CHAPTER X DISEASES OF THE URINARY TRACT (Part 1)

CHAPTER X DISEASES OF THE URINARY TRACT The urinary tract consists of the kidneys, two in number, situated on the right and left side of the body beneath the edge of the ribs, posteriorly; the ureters, which run from the pelvis of the kidneys; the bladder; and the urethra. THE KIDNEYS Anatomy. — The kidney is divided into the cortical area, the medulla or pyramidal, and the pelvis. The urinijerous tubules start in the glomeruli which are situated in the cortical area of the kidney. The glomeruli are tufts of capillaries surrounded by a capsule. The epithelial cells lining the capsule and tubes abstract from the blood current the products which form the urine. The tubes run from the capsules and after pursuing a very tortuous course they empty at the apex of one of the Malpighian pyramids. It is in these tubules that the urinary products are formed. They are emptied from the mouths of the uriniferous tubules, at the apices of these pyramids, into the pelvis of the kidneys, and from here the urine passes through the ureters into the bladder and is voided through the urethra. From these tortuous uriniferous tubules the tube-casts are formed. They are cylindric in shape and usually composed of the lining epithelium in various stages of i96 DISEASES OF THE URINARY TRACT I9; degeneration. Their formation is something on this order: The lining epithelium of these tubes is the filter which extracts the uriniferous products from the blood. As long as this epithelial lining is intact the urine is normal; when there is congestion or inflammation of the kidneys the tubules shed this lining membrane. This appears in the urine as casts, and as the wall between the Fig. 60. — A longitudinal section of the kidney, a. Renal artery; c, cortex; m, medulla; u, ureter (Leroy). blood current and the tubules is destroyed there is an outflow of red blood-corpuscles and albumin. This is the condition seen in acute congestion, or acute nephritis, the name for inflammation of the kidneys. In chronic nephritis these epithelial casts degenerate and form hyaline casts. Malformations of the kidneys are not common. Those seen occasionally are horseshoe kidney, where I98 DISEASES OF CHILDREN FOR NURSES the two are fused, forming one large crescentic kidney; supernumerary ureters; floating kidney; and single kidney. THE URINE Normal urine is pale, amber colored, of acid reaction, and has a specific gravity of 1015 to 1025. Polyuria is the term applied to an increase in the quan- tity of the urine, and may be a temporary polyuria, such as is seen in excessive ingestion of fluids, the suppresison of perspiration, etc. Permanent polyuria may result from such conditions as diabetes mellitus, diabetes insipidus, chronic interstitial nephritis, and amyloid kidney. Anuria is the term applied to a diminution in the flow of urine. It is seen in the following conditions: Excessive secretion through other channels, such as profuse perspira- tion and diarrhea; in fever; passive renal congestion from obstructive disease of the heart, lung, or liver; organic obstruction in the urinary passages; in acute or chronic parenchymatous nephritis; from nervous causes such as hysteria; and in the reflex inhibition after abdominal injuries or operations. Urea results from the perfect decomposition of the nitrogenous elements of food and tissue. It is, therefore, a normal constituent of the urine. In health the amount excreted varies greatly. Normal urine contains about 2 to 2 h per cent, of urea. When there is imperfect meta- morphosis of tissues and nitrogeous food there is the formation of uric-arid crystals in the urine. When they are in excess the urine is heavy, dark in color, and on cooling throws down a brick-red deposit. When uric acid or urates are found in the urine it is termed lithuria. DISEASES OF THE URINARY TRACT 1 99 Glycosuria is the name applied to urine containing sugar. It is caused by diabetes mellitus and at times by chorea, tetanus, and functional nervous affections; in- digestion of a large amount of saccharine material, lesions of the pancreas, liver, and base of the brain. Albuminuria is the name applied to the presence of albumin in the urine. It is found in all forms of nephritis and in congestion of the kidneys, resulting from chronic disease of the heart, lung, or liver. Cyclic Albuminuria. — The urine may be albuminous at certain times, as after meals, bathing, or rising in the morning. Accidental albuminuria results from the admixture of