usually necessitates the h}^odermatic administration of morphine, i to •^
of a grain (0.016 to 0.022) or the employment of suppositories containing i
to 2 grains (0.065 to 0.13) of opium. Attempts should be made to dilute
the urine by drinking freely of the mildly alkaline waters or of plain water.
Probablv the only drug which we have, which possesses any influence over
the suppurative process, is hexamethylenamine. This is a urinary antiseptic
of considerable potency, although unfortunately it appears to have but httle
effect in tuberculosis of the urinan' tract. When given in combination with
sodium benzoate, gr. v to \diss (0.33 to 0.5) of the former, gr. x to xv (0.66 to
i.o) of the latter, it renders an alkaline and ammoniacal urine acid, lessens
the lumbar pain and may influence the amount of pus. Sandal oil, of which
15 to 20 minims (i.o to 1.33) may be taken three times daily in capsules, may
also lessen the pehdc inflammation and may be given alone or in conjunction
with sodium benzoate or benzoic acid. The vegetable diuretices, buchu, kava
kava, pichi, pareira, etc., may be employed but are seldom effective.

Tonics should be given to combat the tendency toward progressive weakness
and emaciation; here codliver oil, iron, quinine and strychnine wiU be found
useful.

The diet should be bland and nourishing; milk either plain or fermented
may be drunk in considerable quantity. The clothing should be warm and
aU exposure should be avoided.

:..) HYDRONEPHROSIS.

Synonym. Nephn^drosis.

Definition. An accumulation of xrrine in the pelvis and calices of the
kidney caused by an obstruction of the ureter and resulting in more or less
dilatation.



HYDRONEPHROSIS. 695

Etiology. The condition may be either congenital or acquired and is
the result of obstruction of the urethra or ureter. Congenital instances may
be due to stricture of the ureter or urethra, the insertion of the ureter into the
kidney at an abnormally acute angle, to twists of the ureter or to congenital
defects of the abdominal muscles. The tumor caused by the hydronephrosis
in the foetus may be so great as to interfere with parturition.

Acquired hydronephrosis may result from urethral stricture or prostatic
enlargement, in which case the affection is bilateral; from ureteral obstruc-
tion due to impacted calculi; from ureteral strictiire following ulcerous or
other inflammation; from kinking of the ureter which may occur in instances
of movable kidney; from external pressure upon the ureter by intra-abdominal
tumors, uterine and ovarian in particular, or peritonaeal bands; from obstruc-
tion of the cystic orifice of the ureter due to tumors (malignant or otherwise)
and inflammations of the bladder.

Pathology. The condition is usually imilateral, the obstruction to the
outflow of urinary secretion resulting in a gradually increasing dilatation of
the pelvis and calices which presses upon the renal tissue and finally produces
atrophy and distention of the kidney. Infection with consequent pyelitis
and pyelonephrosis may take place. In marked instances there is inflam-
matory thickening of the pelvis of the kidney while the organ itself is wasted
to a thin she] , in the wall of which little or no renal tissue remains.
This sac contains a thin yeUomsh fluid, usually clear, but at times turbid
due to the presence of smaU amounts of pus. The specific gravity is
low and the reaction is often alkaline. SmaU amounts of the urinary
salts, urea and uric acid are present and perhaps a trace of albumin may be
found.

The ureter may be the seat of marked dilatation, depending upon the site of
the obstruction, and there is often h}^ertrophy of the unafl'ected kidney and
of the left ventricle of the heart.

Symptoms. Bilateral congenital hydronephrosis is incompatible with life,
but the unilateral t}'pe may cause no symptoms whatever until the result-
ing tumor becomes apparent upon inspection and palpation. Acquired
instances of the disease also may exist for considerable periods without being
evidenced by symptoms or if present, these may be obscured by those of the
causative disease, uterine or ovarian tumor, etc.

Pain in the lumbar region shooting down to the groin or thigh, a feeling
of weight, and a progressive loss of flesh are not infrequent symptoms. With
these lack of appetite and various digestive disturbances, such as nausea,
eructations and constipation, which may be of obstinate t\^e if the large
intestine is pressed upon by the accumulation of fluid, mav be associated.
Irritation of the colon by pressure, without interference with the passage of
faeces, may cause diarrhoea. The patient may detect a fulness in the region



696 DISEASES OP THE URINARY SYSTEM.

of the kidney and in marked instances the abdomen may be so distended
as to suggest ascites.

