Traumatic Pyelitis,—Pus appears for a short time after any blow upon the kidney of force sufficient to produce hoematuria, and will continue in direct proportion to the extent of the injury. Usually, however, if the lower urinary tract does not become seriously inflamed the pus will disappear as health is regained. Some cases of trau matic renal pyuria prove extremely obstinate, and in these it may be that a calculus has formed or a marked tubercular inheritance or in fection causes a sluggish healing of the renal wound. Occasionally a perinephritis is first produced by the blow and the collection of pus ' bursts into the pelvis of the kidney. This is, I believe, rare. I have recently performed nephrectomy for a pyelitis following a blow.
A young man, aged 24, whose father and brother were reported as having died of phthisis, presented himself with a large pyone phrosis, which was visibly occupying the left side of abdomen. Six months previously he was struck violently in the left loin, and he attributes the cause of the present swelling to the blow. He did not pass blood and he never noticed his water murky until recently, when its very offensive smell and thickness prompted him to seek relief. The urine was turbid and very fetid, it was acid in reaction, specific gravity 1.019, and contained albumin and one-third pus. On my seeing him a day or two after admission, he was just beginning to suffer from pain in the loin, and I was struck with the coincidence of rapid enlargement of the tumor and decomposition of the urine with normal temperature. No vesical or urethral intervention had been at tempted. I learned that he had had an obstinate attack of profuse diarrhoea three weeks ago, which may have been the consequence or the cause of the fetid character of the pyonephrosis. Until the tumor appeared he could retain his water for five or six hours, but since then he had been forced to micturate every hour; he did not rise at night. On performing lumbar nephrotomy, I evacuated eighty ounces of the most nauseous puriform urine from a superficial renal sac and found another large cyst deeper, which I tore into by means of a large probe. A still deeper though smaller collection was found. I therefore slipped the kidney out of its capsule, tied off the pediclo and removed it. There was no stone ; the entire kidney had been transformed into an enormous loculated thin-walled sac. The ureter which was not dilated was tied off, and dropped back. The urine
cleared immediately, it was passed at a long intervals, and the wound rapidly healed.
Secondary Pyelitis.—Probably the most usual cause for pyelitis lies in an upward extension, along the ureters, of the inflammation which has originated in the bladder, prostate, or urethra, and it is in these cases that the diagnosis of pyelitis is so difficult and uncertain. It is often impossible to state with certainty how much of the pus is contributed by the original disease, and Low much by that grafted on to the secondary extension. It is, therefore, in this class that so many mistakes are unwittingly made, and attention and treatment are directed to the bladder ailment long after that viscus has become a subsidiary factor as a pus producer. The cystoscope, in the hands of skilled workers, certainly enables a correct diagnosis to be made, but in general practice the cystoscope is impractical, and clinical grounds are all that can be depended on. These are frequently un satisfactory and misleading. The ureter, pelvis, and kidney may be come affected from the bladder either rapidly or gradually.
Rapid Invasion of the Renal Pelvis from a Bladder Source.—A rapid invasion of the renal pelvis is comparatively uncommon, and fortunately so, for it is often fatal. Usually the extension is slow in progress. Probably a rapid invasion greatly depends, in non-tubercu lar cases, on the previous health of the ureters and kidneys; e.g., pro longed lithiasis acts as an injurious depressor to the power of resist ance of these organs to septic invasion. The barrier which the tonic muscles of the ureter oppose to ascending changes is an important factor in resisting invasion, for if the ureters have become dilated by backward pressure, and the' is proportionately thinned, the septic wave may ascend in a few hours and a fatal re sult ensue.
The most marked and the most frequent examples of rapid invasion are to be found in consequence of injudicious instrumentation, in vesico-prostatic tuberculosis, in uratic stones in gouty patients'over fifty, and in the advanced vesical atony of prostatic enlargement. It is rare that gonorrhoeal extension to the kidney is of the rapid type, but I have met with a few instances of undoubted chronic invasion. The features and dangers of this aspect of these three diseases may be briefly illustrated by the following cases and remarks.