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Full text of "Diseases of the kidneys, ureters and bladder v. 2"

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Girt 
Dr.J.underwood Hall 



USDERVOOD HALL 



DISEASES OF THE KIDNEYS. 
URETERS AND BLADDER 



DISEASES OF 

THE KIDNEYS, URETERS 

AND BLADDER 

WITH SPECIAL REFERENCE TO THE DISEASES IN WOMEN 



BY 

HOWARD A. KELLY, M.D., LL.D. 

or GTNECOLoaiCAL SUBOEilT IN THE JOIINH HOPKINS UNIVEBSITT, AND OTNEOOLOGin 
TO THE JOHNS HOPKINS HOSPITAL. BALTIMOBE 



AND 

CURTIS F. BURNAM, M.D. 

ASSOCIATE IN QTNECOLOOT JOHNS HOPKINS HOSPITAL 



VOLUME II 




WITH 628 nXUSTTRATIONS. FOR THE MOST PART BY 
MAX BRODKL 



NEW YORK AND LONDON 

D. APPLETON AND COMPANY 

1914 



COFTRIOHT. 1914, BT 

D. APPLETON AND COMPANY 



Printed in the United SUtes of Ameiiea. 



CONTENTS. 

CHAPTKB TAOM 

XVIIL Essential Hekaturia and Nephralgia 1 

Etiology and Pathology 2 

Clinical Symptoms 5 

Diagnosis 6 

Treatment 6 

Illustrative Cases 8 

XIX. Tuberculosis of the E^idnet 19 

History 19 

The Occurrence of Kidney Tuberculosis 21 

Portal of Entry of Tubercle Bacillus to the Kidney . . 26 

Pathology 31 

Symptomatology 53 

Diagnosis 61 

Prognosis 71 

Treatment 73 

Tuberculosis of the Ureters 85 

Tuberculosis of the Bladder 86 

XX. Renal and Ureteral Stones 90 

History 90 

Etiology 92 

Pathological Changes in the Kidney Produced by Stone . . 104 

Symptoms of Stone in the Kidney 106 

Diagnosis 114 

Summary 163 

XXI. Bladder and Urethral Stones 165 

Bladder Stones 165 

Stone in the Urethra 183 

XXIL Syphilis, Echinoooccus, Actinomycosis, and Other Parasitic 

Diseases of the Urinary Organs 187 

Syphilis 187 

Echinococcus Disease 188 

Bilharziosis 192 

Actinomycosis 196 

Chyluria 201 



53 //f 



vi CONTENTS. 

CHAPTER PAOR 

XXIII. Pyelitis 203 

Pyelitis in General . . .203 

Pyelitb in Children \ . 212 

Pyelitis of Pregnancy and the Puei-perium 213 

XXIV. Pyelonephritis, Pyonephrosis, Multiple Abscesses and Af- 

fected Infarcts of Kidney, Perirenal Inflammation . . 216 

Inflammation of the Kidney Pelvis or Parenchyma . . . 216 

Perirenal Inflammations 231 

XXV. New Growths of the Kidney, Ureter, Perirenal Tissues, and 

Adrenal Glands 236 

Tumors of the Kidney and Ureter 236 

Adrenal Tumors 265 

Perirenal Tumors 270 

Cysts of the Kidney, Otlier than Polycystic Kidney . . . 271 

Polycystic Kidney 275 

XXVI. Surgical Trf^tment of Bright's Disease 2S8 

General Considerations 288 

History of Sui*gical Treatment 289 

Indications for Operation 292 

Preparati(»n for Operation 293 

Technique of Operation 293 

Results of Operation 294 

XXVII. Traumatic Injury of the Kidney and Ureter .... 296 

Injuries to the Kidney • . 296 

Injuries to the Ureter 303 

XXVIII. Maldevelopment of the Kidney and Ureter 307 

Maldevelopment as to Number 307 

Maldevelopment as to Fonn 312 

Maldevelopment as to Position 321 

Embryolofrical Notes on the Maldevelopment of the I'reter and 

Renal Pelvis 326 

Malformation of Renal Pelvis and Ureter of Lesser Depjce . 331 

Ureters (Single and Supernumerary) with Abnormal Orifices . 336 

Bibliography 348 

XXIX. Stricture and Other Diseases of the Ureter .... 349 

XXX. Anatomy and Topography of the Female Bladder and Urethra 361 

The Bladder 361 

The Urethra 370 

XXXI. Diverticulum of the Bladder 372 

Occurrence 372 

Etiology 375 



CONTENTS. vii 

CHAPTKB PAGB 

Symptoms 375 

Diagnosis 376 

Treatment 379 

Literature 384 

XXXII. ExSlSiOPHY OF THE BLADDER 385 

Treatment 389 

Fissura VesicaB Superior 403 

XXXIII. Vesical, Ureteral, and Urethral Fistula 404 

Vesical Fistulas 404 

Ureteral Fistula 435 

Urethral Fistula 441 

XXXIV. Cystitis . 443 

Etiology 443 

Symptoms 449 

Diagnosis 449 

Treatment 456 

Contracted Bladder 477 

Ulcer of the Bladder 479 

Cystitis in Children 480 

Exfoliative Cystitis 480 

Syphilis of the Bladder 483 

Malakoplakia 485 

XXXV. Injltiies op the Bladder and Urethra 486 

Etiology 488 

Classification 489 

Sequelae 489 

Diagnosis 480 

Treatment 492 

XXXVI. Diseases of the Prevesical Space 497 

Literature . 505 

XXXVII. Tumors of the Bladder . . . 506 

Classification 507 

General Consideration 508 

Tumors of the Bladder in Children 520 

Symptoms of Tumors of the Bladder 529 

Treatment 533 

XXXVIII. Neuroses of the Bladder ........ 553 

Sensory Disturbances 554 

Incontinence of Urine 557 

Enuresis . . *. 560 

Retention of Urine 562 



viii CONTENTS. 

