PERINEPHRITIC AND NEPHRITIC SUPPURATIONS.
I will now pass on to notice the suppurative effects of inflamma tion as observed around and within the kidney requiring surgical at tention. Situated as these organs are, the consequences of a lesion from without, as a blow on the loins, or the irritation proceeding from within, as by the presence of a renal stone or tubercle, may be to excite suppurative inflammation in the fat and cellular tissue in which they are more or less loosely embedded. This condition is known by the term of perinephritis.
When we consider how deeply the mischief is in the first instance situated, and the nature of the texture in which it is located, it is easy to appreciate the difficulty of making an early and correct diagnosis, and to understand how readily, before the superficial tissues are implicated, the products of inflammation may travel to and involve neighboring parts. When suppuration has occurred, as is usually the case, numerous instances are recorded showing how the pus, when left to its own direction, has found its way into the corre sponding kidney or into the adjacent spaces of the thorax and ab domen or their respective viscera. Hence a severe blow over the loin, the sudden movement of a calculus within the kidney, are conditions which are not to be looked upon too lightly, especially when either happens in persons who are to be regarded as cachectic, or in poor physical condition.
Though most frequently caused by direct violence applied over the loin, or by disorders of the urinary tract which render all parts of the apparatus susceptible to inflammation, perinephritis is some times produced by inflammatory extensions from such other parts as the liver, gall-bladder, spleen, coecum, and vertebra. It is in tissue like the subperitoneal that inflammatory burrowing may occur with considerable facility.
Perinephritis is characterized by the local and general symptoms of inflammation : there is usually some swelling in the loin as com pared with the opposite one; tenderness on pressure may be discov ered if sought for, and the actual occurrence of suppuration, or the presence of pus around the kidney, leads to those variations in the temperature as shown by the thermometer, which the surgeon is not at all likely to disregard. Very little reliance can be placed on the discovery of fluctuation as an indication that pus is present, perhaps two or even three inches from the surface. Long before this is de monstrable to the touch the practical surgeon will have reached it by an exploratory incision in the loin under an anaesthetic, in the course of which many ounces of matter may escape. To wait until fluctuation can be made out is often to allow valuable time to elapse in which serious if not fatal mischief may be done. Mr. Morris refers to an inability to extend the thigh of the affected side as in his experience an early sign of mischief. The matter evacuated in ab scesses of this kind is variable in character; in some it is thin and ichorous, in others laudable, while occasionally it is most offensive with a decidedly fEecal odor.
In the treatment of this affection, though sedative applications to the part in the way of fomentations and poultices of flax-seed often afford great relief in the early stage, the surgeon should not be tempted to unduly postpone the search for and evacuation of matter. When the part becomes tense and hard, and the swelling and uneasy sensations of the patient are not subsiding, the presence of pus should be ascertained either by means of the aspirator or by an ex ploratory incision in the loin. The opening, as a rule, should be sufficiently free to enable the abscess to empty itself easily without the use necessarily of a drainage-tube, though the latter need not be dispensed with. As the abscess contracts the drainage-tube may be gradually shortened, but this process should not be unduly hur ried, otherwise a troublesome sinus may be the result. It is hardly necessary to remark that all antiseptic precautions are to be taken.
Nephritis, resulting in abscess of the kidney independent of gen eral septic conditions, is most frequently caused by injuries, and irri tants such as calculi impacted within the organ and suddenly sub jected by the movements of the body to some change in position. The suppurations here referred to, though often formed by the fusion of two or more primary foci, are of a more extensive character than those which will be brought under notice iu connection with what is known as surgical kidney. Nor are they to be confounded with those chronic forms of suppuration where the whole organ is con verted into a sac of pus of which the capsule and its septa are the boundaries.
I am speaking of that kind of suppuration where an abscess forms within the confines of what is practically a normal organ. Hence these suppurations are not as a rule of considerable extent and are usually limited, I will say, to half an ounce or so of matter. We may reason ably assume if the fluid can be evacuated, or can escape naturally, re pair may be complete. I have seen kidneys containing foci of putty like paste which I believe, though originally abscesses, were in the course of absoption. There can be no doubt that in some of these in stances the matter finds its way into the pelvis of the kidney and escapes with the urine, recovery eventually taking place.
Local and general symptoms of inflammation in the neighborhood of the kidney would warrant the performance of a lumbar exploratory incision. In many cases an opening has resulted in the discovery of fluid beneath the capsule of the organ, and the evacuation of matter has been followed by recovery. Such a proceeding should always be undertaken when persisting symptoms point to some structural mischief of this kind. I have never known harm result from an ex ploration of this nature, even if the result has been of a negative char acter, but on several occasions autopsies have caused me to regret its omission.