Acute Ascending Pyelitis Following the Removal of Large Amou.nts of Urine in Prostatic .Enlary ement . —Instead of laboring to excrete salts as in the previous disease the renal tissue may become so impoverished by unsuspected backward pressure from an enlarged prostate that water only filters through. A patient about sixty years of age may be a martyr to aggravated dyspepsia and increasing weakness, the excre tory needs of the body being barely maintained by the insufficient renal function. Suddenly the medical attendant discovers the blad der well above the umbilicus, and disregarding the three great danger signals which accompany the pus in the urine—morning vomiting, intense thirst, abundant urine of a low specific gravity—he passes an instrument and withdraws all or most of the urine. At once the mild cystitis is aggravated, or if it was not present before it now appears, acute ascending pyelitis ensues, and renal syncope supervenes in from seven to ten days.
Gradual Invasion of the Renal Pelvis from a Lower the method of invasion of ascending pyelitis is chronic and progres sive, the pathway being prepared by a more or less gradual dilatation of the ureter or ureters by backward pressure. It might almost be as serted that chronic ascending pyelitis is a late stage of, often a sequel to, most chrothe diseases of the urinary tract, and that its grade is in direct proportion to the duration and severity of the vesico-urethral obstruction.
Especial attention may be directed to two diseases which are most prone to affect the ureters although no previous distention of their channels have occurred. These are cystitis in the female, following pregnancy, and primary tubercular disease of the bladder.
Pyuria of Vesical Origin.—All the diseases of the bladder provoke the appearance of pus, either in an early or in a later stage; the char acter of the discharge is of no diagnostic value, though much can be gathered concerning the grade of the inflammation, and the depth to which it has penetrated the vesical wall, from its aspect and smell. Thus, very slight amounts of pus in acid urine, with vesical symp toms, denote localized surface changes such as are seen in early tuber culosis, or in the cystitis of the female bladder of uterine or ovarian origin. The thick, ropy pus which is alkaline, and ammoniacal in
smell, denotes a more chronic form in which there is some general and deeper penetration, and some constant source of irritation, such as a calculus or decomposing residual urine. When the entire thick ness of the wall has been implicated (parenchymatous cystitis), the feculent odor denotes the transmigration of micro-organisms and their products from the adjoining gut. The age of the patient in whose urine vesical pus appears affords some clue to the origin of the pus. It is rare in childhood, unless stone is present. Between puberty and adult life, if gonorrhoea is excluded, it is generally due to tubercular affection. Between twenty and thirty most of the so called inflammations of the bladder are really cases of posterior ure thritis of gonorrhoeal origin involving the bladder neck. In women between twenty and thirty-five the pressure and inflammatory troubles of pregnancy account for many of the inflammations to which the female bladder is liable, and the obstinate character of the disorder would be incomprehensible were it not realized that the original focus of the inflammation remains unabated in the shape of some chronic uterine mischief. In mid-adult life the cystitis of stricture and some times that of spinal atones are encountered, but usually the most fruitful cause of pyuria commencing at or about the age of fifty, is found in the changes to which the prostate is liable, and in the many secondary inflammatory conditions which it induces.
Pyaria of Urethral Origin.—In the strict sense of the term, ure thral pyuria merely relates to- inflammatory conditions arising behind the compressor urethan, for pus arising from diseases of the penile urethra issues independently of micturition, since there is no muscle in the urethra between the compressor and the meatus to check the free exit of the discharge. Inflammation of the posterior (deep) urethra is usually accompanied by irritability of the bladder and usually by some sense of obstruction to the stream. The three-glass test serves, however, to divorce it from an inflammation of that viscus.