Physical examination reveals a tumor which upon inspection is evidenced
by a fulness of the hypochondrium and in the lumbar region; this tumor is
likely to enlarge gradually, the increase in size being detected by measur-
ment of the abdomen at intervals. Upon palpation a rounded, firm and
elastic tumor is felt. Fluctuation may be elicited and tenderness may be
present. Percussion over the tumor elicits a dull or flat note unless the colon
passes between it and the abdominal vs^all; over the colon the note is tympanitic.

Intermittent hydronephrosis is an interesting condition in which the tumor
disappears or varies in size from time to time; this occurrence is due to sudden
removal of the cause of the ureteral obstruction. This is likely to take place
in hydronephrosis due to kinking of the ureter which is common in movable
kidney, and also may be observed when there is a valvular stricture of the
ureter or an abnormal insertion of this structure into the kidney. With the
diminution in size of the tumor comes a sudden increase in the flow of urine.
Previous to this occurrence colicky pains may be observed..

Uraemia may take place if a double hydronephrosis is present.

The diagnosis is difl&cult if the retained fluid is small in quantity but when
the condition is evidenced by a gradually increasing tumor in the flank which
diminishes or disappears with greater or less suddenness with an associated
augmentation of the urinary secretion, the affection can hardly be mistaken.
Large hydronephroses may be confounded with ovarian cysts or even with
ascites, but the demonstration of the colon anterior to the tumor will exclude
these latter conditions and aspiration of a small portion of coUected fluid by
means of an exploring needle will reveal the characteristic fluid of a nephry-
drosis. Pyonephrosis is characterized by the presence of a febrile move-
ment and pyuria. The diagnosis in doubtfiil instances may be confirmed
by means of tireteral catheterization. While the obstruction is present little
or no urine will be drawn through the catheter passed into the ureteral orifice
of the affected side.

The prognosis is usually grave although certain instances have been
reported in which a disappearance of the tumor due to unblocking of the
obstructed ureter has not been followed by re-accumulation. Rupture of the
sac rarely takes place. Double hydronephrosis is an especially unfavorable
condition owing to the danger of iiraemia, and infection of the cyst contents
with resulting pyonephrosis is likely to prove fatal unless prompt surgical
intervention is instituted.

Treatment. Hydronephroses of intermittent type seldom need radical
treatment and the management of the patient should be along dietetic and
hygienic lines such as those advised in pyelitis and pyonephrosis. Very
careful massage of the tumor in certain instances may bring about a removal



PARANEPHRITIS. 697

of the obstruction and a partial or complete emptying of the sac. All cases
should be studiously watched for the occurrence of infection of the cyst con-
tents. If the nephrydrosis is due to the movability of the kidney the treat-
ment, after the emptying of the sac, is that of this condition (see p. 663).

The treatment is, with the exception of the above points, whoUy surgical,
and the measures which may be employed should be varied to suit the case
in hand. Simple aspiration often becomes necessary when the quantity of
fluid becomes large and -re-accumulation may necessitate a repetition of the
operation. The needle is usually introduced in the flank at a point midway
between the twelfth rib and the iliac crest. More radical procedures which
may be undertaken upon the advice of the surgeon are incision and drainage
of the sac with establishment, if necessary, of a permanent urinary fistula, or
complete nephrotomy,

PARANEPHRITIS.

Synonyjns. Perinephritis; Perinephritic Abscess.

Definition. A suppiirative inflammation of the connective tissues about
the kidney.

.Etiology. Primary paranephritis occiurs as a result of infection foUow-
ing traumatisms of the region of the kidneys. Secondarily the condition
develops as a result of one of the acute infectious diseases, especially in chil-
dren; of extension of some suppurative process in the kidney itself , its pelvis
or the ureter; of intestinal perforation, particularly that due to appendicitis;
of spinal suppuration and the caries of Pott's disease; and of extension of an
empyaema.

