symptoms of the disease, and with the negative evidence that the bladder is unaffected. The amount of albumen in pure pyelitis is proportioned to that of the pus or blood; but very frequently the signs of pyelitis are combined with those of congestion or degeneration of the kidney; the amount of albumen is then much greater, and the evident disproportion between its amount and that of the pus or blood which may be present proves the co-existence of renal disease. When the obstruction of the ureter is complete (either by stone or acephalocyst), the urine and pus accumulate above and distend the pelvis and calices. All the urine that is passed comes from the sound kidney, and is clear and free from deposit. The sudden change from a purulent to a clear non-sedimentous urine may lead to a diagnosis of this condition; if the bladder be coincidently affected, of course the pus will not disappear. In pyelitis from other causes than calculus, there is no diagnostic sign, except the pelvic epithelium. Slight pyelitis, leading to desquamation, is extremely common in cases of acute and sub-acute Bright's disease, and in cystitis. SECTION V. ACUTE CYSTITIS. The urine is scanty and high-coloured, as in all febrile maladies; there is a white or yellowish-white deposit of epithelium, pus, and granular cells. Blood in any quantity is rare, but some blood-globules are usually seen on microscopic examination. There is a little albumen in proportion to the amount of pus. SECTION VI. CHRONIC CYSTITIS. The urine is in normal amount; is acid when passed, but soon becomes alkaline from the decomposition of the urea; its colour is sometimes pale or natural, but very often it is darker than usual, and in some cases (sub-acute) it has a reddish-brown hue, as if it contained dissolved hæmatin; this is not the case, however, for the amount of albumen may be extremely small. There is a large deposit of pus; as long as the urine is acid, this forms a white or yellowish sediment, which, under the microscope, presents only pus-cells, with some imperfect epithelium; sediments of urates are not common. When the urine becomes alkaline, the pus becomes viscid, tenaceous, and stringy; phosphate of lime, ammoniaco-magnesian phosphate, and sometimes urate of ammonia, are deposited among the pus-cells; the colour of the sediments becomes greenish or brown. After some hours, the sediment runs together so completely, as to form one single glairy mass. Sometimes in feebly acid urine, the pus within the bladder takes on this viscid and tenacious character; it may then block up the urethra at the commencement of micturition; more often it is discharged at the end of micturition, and forms tough, whitish threads, which are pulled out of the urethra. Albumen exists in small quantities in the supernatant liquid. Blood is not often present if there be no calculus, and is always in microscopic amount. It is often extremely difficult to know if, with the cystitis, there is pyelitis or disease of the kidney itself. Pyelitis must be distinguished by other symptoms, or by the existence of pelvic epithelium. Disease of the kidney can only be distinguished by the amount of albumen being manifestly greater than could be furnished by the pus, and by the discovery of casts or renal epithelium. The urine in chronic cystitis, apart from the structures mechanically suspended in it, is not, as far as is known, altered in composition. The alkalinity in cystitis is often owing to ureal decomposition, but in addition, as pointed out by Dr. Owen Rees,1 the mucus poured out from the mucous membrane is itself alkaline, and either lessens the acidity, or is sufficient per se to make the urine alkaline. A peculiar faint, nauseous odour is often perceived, and appears to arise from changes in the mucus or albumen. Vibriones rapidly form after emission. If the cystitis arises from calculus, the appearances are the same, except that blood is in larger quantity, and is more frequently seen. 1 Med. Gazette, 1851. 399 SECTION VII. DISEASES OF THE PROSTATE. Acute or chronic inflammation of the prostate is frequently accompanied with inflammation of the urethral mucous membrane; and the microscopic appearances of the urine are the same as in urethritis and cystitis. Sometimes prostatic cylinders are seen, and little albuminous masses, which have been detached. The thick, albuminous secretion which sometimes flows from the urethra, when efforts are made at stool, may also find its way into the urine. Organic Disease of the Bladder. Villous cancer, at a certain stage, is generally attended with much bleeding. Epithelium, pus, and granular cells are present in the urine in most cases, and sometimes some portion of the tumour becomes detached. If it be a fungoid growth, minute parts of vessels, or proliferating connective tissue, may be thrown off by slough, and appears in the urine; but this is, perhaps, not common, and frequently the urine presents no other signs than those of chronic cystitis. SECTION VIII. AFFECTIONS OF THE FEMALE GENITO-URINARY ORGANS. The appearances in the urine from diseases of the bladder and ureters are similar to those in men. The frequent coexistence of leucorrhoea, however, with cystitis causes the appearance of vaginal epithelium and cells derived from rapid exfoliation, which have been so well described by Tyler Smith. A very large quantity of albumen is thus sometimes added to the urine, and, until after exploration of the vagina, it might be supposed that the albuminuria owned a renal origin. Sometimes little masses of albuminous substance, mixed up with epithelium-cells, are seen. |