albuminous substances with the urine, as pus and blood. It is found in certain nervous diseases, as epilepsy, tetanus, and injuries to the brain, extreme anemia, and the ingestion of large amounts of albuminous foods. Hematuria. — Blood in the urine. Hemoglobinuria. — Blood-pigment in the urine. Choluria. — Bile in the urine. Chyluria. — Chyle in the urine. Pyuria. — Pus in the urine. Indicanuria. — Indican in the urine. It is a symptom of chronic indigestion. Method of Collecting Urine. — In males the penis can be placed in the neck of a bottle which lies between the thighs, and is held in position by a bandage tied around the neck of the bottle and then carried around the hips and between the legs. In females a small pan placed under the buttocks will answer. If these methods fail, catheterize. (See page 401.) 200 DISEASES OF CHILDREN FOR XURSES Average Daily Quantity of Urine in Health Age Ounces First twenty-four hours o to 2 Second twenty-four hours \ to 3 Three to six days 3 to 8 Seven days to two months 5 to 13 ' Two to six months 7 to 16 Six months to two years 8 to 20 Two to five years 16 to 26 Five to eight years 20 to 40 Eight to fourteen vears ^52 to 48 (Holt). Examination of Urine. — The color is noted and any sediment is recorded. The acidity or alkalinity is deter- mined. The specific gravity is found by means of a urinometer. This is an instrument weighted with mercury and having a scale on the stem graduated from 1000 up. By floating this instrument in a quantity of urine the specific gravity of the specimen can be read off. The point at which the top of the liquid is indicated on the scale is the proper specific gravity. Albumin is tested for by boiling a small quantity of urine in a test tube. It should be clear urine, filtered if necessary. If albumin is present the urine will cloud when boiled, and if upon the addition of a few drops of acetic acid it does not clear, albumin is present. If it does clear the precipitate is composed of phosphates. Heller's Test. — Another test used consists in placing a small amount of nitric acid in a test-tube and allowing the urine to run slowly down the sides of tube in such a manner that it will float on the surface of the nitric acid. If albumin is present there will be a white line at the point of contact of the two liquids. A brown line denotes uric acid. DISEASES OF THE URINARY TRACT 201 Sugar is tested for by Fehling's solution. This consists of two parts: One is bluish-green (composed of copper sulphate) and the other is white (composed of rochelle salts and caustic potash). Equal parts of each are added to four times their volume of water and the mixture boiled. If it retains its bluish color it is suitable for a test. A few drops of urine are added to the solution and boiled, and if sugar is present, a reddish-yellow precipitate is thrown down. The test is very accurate. Microscopic examination is necessary to determine the presence or absence of casts, red blood-cells, white blood- cells, and epithelium. Such substances as bile in the urine have special tests. DIABETES INSIPIDUS Diabetes insipidus is a' chronic condition characterized by the excretion of large quantities of pale, limpid urine of low specific gravity and free from albumin and sugar. In addition to the urinary symptoms there is an insati- able thirst, good appetite, a harsh, dry skin, a dry tongue, constipation, mental apathy, and emaciation. RENAL HYPEREMIA Active hyperemia is caused by arterial blood and is found in all acute congestions. It is due to exposure when the body is overheated. The same cause, aggra- vated, would cause acute nephritis. Passive hyperemia is due to venous stasis and is found in all chronic congestions. Acute Congestion. — Symptoms of acute congestion are pain over the loins; dark and scanty urine of high specific gravity, and perhaps containing a trace of albumin, a few hyaline casts, and some free blood. 