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 {52} 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.
{53} 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 {54} 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 {55} 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 {56} 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.
[Footnote 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 {57} 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.
{58} 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.