Pathology. There may be several smaU abscess cavities in the tissues
posterior to the kidney, or this organ may be found lying in a single abscess
cavity of larger size. The process usually begins behind the kidney, conse-
quently most of the pus is found in this situation, though more rarely it may be
found between the organ and the peritonaeum. The pus is often of foul
odor as a result of its contiguity to the large intestine. If the condition is
the result of intestinal perforation the odor is likely to be faecal. The pus
most frequently burrows downward and may reach the surface through
the tissues of the groin or it may perforate the intestine, the peritonaeal cavity,
the vagina or the bladder. More rarely it works its way outward through the
lumbar tissues or upward through the diaphragm into the lung whence it is
discharged through the bronchi.

A seldom observed condition is a chronic perinephritis which has given no
symptoms during life and which is characterized by a firm and fibrous capsule
surrounding and adherent to the true capsule of the kidney, which is the result
of an inflammatory degeneration of the perirenal fatty tissue.



698 DISEASES OF THE URINARY SYSTEM.

Symptoms. In instances secondary to other disease the symptoms of the
primary affection are present; suppuration of the perirenal tissues is evidenced
by pain and tenderness upon pressure in the neighborhood of the kidney.
The lumbar tissues may be oedematous. The pain is referred not only to
the region of the kidney but also in many cases to the hip or knee, this is due
to the pressure of the suppiurating mass upon the nerves of the lumbar plexus,
terminal branches of which are distributed to the vicinity of these joints.
While lying, the patient finds relief from the pain by flexing the thigh of the
affected side upon the pelvis and if able to stand, he rests most of his
weight upon the leg of the sound side and stoops forward. Adduction of
the thigh is difficult and painful. After the formation of pus there are chills,
an irregular fever and sweats. If rupture has taken place into the pelvis
of the kidney or if the perirenal process has resulted from pyelitis or renal
suppuration, there is pjoiria. Palpation of the abdomen and lumbar region
reveals an indurated area between the twelfth rib and the iliac crest and a
definite tumor may be felt in some instances.

The diagnosis is usually not difficult. The history of traumatism or of
primary disease is important. Hip and knee-joint disease may be excluded
by examination of these parts. The tumor is less distinct in outline than that
of renal abscess and in uncomplicated instances the urine is unaffected.
Movements of the thigh, especially adduction and flexion, are painful.

The prognosis is most favorable in the traumatic cases and when early
diagnosis is made. Rupture in the lumbar region is more favorable than
into the groin, peritonaeum or elsewhere.

Treatment is entirely surgical and consists in free incision, thorough evacu-
ation of the pus and drainage. Involvement of the kidney itself in the sup-
purative process may necessitate nephrectomy.

NEPHROLITHIASIS.

Synonyms. Renal Calculus; Kidney Stone; Gravel.

Definition. Nephrolithiasis is the term applied to that condition of the
kidney and renal pelvis which is characterized by the formation or presence,
in either of these structures, of concretions resulting from the precipitation
of any of the solid elements of the lu-ine.

.etiology. It is difficult to explain the cause of the precipitation which
results in the formation of a renal calculus. The condition is more common
in men than in women and is chiefly seen in childhood and beyond middle
life. Heredity seems to have a certain influence in many instances and as
other predisposing causes sedentary life, the purinaemic state and kindred
conditions may be mentioned.

Speaking generally it may be stated that the formation of calculi is encour-



NEPHROLITHIASIS. 699

aged by the presence in the urine of an excess of normal solid constituents
or of abnormal solid ingredients. Many stones which have as their origin
collections of bacteria, bits of epithelium or mucus, the eggs of parasites,
coagulated blood and casts, around which crystals have been deposited, have
been observed, which shows that the presence of foreign substances is a causa-
tive factor in many instances. Uric acid calculi, the most frequent variety,
are believed to be likely to occur in the presence of a urine of increased
acidity containing a large amount of uric acid, but a smaU quantity of salines
and possessing a light color.

