Part 43

Lesions. There may be a circumscribed renal abscess like a good large orange, or many small gray spots like millet seeds, peas or hazel nuts, having purulent centres and containing pus cocci or bacilli. In other cases a diffuse inflammation suppurates throughout till the whole gland becomes a pulpy mass of pus, blood and broken down kidney tissue (pyonephrosis). In traumatic cases the pus centres around the wound or injury, perhaps invading adjacent parts, and even communicating through the skin externally along the line of the original wound. The pus may burrow in different directions in the cortex or under the capsule with abscess at intervals (perinephritis), or along the vessels to the medullary structure.

Symptoms. These are often obscure. The sudden appearance of kidney disease in the course of a suppurative affection elsewhere, the extension being ushered in by a chill or rigor or attended by a succession of these, and the course marked by a variable hyperthermia is very suggestive. Stiffness and weakness of the hind parts and tenderness of the loins are significant; also, in carnivora and omnivora, nausea and vomiting. When the kidney can be felt by the hand in the rectum or in the small animals, through the flaccid abdominal walls, the manifest enlargement, the tenderness, and in some cases even fluctuation will assist in diagnosis. In such cases, puncture by a large hypodermic needle, or a small trochar may betray the presence of pus and complete the diagnosis. If the pus escapes into the pelvis of the kidney it may be recognized in the urine. The case is very liable to become chronic, and is then marked by anæmia and emaciation.

Treatment. When an external wound exists it must be treated, antiseptically, with boric acid, potassium permanganate, or other antiseptic lotion. If a single large abscess exists, puncture evacuation through needle or trochar, and washing out with an antiseptic solution is the obvious resort. Any foreign body must of course be removed. If the suppuration is diffused through the whole mass of softened kidney, the resort of extirpation may be considered. This is always dangerous as provocative of infectious peritonitis, but it is less so in dogs and swine than in other animals owing to their natural antagonism to pus microbes. The operation should be attempted extraperitoneally, the incision being made beneath the anterior lumbar transverse processes and carried inward through the sublumbar connective tissue. The renal artery will require ligature with antiseptic catgut and all manipulations should be aseptic or antiseptic. Even if successful, this operation leaves the subject in a dangerous state, as in case of kidney disease at any future time, there is no second kidney to compensate for the temporary loss of function and uræmic poisoning is to be dreaded.

Apart from surgical measures the general treatment would be largely the same as for acute infectious nephritis. As antiseptics calcium sulphide, the different sulphites, copiaba, etc., will be indicated.

PERINEPHRITIS.

Definition. In cattle on low damp lands, acrid plants, sprain, blow, calculus, from purulent nephritis, in anæmia. Symptoms: of nephritis, soiling of tail or prepuce, albumen, pus or blood in urine, lameness, unilateral or bilateral, lumbar swelling, in small animals fluctuation, history. Lesions: abscesses around kidney, under capsule, intercommunicating. Treatment: as in purulent nephritis.

Suppuration in the connective tissue between the kidney and its capsule is seen in cattle in low condition, on damp, unimproved soils like undrained river bottoms and estuaries, abounding in acrid and diuretic plants. Even among such animals it is rare and has probably a directly exciting cause in a sprain or blow on the loins, or the presence and movement of a renal calculus. It may extend from suppurations in the substance of the kidney and to such extension the weak or anæmic condition materially contributes. In man, in which such conditions have been more frequently observed, a weak or cachectic condition is considered as an essential accessory factor along with the traumatic lesion (R. Harrison). Similar conditions may be expected to bring about perinephritis in any one of our domestic animals. The author has observed it especially on the low lands on the banks of the Ouse in Yorkshire, England.

Symptoms. These are mainly those of nephritis in general, shivering, stiff movement in the hind limbs, straddling, frequent passage of urine, straining, difficulty in lying down and rising, tenderness of the loins, dropping when mounted, groaning when turned in a short circle. If the suppuration communicates with the pelvis of the kidney there may be, in females, soiling of the tail, and in males of the prepuce. Blood may be passed with the urine, and pus cells and albumen are found when it is examined. If one kidney only is affected, there is lameness in the corresponding hind limb, the special feature being inability to extend it backward. A swelling on the one side of the loins, and beneath the lumbar transverse processes just posterior to the last rib, is likely to be a marked symptom, and if this persists and is especially prominent at one point, an exploratory incision or puncture will detect the presence of the pus. Fluctuation can rarely be detected, yet in small animals with very flaccid abdomen, the swollen, tender kidney and even fluctuation should be detected at times. The history of the case, the low, damp pasturage, the access to acrid plants, the alimentation with hay or grain covered with cryptogams, the fact of an injury and the low, weak, anæmic condition of the animal should contribute to a satisfactory diagnosis.

