treatment planned. The site of the obstruction may have been determined by preliminary passage of a ureteric catheter, which may be left in situ. If the obstruction is in the bony pelvis and cannot be remedied via the bladder, the ureter is dilated through most of its length, so that it can be exposed without much difficulty in the bony pelvis by the lumbar inguinal retroperitoneal route. Stricture or stone may be encountered, but too often a defect is found which it is impossible to remedy, and the kidney will have to be sacrificed; nor is it worth while wasting time over a difficult plastic operation in the pelvis if the kidney itself is almost obsolete. If, on the other hand, the cause is at or near the ureteropelvic junction (as it will be in at least half the cases), a plastic operation on ureter and pelvis can often be carried out with success, such as Fenger's operation of ureteroplasty or an operation of anastomosis between ureter and pelvis resembling Finney's operation of gastro-duodenostomy. When an aberrant renal artery is found "bowstringing the ureter, the simplest course is to ligature the artery in two places and cut it across. This has the disadvantage of cutting off the blood supply of the lower pole of the kidney, and leads to destruction of an appreciable quantity of valuable kidney substance, and does not always relieve the obstruction. For these reasons an effort might be made to get round the artery without cutting it, by means of ureteropelvic anastomosis performed as for lateral anastomosis of two segments of gut. When a twist or kink is found it is best to cut the ureter across below the kink and stitch it into a hole made in the lowest part of the dilated pelvis. Sometimes but this is not so often as was once thoughtit appears that the kidney is unduly mobile and that this is the cause of the kink rather than the result. Anchoring the kidney in a higher situation may then suffice to relieve this condition, though the results of such operations are not always encouraging. Nephrostomy with secondary nephrectomy is seldom. required at the present day, as the functional power of each kidney can usually be determined before the operation. Until more of these operations have been watched to their ultimate results it is impossible to know how much regeneration of the kidney substânce can occur, so that it is not right to sacrifice the kidney straight away because it appears to be in a condition of atrophy. Whenever possible a plastic operation should be attempted, accurate record of the kidney condition kept, and periodic and systematic ureteric catheterisation should be carried out for some years afterwards under strict aseptic precautions with the object, first, of resisting the tendency to stricture, and secondarily, to enable estimations of renal function to be made. CHAPTER VII. INFLAMMATION OF THE PELVIS AND KIDNEY. PERINEPHRITIS ; RENAL INFLAMMATION of the kidney and pelvis is caused by the action of irritants, living or non-living, which can reach these parts by way of the blood-vessels, or locally in the urine or the lymph-stream. Either a non-living or a living irritant can act alone and set up inflammation, but in most cases a mechanical or chemical irritant acts first as a predisposing cause injuring the kidney, so that it then falls a prey to micro-organisms, which else had been powerless to attack it. Surgery, therefore, must not only concern itself with inflammation caused by bacteria, but must also take stock of the mechanical and chemical agents which predispose a kidney to bacterial infection. Mechanical and chemical irritants can act on the kidney in two ways: (1) As exciting causes of simple exudative inflammation, followed by resolution, or leading to degeneration of the kidney; (2) as predisposing causes, rendering the kidney liable to attacks by bacteria. Bacteria, on the other hand, seldom attack a healthy kidney, but in the majority of cases can only attack a kidney already damaged by other irritants. Causes of Inflammation of the Kidney and its Pelvis. A. Mechanical. 1. Blows on the loin. 2. Calculus. EXCITING CAUSES. 3. Movable kidney (pressure on vessels or ureter). 4. Back pressure-Ureteric, unilateral) B. Thermal. Urethral, bilateral (see p. 112). 1. Burns (toxic products of cell-destruction absorbed into the blood). 2. Cold (reflex flushing of kidney, the skin being deprived of blood). c. Chemical. 1. Inorganic poisons, e. g. lead, mercury. 2. Vegetable poisons: The balsams, e. g. sandal oil, turpentine, mustard. 3. Organic poisons, e. g. alcohol, cantharides. Toxins of infectious fevers, e. g. scarlet fever. Auto-intoxication, gout, arterio-sclerosis, pregnancy. D. Living organisms (pure or mixed infections). 1. Bacteria. Common Rare. Tubercle bacillus (see Ch. VIII). Bacillus coli and its varieties (85 per cent.). Staphylococci. B. typhosus. Anaërobes (Albarran). B. pyocyaneus, lactic acid bacillus. etc. Anthrax, glanders. 2. Fungi. Actinomycosis. 3. Protozoa. Syphilis (Spirochata pallida). Malaria. 4. Gross parasites, e. g. hydatid cysts, Bilharzia hæmatobia. 1. Local. PREDISPOSING CAUSES. A. Trauma. Bruising, calculus, movable kidney, back pressure. B. Previous attacks of inflammation. 2. General. Reflex nervous flushings. Instrumentation of urethra and bladder. Cold, alcohol. A. Poisons in blood, e. g. lead, balsams, alcohol, bacterial toxins, auto-intoxication, diabetes, gout, pregnancy, malignant dis ease. Bacterial Infections. Mode of Attack. Bacteria may reach the kidney by three routes: 1. The blood-vessels ("hæmatogenous," "descending infection). 2. The lower urinary tract (" ascending" infection). A. In the urine. B. In the lymphatics of the ureter. 3. The local tissue or lymphatic spaces— A. Through open wounds. B. Through inflammation of neighbouring organs, e. g. peritoneum, pleura, retro-peritoneal tissues, liver, colon, etc. I. HEMATOGENOUS INFECTION. A. This is the Common Mode of Infection. The idea that infec In the large majority of cases of pyelo-nephritis bacteria reach the kidney by the blood-stream. tion is commonly ascending is due to faulty methods of diagnosis in cases seen late in their course. The early sym دو ptoms of pyelo-nephritis-bladder tenesmus and increased frequency of micturition-appear to accuse the bladder, and the cases are labelled "cystitis," are treated with lavage, and do not clear up. "Drink-cures in some cases prove effective, but more often the condition becomes chronic, and eventually declares itself as one of pyelo-nephritis, the faulty inference being drawn that the kidneys have become infected secondarily to infection of the bladder. Recent observations by means of the ureteric catheter, supplemented by operation and post-mortem findings, point more and more to the conclusions that : (1) Most cases of pyelo-nephritis are hæmatogenous in origin. (2) In the early stages they are unilateral. In fact, just the same conclusions as have been reached with regard to tuberculous infections (see Ch. VIII) are found to hold good for infection with other organisms. B. Sources of the Bacteria. What are the paths by which the bacteria reach the bloodstream? Occasionally some obvious source of infection can be |