202 DISEASES OF CHILDREN FOR NURSES Passive congestion of the kidneys is caused by condi- tions which obstruct the general circulation, such as chronic disease of the heart, liver, and lung; pressure of tumors upon the renal veins, and, rarely, thrombosis of the renal veins. The kidney is swollen, and in protracted cases becomes hard from an overgrowth of connective tissue. Symptoms. — There is a sensation of weight over the loins; the urine is usually diminished in quantity; rarely increased. Free blood, a trace of albumin, and occa- sionally a few hyaline casts are found. UREMIA Uremia is the name applied to a group of symptoms which result from the retention of toxic materials in the blood which should have been eliminated by the kidneys. Symptoms. — The disease may develop slowly or abruptly and may manifest any of the following phenomena : head- ache, vertigo, delirium, epileptiform convulsions, coma, sudden blindness (unassociated with any retinal change), and transient paralysis from congestion of the brain or cord. Pulmonary symptoms are dyspnea (uremic asthma), and Cheyne-Stokes respiration. Abdominal symptoms are hiccough, obstinate vomiting, and purging. General Symptoms. — The skin is dry, the breath has a urinous odor, the urine is scanty and deficient in urea. The pulse is slow and full, the temperature is subnormal, but during a convulsion the temperature may rise and the pulse become rapid and feeble. Prognosis. — Grave, but always guarded, for recovery DISEASES OF THE URINARY TRACT 203 is possible after the most serious complications and manifestations. Treatment. — The object of the treatment is to eliminate the poison as rapidly as possible. To accomplish this the physician takes advantage of every possible excretory function. He promotes catharsis (purging) and free diaphoresis (sweating). In some cases bleeding and the intravenous injection of normal salt solution is prac- tised. Convulsions may be controlled by inhalations of chloroform. Morphin should be used with great care, as it frequently aggravates the case. NEPHRITIS Acute nephritis is an acute inflammatory disease involving more or less of the whole kidney, but it especially affects the epithelium of the tubes and glomeruli. Other names given to this condition are acute Bright's disease and acute parenchymatous nephritis. Etiology. — Exposure to cold and wet, the specific fevers, especially scarlet fever, and certain poisons. Pathology. — The kidney is swollen, the capsule is nonadherent. At first the organ is bright red in color, but it soon becomes pale and mottled in appearance. Histology. — The epithelium of the tubes and of the glomeruli is the seat of the cloudy swelling and, later, of fatty degeneration. Desquamated epithelium, blood cor- puscles, and an albuminous exudate block up the tubules. Symptoms. — In some cases moderate fever with its associated phenomena, dull lumbar pains, nausea and vomiting, dropsy, beginning in the face and becoming general, and rapid anemia. Uremic symptoms may develop at any time. The urine is scanty and at times 204 DISEASES OF CHILDREN FOR NURSES suppressed. It is smoky in appearance, of high specific gravity, rich in albumin, and throws down a heavy sedi- ment which contains hyaline, blood, and epithelial casts and free blood and epithelial cells. As the general symp- toms are often slight, the diagnosis of the condition must rest upon the urinary analysis. Prognosis. — Guardedly favorable. It may kill by ex- haustion, uremia, or dropsy, and it may become chronic. Treatment. — The disease demands absolute rest in bed until the albumin has entirely disappeared from the urine. Milk is the best food, although butter-milk, gruels, and light broths are admissible. The free use of water should be encouraged. Free action of the skin is secured by means of vapor baths and the bowels are kept loose by concentrated saline draughts, as Rochelle and Epsom salts. Uremia will call for its appropriate treatment. Marked effusions in the serous cavities will sometimes demand aspiration. Convalescence should be protracted. Chronic parenchymatous nephritis may result from acute nephritis or it may be chronic from the beginning. Congestion from heart disease is the usual cause. Pathology. — In the first stage the kidney is large and pale yellow in color, the pallor depending upon the anemia and the fatty degeneration. The tubes are filled with fatty epithelium and casts, and there is always some over- growth of the interstitial connective tissue. In the second stage the organ is small, pale in color, its surface rough, and its capsule somewhat adherent. The reduced size depends upon the destruction of the renal epithelium and the contraction of the overgrown connective tissue. Symptoms. — As the disease usually begins as a chronic DISEASES OF THE URINARY TRACT 205 affection the following symptoms slowly make themselves manifest: progressive loss of flesh and strength, marked anemia, gastro-intestinal disturbances, dropsy, often first noted in the face on arising in the morning; increased arterial tension, some hypertrophy of the left ventricle of the heart so that