Pathology. Renal concretions may be classified according to their size
and their chemical constitution. The former classification is as foUows:
a. Renal sand which consists of fine gritty particles which usually are single
uric acid cr}7Stals or a number of these adherent to one another, h. Renal
gravel which is made up of coarser grains which may even be larger than a
good-sized pea. c. Renal stone which may attain the size of a hen's egg.
These often form casts of the pelvis of the kidney or its calices and may be
branched (dendritic or coral calculi). Chemically kidney stones are composed
of: a. Uric acid and its sodium, ammonium or potassium salts. These are
of any size from the largest to the smallest, and are hard, brownish or black
in color and of irregularly smooth surface, h. Calcium oxalate (mulberr}^ calculi).
These stones are hard, of uneven and rough surface, may be of any size and
are often formed about a nucleus of uric acid. c. Phosphatic calculi are less
common than either of the preceding varieties. They often reach a very large
size, are grayish or white in color and may be so soft as to permit of crushing
between the fingers. They are more frequently observed in the bladder
and are composed of calcium and ammonium-magnesium phosphate often
deposited about a nucleus of uric acid or calcium oxalate, d. Rarer varieties
of renal calculus are composed of cystine, xanthine, urostealith, calcium car-
bonate, fibrin and indigo.

The changes in the kidney due to the presence of calculi vary with the
irritation which they cause, their size, their number and with their passage
or retention. Numerous stones may exist in the calices without causing any
abnormal condition of the lining of the pelvis; on the other hand their presence
may cause turbidity of the \irine and desquamation of the pelvic epithelium.
Gravel may be passed at intervals without causing symptoms or pelvic lesions
and larger stones may cause successive attacks of renal colic in their passage
while no changes take place in the kidney or its pelvis. Dendritic calculi
may exist in the pelvis for years without causing inflammation but their con-
tinued presence ultimately results in induration of the kidney. Serious con-
sequences of kidney stone are pyelitis and pyonephrosis, and hydronephrosis
may be caused by the impaction of a calculus in the iireter.

Symptoms. The most constant symptom of calciilus in the kidney is pain



700 DISEASES OF THE URINARY SYSTEM,

in the region of the kidney; with this is associated, in greater or less degree,
tenderness. The pain is usually referred to the affected kidney but some-
times to the normal side; it may radiate in the direction of the course of the
ureter and even as far as the penis or scrotum and is increased upon motion.
Haematuria is sometimes present. The blood is seldom of large amount and
may be absent from time to time; it is increased by exercise or violent motion
of any kind. A small number of pus cells is frequently present in the urine
even if true pyelitis does not exist; mucus and the brick dust crystals of uric
acid are often found; calcium oxalate crystals are also common. The reaction
of the urine is alkaline in the presence of phosphatic calculi, acid with those of
uric acid, while with calcium oxalate stone the reaction may be acid, alkaline
or neutral. Complete occlusion of the ureter by a calculus results in hydrone-
phrosis with its attendant symptoms (q. v.).

Renal colic is caused by the entrance of a stone into the ureter and its attempt
to force a passage. Its onset may be sudden without assignable cause or it
may follow muscular exertion. It is evidenced by most extreme pain begin-
ning in the region of the kidney and radiating along the course of the ureter
to the groin, inside of the thigh or testicle, which last may be retracted. More
rarely the pain extends through to the back or upward to the diaphragm. A
chill followed by a considerable rise in temperature may usher in the attack.
Nausea and vomiting are frequent symptoms and localized tenderness may
be present; cold, clammy sweat may break out upon the skin and a condition
of collapse may ensue. The attack may last from an hour or two to a day
or more and ceases when the calculus has reached the bladder. In the pro-
longed paroxysms periods of intermission are common. There is frequent
passage of urine which usually contains blood. Each urination as a rule
is small in quantity but at times clear urine may be voided in considerable
amount from the normal kidney. Suppression of urine with consequent
uraemia may occur. After the attack there is more or less localized pain
over the region of the kidney and ureter, and the testis of the affected
side may be swollen and tender. Intermittent discomfort in the lumbar
region may remind the patient for months afterward of his paroxysm. The
stone may remain in the bladder or be passed through the urethra. Succes-
sive attacks often are observed but certain patients after having suffered from
one never experience another.

The diagnosis. The condition may be confounded with intestinal or
hepatic colic; in most instances, however, renal colic possesses certain char-
acteristics, such as pain radiating down the ureter to the testis, retraction of
this organ and the characteristic urine, which render the exclusion of the
two former conditions easy. Intestinal colic is likely to follow errors of diet,
the pain is most often in the umbilical region and there are associated flatu-
lence and constipation. In hepatic colic there is likely to be jaundice, with



NEPHROLITHIASIS. 70I

clay-colored stools and pigmented urine and the pain is usually referred to
the region of the gall-bladder. Vesical calculus when causing pain which
cannot be differentiated from that of ureteral calculus, may be diagnosticated
either by means of the "searcher" or the cystoscope; in bladder stone the
reaction of the urine is usually alkaline, while in calculus higher in the
urinary tract is commonly acid. Calcium oxalate calculi, being more rough
of surface, are said to cause a more severe type of paroxysm than those of
uric acid, while the pain of phosphatic stone is considered to be even more
marked.

