CRITICAL EXAMINATION OF THE SYMPTOMS OF BLOOD IN THE URINE.
In the larger proportion of cases the appearance of blood in the urine is heralded by symptoms of pain or uneasiness in the kidneys, ureters, bladder, prostate, or urethra, or by functional disturbances of the bladder such as obstruction to the stream or frequency of micturi tion. Such symptoms direct the practitioner's attention to the part and permit him to locate the probable source of the hemorrhage. This is, however, not always so. There are a certain number of patients—the minority—who complain of no other symptom beyond the appearance of blood in the urine, and who assert that if they were blind or urinated in the dark they would believe themselves to be in perfect health. This circumstance allows of the subject of hma turia being discussed under the headings of Symptomless Hwmaturia and neematuria with Symptoms, and to establish these very obvious classes the practitioner must tactfully elicit the exact character of the onset symptoms.
I hold that an accurate history of the character of the onset of the urinary symptoms is one of the most important factors in shap ing the diagnosis of the site and cause of the bleeding.
But there are other atoms which go to form the molecule of accu rate diagnosis, and these also should be included in a preliminary consideration of each case. The age, the sex, the pre-existence or coexistence of grave constitutional disorders, the exhibition of drugs, errors in diet, the occurrence of direct or indirect violence, all these, though in themselves of but slight diagnostic import, are fac tors which prove. of value in forming rapid conclusions.
Sex.—Heematuria is uncommon in the female. When it occurs in the young adult before marriage, and urethral carbuncle is elimi nated, vesical ulceration of a tubercular type ought to be considered. If it occurs after marriage and before the age of forty, a careful ex amination of the uterus should be made, for this organ is often at fault. As a result of dragging by the uterus on the bladder or of the extension of inflammation to the base of that organ cystitis is com mon. The bladder is frequently affected by carcinoma propagated from the uterus. Vesical stone is rare, but inflammatory renal mis chief from ascending pyelitis is comparatively frequent. Males are much more prone to hemorrhage from all parts of the urinary tract. This is probably due to their greater exposure to accidents and to the sequelm of venereal diseases. Primary growths of the bladder occur five times more often in man than in woman, and I believe the young male is more often affected than the female with tuberculosis and renal stone.
Age.—Before five the causes of limmaturia are more commonly those due to scorbutic troubles from dietetic errors ; renal concretions come next, while sarcoma of the kidney and myxosarcoma of the blad der are very rare.
Between puberty and twenty, tubercle of the bladder and renal stone furnish the larger proportion, but prostatic congestions due to excessive masturbation or venereal indulgence are not to be for gotten.
Between twenty and thirty, prostatic congestions due to gonorrhoea or leucorrhceal urethritis, urinary tuberculosis, chronic Bright's dis ease, villous papilloma, and vesical stone are met with.
Between thirty and forty, stricture (rare),and vesical papilloma.* After forty, vesical papillary growth with a tendency in the base to become carcinomatous.
About and after fifty, renal growth, prostatic hemorrhage, vesical stone, and carcinoma of the bladder are the usual causes for hmna turia.
Grave Constitutional Disorders.—Blood in the urine appears in the course of some malignant fevers, such as measles, small-pox, typhus fever, septicaemia, or after cholera (Prout). The appearance of blood under these circumstances is considered as a very grave sign indeed, but of the renal origin and cause there is no doubt. It is also not uncommon in malaria and scurvy. Lastly, evidence is slowly collect ing of a distinct and exhausting renal hemorrhage which occurs in cases of the hemorrhagic diathesis.
After Certain Forms of Diet.—Certain articles of diet are known to produce limmaturia if indulged in too freely, or if taken by per sons of gouty habit, or by those who have a special idiosyncrasy. Thus the common or garden rhubarb' may produce a sharp attack of limmaturia, with frequent and painful micturition, more or less pain in the loins, and general indisposition. The blood emanates doubtless from the kidneys in these cases. Hard drinking-water, supplying the lime for the oxalic acid of the rhubarb to combine with and form oxa late of lime, is suggested by Dr. O'Neill as being a necessary factor.
Some fruits, such as gooseberries, unripe apples, and certain species of strawberries, are credited with the same powers.
Although asparagus is known as a diuretic,' it is not, I believe, generally supposed to induce hrematuria. Mr. Reginald Harrison' has, however, mentioned the occurrence of two cases of this kind in his practice.
Other vegetables and some fruits color the urine like blood, but there is deficient evidence as to whether they actually cause bleeding.
After Exhibition of Certain Drugs.*—Cantharides and turpentine are the two chief drugs which excite lnematuria. They cause so much renal or vesical congestion as to produce the escape of blood. The former, being a constituent of certain quack aphrodisiac medi cines, is not an uncommon evoker of hmaturia. Spanish-fly blis ters produce 'similar results in patients who are sensitive to the use of cantharides. Mr. Shalford Walker brought before the notice of the Liverpool Medical Institute in 1866 the history of a whole crew of a ship carrying a cargo of turpentine being affected during the voyage with hmmaturia, and in one case a fatal result followed. Mr. Harrison suggested that this was due to inhalation.