It could not be said that the bladder was found altogether free from disease, but the morbid appearances were so slight, compared with those observed in the kidney, that it seemed impossible to doubt that the last-mentioned organ had been the seat of the primary disease, and that the bladder was affected only in a secondary manner. It was contracted and the muscular tunic was somewhat thickened, but not more so than must have been the case in a person who from any cause had been teased for a considerable time by an incessant inclination to void his urine.
I have encountered several instances lately,—one of an adult who had such irritability of the bladder and such agonizing pain on mic turition* that a colleague performed suprapubic cystotomy, but found nothing to account for the symptoms. After death a month later the entire left kidney was found transformed into a sack of pus and the ureter was much thickened and almost impervious. No tubercle existed anywhere. Another case was that of a lady who for many years had been tormented by frequency of micturition but by no ac tual pain. Lately she had suffered from pain of a very severe charac ter in the urethra independent of micturition. The free exhibition of morphine became necessary. On cystocopy the bladder was found to be quite free and capable of containing many ounces, but an in tensely sensitive right renal tumor was discovered, anal this probably was the cause of the vesical symptoms. It must be remembered, however, that such cases are undoubtedly rare, and it is generally the acid pus flowing over the sensitive neck of the bladder and irritat ing it, or the descending effects of tuberculosis, that produce vesical symptoms in renal disease. Conversely cases occur in which the renal pelvis becomes inflamed and sensitive from ascending pyelitis of simple or tubercular character, and the pain is felt mostly in these more recently attacked parts.
The following case illustrates the usual way in which a renal dis ease evokes vesical irritability : A lady of sixty, who at the age of thirty had suffered from pyuria for seven years, and who had complained for thirty years of an aching left kidney, was suddenly seized with symptoms of epidemic influenza.
On the third day of the attack the left kidney became swollen and tender and pus again appeared in the urine from which it had been so long absent. I performed nephrotomy and evacuated and drained a large abscess iu the cortex; there was a small sinus communicating between the sac and the pelvis. The urine promptly cleared, but as soon as the drainage-tube became blocked, frequency of urination and scalding were suffered from, but subsided on the re-establish ment of the discharge into the dressings. This train of symptoms happened on several occasions.
In tubercular disease of the kidney, even when the bladder is slightly implicated, the vesical symptoms are greatly ameliorated if not entirely subdued by diverting the acrid pyelitic pus through a nephrotomy wound. A well-built young fellow came to me com plaining of frequency of micturition. This he had had for six months. Latterly he had been unable to work on account of a grip ing pain which used to seize him in the lower part of his belly and double him up. The spasm was at once relieved by passing water. Cystoscopy revealed an ulceration of the base of the bladder on the right side, and rectal examination showed that the right lobe of the prostate contained a small deposit of tubercle. In a few weeks the temperature began to oscillate, the right kidney became tender. Nephrotomy was performed, and an abscess evacuated from the cor tex. All the symptoms of vesico-urethral disease thereupon disap peared.
In rare cases the local symptoms are excited by pus flowing into some part of the conducting or collecting channels, and unless the real source of the pus is discovered the irritated organ will continue not only to mislead the medical attendant, but also to cause the most skilful and assiduous treatment to miscarry.