6. The Microscopy of Purulent Urine.—Much stress is laid upon this by many authorities. It is asserted by Ultzmann that short, thick cylinders formed by the aggregation of pus cells come from the papillary ducts and are of great diagnostic importance. He mentions also that renal epithelial scales baked as it were into pus casts, and isolated epithelial cells coming from the main ducts of the urinary tubules, are recognizable. This is in accordance with the teaching of continental authorities. The accurate recognition needs, I am sure, long practice. In calculous pyelitis blood corpuscles are often pres ent and the variety of crystals which corresponds to the stone in pro cess of formation. In tubercular cases the debris may show the ba cillus on double staining, but this can only be discovered after much examination and in fresh acid urine. When during a chronic pyelitis there is an exacerbation of fever, short and thick granular casts are found during the first few days coming from the larger urinary tu bules. Blebs directs attention to large clumps of bacteria and cocci, and states that these emanate from the straight tubes, and describes them as characteristic of " pyelonephritis parasitica." 7. Experimental Inoculation and Culture.—A rabbit should always be aseptically injected with the freshly passed urine in doubtful tubercular cases, and culture experiments also attempted.
B. Examination of the Patient.
A careful examination of the patient should be undertaken for evidences of disease in the region in which pain is complained of. The kidney is palpated for the detection of tenderness on pressure, of enlargement, or of excessive mobility ; calculus, pyelonephritis, tuber culosis, and pyonephrosis being the main causes of an excessive amount of pus in the urine. The bladder should be examined biman
ually, both when empty and when full. Inflamed bladders are al ways tender, and if ulcerated are acutely sensitive. Carcinomatous or tubercular deposits are nearly always recognizable, and calculi when large oan be felt through the base.
The prostate, vesiculee seminales, vasa deferentia, and epididy mis, are examined for tenderness, enlargement, or deposit of tubercle. The projection of stones in the prostate is detected by the hardness and grating, for they usually are multiple. The Bougie will eliminate stricture, and the sound will serve to detect prostatic or vesical stone. Both instruments should be passed with the same precaution as those observed in Inematuria, but the objection to using them is less in pyuria than when blood only is present. The cystoscope will dem onstrate a stream of pus issuing in a dull muddy current from either ureter, and will establish the presence or absence of vesical causes for pyuria. The spine and ribs are to be thoroughly searched for tuber cular lesions, which may be discharging their pus into the upper urinary tract. The uterus and its surroundings are examined in the knee-and-elbow position, in order to ascertain if any inflammatory adhesions exist between these organs and the bladder; while in hip disease the inner side of the true pelvis is thoroughly swept by the finger in the rectum, to make sure that no abscess from the obturator cavity is approaching or discharging into the bladder.