As I have urged that in the ordinary forms of ascending ureteral and renal dilatation and disintegration, observed in connection with serious kinds of obstructive disease lower down, other measures fail ing, free and incontinent urine drainage should be established, I will proceed to notice some indications relative to the incidence of these serious and very fatal complications.
In the first place it must be remembered that they are the out come and natural termination of the most serious forms of prostatic and urethral obstruction. I have seen many cases of traumatic stric ture ending in this way and in death from uremia by reason of the almost entire absorption of kidney tissue. Sufficient stress, how ever, has already been laid upon this point.
The probability that these ascending changes are advancing is frequently indicated by certain abdominal expressions which, taken in connection with the nature of the obstruction, cannot be otherwise than highly suggestive. Where the ureters have been very large I have distinctly been able to make out by deep pressure with the hand bilateral vertical prominences in the direction of the kidneys in con tradistinction to the feel that ordinary intestine affords to the touch. Lines of perpendicular sensitiveness can thus often be made out. Though tenderness over the kidneys can generally be discovered if looked for, perceptible fulness or swelling is •rarely made out until these organs have become seriously involved. Sensitiveness on pres sure over the kidneys in both prostatic and urethral obstruction is often significant.
In this aspect of obstructive disorders below the bladder ther mometric observations are often of much value. A dilated ureter is a tube that is rarely empty. Small quantities of urine collect in de pendencies within it, and local inflammation is excited, and this is often indicated by irregular temperatures. I have made many obser vations of this kind in connection with chronic prostatic and stricture cases where the ureters and kidneys have eventually proved to be both dilated and inflamed. It is quite a different temperature chart to that which is seen in the ordinary forms of urethral fever following the use of instruments. In the former case the variations are more like those which occur in what we used to speak of as hectic fever.
Then again there is often thirst and a dry tongue, and the patient is generally materially relieved by flushing the kidneys with some bland antiseptic fluid. There is difficulty in doing this when the obstacles in the way of expelling urine from the bladder are considerable. On the other hand, when bladder drainage has had to be provided to secure incontinent and free expulsion of the urine from the bladder, independently of the will, a diuresis of this kind is often most beneficial.
Then in the last place the urine of back-pressure and supra-vesi cal dilatation may be suggestive. It is often purulent, with a faintly acid reaction when recently passed, and with a low specific gravity. It is to this class of cases irrespective of age that Sir James Paget's" remark is appropriate: "Let me tell you of a symptom which must make you specially cautious if you have to catheterize elderly or old men. If they are passing large quantities of pale urine of a very low specific gravity, whether containing a trace of albumin or not, they will be in danger from even the most gentle catheterism. For this condition of the urine is often due to some advanced defect of action in the kidneys, and a catheterism will be followed by inflammation of the bladder and the so-called urinary fever, and death will hardly be escaped." The urine that is secreted under a high pressure, as where ob struction, though not complete, is considerable, is described by Sir William Roberts as "very pale, watery, devoid of its proper coloring matter, poor in urea, and of low specific gravity. It may indeed be tinged with blood, but this is an accidental circumstance." I have frequently seen urine which for some time had presented these char acteristics in some advanced forms of traumatic urethral stricture where dilatation of the ureters and kidneys was probably going on, immediately assume more healthy characteristics after all tension has been taken off by a suitable bladder drainage being provided. By these means the excretion may be observed to return gradually to a normal standard, with permanent advantage to the patient. This is an expedient which must not be lost sight of in connection with the mechanical treatment of these progressive dilatations.