• Concerning this operation only the following remarks need be added : When the calculous pyelitis has been in existence for some time, the surroundings of the kidney will be found very densely matted and adherent, and in some cases they will resemble the gelat inous surroundings of advanced tuberculosis of the kidney. Al though the stone may be removed a permanent sinus may be left, and to avoid this the surgeon must decide whether nephrectomy ought not to be done, the stress resistance of the opposite kidney having been previously ascertained. * In calculous pyonephrosis the operation, consisting merely in clearing away the calculi and washing out the sac, is easy, but the re sulting shock is often severe and this apparently in proportion to the size of the tumor. In some instances the patient has died suddenly a few hours after the operation. It may be that the cardiac muscle had become affected by absorption from the puriform sac, for shock does not follow the removal of large amounts of urine from hydrone phrotic sacs. When perinephritis has ensued on perforating pyelitis, it will be better in most cases to remove the kidney at the same time that the perinephritic collection is evacuated; or, if the sac is so enor mous that the kidney has been pressed out of reach, then nephrec tomy had better be postponed for a week, after which time the kidney will have regained its normal position.
Probably Dickinson " has since seen fit to alter the following cautious opinion which he expressed in 1885: " Where pyelitis is con joined with obstruction of the outlet and has led to so much accumu lation of pus as to cause bulging in the loin, the question of puncture or incision may be entertained, but I think it is generally safest to wait until the matter has worked through its renal investment and presented in the back, and even then until it is nearly subcuta neous, rather than to seek for it deeply." Primary Tubercular Pyelitis.—The only reasonable chance of suc cess in this disease is the early removal of the diseased kidney and as much of the ureter as is possible. Nephrotomy has not proved of much assistance, although the incision through the capsule has re lieved the intense pain that is often suffered in the renal region. Also by diverting the tide of acrid pyelitic urine through the loin the irritability and frequency of micturition are allayed. Merely scoop ing out scrofulous deposits and stuffing the cavity of the abscess with iodoform gauze is rarely curative, for many other deposits in the parenchyma usually coexist, and these, if they are overlooked, be come infected and the temperature does not drop. Besides, the ure ter is imperfectly drained, and the disease progresses more rapidly because septic changes have been set in action by the exploration.
Ascending Pyelitis.—The great secret of the prevention of ascending pyelitis rests in asepticism, extreme gentleness, and free bladder drainage. This is especially the case when the deep urethra is resent ful, as in the case of gouty and onanitic prostates. Probably the reason why Frere Come was so successful in suprapubic cystotomy was be cause of the perineal drainage he invariably employed. Much of the ascending pyelitis now grafted by surgery on a diseased and dilated ureter might probably be avoided by bladder drainage through a small perineal wound. This is especially indicated in calculous af fections of the bladder in old age, the stone being the result and not the cause of the chronic cystitis. Ascending pyelitis is often mark edly and distinctly improved by bladder drainage, a subject to which Mr. Harrison and Professor Guyon" have lately drawn special at tention. The latter authority, in a clinical lecture based upon two cases of women with simultaneous pain in the bladder and kidneys, has emphasized the value of drainage. One patient passed urine full of pus, the kidneys were large and painful, and she suffered from agonizing attacks of vesical spasm. There was also feverishness with dry tongue and dyspepsia. M. Guyon concluded that the origin of the trouble lay in the bladder, and that it was not advisable to operate on the kidney at once. The bladder was therefore laid open from the vagina, and kept open. The vesical pains at once ceased and the spasms never returned. The condition of the kidneys slowly improved, and the pain disappeared; they ultimately diminished in size and ceased to be palpable on manual exploration.
M. Guyon bases treatment of this kind on careful examination of the bladder. When, as in this case, the sound causes severe pain when it touches the mucous membrane, when the bladder is ten der on pressure of the hand over the pubes, or of the forefinger against the anterior vaginal wall, the primary lesion will be in the bladder, and the renal swelling and pain will be secondary. Let the bladder rest then, and the kidney will empty itself, and this will cause subsidence of the pathological changes in the renal pelvis and glan dular tissue. All such cases do not demand such active treatment as cystotomy. Simple medical treatment of cystitis, rest and weak anti septic injections may be sufficient if taken in time. On the other hand, Bozeman's treatment of pyonephrosis by the establishment of a vesico-vaginal fistula, and subsequent catheterization of the ureters, cures the renal complication on the same principle, but the practice is only to be undertaken by experts.