A most important aid, and one never to be neglected in doubtful instances
or before the institution of surgical measures, is examination by means of the
Rontgen ray. Properly taken plates, will, with hardly an exception, prove
the presence or absence of a stone and are also useful in locating its position.
Fluoroscopic examination is unsatisfactory and it should be remembered
that the skilled eye can often demonstrate a calculus upon a plate which to
the untutored appears wholly negative.

The prognosis. While a single attack of renal colic may be all to which
the patient is subjected, more frequently others will ensue and the continued
irritation of the kidney and its pelvis is likely to result in a suppurative con-
dition. Large calculi remain permanently in the pelvis of the kidney unless
removed by operation. Fatal attacks of renal colic have been reported.
Under the present day surgical treatment of kidney stone the prognosis has
become far more favorable than previously.

Treatment. As a prophylactic measure all persons possessing the so-called
uric acid or purinsemic tendency should be subjected to the dietetic and other
measures suggested under the treatment of purinsemia (see p. 252); that is to
say the nitrogenous elements of the diet should be to a considerable degree
restricted and for them carbohydrates should be substituted. The urine
should be kept abundant in amount and its acidity should be diminished by
the free drinking of any pure water. The much exploited alkaline and lithia
waters are probably in no way superior to ordinary pure distilled water but
it is often wise to prescribe them since the patient will take a prescribed daily
amount of a named and supposedly medicinal water when he will whoUy
neglect his physician's advice if the agent prescribed is nothing more than
the fluid which flows from the tap of his kitchen sink. Any of the various
"lithia" waters is to be recommended since these are usually pure. Likewise
the patient who will not drink a sufficient quantity of plain water will often
take it contentedly if advised to add to each glass 10 grains (0.66) of lithium
carbonate or citrate. The quantity of water advisable for these cases is from
I to 2 quarts (i to 2 litres) daily. The diuretic and antacid effect of the water
may be augmented by taking in addition 15 to 20 minims (i.o to 1.33) of
liquor potassse well diluted, potassium citrate, 20 grains (1.33), or potassium



702 DISEASES OP THE URINAE.Y SYSTEM.

bicarbonatCj 20 to 30 grains (1.33 to 2.0), three times a day. Ttie possibility of
rendering the urine so alkaHne as to predispose to the formation of phosphatic
calculi must not be forgotten, for calculi composed of phosphates about a
nucleus of uric acid have been observed. Consequently the urine should be
frequently examined and the appearance of an excessive alkalinity should be
considered a signal for a diminution or an intermission of the measures
which have brought about this state.

The employment of calcium carbonate in doses of from x to xx grains (0.66
to 1.3 3 J thiee times a day has recently been advocated upon the hypothesis
that the combination of the calcium with the acid phosphates in the alimentary
tract diminishes the deutero-phosphates of the urine with the result that the
proto-phosphates remain to dissolve the uric acid.

Calcium oxalate calculi should 'be treated both dietetically and medicinally
along the same lines as those advised for uric acid stone but in phosphatic
calculi a different mode of treatment is necessary. Here the problem is to
render the xirine acid and the best means of accomplishing this object is by
the employment of a diet directly the opposite of that indicated in hyperacid
conditions. The food should be chiefly of meat and the carbohydrate ele-
ments should be restricted. The urine should be kept diluted and increased
in quantity by the free use of a water not alkaline. The most serviceable
drugs in rendering the urine acid are benzoic acid and its sodium and ammo-
nium salts; the latter are preferable because of their greater solubility. The
dose of either is from 10 to 15 grains (0.66 to i.o). Boric acid also will render
an alkaHne urine acid and is most effective when employed as potassium tar-
traborate; its dose is 20 grains (1.33) three or foiir times daily diluted in a large
amount of water. Its taste may be disguised with licorice or syrup of orange peel.

The so-called uric acid solvents, piperazin, lysidin, lycetol, etc., may be