Uraeus

“ Malignant disease of the bladder is almost always the warty form of cancer known as epithelioma. It springs as a sessile growth from the mucous membrane of the floor near the opening of one of the ureters, and, worrying the sensory nerves, causes irritability of the bladder and incontinence of urine. In due course septic germs reach the bladder, either from the urethra, the bowel, the kidneys or the blood-stream, and cystitis sets in. When ulceration has taken place, blood occurs in the urine, and the patient—generally beyond middle age—suffers dull or lancinating pains. ”

“ Hydronephrosis, or distension of the kidney with pent-up urine, results from obstruction of the ureter, although all obstructions of the ureter are not followed by it, calculous obstruction, as already noted, often causing complete suppression of urine. Obstruction of the ureter, causing hydronephrosis, is likely to be due to the impaction of a stone, or to pressure on the ureter from a tumour in the pelvis—as, for instance, a cancer of the uterus—or to some abnormality of the ureter. Sometimes a kink of the ureter of a movable kidney causes hydronephrosis. ”

“ If at any time he should fail to perform the act of micturition, he ought not to strain, but should quietly wait for a little before making any further effort. Regularity in the times of making water is also of much importance.
Retention of urine may occur in paralysis of the bladder, or in conditions where the patient is suffering from an illness which blunts the nervous sensibility, such as apoplexy, concussion of the brain, or typhoid fever. It is, however, more commonly due to obstruction anterior to the bladder, as in stricture of the urethra or enlargement of the prostate. ”

“ Thus, vesical tumours pressing on the orifices of the ureters, calculi which have become fixed in them, torsion or “kinking” of the ureters, may bring about hydro-nephrosis. The urine secreted by the kidney being unable to escape, accumulates in the pelvis of the kidney, in the ureter, and uriniferous tubules, producing dull colic, which escapes observation, or the exact cause of which is not discovered, because the second kidney vicariously acts for the one affected, and urination continues regularly. ”

“ It may be possible too that no stone exists, but the urethra is obstructed or closed by pure coagulated blood. Perhaps there may have been a wound of the bladder, although no external haemorrhage has appeared, but the blood coagulating gradually in the bladder has occasioned an obstruction or narrowing of the urinary passage. Or possibly the blood from a renal haemorrhage has descended into the bladder and obstructs the urethra. Hence I say that the sound is useful in these cases where the urethra is obstructed by blood or gross humors. ”

“ But more usually the organ is loose under the peritoneum, and not efficiently supported in its fatty bed. Movable kidney produces a variety of symptoms, such as pain in the loin and back, faintness, nausea and vomiting—and the function of the organ may be seriously interfered with, owing to the ureter becoming kinked. In this way hydronephrosis, or distension of the kidney with urine, may be produced. The return of blood through the renal vein may also be hindered, and temporary vascular engorgement of the kidney, with haematuria, may be produced. ”

“ The kidney in the foetus is lobulated, but the intervals between the lobes become smoothed out in later years of childhood. Each gland is invested the renal artery from the aorta passes. Here also the renal vein escapes and joins the vena cava inferior. The ureter or metanephric duct, always behind and below the blood vessels, emerges here and passes downward to the bladder. When the kidney is longitudinally divided from hilum to outer edge, the cut surface is seen to consist of two parts-an outer layer, the cortex, and an inner part, the medulla (fig. 1) . ”

“ In most diseases the quantity of urinary water is diminished, especially in those in which the activity of the circulation is impaired. There are diseases, however, more especially the granular kidney and certain forms of chronic Bright’s disease, in which the quantity of urinary water is considerably increased, notwithstanding the profound anatomical changes that have occurred in the kidney. There are two forms of suppression of the urine: one is obstructive suppression, seen where the ureter is blocked by stone or other morbid process ”

“ Essential hypertonia with its normal blood chemistry is differentiated from arteriosclerosis with its frequent nitrogen retention. The imminence of uraemia may be judged by the extent of the nitrogen retention. We have an aid in the differentiation of the uraemia of nephritis accompanied by a flagging heart from the passive congestion of cardiac decompensation, especially as to which is the secondary condition, and thus therapeutic indications relative to mooted questions of treatment (hot packs, morphine, renal stimulants, etc.) ”

“ Rupture of the kidney may result from a kick or other direct injury. Vomiting and collapse are likely to ensue, and most likely blood will appear in the urine, or a tumour composed of blood and urine may form in the renal region. An incision made into the swelling from the loin may enable the surgeon to see the torn kidney. An attempt should be made to save the kidney by suturing and draining; unless the damage is obviously past repair, the kidney should not be removed without giving nature a chance. ”

“ When urine contains a larger amount of chemical constituents than it can conveniently hold in solution, a certain quantity crystallizes out, and may be deposited in the kidney or in the bladder. If the crystals run together in the kidney the resulting concretion may either remain in that organ or may find its way into the bladder, where it may remain to form the nucleus of a larger vesical calculus, or, especially in the case of females, it may, while still small, escape from the bladder during micturition. ”

“ The tubules become blocked by the epithelium, and distended with the pent-up urine; this is one cause of the increase in size that the kidneys undergo in certain forms of Bright’s disease. The lesions in the tubules and in the glomeruli are not generally uniform. The interstitial tissue is always affected, and exudation, proliferation and formation of fibrous tissue occur. In the granular and contracted kidney the lesion in the interstitial tissue reaches a high degree of development, little renal secreting tissue being left. ”

