EXTRA-URINARY SOURCES OF PYURIA.
The source of the pyuria which is occasioned by an abscess burst ing into some part of the urinary tract is usually located without much difficulty. Much depends on the cross-examination of the pa tient regarding the onset of the trouble. The symptoms are com pounded of those specially evoked by the original suppuration and of those referable to that section of the urinary apparatus which is thus irritated. A neighboring bone lesion, some source of inflam mation in the female pelvis, or perchance some external pyaamic attack coupled with the prodromes of an acute abscess and with the local pain which. it evokes, taken in conjunction with the subsequent distress of that part of the urinary tract which it is approaching, will warn the practitioner of the probable cause and course of the distur bance. The abrupt relief from symptoms of tension, coincidently with the sudden appearance of a large quantity of pus in hitherto nor mal urine, its subsequent intermittent discharge, and the functional irritability of the viscus into which it is escaping, will confirm the diagnosis of the cause of the pyuria and the site of the irruption of the morbid product.
One of my first cases for electric cystoscopy was that of a lady suffering from profuse pyuria, from a residual abscess due to caries of a rib. The history of the patient was as follows : Twenty years before consulting me she had had strumous caries of one of the right lower ribs. A deep scar not far from the right renal region marked the orifice of the abscess which then existed. In January, 1887, a sudden attack of pain in the scar region was com plained of, and the symptoms which followed resembled biliary colic. The pain continued off and on, gradually descending, how ever, at each attack somewhat lower in the abdomen until it became very similar to renal colic. Eventually extreme pain in the bladder, and frequency of micturition, culminated in an acute cystitis. Vari ous special opinions had been taken, as regards both- the uterus and the kidney, but these were very conflicting and for the most pait undecided. On cystoscopy the bladder was seen to be covered with hemorrhagic petechi, which were more numerous toward the orifice of the right ureter. A dull, flapping stream of dark, murky pus issued sluggishly, but at regular intervals, from the right ureteral orifice. The left ureteral opening was small, and was ejecting healthy urine. The pus was evidently coming from the right renal pelvis, and this taken in conjunction with the scar and the history of the recent attack, established the diagnosis of an extra-urinary abscess. After some months the pus diminished and then ceased, and the lady recovered her health and strength completely.
Pycemic Abscess in the Cellular Tissue. of the Female Pelvis, emptying into the Bladder by a Minute Aperture ; Cystoscopy, Laparatomy, Cure. —A lady, aged 37, under Dr. Valentine Rees of Brecon, was sent me for treatment for a constant pyuria and for a most troublesome pain in connection with the bladder. Nine months previously she had had a pyinic attack with multiple abscesses in various joints due to a miscarriage. After these had been freely opened and had healed, sudden and severe pelvic pain with constitutional disturbance supervened. This was followed by great irritability of the bladder, which culminated in the discharge of a large quantity of pus in the urine. The symptoms indicated that a pelvic abscess had opened
into the bladder or lower ureters, but the exact site was uncertain. Heavy doses of morphine injected into the bladder became necessary, for her life was otherwise unbearable from severe perivesical and urethral pain and from straining and frequency of micturition. The morphine gave her perfect freedom from pain and ability to hold her water five hours. The urine was acid and contained a variable amount of creamy pus, its specific gravity was 1.020. Latterly the pus had been noticed in the form of long, thick, taper-like pieces. Cystoseopy : Bladder held eight ounces of fluid easily. The mucous membrane of the posterior wall had lost its sheen, and the muscular fascjculi were becoming hypertrophied. There was no abscess opening here. The surface of the left wall low down was heaped up in enormous folds of oedematous and inflamed mucous membrane. So much was this swollen that it looked like a gelatinous epithelioma. The right lateral wall was covered by a similarly swollen mucous membrane, but this change from the normal extended over a wider area and was more pronounced. As I was watching the latter surface I saw a most re markable sight. From a minute crack in a depressed furrow between two prominent folds a long tapeworm-like body was being gradually extruded. It was flat, white, and square-ended. After one-third of an inch had protruded, it broke off by its own weight and fell heavily to the base of the bladder. I followed it to its resting-place and found a small collection of similarly flattened, ribbon-like white bodies. Returning to the crack I saw another in the process of being forced out. My assistants, the anesthetist, Mr. Woodhouse Braille, and I watched this performance with great curiosity for some time. It never ceased. I washed out the pieces of ribbon and measured them. They were about one-third of an inch long, one-sixteenth of an inch thick, and about one-eighth of an inch wide. The diagnosis was at once established. Au abscess, probably ovarian, had burst into the right sitle of the bladder, and was now probably obsolescing. The patient was advised to wait three mouths longer, which she did without benefit. I therefore, guided by the cystoscope, passed a probe through the ure thra to the vesical opening of the sac. As the probe dilated the opening a rush of thick fluid pus issued, and nothing more was seen. The pa tient was at once elevated into a Trendelenburg position, and a median laparatomv was performed, the probe being retained in position as a guide. Adhesions being broken down, the intestines were lifted out of the pelvis and an electric light thrown down on to the floor of that cavity ; it was then seen that the abscess was beneath the peritoneum and unconnected with the ovary. The wound was, therefore, closed and the vesical opening of the abscess dilated with the probe as far as possible. An incision was made through the vaginal roof on to the floor of the abscess wall but not opening into it. There was no re action, and the patient returned home in three weeks. The subse quent course was uneventful. Pus gradually diminished, pain and frequency of micturition ceased, and the patient reported herself cured in about four months' time.