Lesions. In bovine kidneys affected in this way we have found general inflammation and exudation around the entire kidney and inside the capsule, with numerous small abscesses, in many instances communicating with each other. They may extend through the capsule and invade surrounding organs.

Treatment. In the treatment of cases of this kind the general principles of therapeutics for nephritis are about all that can be attempted in the lower animals. Fomentations over the loins are especially desirable as a means of relieving the suffering, and moderating inflammatory action. To the same end is the allowance of plenty of pure water as a diluent. Then the various agents that antagonize suppuration may be thought of, and some one selected for use. Beside the antisuppurants already mentioned one may use copiaba, cubebs, or turpentine in small doses, salicylates, or the sulphide or sulphite of calcium. Surgical interference by puncture or incision and antiseptic irrigation can only be thought of when the abscess is single and circumscribed; never when the whole periphery of the organ is involved. In the latter case the only rational surgery would be the desperate resort of the removal of the entire kidney.

PYELITIS. PYELONEPHRITIS. INFLAMMATION OF THE RENAL PELVIS.

Definition. Causes: primary from vegetable irritants in food, toxins, cryptogams, pelvic calculus, strongylus gigas; secondary from renal calculus, parasite, tubular urethral or vesical infection, infecting deposits, metastasis. Symptoms: as in nephritis, pus, blood, or albumen in urine, tender, arched loins, purulent polyuria, with spheroidal epithelium. Diagnosis. Lesions: inflammation, calculus, etc., in pelvis. Treatment: pure water, sodium bicarbonate, antiseptics, balsams, fomentations, piperazin, extraction of calculus.

Suppurative inflammation of the mucosa lining the renal pelvis may occur in the acute or chronic form.

Causes. It may be either primary or secondary. As a =primary= disease it may be the result of poisoning by irritant diuretics such as cantharides, turpentine, colchicum or balsams, or shoots of the coniferæ, it may be due to the passage of the irritant products of cryptogams found in musty fodder or grain, or it may come from the irritation caused by the toxins of bacteria developed in the system or in food or drink. Cases that develop from the irritation of a pelvic calculus or precipitate, and from the presence of the strongylus gigas (in dogs) may also be placed in this class.

As =secondary= causes are those in which the inflammation starting in the uriniferous tubes extends down to and implicates the pelvis, and the still more frequent instances of extension of purulent infection upward from the ureter, bladder or prostate, so as to involve the pelvis. So in blocking of the urethra by strongylus, stricture, clot or calculus, and in spasm of the sphincter vesicæ, the delayed urine is liable to undergo fermentation with evolution of ammonia, and not only the bladder but the ureter and renal pelvis may suffer. Again, the occurrence in the kidney of the hyperplasia of cancer, glanders (horse) and tuberculosis (cow) may be the direct cause of pyelitis. Similarly foci of infection in the kidney may be found in distemper in the dog, and in the contagious pneumonia and influenza of the horse. In man infection from the bowel through the migration of the bacillus coli communis to the devitalized kidney and contents in hydronephrosis, has been traced, and the liability to this must be still greater after the surgical insertion of the ureters in the rectum as a substitute for the obliterated bladder and urethra. Again, in the intra-arterial migrations of the strongylus (sclerostoma) armatus pus microbes may be carried to the kidney and reach the pelvis.

Symptoms. These are in the main those of nephritis with marked rigors. The presence of pus cells and albumen in the urine may come from suppuration in the substance of the kidney itself, or sub-capsular abscess opening into the pelvis, or it may come from cystitis, prostatitis or urethritis. The special stiffness and tenderness of the loins, polyuria in which the liquid is purulent, but free from uriniferous casts, and in which it is charged with the spheroidal epithelium of the pelvis (not the columnar of the tubules), may afford presumptive evidence of pyelitis. But pyelitis is usually combined with nephritis or cystitis and the complications prevent diagnosis. In some cases the urine is scanty and strongly albuminous, and in others a round calculus will block, at intervals, the opening of the ureter giving rise to obstruction of the flow from that kidney and the occurrence of violent renal colic lasting until the stone is again dislodged backward.

Diagnosis cannot often be certain. Purulent urine, with a considerable number of the spheroidal cells of the pelvis, and the general signs of nephritis may be taken as diagnostic. A great excess of such epithelial cells would on the contrary point to cystitis.

