CHAPTER V.

DISEASES OF THE URINARY SYSTEM.

I. INTRODUCTORY REMARKS.

THOUGH the subject of renal diseases in early life is one which does not usually receive any very great amount of attention from systematic writers on children's diseases, there is, nevertheless, sufficient evidence in our mortality tables to prove that, measured by this standard, it is a matter of great importance. We find, for instance, that in the Report of the Registrar General for the year 1866, there died from renal disease in England alone, no less than 720 children under fifteen years. of age, and of these 272 died under five years of age. When we come to analyze these facts a little further, we find that the following were the speicfic renal diseases with the numbers of fatal cases of each:

The term Nephria in this table is used as synonymous with Bright's Disease, and it thus appears that out of a mortality of 720 from all kinds of renal disease in children under fifteen years of age, no less than 245 died of Bright's disease, of which 164 were between the ages of five and fifteen.

It is not improbable that, if greater attention were given to the subject, the mortality from renal diseases would be found to be much greater than is here indicated; for in our own experience we have noticed, that morbid conditions of the urine, and especially albuminuria, are much more frequent accompani

ments of other diseases in children than is commonly supposed. It is likely, therefore, that the supervention of renal disease may not seldom be the turning point in the history of other acute diseases of childhood, though the fact eludes observation. Before proceeding to the consideration of the diseases of the kidney, we may profitably notice three conditions connected with the voidance of the urine, which may or may not be due to renal disease, but are often associated with it-viz., difficult micturition, or dysuria; excessive secretion of urine, or diuresis ; diabetes; and incontinence of urine.

II. DYSURIA.

Dysuria, or painful micturition, may occur as the result either of a morbid condition of urine, the characteristic feature of which is great acidity, from an excess of uric acid; or it may result from a diseased state of the urinary passages. In boys, from elongation of the pupuce and its consequent irritation and inflammation; or in either sex, from inflammation of the meatus urinatius; or, lastly, from the presence of a urinary calculus in the bladder. Ascarides in the rectum also occasionally leads to some difficulty in micturition, though generally this is rather in the way of incontinence than of dysuria.

The amount of pain varies greatly; in some it is only a passing discomfort due merely to slight acidity of urine, the result of febrile disturbance, while in others the pain is so excessive that the child screams out and is sometimes almost in

convulsions with agony. Whenever the urine is scanty in amount, from whatever cause, it is sure to be high coloured, rich in lithic acid by mere concentration, and consequently difficult to pass. A condition such as this is known at once, in the absence of any more positive signs, by the evidence afforded by test paper, perhaps by the presence of lithic acid deposits, if not naturally, yet always and quickly, by the addition of a little nitric acid. Such a state is usually associated with some feverishness, often with disturbance of the digestive functions, and is very commonly connected with chronic skin disease, with rheumatism, or with a generally acid state of the system. But the urine may be perfectly normal, at least it may be free from any excess of acidity, and the fault may rest in the urinary passage. With boys it sometimes happens that the foreskin is abnormally long, and the orifice preternaturally contracted. In such a case the loose integument becomes irritated and inflamed, either by the urine passing over it, or perhaps from friction with the child's clothes, and on examination it will be found that the orifice of the pupuce is red, swollen, and

painful to the touch, micturition in such a case being often extremely painful. Sometimes another abnormal condition exists to which the name Phymosis has been given.

This term signifies a preternatural constriction of the orifice of the prepuce, so that the glans penis cannot be uncovered. Most children are born with the opening of the prepuce too small to allow of the complete retraction of the foreskin; but as the orifice becomes naturally dilated about the time of puberty, nothing need be done unless the opening is so small as not to allow the urine to pass except with great pain, a condition which often occurs if the part be at all inflamed. Should this prove to be the case, the preputial orifice must be cautiously slit up, or circumcision may be performed; the latter is the most advisable proceeding wherever there is in conjunction with the above an elongated condition of the foreskin.

Another condition sometimes met with in boys, and which may also give rise to great difficulty in micturition, is that known. by the term PARAPHYMOSIS, which consists of the retraction of a tight prepuce over the glans penis, with swelling of the parts so as to prevents its return. This swelling is quickly followed by inflammation, which may even run on to gangrene of the constricted glans as well as of the constricting ring of foreskin. In such a case the everted prepuce should be replaced as quickly as possible. Ice or cold water should be applied for a few minutes to reduce the swelling, and then gentle but persevering attempts should be made to draw the prepuce gently forwards whilst the glans is pressed back: chloroform will greatly aid this proceeding. If these attempts fail, the constricting ring of foreskin must be divided with a bistoury, and simple waterdressing be applied till the part has healed.