CUAPTEB PACK 

XXXIX. Malformations of the Urktiira 564 

Absence of the Urethra 5(54 

Double Urethra 564 

Hypospadias or Vaginal Urethra 565 

Epispadias 568 

XL. Prolapse of the Urethral Mucosa 574 

Prolapse of the Urethra in Adults 574 

Prolapse of the Urethra iu Girls 577 

XLL Urethritis 579 

Acute Urethritis 579 

Chronic Urethritis 579 

Inflammation of Skene's Glands 581 

External Urethritis 582 

Suburethral Abscess 582 

Syphilis of the Urethra 583 

Stricture of the Urethra 585 

Periurethritis Chronica 587 

XLII. New Growths of the Urethra 588 

Caruncle 588 

Mucous Polypi 591 

Fibroma, Myoma and Fibromyoma 592 

Carcinoma 593 

Sarcoma 597 



LIST OP ILLUSTRATIONS. 

TIG. PAOB 

275. — ^Microscopical section of tubercular kidney 33 

276. — Section of kidney from papilla to surface 34 

277. — Tubercular process in upper pole of kidney 36 

278. — Kidney showing disseminated tuberculosis of cortex of its upper pole with second- 
ary <lestruction of papilla 39 

279. — Diagn'^inmatic representation of upper pole of kidney shown in last figure . . 40 

2vS0. — Large tubercular kidney 41 

281. — Tuberculosis limited largely to the lower pole of kidney, which has two pelves and 

double blood supply 42 

282. — Tuberculosis of left kidney 43 

283. — Massive tuberculosis of the kidney 44 

284. — Tuberculosis of kidney and ureter 46 

28,'>. — Tuberculosis of the kidney with cystic transformation of upper pole . , , 48 

286. — Tuberculosis of kidney and ureter 50 

287. — Transverse section of the ureter 52 

288. — Early tuberculosis of the ureter due to tuberculosis of the kidney ... 53 

289. — More advanced stage of tuberculosis of the ureter 54 

290. — Still more advanced stage of tuberculosis of the ureter 55 

291. — Healed tuberculosis of the ureter 55 

292.— Tubercular kidney 66 

293. — Nephrectomy from above downward for tuberculosis of the kidney ... 77 

294. — Second step in nephrectomy from above downward for tuberculosis ... 78 

295. — Nephrectomy from below upward for tuberculosis of the kidney .... 79 

296. — ^Kapid removal of kidney, clamp method 80 

297. — Kidney ureter and part of the bladder including ureteral orifice removed in one 

piece for tuberculosis of parts concerned 81 

298. — ^View of the abdomen showing position and extent of incisions necessary for re- 
moval of specimen shown in preceding figure 82 

299. — Cystoscopic view of right and left ureteral orifices; tuberculosis of left kidney . 86 

300. — C-ystoscopic view of patch of discrete tubercles on mucous membrane of bladder 87 

301. — Coral calculi choking pelvis and calices of kidney 94 

302. — Large coral stone in pelvis of kidney, extending into calices 95 

303. — Immense stones filling lower half of kidney, with normal upper half ... 95 
3W. — ^T^iarge bilateral coral stones filling pelvis and calices of both kidneys, and making 

perfect casts of them 96 

305. — Ureteral calculus presenting a smooth and highly polished surface . . .97 

306. — Ureteral stone with grooved passage for urine ....... 97 

307. — Ureteral calculus forming a hollow shell that is obviously no obstacle to the excre- 
tions of urine 97 

308. — Hydronephorosis and hydro-ureter of right kidney due to obstruction of ureter 

by stone about 10 cm. from vesical orifice 100 

309. — Chain of pocketed stones extending several inches down ureter .... 101 

iz 



X LIST OF ILLUSTRATIONS. 

no. PAOB 

310. — Enormous hydronephrosis and hydro-ureter with 47 stones in vesical end of ureter 102 

311. — Stones in kidney associated with distended pelvis and calices 104 

312. — Massive hydronephrosis due to stone in upper end of ureter .... 105 

313. — Section through kidney shown in last figure, showing size and site of stones . 106 

314. — Large stone in pelvis of kidney and calices with complete destruction of the kidney 107 

315. — Stone in the pelvis of the kidney 108 

316. — Small stone measuring 12x6x4 mm.; passed spontaneously 110 

317. — Long calculus passed spontaneously Ill 

318. — Palpation of ureteral stone through the rectum 118 

319. — Stone protruding from ureteral orifice into the bladder 119 

320. — Prolapse of vesical end of ureter into bladder, due to stone 120 

321. — Determination of the distance of an obstruction in the ureter from the bladder . 121 
322. — Gouged renal catheter holding in its eye a small fragment of stone . . . .121 

323. — Bilateral stone kidney; large coral stone filling pelvis and calices of right kidney 122 

324. — Renal catheter entering pelvis of kidney and striking a large branched stone . 123 

325. — Wax- tipped catheter scratched on both sides 124 

326. — Waxing tip of renal catheter 125 

327.— Wax-tipped catheter 126 

328. — Flat facet on wax-tipped catheter, duo to rubbing side of speculum . . . 126 

