DIAGNOSIS OF THE SOURCE AND CAUSE OF URINARY HEMORRHAGE.
The objective signs and subjective symptoms furnished by each patient permit of certain guidance rules being framed for the deter mination of the source aid cause of the bleeding. These, though by no means infallible, may be accepted as reliable. They are based upon (A) Examination of the urine; (B) Examination of the patient; (C) Critical examination of the symptoms complained of.
A.—Examination of the Urine.
(1). The Color—Some knowledge may be gleaned from the color of the urine.
Axiom,: " The brighter and more arterial the color of the urine, the nearer the source of the bleeding is to the meatus urinarius." Qualification: This is correct to a great extent, but it must be remembered that in severe injuries to the kidney, and in some cases of renal sarcoma and carcinoma, the blood is poured out so rapidly, and enters the bladder in such large quantities, that it is expelled therefrom almost as bright in color as when it issued from the rupture or from the vascular growth.
If, then, traumatism of the kidney and renal tumor before the age of five or over forty-five be excluded, bright arterial bleeding usually emanates from the lower urinary passages.
Fallacy : There are some pitfalls which must be exposed. It is taught that smoky or beef-tea-looking urine is always renal in its source, "because of the action of the acid urine upon the hemoglobin of the blood." If this colored urine is accompanied by other signs of renal disease, such as casts, excess of albumin, and lowered speci fic gravity, the color indication is correct, but without these corrob orative evidences it is a fallacy to diagnose a renal source solely upon the color of the urine. This pitfall must be studiously avoided, es pecially iu the male subject.
A small amount of blood leaking into the bladder in any form of atouy (such as that induced by stricture or prostatic enlargement) causes the urine to assume a beef-tea color, for the blood remains for some time in contact with the residual urine left in the viscus by in efficient expulsion. Moreover, in certain cases, although there is no residual urine, the blood leaks from an abraded surface so slowly that it becomes mixed with a large amount of the healthy secretion.
It is, therefore, voided merely "smoky." Still more incorrect is it to insist upon a renal source because the blood is coffee-colored or black. The best example of " black bloody urine" is to be found in cases of profuse hemorrhage into the bladder accompanied by retention from clotting. It varies under these circumstances from the color of porter to a jet-black.
I could quote many cases illustrative of a wrong diagnosis of renal disease having been given, upon the ground that the urine was dark in color. One struck me especially : A lady aged fifty-two, of sedentary habits, had been in the habit of passing coffee-colored urine at rare intervals during two and a half years. Her medical attendant had persistently treated her for kid ney disease. One day she was suddenly forced to take a long rail way journey, and in consequence probably of this unusual amount of exertion she began to pass very bright-colored blood and clots. Sus picions were at once aroused that the source of hemorrhage was the bladder, and I was asked to use the cystoscope. A large villous pa pilloma the size of a tangerine orange was discovered in a very capacious bladder. It was removed and the patient recovered.
This mistake is, I believe, the more readily made in early stages of the harder forms of carcinoma of the male bladder. The malaise or initial irritability of the bladder induces the practitioner to test the urine. Albumin to a slight amount is discovered in clear urine; this albumin is clue either to serous leakage from the latent growth or to a microscopic escape of blood. The practitioner assumes it to be from the kidney, and later on, when the vesical growth begins to bleed slightly into acid urine, and coffee-colored or beef-tea-like urine is passed, the diagnosis of a renal source is supposed to be con firmed, and it is only a month or two later, when a sharp rush of bright-colored blood appears, that the bladder is examined and the diagnosis is corrected.