SUPPURATIVE PYELONEPHRITIS WITH CYSTITIS.
Both kidneys become inflamed. The pelves are congested and coated with pus or fibrin. The kidneys are swollen, congested, and studded with foci of pus. The smallest foci are not visible to the naked eye, but with the microscope we find collections of pus cells between the tubes, with swelling and degeneration of the epithelium within the tubes. The larger purulent foci look like white streaks or wedges running parallel to the tubes and surrounded by zones of congestion. The larger abscesses replace considerable portions of the kidneys.
The ureters in some cases are inflamed, their walls thickened, their inner surfaces coated with pus or fibrin. The bladder presents the lesions of acute or of chronic cystitis.
Etiology.—This form of nephritis seems to be always secondary to a cystitis, the infection extending from the bladder through the ureters to the kidneys. The cases of cystitis in which a suppurative nephritis is likely to be developed are those due to strictures of the urethra, stone in the bladder, operations on the urethra, bladder, and uterus, paraplegia, gonorrhoea, and enlarged prostate.
Symptoms.—When the nephritis occurs with cystitis due to stone in the bladder, strictures of the urethra, or operations on the genito urinary tract, the symptoms are much the same. The patient has first the symptoms belonging to the cystitis, then he is attacked with chills and a rise of temperature. The chills are repeated, the tempera ture is irregular and accompanied by profuse sweating. There is a rapid change in the general condition of the patient, he becomes more prostrated and emaciated from day to day. The face is drawn and anxious, the tongue dry and brown, the pulse rapid and feeble; delirium is developed and the patient finallydies in the septic condi tion. The urine is diminished in quantity or suppressed; it contains blood, pus, and mucus derived partly from the bladder, partly from the kidneys.
Cases of suppurative nephritis due to a gonorrhoeal cystitis are not common, but several of them have been observed. Murchison
describes two cases, in both of which the cerebral symptoms were very marked—delirium, convulsions, and coma. I have seen one such case. The patient was a prostitute who came into the hospital with a specific vaginitis. After a few days she developed the symptoms of an acute cystitis ; then, after a few more days, she was attacked with chills and a rise of temperature, passed rapidly into the septic condi tion, and died. At the autopsy there were found acute cystitis, pyelitis, and numerous small abscesses in both kidneys.
When suppurative nephritis complicates the cystitis clue to en , larged prostate, the symptoms are somewhat different. The patients are usually men over fifty years old. They have generally suffered from the symptoms of enlarged prostate, retention of urine either constant or intermittent, and more or less cystitis with pus and mucus in the urine. Sometimes, however, no such history is obtained; the patients assert that they have had no previous bladder trouble. The first symptom is a diminution in the quantity of urine, with the ap pearance of blood mixed with it, or the urine may be suppressed alto gether. The blood may be present in considerable quantities so that the patients seem to pass blood instead of urine. The patients rapidly become prostrated and very anxious. There are usually no chills, and there may be no rise of temperature. The prostration becomes more marked, the pulse is rapid and feeble, the skin is cold and bathed in perspiration, and the patients die in collapse at the end of a few days. Or, instead of such a history, the patients may behave as if they were the subjects of septic poisoning.
Pro g osis. —Suppurative nephritis secondary to cystitis is a very fatal disease; so far as I know all the patients die.
Treatment.—The treatment for these cases is altogether a preven tive one directed to the cystitis. When the nephritis is once estab lished we have no further control over the case.