Acute Ascending Pyelitis from a Tubercular Vesical Source.—The presence of a secondary tubercular pyelitis can only be expressed by the suppurative destruction it causes in the kidney. The latter is probably affected previously, though latently, by the lymphatics along the ureter.
The septic invasion following instrumentation of the bladder is merely a spark to ready tinder. Vesical tuberculosis, however, differs in its resentment to instrumentation according to the sex of the patient, and the stage of the disease in which this in strumentation is commenced. The tubercular bladder of a female • patient may be lightly sounded and even washed out with compara tive impunity in the first few months of the onset of the disease, and this without much risk being incurred. There comes, however, a time•unmarked by danger signals, in which washing out of the blad der is fatal to the integrity of the kidney, though the sound may still be used without inducing this untoward result. Still later the sound is dangerous.
In the male the sound is as dangerous as the catheter and wash ing, in all cases where the prostate is nodular and the bladder is in flamed. Either instrument is sooner contra-indicated than in the female. The actual invasion is usually along one ureter, and differs from the other ascending forms to be immediately described, in that one kidney only suffers and that by a localized abscess. Later still where both kidneys have been crippled, and the ureters are involved, the mere introduction of a boogie through the prostatic urethra is sufficient to muse rapid and fatal suppression. I regret that I can furnish many examples, but the following will suffice : Left Renal Tuberculosis, Instrumentation, Acute Pyelitis, Renal Ab scess, Nephrotomy.—I saw in consultation a patient, who had applied a few days previously to a well-known surgeon for the relief of a fre quency of micturition and of a dull fixed pain in the left kidney. .The irritability of the bladder was not excessive, and the urine was quite clear, so he was sounded for stone in the consulting-room. Two hours afterward his temperature suddenly rose without a rigor, the dull pain in the left loin increased in severity, and the urine passed was slightly murky. The temperature remained above 102° and he began to lose ground rapidly. The left kidney was slightly enlarged and
intensely sensitive to pressure. The urine contained pus to a small amount; it was acid, pale, specific gravity 1.010. On inquiry I learnt there was a family history of diabetes, and that three of his imme diate relatives had died of phthisis. Nephrotomy was performed. The surface of the kidney was seen to be of a mottled yellow, and a quantity of pus and white flaky easeous material was evacuated from the cortex of the kidney. Obviously a tubercular deposit had broken down under the influence of an ascending pyelitis. He was tempo rarily relieved.
Ascending Pyel'itis due to Instrumentation in Gouty Kidneys.—It is known that kidneys which habitually cast off uratic deposits become less effective as time goes on, and less able to withstand sudden reflex shocks and inflammatory invasions, but the caustic effect which a constant stream of uric acid, or of its salts, produces upon the urinary mucous membrane is hardly appreciated by the profession. This is probably because the parts upon which most of our pathological knowledge is based are examined after death when congestion has disappeared, and all granulation of surface has become invisible from post-mortem change. It is quickly realized, however, if the bladders of those passing uric acid are examined with the cystoscope. The vesical neighborhood of the ureter is reddened, the surface is blurred, and often granular. It is highly probable that these conducting channels are affected in a similar way. It is abundantly proved that such changes in the urethra predispose, on the slight provocation of an error in diet, of a chill, or the traumatism of a connection, to the production of urethritis. The entire urinary tract of a patient who has been voiding uratic urine for years is nothing more than surgical tinder.
Let a typically gouty man, over fifty years of age, with clear sterile urine, suddenly get a small renal calculus trapped behind a large prostate, and he is frequently in more danger from the action of a rough, unskilful surgeon than from his stone. After litholapaxy the temperature rises, pus appears in the urine from cystitis, ascending pyeli tis supervenes, and the patient may even succumb from renal suppuration.