329. — Method of examining wax-tipped catheter 127 

330. — Gouges on wax-tipped catheter from impact against a ureteral stone . . . 128 

331. — Wax-tipped catheter deeply gouged by impact against stone in right kidney . 128 

332. — Gouged wax-tipped catheter 128 

333. — Gouged wax-tipped catheter making positive diagnosis where X-ray pictures had 

faile<l to show stone 128 

334. — Deeply scratched wax-tipped catheter, due to impact against a stone in left ureter 128 

335. — Gouged wax-tipped catheter, from impact against stone in pelvis of right kidney . 128 
336. — Gouged wax-coated catheter and the stone which caused gouges . . . .129 

337. — Gouged wax-tipped catheters 130 

338. — Deeply gouged wax-tipped catheter, from impact against stones in pelvis of kidney 

as well as in ureter 130 

339. — Gouged ureteral catheters obtained from catheterizing the two kidneys . . 130 

340. — Gouges in wax-tipped catheter due to stone in right ureter 130 

341. — Appearance of calculus which caused scratch-marks shown in Fig. 340 . . .131 

342. — Gouged tips of waxed catheters, due to stone in vesical end of right ureter . . 132 

343. — The ureteral stone which scratched catheters shown in preceding figure . . 133 

344. — Shadowgraph of right kidney, showing a large stone 134 

345. — Skiagram showing immense stone occupying pelvis and calices of the kidney . 135 

346. — Large stone in left kidney successfully removed by pyelotomy .... 140 

347. — Hydronephrotic right kidney due to obstruction of the upper ureter by stones . . 141 

348. — Pyelotomy for stone in the pelvis of kidney 142 

349. — Suturing of pyelotomy incision after removal of stone 143 

350. — atones filling the lower calyx of kidney 144 

351. — Removal of large coral stones from renal pelvis and calices through nephrotomy 

incision 145 

352. — Deeply scratched wax-tipped catheter 146 

353. — Ix^ngth and position of nephrotomy incision in case illustrated in three succeeding 

figures 146 

354. — Fragments of stones removed in the case shown in preceding two figures . . 147 

355. — Kidney removed one year after nephrotomy, for stone 147 



LIST OF ILLUSTRATIONS. xi 

no. PAOB 

356. — Kidney shown in preceding figure laid open 148 

357. — Wax-tipped catheter showing gouges from large stone in pelvis of left kidney . 149 
358. — Nephrotomy incision in the non-vascular plane used in the ease shown in preceding 

and following figures 149 

359. — ^Large coral stone in right kidney, filling pelvis and calicos 150 

360. — Case of stones in kidney and ureter, bilateral renal tuberculosis and tuberculosis 

of the bladder 151 

361. — Shrieveled kidney surrounded by fat which on palpation simulated a normal kidney 152 
362. — Extraction of stone in the ureter by means of stone forceps, introduced through 

incision in manner shown 154 

363. — Diagram of the right kidney and ureter — stone in ureter at pelvic brim; incision 

made to remove stone 154 

364. — Elxtra-peritoneal exposure of portion of ureter containing stone, shown in last figure 155 

365. — Incision and removal of stone below the stricture 156 

366. — Calculus in lower ureter, causing hydro-ureter 156 

367. — Ureteral calculus lodged in vesical end of ureter 157 

368. — Combined abdominal and vaginal incisions to remove stone shown in Fig. 367 . 158 

369. — Stones removed from ureter in case shown in preceding figure, also Fig. 325 . 159 

370. — Gouged wax-tipped catheter due to passage over stone in right ureter . . . 159 
371. — Transvesical removal of stones from vesical end of ureter, through vesico- vaginal 

incision 160 

372. — View of bladder and uterus in the knee-chest posture, showing opening in trigonum 

as pictured in last figure 161 

373. — Stones removed at operation and passed subsequent to operation, in case illustrated 

by two preceding figures 162 

374. — Piece of rubber dropped through suprapubic opening into bladder and remaining 

there three weeks 165 

375. — Hairpin calculus 166 

376. — Hairpin calculus 167 

377. — Incrustation about rubber tube 168 

378. — Vesical calculus 169 

379. — Section of a large stone removed from tlie bladder of an eight-year-old girl . 170 

380. — Eight pyramidal stones of almost identical size and shape 171 

381. — Transverse section of one of the pyramidal stones shown in last figure . .171 
382. — Removal of stone from diverticulum in bladder through open-air cystoscope . .172 

383. — Skiagraph showing stone in vesical diverticulum 173 

384. — Demonstration of small stone in bladder through open-air cystoscope . . . 174 

.385. — Open-air speculum view of stone showTi in last figure ♦ 175 

386. — Glass catheter splintered in bladder during labor 175 

387.— Bigelow's lithotrit« 176 

388. — Bigelow's evacuating apparatus 176 

389. — Young's combined lithotrite evacuator and cystoscope 178 

390. — Enlarged view of Young's lithotrite 179 

391. — ^Vesico- vaginal incision for removal of stones in bladder and lower ureter .. . 180 

392. — Bemoval of stone from bladder through a vesico-vaginal incision .... 181 
393. — Pipe-shaped articulated calculi lying in a urethral diverticulum and extending into 

the urethra 184 

394. — Sediment from echinococcus cyst 190 

395. — Characteristic group of eggs of the Bilharzia hematobia 193 

396. — Schistosoma hematobium 194 



xii LIST OF ILLUSTRATIONS. 

