody casts moulded in the uriniferous tubes. This will be proof that the hemor rhage is from the kidneys. If coma and convulsions supervene, they are to be attributed to uræmia.

The diagnosis of pyelitis is to be based on the presence of pus or mucopus in the urine, in conjunction with more or less pain and constitutional disturbance, cystitis being excluded. The occurrence of paroxysms of pain characteristic of the passage of a calculus along the ureter, and the expul sion of calculi or gravel from the bladder, are important diagnostic events. If the pyelitis be due to calculi, the urine may be bloody, but casts of the uriniferous tubes will not be found in the sediment of the urine. The sudden discharge of pus, in more or less abundance, with the urine, shows that an accumulation in the pelvis of the kidney has escaped through the ureter into the bladder.

Pyelitis caused by calculi will be likely to be limited to one kidney, but if it follow cystitis, or retention of urine from an obstruction beyond the ureter, both kidneys will be likely to be affected. Complete or very great obstruction, causing an accumulation of urine within the pelvis of both kidneys, would lead speedily to uræmia. Complete obstruction, however, limited to one kidney, may exist for an indefinite period, without leading to uræmia, the other kidney being sufficient for the elimination of urea. The accumulation in the pelvis of one kidney may be sufficient to occasion a tumor which may be felt through the abdominal walls. The tumor may be caused simply by retention of urine, without pyelitis, constituting the condition called hydro-nephrosis. Such a tumor is to be distinguished from that caused by an accumulation of urine and pus, that is, with pyelitis, by the absence of pain, tenderness on pressure, and the constitutional disturbance due to inflammation.

An accumulation of purulent matter within the pelvis and calices, forming an abscess, if the ureter remains permanently obstructed, eventuates in perforation and the discharge of the pus in some direction, if the life of the patient be sufficiently prolonged. The source of the pus is to be determined by the antecedent and coexisting symptoms which point to the seat of the affection. I shall subjoin a condensed account of a case of suppurative pyelitis, in which the pus made its way outwardly, forming a subcutaneous abscess which was opened, perforation subsequently taking place into the