the second sound at the aortic cartilage is accentuated. Uremic symptoms may develop at any time. The urine is usually diminished although it is often normal in color and appearance. It is highly albuminous and throws down an abundant sediment which contains hyaline, fatty, and granular casts, and fatty epithelium. The process is a chronic one and the epithelium and the casts have undergone fatty degeneration. Complications. — These are numerous and often suggest the diagnosis. The most common are uremia, extensive dropsy into the tissues or serous cavities, valvular heart disease, albuminuric retinitis (an eye condition interfering with vision), and acute exacerbations (an acute paren- chymatous nephritis occurring during the course of the chronic attack). Treatment. — The treatment is largely hygienic and dietetic. Residence in a dry, warm, and equable climate may prolong life or affect a cure. Rest is an essential element in the treatment. The underclothing should be woolen or silk in order to keep the skin constantly active. The diet should be non-nitrogenous and in severe cases an absolute milk diet may be of extreme value. The bowels should be kept active by mineral waters. Chronic Interstitial Nephritis. — This disease, rare in childhood, is a chronic inflammatory condition of the kidney characterized by a reduction in its size due to an 206 DISEASES OF CHILDREN FOR NURSES overgrowth and a subsequent contraction of its connective- tissue elements. It may be associated with general arterio- sclerosis and cardiac hypertrophy. Etiology. — The disease may be secondary to paren- chymatous nephritis or it may result from the chronic congestion of chronic heart disease; but it generally arises as a primary condition and results from the causes which predispose to sclerosis in other organs. Pathology. — The kidneys are small and red in color. The surface is granular and the capsules adherent. Small cysts arc often present. The microscope shows a great overgrowth of connective tissue which has contracted, narrowing the lumen of the tubules and interfering with the nutrition of the epithelium, and as a result the epithe- lium may show fatty degeneration with desquamation. The arteries throughout the body may show sclerosis, and from the resistance thus offered hypertrophy of the heart results. Symptoms. — A slow loss of flesh and strength with pro- gressive anemia. Gastric disturbances are very common. The arteries may be rigid and the pulse is of high tension, so that the second sound of the heart is accentuated at the aortic cartilage. Palpitation of the heart is often noted. Dyspnea is a prominent symptom and may result from heart weakness, uremia, or edema of the lungs. Head- ache, vertigo, and insomnia often result from disturbed cir- culation and dimness of vision from albuminuric retinitis. Dropsy is often absent or is slight and appears late in the disease. The urine is increased in quantity, pale in color, and of low specific gravity, 1005 to 1010; it contains but a trace of albumin and a few narrow hyaline casts. DISEASES OE THE URINARY TRACT 20/ Diagnosis. — The difference between chronic interstitial nephritis and chronic parenchymatous nephritis is that in the latter the urine is rich in albumin and tube-casts and the disease is seen in earlier life; it lacks much arterial change and produces considerable dropsy. Chronic interstitial nephritis is so insidious that it is scarcely ever discovered except by accident. Either it is discovered in the routine examination or, as frequently happens, not until uremia develops, when often it is too late to do anything. The treatment is practically the same as in chronic parenchymatous nephritis. ^ AMYLOID KIDNEY Amyloid kidney is a name given to the large white kidney found after prolonged suppuration, particularly bone disease; in tuberculosis, syphilis, and malarial cachexia. The urine is increased, there is considerable albumin, and wide hyaline and granular casts. RENAL CALCULUS Renal calculus is a precipitated urinary concretion found in the kidneys. The stone may lie latent indefi- nitely or it may pass out with or without symptoms of colic. It may obstruct the ureter or excite inflammation of the kidney or even abscess. Symptoms of Renal Colic— Sudden onset with sharp pain, starting in the back and radiating down the ureter into the penis, testicle, or thigh. The symptoms of intense pain are present: pallor, cold sweats, weak pulse, and 2o8 DISEASES OE CHILDREX FOR NURSES reflex vomiting. The urine subsequently