no. Txam 

397. — Portion of bladder viewed from interior showing lesions due to Bilharzia hematobia 195 

398. — Actinomycosis of the kidney 198 

399. — Simultaneous lavage of pelves of both kidneys 208 

400. — Multiple infected infarcts of kidney 218 

401. — ^Pyonephrotomy. First step in exposure and evacuation of pus kidney . . . 227 

402. — Pyonephrotomy. Second step in enucleation of a large pyonephrotic kidney . . 228 

403. — Pyonephrotomy. Third step in intracapsular enucleation 220 

404. — Pyonephrotomy. Fourth step in intracapsular enucleation 230 

405. — Carcinoma of the kidney 238 

406. — Carcinoma of the kidney 240 

407. — Carcinoma of the kidney 242 

408. — Sarcoma of kidney 244 

409. — Tubular Adenoma of the kidney 246 

410. — Papillary cyst-adenoma of the kidney 247 

411. — Hypernephroma 248 

412. — Hypernephroma 249 

413. — Hypernephroma 250 

414. — Coronal section through tumor shown in last figure 251 

415. — Mesial view of hypernephroma of right kidney 252 

416. — Transverse section of tumor shown in last figure 253 

417. — Hypernephroma and metastases . 254 

418. — ^Variations in structure of different parts of tumor shown in Figure 412 . . 256 

419. — Section through edge of tumor shown in Figure 411 258 

420. — Section of tumor shown in Figure 411 under slightly greater magnification . 259 

421. — Another section through tumor shown in Figure 411 . 259 

422. — ^Papilloma of the renal pelvis 260 

423. — Embryonic tumor 263 

424. — Embryonic tumor 263 

425. — Typical embryonic kidney between third and fourth month 264 

426. — Enlargement of previous section, showing glomeruli 264 

427. — High magnification of embryonic tumor, showing glands, striated muscle and em- 
bryonic tissue 265 

428. — ^Fibromyxo-sarcoma of right suprarenal gland 266 

429. — Section of tumor and growth shown Mn Figure 428 267 

430. — ^Remarkable case of giantism associated with adrenal tumor 269 

431. — Blood cyst of right kidney . 273 

432.— Cyst of kidney 274 

433. — Bilateral congenital cystic kidneys in the adult 277 

434. — Coronal section of right kidney of case shown in Figure 433 278 

435. — Section of portion of large polycystic kidney 279 

436. — Bilateral cystic kidneys in still-bom babe 280 

437. — View obtained at operation of large hypernephroma 283 

438. — ^Longitudinal section of tumor shown in last figure 285 

439. — Method of removing tumor plug from renal vein and vena cava .... 286 

440. — ^Decapsulation of the kidney for nephritis 294 

441. — Rupture of aneurysm between leaves of renal fatty capsule 297 

442. — Ruptured aneurysm, as in last figure, in transverse section 298 

443. — Operative injury to ureter, in removing large cancerous tumor of ovary . . 304 

444. — Completed uretero-vesical anastomosis 305 

445. — Solitary ectopic kidney and pelvic organs seen through a median abdominal incision 308 



LIST OF ILLUSTRATIONS. xiii 

no. PAOB 

446. — Coronal section of horseshoe kidney shown in next figure 313 

447. — Horseshoe kidney with aortic aneurysm 314 

448. — Unilateral horseshoe kidney 315 

449. — Horseshoe kidney of remarkable type 316 

450. — Horseshoe kidney of remarkable type 317 

451. — Unilateral horseshoe kidney 318 

452. — ^Two cases of sigmoid kidney 319 

453. — Lump kidney (so-called) 321 

454. — Ectopic kidney on left side, with a normal right kidney 322 

455. — Ectopic left kidney with abnormal internal generative organs .... 323 

4.56. — An unusual abdominal tumor shaped like a kidney situated in the middle line . 324 

457. — Section of tumor shown in previous figure 325 

458. — Division of renal pelvis into upper and lower branches 326 

459. — Diagrams from actual cases, showing anomalies of ureters and renal pelves . . 328 
460. — Diagrams illustrating the origin of a divided renal pelvis as compared with that of 

a single pelvis 330 

461. — Four diagrams illustrating the development of a kidney with divided pelvis and 

double ureter 332 

462. — Actual case of double pelvis and double ureter, representing the most usual tyx>e . 335 

463. — Kidney with double ureter and two openings into bladder 336 

464. — Speculum views of urethral orifice of ureter 340 

465. — Sagittal view of method for treating dilated anomalous ureter opening into urethra 341 

466. — Determination of distance of stricture of ureter from vesical orifice . . . 350 

467. — Series of catheters of bougies used to dilate stricture of the ureter . . . 353 
468. — Measuring the force needed to withdraw a renal catheter held in the bite of a 

strictured ureter 354 

469. — Uretero-vesical anastomosis 355 

470. — End-to-end anastomosis of cut ureter 356 

471. — Prolapse of right ureter into bladder, forming a cyst 357 

472. — ^Prolapse of vesical end of ureters into bladder, due to stricture induced by cystitis 358 
473. — ^Distended bladder and its topography in relation to peritoneum, intestines, and 

pelvic bones 362 

474. — Anterior view of distended hardened bladder 363 

475. — Section of the bladder showing general disposition of coats 364 

476. — ^Relations of urethra and trigonum of bladder as seen from vaginal side . . 365 

477. — Musculature of the bladder and urethra 366 

478. — ^The arterial circulation of the bladder and urethra as seen from the side . 368 