The only remaining cause of dysuria to which we need now refer is, the presence of a calculus in the urinary bladder. It does sometimes happen, though it is an occurrence of great rarity in childhood, that a calculus forms in the kidney, and may become lodged in the ureter. The symptoms of stone in the kidney are, pain of a continuous and severe form, situate in the loins, but most in the affected side, extending through to the front and all round the waist, as if girt with a tight cord, shooting also down the ureter and causing retraction of the testicle. If the stone emerges from the kidney, and enters the ureter, but can get no farther, its presence there will be indicated by severe pain which shoots down through the groin, and along the inner side of the thigh, as well as into the scrotum. When the stone has entered the bladder, there is frequent micturition, with occasionally severe dysuria, the flow of urine.

often suddenly stopping with an accession of pain, especially at the extreme end of the penis, occasionally hæmaturia, sometimes pus is present in the urine, and sometimes there are lithic acid deposits.

In the case of girls, dysuria is generally due either to excessive acidity of the urine, or to inflammation of the passages, or to the existence of a vasular growth at the orifice of the meatus.

The Treatment of dysuria, whether in boys or girls, will of course vary with the cause. In both, when the pain is due to excessive acidity, alkalis, and salts of the vegetable acids, acetates, tartrates, and citrates, which are converted into carbonates in the system, together with the liquor potassæ, will be the most fitting remedies. Much relief will also be afforded by the free administration of the so-called diluents, of which plain water or mucilaginous liquids are perhaps the best. Diet is of course a matter of great importance in these cases; no malt liquor nor any but the most delicate white wines, and perhaps not even these can be allowed, while a sparing and non-stimulating dietary must be strictly enforced. When any malformation exists, such as has been alluded to, the proper remedy will be an operation for its removal. Stone in the kidney admits of no cure by art; our only resource lies in the mitigation of pain, and in the free dilution of the urine by alkaline or other drinks. Stone in the bladder is to be remedied either by lithotomy or lithotrity, the latter being seldom practiced in the young.

The existence of a vascular tumour of the meatus in girls can be demonstrated only by ocular examination, and is best treated by ablation with the knife.

III. INCONTINENCE OF URINE.

Incontinence of urine may in some respects be regarded as the opposite of that we have just considered; it occurs in early life from a great variety of causes: may exist in both sexes, by night or by day, or both, but in much more frequent by night only. In some cases we have met with it in all the members of a family, and it has seemed to be due then to constitutional peculiarity. It may be associated with renal disease, or with a disposition to gravel, or it may depend upon constitutional weakness and irritability, or it may be due to an increase of uric acid in the urine.

The incontinence of urine which occurs during sleep, and is so common in young children, may result from any of the causes last specified; in all cases therefore the renal secretion should be examined. Very frequently this affection is the

consequence of bad habits; being favoured by the free use of fluids during the after part of the day, by exposure to cold in the night, and by lying on the back,-a posture which seems to be very unfavourable to the retention of the urine, especially when the natural sensibility of the mucous membrane of the neck of the bladder is at all increased. Another cause of incontinence of urine is the presence of ascarides in the rectum. This we have observed in many instances; a loaded state of the bowels will also induce, and sometimes we have known it result from, the presence of a small calculus in the bladder.

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In the Treatment of these cases we must be careful to make the little patient abstain from fluids for three or four hours before going to bed: he should also be taken up to empty his bladder twice or thrice during the night and when the position appears to influence the case, some good may result from tying a cotton reel over his spinal column, so that when he turns round upon his back he may at once be awoke. At the same time we should try to give strength and tone to his system, by the administration of the tincture of the sesquichloride of iron with quinine. In some very inveterate cases, the application of a succession of small blisters over the sacrum has effected a cure: but such agents should be avoided, if possible. Where the bladder is very irritable a belladonna plaster over the loins and sacrum will often be very useful: or four or five grains of the extract of this drug may be rubbed into the same region every night. In other cases where there seems to be a want of power in the bladder generally, we have found good result from the addition to the sesquichloride of iron and quinine mixture of ergot of rye in 5 minim doses of the extract to a child five or six years of age. Nux vomica in the form of tincture in doses of one to two minims for a child six or eight years of age is also very useful, and in cases where the urine is thick with lithates, the dilute nitro-muriatic acid is of great service. Lastly, belladonna is a remedy which has found. favour with many practitioners, though it has signally failed in our hands. Of course none of these remedies will be of any avail if the symptoms are due to the presence of stone; nor will much good result from either of them if the condition in question be the result of bad habits.

IV. DIURESIS.

The term diuresis merely implies the existence of an increased flow of urine: it may occur in young children as in adults, from a variety of causes, and is a symptom of very various diseases.