Lesions. In the early stages the mucosa of the pelvis is congested, red, and sometimes, with calculus, hæmorrhagic. Later it becomes thickened by exudate, which fills also the submucous tissue. In some instances the pelvis is distended by an impacted calculus, in others the obstruction of the ureter by an impacted calculus or a swelling has led to overdistension of the pelvis, and ammoniacal fermentation of its contents. Coincident inflammatory lesions of the kidney, ureter, or bladder are common.

Prognosis is not hopeful. Where it has resulted as a descending infection from the kidney, the severity of the primary lesion renders the case a grave one, while if it has been an ascending inflammation from the bladder it is no less so.

Treatment. Diluent (watery) diuretics are especially indicated. Pure water may be given ad libitum. To this may be added if necessary moderate doses of bicarbonate of soda or potash with such non-irritating antiseptics as salicylic acid, salicylate of soda, sulphite of soda, sulphide of calcium, quinia or chamomile. Trasbot even recommends small doses of vegetable astringents, balsam of Tolu, or Peru or of Copiaba, or oil of turpentine or tar water. Apart from simple water, the diuretic agents may be used with greater freedom if the solid parts of the kidney are little or not at all involved and if the urine contains no casts of the uriniferous tubes.

Benefit may also be obtained from fomentations, or cupping of the loins, and even from the application of mustard and counter-irritants.

If the active symptoms subside the continued use of tonics would be indicated, especially quinia, and also of the balsams with the view at once of antisepsis and toning up of the mucous membrane.

In case of calculus of the pelvis surgical extraction is virtually the only resort, though a very desperate one. Its increase may be retarded or prevented by antisepsis, a liberal use of water, and the exhibition of piperazin or some of the essential oils.

CHRONIC NEPHRITIS.

Cases destroyed as eating their heads off. Causes: sequel of acute nephritis, swill, lead, experimentally, microbian invasions, toxins, metastatic embolism, extension from aortic disease, sclerostoma, nitrogenous overfeeding, toxins of putrid food, or cryptogams, valvular disease of the right heart, rheumatism, heaves, calculus, starvation, debility, retention of urine. Symptoms: emaciation, flabby muscles, lack of vigor, stiff loins and quarters, short step, straddling, fatigue under slight exertion, groaning in trot, or in turning, droops when mounted, slow to rise on hind limbs, poor capricious appetite, anæmia, stocked legs, dropsies, urine of lower density, albuminous, with granular epithelium and casts, abundant in early stages, scanty with weakened heart and degenerated kidneys. Secondary palpitations, bronchial catarrh, pneumonia, hemorrhage, stupor, lethargy, vertigo, etc. Lesions: recent cases, kidney large, cortex firm, capsule adherent, with granular fatty debris, and tubular casts; old cases, kidney contracted, fibroid, glomeruli and tubules atrophied. Bronchitis, pneumonia, hepatic cirrhosis, heart enlarged, fatty, dilated, insufficient valves. Prognosis unfavorable. Treatment: gentle exercise, warmth, succulent food, amylaceous, tonics, iron, bitters, mineral acids, heart tonics, for polyuria bromides or iodides, balsams, pilocarpin, fomentations or sinapisms to loins.

Chronic nephritis has received little attention in the lower animals for various reasons. The lower animals largely escape the causative factors of alcoholism and chronic lead and copper poisoning, and when suffering from any chronic affection that disqualifies the animal for use and renders it anæmic and emaciated it is naturally sacrificed to save the cost of maintenance. In spite of this a considerable number of cases have been recorded in horses, and cattle and especially in dogs and cats.

Causes. Cases of acute nephritis sometimes improve and give promise of recovery without completing the work of convalescence. Trasbot notes such cases in the dog, and Dickinson in the ox. Alcoholic nephritis and degenerations are to be sought for especially in cattle kept on distillery and brewery dregs. Lead taken in small quantities in soft water that has run through lead pipes or stood in leaden cisterns produces in cows and other animals chronic affections of the kidney. Ellenberger and Hofmeister have produced the disease experimentally with lead and copper respectively.

Microbian invasions of the kidney that advance slowly like glanders and tubercle are further causes of chronic nephritis. Other secondary microbian infections of the kidney are complications of infectious diseases in other parts, including abscess, pyæmia, septicæmia, ulcerative endocarditis of the left heart, bronchitis, pneumonia (Fröhner), and of others less directly in the line of the circulation, as omphalitis, uterine phlebitis (Lustig), abscess of the nasal sinuses, bones, and fistulæ (Trasbot).