479. — The arterial circulation of the bladder as seen from in front and above . . 369 

480. — Urethra showing pronounced labia 370 

481.— Loculate bladder 374 

482. — Diverticulum of the bladder 376 

483. — Demonstration of diverticulum by introduction of catheter 378 

484. — Method of treating diverticula through open-air cystoscope 380 

485. — Papilloma in diverticulum 381 

486. — Diverticulum closed; sphincteric action of the orifice 381 

487. — Diverticula of the urinary bladder with special reference to Bontgen-ray diagnosis 382 

488. — Badiograph of diverticulum and bladder taken from the left side . . . 383 

489.— Eversion of bladder 385 

490. — Exstrophy of the bladder in girl with prolapse of the rectum .... 386 

491.— Exstrophy of bladder in adult female . .387 



xiv LIST OF ILLUSTRATIONS. 

na. PAGM 

492. — Extensive cancer of exstrophied bladder 388 

493. — Operation for exstrophy of the bladder in male subject 392 

494. — Suturing of freed bladder, as shown in last figure 393 

495. — The last step in the operation shown in two preceding figures .... 394 

496. — Sonnenberg's method of treatment of exstrophy 39.5 

497. — G. R. Fowler's case of epispadias . • 397 

498. — G. R. Fowler's case of epispadias 398 

499. — Fistula between small intestine and bladder 405 

500. — Adherent bladder and bowel shown in last figure separated 406 

501. — Exposure of a difficult vesico-vaginal fistula, following hysterectomy . . . 408 
502. — Sagittal view of vesico-vaginal fistula, with open-air si)eculum in urethra .410 

503. — Exposure of small vesico-vaginal fistula 411 

504. — Sponge on clamp introduced into bladder through fistula as aid in denudation . 412 

505. — Sickle-shaped knife — sharp on both sides 413 

506. — Delicate scissors curved on the flat, for paring edges of vesico-vaginal fistula? . . 413 

507. — Immense vesico-vaginal fistula, involving entire trigonum, including sphincter area 414 

508. — Fistula shown in last figure, with sutures tied 415 

509. — Paring edges of vesicovaginal fistula preparatory to closure 416 

510. — Closure of vesico-vaginal fistula 416 

511. — Closure of a vesico-vaginal fistula with sutures placed in antero-posterior direction, 

making a transverse line when tied 417 

512. — Closure of vesico-vaginal fistula, as in last figure, with a separate layer of sutures 

for the bladder 417 

513. — Three styles of self -retaining catheter 418 

514. — ^Vesico-cervico-vaginal fistula 418 

515. — Vesico-cervico-vaginal fistula 418 

516. — Vesico-cervico-vaginal fistula 419 

517. — Closure of vesicouterine fistula, from below . . . . . . . .419 

518.— Vesicouterine fistula 420 

519. — Vesicouterine fistula treated through median abdominal incision .... 420 

.520. — Treatment of vesico-uterine fistula by abdominal incision 421 

521. — Vesico-uterine fistula closed by operation from above 422 

522. — Largo fistula with rigid vaginal walls 424 

523. — ^Dudley's operation for large vesico-vaginal fistula with rigid edges . . . 425 

524. — Dudley's operation completed 425 

525. — Double vesico-vaginal fistula, I 426 

526. — Double vesico-vaginal fistula, II 427 

527. — Double vesico-vaginal fistula. III 428 

528. — ^Vesico-vaginal fistula near vault of vagina rigidly fixed by dense scar tissue . . 429 

529. — Treatment of fistula pictured in last figure through a median abdominal incision . 429 

530. — Completed operation illustrated in two preceding figures 430 

531. — Vesico-vaginal fistula with pelvic inflammation, J . . . . . . . 430 

532. — Vesico-vaginal fistula with pelvic inflammation, II 431 

533. — ^Vesico-vaginal fistula with pelvic inflammation, til 432 

534. — Uretero-vaginal fistula 432 

535. — Urethrovaginal and recto-vaginal fistula at the same level 433 

536. — Urethrovaginal and recto-vaginal fistula 434 

537. — Sagittal view of end of ureter, bladder and vagiiia in case of double uretero-vaginal 

fistula 436 

538. — Completion of operation seen in last figure 437 



LIST OF ILLUSTRATIONS. xv 

no. PAGE 

539.>-nretero-vagijial fistula, I 438 

540.— Uretero-vaginal fistula, II 439 

541.— Uretero-vaginal fistula, III 440 

542. — Another method of treating uretero-vaginal fistula .441 

543. — Section through part of bladder wall, showing changes in acute cystitis . . . 446 

544. — Schematic representation of down-dipping of epithelium simulating gland structure 447 

545. — Extensive pseudo-gland formation in a case of chronic cystitis cystica . . . 448 

546. — Extensive calcareous deposits in bladder in case of chronic cystitis . . 449 

547. — Calcareous deposits on bladder wall 450 

548. — Inspecting and plotting out a focus of disease in bladder with open-air cystoscope 451 

549. — ^Ulcers on trigonum 453 

550. — Calcareous deposits surrounded by marked injection of bladder .... 453 

551. — Linear healing ulcer on posterior bladder wall, as seen through cystoscope . . 454 

552. — Enormous hypertrophy with edema of anterior vaginal wall simulating cystocele . 455 

