THE 3234 Medical Review of Reviews, A Monthly Review of Current Medical Literature. EDITED BY DANIEL LEWIS, A. M., M. D. VOLUME IV. JANUARY TO DECEMBER, 1898. NEW YORK. THE SOURCES Howard A. Kelly, AND DIAGNOSIS M.D., of Baltimore, read OF PYURIA. a paper on this subject at a meeting of the Southern Surgical and Gynecological Society, held in St. Louis, November, 9, 10, and 11, 1897, which appears in the Medical News, December 11, 1897. A valuable part of the paper is the illustrations, some of which we reproduce. Dr. Kelly says: is being lost; and that the investigation of the source of a pyuria is not difficult to make, simply requiring some special instruments and a little practice in using them. "The investigation of the cause of a pyuria must be analytic, taking the symptom and tracing it to its source by a process of exclusion. Your patient comes to you with a more or less definite complaint of a disturbance along the urinary tract, often exceedingly vague, and you examine the urine and find that it contains pus, you then naturally conclude that if you can find the source of the pus you will locate the disease. While the question presents itself in this way, the means which we have hitherto had at our command for making such a determination have been generally most unsatisfactory. If an enlargement is not found in the loin suggesting a kidney containing pus, or if a point of tenderness is not found somewhere along the accessible part of the urinary tract, how is it to 299214 "If I were asked what subject of all others in the range of medicine I considered it most important to bring prominently before the profession at this juncture of the advancement of our art, I think I would reply, on the spur of the moment, pyuria. Let me emphasize the importance of my subject by saying that there are to-day thousands of women in our country going about with a pyuria of undetermined origin; that in most instances the disease is progressive, going from bad to worse, and for this reason valuable time be determined where the pus comes from? Moreover, the clinical signs themselves may be most misleading; for a stone in the kidney or a tuberculous kidney may give no other sign than a vesical tenesmus; and then, too, if both kidney and bladder are inflamed, how is one to ascertain this fact and to determine the extent of the involvement of each? It is my desire, therefore, to emphasize the importance of the direct methods of inquiring into the sources of pus in the urine, and I shall, for this reason, but briefly refer to the other accessory diagnostic procedures at our command. The history of the case must be carefully considered, and the duration of the disease, the exact character and location of the pain, the frequency of urination, the existence of morbid processes elsewhere, such as phthisis, etc., must be noted. The microscopic characteristics of the urine are of the utmost importance, as the quantity of pus present, variation in the amount, the character of the pus-corpuscles themselves, the presence of blood, crystals, or cellular debris in the urine are all factors liable to afford a clue to the source of the pus. "An infection is almost always the basis of a pyuria, and this may be due to any one of the pus-producing organisms. A scientific investigation will aim to determine which one of a large number of such organisms is present. Such a determination is not without a high degree of practical importance, as some of them exhibit a marked predilection for a special portal of entry; the gonococcus, for example, enters the urinary tract by the urethra, and the colon bacillus is more apt to be an invader from a neighboring bowel. "A little pus found microscopically, associated with an irritable bladder, may mean nothing more than a hyperemia of the vesical trigonum or a ureter which is irritated by a concentrated or an intensely acid urine; a large amount of pus almost invariably proceeds from the kidney. Renal pus is usually acid, while pus from the bladder walls is often strongly alkalin; an intermittent or remittent flow of pus is most likely to come from an extravesical source, either from a kidney or an outside suppurating area communicating with the urinary tract. "In investigating a pyuria, we should always bear in mind that it may originate in one of two ways: either in a diseased condition of some portion of the urinary tract itself, or it may depend for its continuance upon a disease located outside the urinary tract and simply discharging through it as an avenue of exit from the body. The principal portals of entry for such an effection are by the pelvis of the kidney and by the bladder; in the vast majority of cases by the latter (Fig. 1). |