Hydatid Sac Bursting into the Left Renal Pelvis, Subsequent StTpura tion.—Hydatid sacs in the cellular tissue in the neighborhood of the kidney evince a singular tendency to burst into the pelvis of that viscus. Occasionally they suppurate, probably because of the pro pinquity of the colon. One patient, of seven cases of urinary by datids, brought with him an eight-ounce bottle of pus, cysts, and thin gruel-like urine, as a sample of what he had passed daily for some weeks. He had had an hydatid cyst the size of a foetal head, which occasionally emptied itself into the renal pelvis, for thirty-one years. A month previous to consulting me the contents of the sac had suppurated, and he began to pass more cysts than he had done during the thirty years of his illness. He refused operation, and got quite well under ordinary medicine, the colic and fixed pain ceasing, the urine clearing, and the sac contracting until it was quite small.
External Pycemia, Acetabular Abscess- Bursting into the Bladder Three Times, Scar in Bladder Seen with Cystoscope.—A young fellow, aged 30, was sent to me by Dr. Ayling for an acute attack of cysti tis. In 1878 he suffered from " pylemia" in Germany, his left hip and right knee being affected most severely, and ankylosing. In 1884 the old abscess in the left hip opened, and in 1885 an abscess formed apparently on the inner side of the acetabulum, for the pa tient states it burst into his bladder and discharged pus and blood into the urethra, the pain ceasing at the same time in the hip. These abscesses have formed three times, and they have 'always_ evacuated themselves by the same route. In 1886 an abscess dischagred by the rectum and a piece of bone came out. Apparently this was the con clusion of the disturbance, for he has since been in perfect health until the attack for which he presented himself to me.
A month previous to seeing me he began to suffer suprapubic pain after passing water. It was not in the penis at first. There was no frequency of urination and no blood. A week before seeing me he was suddenly seized while micturating with a severe pain at the inner side of the suprapubic area and along the penile urethra to the glans. This continued, became constant, and was quite independent of micturition. He urinated every three hours in the day, and once at night; when the call came it was urgent but not imperious; the stream was twisted and curled. He was in terror lest another abscess was forming. The left hip was ankylosed and covered with deep scars both before and be hind. The urine was acid, 1.020, straw-colored, clear, contained one-eighth albumin, irregular-shaped uric-acid crystals, but no casts. With the electric cystoscope I found he had a well-marked patch of sessile warty growth, the size of a threepenny bit, on the left side of the lateral wall low clown. This patch was situated on a healthy base, and the neighborhood was uninflamed. The rest of the bladder was
healthy. From his history and the unusual appearance of this splash of warty growth, I felt justified in considering that it was the relic of an irritation which had approached the bladder from without, and probably marked the site of the opening of the abscess which had burst thrice into the bladder from the neighborhood of the left hip.
Fallacy.—Cases are on record of psoas abscess breaking into the bladder," and even carrying pieces of bone into that viscus, but it is, I believe, comparatively uncommon for these abscesses to break into the ureters or kidney pelvis, for if they do affect this urinary channel it is rather by occluding the ureter, and by producing disorganization of the kidney." In dealing with these cases of angular curvature of the dorsal spine, it is unwise to conclude hastily that urinary toms betoken the irruption of pus into the tract from a spinal tion; it should be remembered that frequency of micturition and pain at the end of the penis, together with small amounts of pus in acid urine, are caused by independent tubercular disease in the renal sub stance. Still more unlikely is a psoas or an iliac abscess which jects into the groin or loin to affect the urinary passages, for it has obviously made its way in another direction. I have made two post mortems which illustrate this.
A man aged 50 developed a psoas abscess in his left thigh which had emanated from caries between the fourth and fifth lumbar verte bra, a curvature at this spot having existed for fifteen years. Pus was passed with the urine. This psoas collection was opened, but the pus in the urine did not diminish. On post-mortem the left kidney was found entirely destroyed by tubercular disease, and the left psoas abscess had no connection with either the ureter or pelvis of the kidney.
A man aged 51 presented himself with a large psoas abscess the size of a child's head simulating inguinal hernia of the left side. The urine was acid and contained much pus, the specific gravity was 1.010. The psoas abscess was opened. On the death of the man from hectic and exhaustion a few days after, a post-mortem was made and the abscess was tracked to the caries of the first sacral and last lumbar vertebra. It was quite unconnected with the urinary tract. The left ureter was enormously thick, its canal was patent, and the mucous membrane was tubercular. The renal pelvis and one or two calyces about the middle of the kidney were also implicated, while the bladder was patched over with crude tubercle and superficially ulcer ated. The trigone and adjoining posterior wall had been cleanly dissected up. The right kidney was healthy. Probably there was direct contagion from the psoas to the ureter, through the medium of the lymphatics.