553. — Irrigation of bladder through two-way catheter 460 

554. — One method of irrigating bladder by means of two-way catheter .... 461 

555. — Dickinson 's two-way catheter 462 

556. — Chart showing progress under distention treatments . 464 

557. — Operative formation of vesicovaginal fistula 467 

558. — Completion of operation shown in last figure 468 

559. — Hunner*s plan of continuous irrigation of bladder with patient in a tub . . . 469 

560. — Continuous irrigation of the bladder with patient in bed on bed-pan . . . 470 

561. — Large solitary ulcer of bladder, as seen through suprapubic opening . . . 471 

562. — Suprapubic excision of ulcer of bladder 472 

56:5. — Seoon*! step in operation shown in last figure 473 

564. — Third step in excision of ulcer from bladder 474 

565. — The last step in excision of ulcer of bladder 474 

566. — Sequestration of bladder to insure against peritonitis after a suprapubic operation 475 

567. — Sequestration of bladder, as seen from front 475 

568. — Sequestration of bladder in male by suturing omentum to its posterior surface . 476 

569. — Alligator scissors 477 

570. — Simple papilloma 508 

571. — ^Papillomatous tumor of bladder showing tips of papillec and finger-like prolonga- 
tions 509 

572. — An apparently simple papilloma with a base almost as broad as the tumor is high 510 

573. — Section from another part of the same tumor as in Fig. 572 511 

574. — Papillary adenocarcinoma, which, to the naked eye, appears to be a simple 

papilloma 512 

57.*^. — High magnification of tumor shown in Fig. 574 513 

576. — Section in deeper part of tumor (adeno-carcinoma), shown in two preceding figures 514 

577. — Squamous-celled carcinoma developing in a case of exstrophy of the bladder . 515 

578. — Carcinoma of the bladder 516 

579. — Higher magnification of tissues at the base of tumor shown in preceding figure, 

showing carcinomatous invasion of the muscle 517 

580. — Carcinoma springing from retro-symphyseal wall of bladder 518 

581. — Carcinoma of ureter, secondary to primary growth in prostate gland and bladder 519 
582. — Sagittal view showing carcinoma which has developed in diverticulum of posterior 

wall of bladder 520 

583. — Thompson's case of dermoid tumor removed from bladder 521 

584. — Mucous polyps (myxosarcoma) in a girl 523 



xvi LIST OF ILLUSTRATIONS. 

no. TAOU 

585. — Large myomatous vesical tumor arising from entire top of bladder and filling viscus 524 

586. — ^Bhabdo-myosarcoma in a child 527 

587. — Bhabdo-myosarcoma in a child 528 

588. — Pedunculate papilloma situated just in front of right ureteral orifice . . . 530 

589. — X-ray picture of bladder injected with bismuth subnitrate suspended in water . 531 
590. — X-ray picture of large papilloma attached to right base of bladder between urethra 

and ureter 532 

591. — Demonstration of method of fulguration through air distention cystoscope . . 535 
592. — Destruction of pedicle of artificial tumor by direct application of electrodes on 

opposite sides (D'Arsonval current) 536 

593. — Cooking off the pedicle of an artificial tumor 537 

594. — Exposure of bladder by means of transverse incision above symphysis . . . 538 

595. — Exposure of bladder by means of transverse incision above symphysis . . . 539 

596. — Exposure of bladder by transverse incision above symphysis 540 

597. — Exposure of bladder by transverse incision above symphysis 541 

598. — ^Air distention of bladder by means of rubber catheter, attached on the outside to 

a bulb, in the operation of suprapubic cystotomy 542 

599. — The succeeding step in suprapubic opening of bladder 543 

600. — Next step in suprapubic removal of papilloma of bladder 543 

601. — Next step in operation shown in two preceding figures 543 

602. — Final step in operation shown in preceding figures 544 

603. — Exposure of pedunculate papilloma near right ureteral orifice through suprapubic 

incision . 545 

604. — Removal of papilloma shown in last figure by clamp and cautery method . . 545 

605. — Appearance of bladder at close of operation pictured in preceding drawings . . 546 

606. — Completion of suprapubic operation for removal of vesical tumor .... 546 

607. — Completion of suprapubic operation for removal of vesical tumor .... 547 

608. — Closure of transperitoneal opening in bladder, I 548 

609. — Closure of transperitoneal opening into bladder, II 549 

610. — Durand*s classification of the various forms of epispadias 566 

611. — Frommel's case of epispadias in a woman 26 years of age 569 

612. — Stiles' method of implantation of the ureter in epispadias 570 

613. — A high grade of hypertrophied and prolapsed urethral mucous membrane . • 575 

614. — Sagittal view of condition shown in last figure 575 

615. — Prolapsed and strangulated urethral mucous membrane 576 

616. — Appearance after circular amputation of prolapsed and hypertrophied urethral 

mucous membrane shown in Figures 613 and 614 577 

617. — Urethral speculum, identical in shape with vesical speculum but much shorter . 580 

618. — Hegar dilators 581 

619. — Improvised syringe for carrying medicaments up the ducts of Skene's glands . 582 

620. — Abscess of gonorrheal origin in Skene's gland to the left of the urethra . . 583 

621. — Large suburethral abscess 584 

622. — Typical urethral caruncle, springing from right posterior margin of urethra . . 589 

623.— Urethral caruncle 590 

624. — Mucous polypi of urethra and sphincter region of bladder 592 

625. — Primary squamous carcinoma of urethra 594 

626. — Ehrendorf er 's case of carcinoma of vestibule completely surrounding and involv- 
ing urethral orifice 595 

627. — Adenocarcinoma of urethra secondary to adenocarcinoma of body of uterus . . 596 

628. — Beigel's case of sarcoma of urethra 598 



DISEASES OF THE KIDNEYS, 
URETERS AND BLADDER. 

