The most usual forms of chronic primary pyelitis are the calcu lous, the tubercular, and the traumatic, with or without ureteral ob structions. The reader must be referred to the article which deals fully with these diseases, but the following brief remarks on their salient features and the accompanying illustrative cases are not irrele vant or beyond the scope of this article.
Calculous Pyelitis.—The following case illustrates the gradual in crease of a calculus in the renal pelvis, its irritation of the mucous membrane producing a symptomless pyuria, the gradual onset of perinephritic inflammation and adhesions, and the final decomposi tion of urine in the renal calyces. This train of changes occurred with renal swelling but without pelvic distention, because no marked obstruction to the corresponding ureter existed.
Case: Calculous Pyetitis of Twelve Years' Standing, Decomposition of Urine, very few Symptoms, Nephrectomy, years ago the patient passed two pieces of stone from the right kidney, since which time he has always suffered a little pain in that organ of a dull character, sufficient to cause him to be aware that he had a kidney. He has not had hwmaturia since the beginning of the trouble. He applied for relief because his urine had been smelling foully for the last year, and he wet his bed at night. His urine was very fetid; its specific gravity was 1.020. Two per cent. of urea was present. The urine was murky, depositing a thick layer of pus, and a fine layer of blood. The right kidney was somewhat enlarged and tender. Over the anterior region of the kidney there was a definite muscular swelling, which disappeared when the patient was under an anesthetic, and was supposed to be due to reflex irritation from the disease beneath. I removed the right kidney by the lumbar route, after considerable difficulty had been experienced from the very dense ad hesions which were present. The entire pelvis was occupied by a large branched phosphatic stone, which had so irritated the kidney as to produce perinephric matting. The kidney was riddled with small walnut-sized cavities, containing pus and urine. The patient recovered promptly and the nocturnal enuresis disappeared.
Calculous Pyonephrosis.—It is remarkable how tolerant the dis tended and inflamed pelvis of the kidney proves itself to be. Large stones are carried almost without any symptom pointing to resentment of their presence. This is especially noticeable in the female kidney.
• hematuria is very seldom observed when pyuria is marked, and rarely is there any complaint of pain, beyond a dull kidney-ache. When, however, an acute pyelitis is grafted on a chronic form, the suffering may be of an extreme character. Women seem particularly prone to the formation of calculi in a distended renal pelvis. * The calculus in such cases may be, and I suspect often is, the result and not the cause of the distention. The latter may be due to intermittent
uterine tugs, and other forms of uterine pressure, e.g., pregnancy, causing first a latent hydronephrosis, and secondarily a pyone phrosis. It will be found that 75 per cent. of cases of calculous pyo nephrosis operated upon were females, and that nearly all these had a well-developed renal tumor.
Mr. Day '° has removed a large right renal stone, weighing 1,331 grains, from a woman, age thirty-two. The symptoms had existed fourteen years, and they consisted in occasional pain in the right loin, lasting perhaps three days, with intervals of complete freedom. Apparently a right renal tumor had been noticed only a year, and coincidently with its appearance was the change of the urine to a thick, slimy condition. The right lumbar incision was made, and the stone, which was mainly phosphatic, was successfully removed in two sittings. Probably this is oue of the largest calculi removed from the kidney.
Mr. Bloxam recently showed a soup-plate full of large calculi (13 ounces) which were removed by him through a lumbar incision from a woman who presented few symptoms of the disease." Tubercular Pyelitis.—Usually primary tubercular pyelitis is a true tubercular pyelonephritis, for it is rare for the pelvis to be affected without the renal tissue becoming rapidly implicated, and vice versa.
Cases have been mentioned in the section on hematuria (tuber cular disease of the kidney). Judging by Brodeur's statistics, it would seem that women were more often affected by this disease than men. This, however, is not so. I believe women are more prone to suppurative renal tumors than are men, on account of the greater chance of pressure on the lower ureters, but most of my renal tubercular cases have occurred in males. I believe that a large number of the cases of suppurative pyelonephritis occur in patients with tubercu lar tendencies, and in these a slight accident or subacute ascending pyelitis is sufficient to cause rapid destruction of renal tissue of weakened resistance. The pyelitis of primary renal tuberculosis may remain subacute for some months, being merely accompanied by termittent attacks of slight pyrexia and pain. The urine is acid, low in specific gravity, and murky with pus, and •contains albumin in excess of what can be accounted for by the pus present. Even at this stage rabbits can be successfully inoculated with it, but the bacillus is difficult to discover, unless the tuberculosis is very acute. The kidney is invariably tender, but unless it has been aggravated into re sentment by vesical washing, it does not rapidly enlarge. Given, however, a septic condition of the bladder, pus rapidly increases, the kidney enlarges, and often perinephritis is superadded.