PYELITIS is either primary or secondary. In the former it has originated in the kidney or its pelvis, and in the latter it has extended to this section from the lower urinary tract. It is of importance to obtain a correct history of the symptoms marking the onset of pyelitic pyuria, for a distinction between primary and secondary pyelitis, which is often possible by means of this knowledge, is a matter of much surgical moment.
Primary pyelitis may arise either from the chemical action of drugs, such as cantharicles, turpentine, balsams, diuretics, or from that of the products of micro-organisms of general diseases, such as typhus, influenza, tuberculosis, which irritate the kidney substance and mucous membrane of the pelvis, as they are eliminated through these great depuratory centres. It may, moreover, be provoked by mechanical causes, as is seen in a hydronephrosis becoming fouled by the bacilli of the adjoining colon. Secondary pyelitis is evoked by the direct extension upward of inflammation from the bladder, prostate, or urethra, such as obtains in vesical calculus, obstructing vesical growth, enlarged prostate, stricture, and gonorrhoea. It is said that the urine in primary pyelitis is usually acid and will often remain so for days, while that in secondary pyelitis is neutral or alkaline, and that it rapidly decomposes. Moreover, Ultzmann asserts that primary pyelitis is never accompanied by frequent or painful micturition, while the pyelitis which is propagated from the bladder or prostate usually is accompanied by these symptoms. I am sure that this cannot be accepted, for pyelitis produces an irri tability of the lower urinary tract either reflexly or directly by the acrid discharge from the renal pelvis irritating the neck of the bladder in its exit. ( Vide Reno-vesical Reflex, p. 692.) Acute Primary Pyelitis.—The general diseases which affect the pelvis of the kidney and evoke a pyuria are many and various. In the acute form a mere catarrh may be set up, or multiple foci of suppuration in the substance of the kidney may be provoked and a true pyelonephritis is the result. These small abscesses may amalgamate and form large cortical or medullary abscesses and burst into the pelvis. The most marked general symptoms are severe rigors, high fever, and lumbar pain. The urine is scanty, albumin ous, and purulent.
Chronic Primary Pyelitis. —This usually presents three stages, onset symptoms, formation of tumor, and stinking decomposition of its contents.
Onset Symptoms.—The onset symptoms vary greatly. In some cases there is no pain until long after pus is noticed in the urine. Usually, however, there is an aching in one loin or the back, a depress ing sense of weakness in the lumbar region, which the patient cannot account for, or which may be connected with a blow on the loin.
Not infrequently a marked polyuria is present. If the pyelitis is caused by a round stone which occasionally drops on the mouth of the ureter, or by some other form of ureteric obstruction, intermit tent colics are suffered from. Hmmaturia, vesical irritability, and vesical colic are often coincident symptoms. * Enlargement of Kidney, or Formation of a Tumor (Pyonephrosis).— I believe the kidneys are more or less swollen in most cases of pri mary pyelitis, the enlargement varying according to the distention of the pelvis or the calyces. Even in cases of calculi in which the ure ters are permanently patent and the upper tract is well drained, the kidney itself is enlarged and the surrounding fatty tissue matted with inflammatory products which add to the apparent bulk of the organ. The appreciation of the actual size of the tumor differs, of course, with the rigidity and adiposity of the abdominal wall.
Decomposition of Residual Pyelitic Urine.—Sooner or later, if the case progresses and is not of a tubercular type, the fluid contents of the kidney or its pelvis become fouled from the adjoining colon or by vesical sepsis, introduced by the surgeon, ascending to the kidney. The laudable pus which, prior to this, separated rapiclly from the acid urine now becomes transformed into a thick, solid muco-pus, very similar to, but probably more offensively f meal in its odor than, the ammoniacal filth which is passed by patients suffering from ad vanced vesical disease. Microscopically, although the secretion may still retain its acid character, large crystals of the triple phosphates are present, their edges being eroded and nipped out by the acid tide which the healthy kidney pours into the bladder. Perhaps the car dinal symptoms of primary pyelitis are the discharge of acid pus in more or less abundance, the formation of a definite renal swelling which is tender on deep pressure, and the detection of fluctuation in the same if the collection is a large one. If a constant irritant is present, such as a stone, the tenderness is accentuated, and should the canal of the ureter draining a unilaterally distended kidney become temporarily obstructed from any cause, as is not unusual, the pus disappears for a time and the renal tumor and tenderness increase, but both diminish again as the pent-up pus suddenly escapes along the unchoked channel. In conjunction with these symptoms, there are others dependent on absorption, infection from the colon, or ex haustion : rigors, often quotidian (Roberts), fever of a hectic grade, loss of flesh, and diarrhoea.