VOLUME II. 

CHAPTER XVIII. 

ESSENTIAL HEMATURIA AND NEPHRALGIA. 

Under the various names, idiopathic renal neuralgia, idiopathic renal 
hematuria, hl?eding from healthy kidneys, renal epistaxis, essential hematuria, 
angio-neurotic hleeding kidney, a characteristic and interesting group of cases 
has been described. Although it has long been known that bleeding may occur 
from an apparently healthy kidney and Rayer has discussed the subject in his 
'*Traite des maladies des reins," 1851, it was Sabatier who opened up the sub- 
ject in 1889 (Rev. de chir., 1889, ix, 62) with the report of a case of what he 
called "nephralgie hematurique." His patient, a woman thirty years old, had 
an association of hematuria and colic in the right kidney, which led him to 
suspect stone in the kidney. He operated, found a normal-looking kidney, and 
did a nephrectomy. Careful microscopical study of the kidney which he re- 
moved showed no alteration in structure, save a slight, chronic interstitial 
nephritis. Reports of other cases have followed rapidly. Our first two cases 
were published by Dr. Albert Staveley in March, 1893 (Johns Hop. Hosp. 
Bull., 1893, iv, 26). The first had the association of an intermittent hematuria 
and renal colic. The second had no colic, and the bleeding had been present 
continuously for a year and a half. In both cases the kidneys looked normal 
macroscopically, and a small piece of tissue removed from the cortex of each 
showed no disease. Several of these cases present themselves every year. Up 
to a few years ago we had had some 24 cases, and as they have been under 
observation long enough to judge of therapeutic results, we have based this 
chapter upon them and give abstracts of them at its close. We have in- 
eluded in this group cases where there has been an association of hematuria 
and nephralgia, and those in which there has been simply hematuria, and a 

1 



2 ESSENTIAL HEMATURIA AND NEPHRALGIA, 

few in which nephralgia was the dominant symptom. In only two of the 
entire list of operated eases did the urinary findings suggest nephritis, and 
this was confirmed by a pathologic examination of small pieces of cortex 
removed at the time of the operation. In all the other cases where bits of 
kidney were removed the organs appeared normal. 



ETIOLOGY AND PATHOLOGY. 

There has been much contention as to the pathologic lesions leading to 
this condition. Many authors assert that almost without exception the under- 
lying cause is the nephritis. Israel, on the basis of a large experience, 
is inclined to believe all cases due to this cause, and makes the following 
points : 

First, a nephritis can be one-sided. 

Second, nephritis of one side can give colic and hemorrhage. 

Third, a double-sided nephritis can give colic in one side only. 

Fourth, severe nephritis can be present without either casts or albumin oc- 
curring in the urine. 

Albarran makes the following points in a publication in La Presse med., 
1904, 657: 

A clear difference exists between nephritides. In some the nephritis in- 
volves the entire kidney equally, and in some it is focal and limited to parts 
of the kidney. JEIe quotes a case where Necholich, after a pathological exam- 
ination, pronounced a kidney normal, and yet Motz, examining it later, found 
a patch of nephritis. 

E. Lewitt (Monatsb. f. Urol,, 1904, ix, 347) reports three cases operated 
on by Casper with one-sided hemorrhage, yet double-sided nephritis. 

E. Stich (MittheiL a, d. Grenzgeb. d, Med. u. Chir,, 1904, xiii, 781) reports 
a case of hemorrhage from one kidney in which an autopsy showed a nephritis 
located in this kidney alone, the other being normal. 

These conflicting views are often of more academic than practical inter- 
est, since there is great difficulty in getting a small piece of focal nephritis sep- 
arated in a kidney which has been removed. The facts are that there are many 
cases on record of hemorrhage from a kidney, where neither the previous 
nor subsequent histories suggested nephritis, where at operation no disease 
could be seen macroscopically, and where the microscopic examination of a 
small piece of cortex indicated a normal kidney. 

Several cases are on record where nephrectomy has been done, and under 



ETIOLOGY AND PATHOLOGY. 3 

most careful microscopical examination of the removed kidney nothing has 
been found. Klemperer, Schede, and others have reported such cases. 

Eecently Dr. J. W. Keefe reported such a case (Am. J. Urol., 1907, iii, 
60). It was the case of a man of 36. There was hemorrhage from the left 
kidney, and thickening of the testicle. The removed kidney was carefully exam- 
ined by Dr. F. Fulton and reported to be normal. H. A. Fowler (Am. J. 
Urol., 1912, viii, 249) reports a case in which he did a nephrectomy for very 
severe hemorrhage and in which the pathological examination failed to show 
any sufficient cause for the bleeding. Benjamin S. Barringer (Am. J. Urol., 
1912, viii, 229) collected 73 cases out of the literature, in 26 of which nephrec- 
tomy was done, and while 3 of the 26 kidneys removed were apparently nor- 
mal, the others showed various degrees of nephritis. In 7 cases out of the 73 
the focus of bleeding was located in the pelvis. Alexander Randall of Phila- 
delphia (J. Am. Med. Assoc, 1913, Ix, 10) considers the causes, in order of 
frequency, to be nephritis, varices of the pelvis and rupture of blood vessels, 
A most interesting group of cases is that in which hematuria is associated with 
appendicitis, and relieved by removal. V. Frisch (Ztschr. f. Urol., 1912, vi, 
245) and E. DuVal (Nortnandie med., 1912, xxvii, 244). To our associate. 
Dr. G. L. Ilunner (J. Am. Med. Assoc, 1908, i, 1328), belongs the credit of 
first drawing attention to this condition. The patient in whom he observed 
it was 38 years old and for several years had been having attacks of pain in 
the right side, associated with throbbing pain in the rectum and accompanied 
by blood in the urine from the right kidney. 

