DIAGNOSTIC SIGNIFICANCE OF THE SYMPTOMS ACCOMPANYING PYURIA.
In mild simple or gouty pyelitis or cystitis, especially when this occurs in the female, there may be no symptoms present to indicate the source of the pus. This is exceptional, for pyuria is usually accompanied by symptoms of functional distress in the organ which is inflamed, and the patient is often able to localize the site of the trouble almost as surely as the medical man. Cases will, how ever; be met with in which the diagnosis is by no means easy on ac count of the conflicting nature of reflex symptoms, for one inflamed portion of the urinary tract may excite another reflexly or by "sym pathy," or acrid pus flowing from an upper source may directly irri tate, in its transit, a lower section of the channel. Complex and mis leading symptoms are thus evoked and attention is drawn to an organ which is not seriously at fault. A brief consideration of these excep tional conditions may not be amiss.
Reno-Vesical has been known since the times of Val salva that certain diseases of the kidney are liable to produce a most distressing irritability of the bladder. A common illustration of this fact is met with occasionally in cases of acute parenchymatous nephritis. The onset of this disease is sometimes heralded by a distressing and urgent frequency of micturition. This symptom usually passes away in a few hours, to be replaced by the character istic features of the disorder, but it is sometimes so severe while it lasts as to mislead the practitioner into believing that the patient is attacked with acute cystitis. The bladder is also sometimes affected in the same manner in chi onic diseases of the kidney. Morgagni " speaks of a patient who complained of very little pain in the region of the kidneys, while he was tormented with pain in the bladder so excruciating in its intensity that five or six physicians who attended him entertained no doubt of the seat of the disease being in that viscus. On post-mortem examination no morbid appearance was discovered in the bladder, but there were large and ramifying calculi in the kidney. Attention has been particularly directed to this sub ject by Sir B. Brodie," who records two cases in which post-mortem examination completed the clinical history. The first instance was
that of a gentleman who voided his urine frequently and in quantity varying from an ounce to an ounce and a half. Always after making water he had a severe pain, lasting a few minutes and extending along the urethra. The urine was pale, semi-opaque, of an acid quality, and when tested with heat and nitric acid it was found to be highly albuminous. Occasionally small masses of a substance resembling coagulated albumin were seen floating in it. He made no complaint of pain in the loins, he was able to empty his bladder by his own efforts, and the urethra was free from stricture. There was no cal culus in the bladder, nor had any sand or gravel ever been observed in the urine. These symptoms had existed ten months and latterly had gradually increased. For a short time the urine had been tinged with blood. In addition to these local ailments the general health was much impaired, the patient had lost flesh, was languid, dejected, and of a pallid countenance. Soon after Brodie was consulted the urine again became tinged with blood. The bodily powers continued to fail, and the local symptoms became more urgent. There was a total loss of inclination to take food, the extremities became cold, the pulse grew feeble, and the man died.
On examining the bladder after death the kidneys were found to be of a dark color from excessive vascularity, and of a soft and some what brittle consistence, the distinction between the cortical and tubu lar portions being less marked than under ordinary circumstances. The investing membrane of the kidney had a very slight adhesion to the kidney itself, but it adhered closely to the adipose substance of the loin. On the surface of each kidney, and partly embedded in its substance, were four or five membranous cysts, each of the size of a large pea, and in one of the kidneys there was a similar one the size of a nutmeg, completely embedded in the cortical substance. The pelvis, infundibula, and ureters were not more capacious than under ordinary circumstances, but on being split open their internal membranous substance presented the evidences of considerable in flammation.