“ The growths bleed very easily on manipulation, and are exquisitely sensitive. The urethral caruncle is the commonest neoplasm of the urethra.
Symptoms.—The most marked symptom of urethral caruncle is pain. Intense pain is experienced at micturition and upon contact with the clothing or other body. Sexual connection is sometimes rendered impossible.
There is usually more or less hemorrhage from the tumor, which may rarely be so profuse as to cause marked anemia. The general health suffers, and nervous symptoms, resulting from the pain and loss of sleep, are often present to a pronounced degree. ”

“ On the other hand, we find that suppression of urine with accumulation of urea in the blood may exist for a long time without cerebral symptoms if the suppression is due to obstruction of the ureters; that with chronic congestion of the kidney, puerperal convulsions, and diseased arteries urea is excreted in fair amount, although cerebral symptoms exist; and that even in cases of cerebral symptoms with chronic diffuse nephritis there may be no increase of urea in the blood. ”

“ We may say in general that with the atrophied kidneys the so-called uræmic symptoms—headache, sleeplessness, delirium, convulsions, coma, dyspnoea—are very apt to occur, and that early in the disease. The urine is regularly increased in amount and of low specific gravity, except [p. 90] during the uræmic attacks, when it is diminished; but the uræmic attacks may come on while the patient is passing 30 to 40 ounces of urine of a specific gravity of 1020. Albumen is regularly present only in small amounts, and not constantly, but exceptionally there will be a good deal. ”

“ From the right kidney, 14 cc. of urine, containing 2.4% urea, and a slight amount of pus; from the left kidney 3⁄4 cc. of urine, a very little urea and a large amount of pus. A nephrectomy of the left kidney a few days later revealed a small tubercular pyonephrotic kidney, with an apparently normal ureter.
In April, 1910, this patient was heard from directly for the last time. By virtue of his social status he was forced to lead a life which was not in conformity with his personal welfare, doing hard manual labor most of the time. ”

“ In children, in whom there is a rapid disintegration of nitrogenized tissues, a uric acid calculus in escaping from the bladder may block the urethra and give rise to sudden retention of urine. On introducing a metal “sound,” the surgeon may strike the stone, and if it happens to be near the bladder he may push it back and subsequently remove it by crushing. But if it has made its way some distance along the urethra, so that he can feel it from the outside, he should remove it by a clean incision. ”

“ When there occurs an external ulcer in the perinæum, and the urine is in part discharged that way, the disease can not be mistaken. Otherwise from the quantity of matter, it is generally supposed to come from the bladder, or prostate gland; and the urine, which escapes from the ruptured urethra, mines its way amongst the muscles and membranes, and the patient dies tabid, owing to the want of an external orifice to discharge the matter. ”

“ This collection takes place in the kidney, the ureters (the vessels that convey the urine to the bladder) , the bladder, and sometimes in the urethra. The stone so formed varies in its composition and size, and is one of the saddest ills that can befall human nature. Hence the importance of watching, and attending to every urinary disturbance, of which gravel forms a prominent feature, the treatment of which has been already stated; but which, as it involves more practised judgment than a non-professional invalid can be supposed to possess, had better be intrusted only to professional hands. ”

“ The hydronephrosis produced by obstruction of the ureter may be intermittent; and when a certain degree of distension is produced, either as a result of the shifting of the calculus or of some other cause, the obstruction is temporarily relieved in a great outflow of urine, and the urinary discharge is re-established. When the hydronephrosis has long existed the kidney is converted into a sac, the remains of the renal tissues being spread out as a thin layer. ”

“ The pulse at the beginning is not remarkably full nor frequent, from which fatal mistakes and irremediable{278} procrastination, have often ensued in medical practice: the urine is in small quantity, or suppressed. It is much more frequent in the narrow than the wide part of the intestinal tube. In the rectum, constant tenesmus, excretion of mucus; and in the male sex strangury are natural consequences and symptoms. Inflammation or nephritick paroxisms in the kidneys and ureters, with which it has been confounded, are hereafter discriminated. ”

“ It is exceptional for the large branches of the renal artery to be blocked, so that the symptoms produced in the ordinary cases are only the temporary appearance of blood or albumen in the urine. Blocking of the main renal vessels as a result of disease of the walls of the vessels may lead to disorganization of the kidneys. Blocking of the veins, leading to extreme congestion of the kidney, also occurs. ”

“ Masses of amorphous urates or phosphates or very small crystals (Fig. 47) , which accidentally take a cylindric form, or shreds of mucus covered with granules, closely resemble granular casts. Application of gentle heat or appropriate chemicals will serve to differentiate them. When urine contains both mucus and granules, large numbers of these "pseudo-casts," all lying in the same direction, can be produced by slightly moving the cover-glass from side to side. It is possible—as in urate infarcts of infants—for urates to be molded into cylindric bodies within the renal tubules. ”

“ The kidneys then are big filter-glands. They, like the lungs, are made up of a mesh, or network, of thousands of tiny tubes of two kinds, one set of tubes being blood vessels, and the other set the tiny branches of the kidney tubes which finally run together to form the ureters. The urine filters through from the spongy mesh of blood tubes (capillaries) into the kidney tubes and is poured out through the ureters. It is very important that the urine should be discharged as fast as it fills the bladder, that is, about once every three hours during the day. ”

“ Normally a man passes about 1200 cc. of urine in twenty-four hours, a woman somewhat less. When the amount is under 750 cc. we have an oliguria. To consider a polyuria as present the patient should pass more than 3000 cc., as this amount may be considered the upper normal limit. In anuria we have a cessation of renal activity.
The disease in which anuria is most characteristic is cholera. During the stage of evacuation the urinary secretion becomes less and less along with the progressive failure of circulation and, during the algid stage, we have a suppression of urine. ”