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CHAPTER 26
fibrosis; in 7 cases the cause was a ureteric kink due to intramural as well as periureteric
fibrosis; in 2 cases the cause of obstruction was not confirmed.
The clinical symptomatology usually starts with a pyrexial attack from which the
patient does not recover promptly in spite of antibiotic treatment; although the initially
high temperature may subside and may even be subnormal, the patient remains listless,
loses appetite, feels 'liverish' and appears ill. There may or may not be increased leuco
cytosis, depending on the effectiveness of antibiotic treatment, but persistent leucocytosis
over 10,000-12,000 may be important for the diagnosis. Blood urea may not be greatly
increased. Lowering of haemoglobin under 70-65 per cent and red cells under 3^ millions
may be an important sign of general toxaemia in cases with long-standing obstruction.
An immediate straight X-ray may be of great diagnostic value in detecting stones as the
cause of obstruction, and in cases without greatly increased blood urea an I.V.P. may
clarify the site of the ureteric obstruction.
The first case of obstructive pyonephrosis due to ureteric stones, admitted to the
Centre in 1944 within the first 3 weeks after its opening, was a soldier who was blown
up by a mine on 4 May 1943 and sustained a complete conus-cauda equina lesion below
L2/3. This case may be recorded in some detail, as it led to our very selective approach
to nephrectomy, which hitherto had been the conventional treatment of pyonephrosis.
This man had had a suprapubic drainage since the day of injury, and he developed several
pyelitic attacks with high temperatures before admission. He was nursed for 6 months on
plaster beds elsewhere, and, apart from ascending infection of the urinary tract, he also
developed pressure sores. The bacteriological examination of the urine showed only
Esch. coli,
but swabs taken from the catheter end (Malecot) within the bladder showed
heavy growth of
proteus, Staph. pyogenes
and
B. haemolytic
streptococci. The bladder
was treated by tidal drainage through the suprapubic catheter, and at first great amounts
ofmucus and debris were removed. The plaster bed was, of course, discarded immediately
after admission.
Two months after admission, he developed another pyelitic attack with rigor and
vomiting, which did not respond to treatment. There was pain in the right upper abdominal
region spreading to the back associated with tenderness. Hgb. 93 per cent, leucocytosis of
22,000, temperature 101° rising to 104° but subsiding within the next 3 days. An X-ray
showed two stones in the right ureter (Fig. 1783). A cystoscopy performed by Mr Riches
(later Sir Eric Riches), the first urological consultant to the Centre, revealed, in addition
to a great amount of dirty granulations hanging like grapes around the catheter beneath
the suprapubic opening in the bladder, a complete obstruction of the right ureter at 10 cm
(upper calculus), and thick pus came from the ureteric catheter. On immediate explora
tion, the right ureter was found to be grossly thickened and intensely hyperaemic, and the
right kidney was extremely congested and greatly enlarged. The ureter above the upper
stone near the pelvis was incised, the stone removed and the distal stone milked up and
removed through the same opening. A catheter passed up to the kidney drained copious
thick pus, and the kidney was thoroughly washed out with saline. Although this was a
classical ezample of a pyonephrotic kidney, which at that time would have been a clear
indication for immediate nephrectomy, Mr Riches agreed, albeit reluctantly, to postpone
the operation until it could be proved that the kidney had not regained its function and