We have never had occasion to remove a kidney for this form of bleeding, 
but in the cases where we have removed small pieces of tissue and there has 
been no evidence of nephritis in the urine there has not been the slightest 
on microscopic examination. In two cases where there w^ere albumin and 
casts before operation these persisted after operation, and the pieces of tissue 
removed showed definite nephritis. 

Various views have been advanced as to the cause of pain in these cases. 
Lennander (MUth. a. d. Grengb. d. Med. u. Chir., 1902, x, 164), thinking 
especially of cases of acute nephritis where associated with oliguria with 
marked pain and sensitiveness over the kidneys, considers that the pain is due 
to a pressure within the capsule, and points to the relief of decapsulation. 
Senator (Berl. klin. Wchnschr., 1895, xxxii, 277) holds that the colic is not 
due to any tension, but to malpositions and adhesions. Israel (Mitth. a. d. 
Grengb. d. Med. u. Chir., 1889, v, 471) supports the view of Lennander. Is- 
rael and Albarran have reported cases of nephralgia and hematuria due to 
ureteritis. A careful review of our own experience leads us to believe that 



4 ESSENTIAL HEMATURIA AND NEPHRALGIA, 

under this head several different conditions are probably grouped. The eases 
of bleeding alone, without any pain or without colic, belong to a different group 
from those in which the two conditions are associated. 

Out of our group of 24 cases 6 were of this kind (2, 3, 4, 9, 14, 15). Of 
the cases with hemorrhage and nephralgia there are 12 (1, 5, 6, 7, 8, 10, 11, 
12, 13, 16, 20, 23). Cases with nephralgia alone are 6 (17, 18, 19, 21, 22, 
and 24). In none of these cases where operation was done, has any cause 
been discovered for the hemorrhage or pain. Nevortheless, every case operated 
upon, except one, case 22, was relieved by the operation. The operations per- 
formed were nephrotomy, times, in cases 1, 3, 4, 5, 6, 7, 8, 17, 22; decap- 
sulation once, case 23; suspension of the kidney three times (cases 19, 21, 
and 22) ; exploration of the ureter twice (cases 18 and 20). There was no 
displacement of the kidney and no adhesions about it to account for the pain 
except in case 23, where decapsulation was carried out with perfect result. 
The cases which were relieved by exploration of the ureter did not show any 
signs of ureteritis. The reason for the exploration of the ureter in place of 
the nephrotomy was that the pain complained of was lower down and appar- 
ently from the ureter more than the kidney. 

We have never had a case attributable to tabes or hysteria. Cases belonging 
to this group should be looked upon with skepticism. Albarran quotes it as 
an occasional cause of hematuria and cites the case of Le Tour, where a 
hysterical woman had had attacks of bleeding in the urine for years when- 
ever she was advised of the infidelity of her husband, and at no other times. 
Some years ago in the gynecological clinic at the Johns Hopkins Hospital we 
had a young colored woman twenty years of age who was very hysterical, who 
had to be catheterized frequently on account of inability to empty the bladder, 
and who presented at times very bloody urine, and at others perfectly clear 
urine. The conditions were a source of great speculation among the internes 
at the hospital, and it was only after weeks that it was discovered that the 
patient was putting the blood in the urine in order to deceive. It was a case 
of malingery to secure a living in the hospital, where she had nothing to do 
and careful nursing and feeding, whereas when she went out it was necessary 
for her to work. 

One of our cases (16) had the bleeding and pain in association with preg- 
nancy. In this case the symptoms disappeared on keeping the patient in bed 
for a week or two. This patient belongs to the class of cases due to pregnancy 
and lactation, which were first described by Guyon and Albarran. Broca (Anru 
d. mal. d. org. genito-urin., 1894, xii, 881) reports a case of a woman 
acting as a nurse who, during lactation, developed a marked hematuria after 



CLINICAL SYMPTOMS. 6 

ceasing to nurse. Albarran supposes that these cases are due to an intoxica- 
tion. It is possible that the congestion due to pressure on the ureters during 
pregnancy may have something to do with the condition. In October, 1902, 
we had a patient four months pregnant who began having pain in the left kid- 
ney and blood in the urine about the seventh week of the pregnancy. This con- 
dition developed into a marked pyelitis, and it was for the pyelitis that she 
came for treatment (see Gynecological No. 9,982). According to Guyon, all 
these cases clear up with the cessation of the pregnancy or the lactation. Hector 
Treub (Monatschr. f. Oeburt. u. Gyn., 1912, xxxvi, 28) reports a case of uni- 
lateral hematuria due to pregnancy, and relieved, after futile attempts, in other 
directions, by interruption of the pregnancy. He has collected 18 similar cases 
from literature. It is interesting to know that out of a total of 24 cases, 22 in 
women and 2 in men, no less than 18 of the women were married and had had 
children. Cases 15, 20, 21, and 24 were in unmarried women. Case 15 was 
a simple hematuria relieved by injecting adrenalin (Dr. W. W. Russell) ; case 
20 and case 21 were patients where the exploration of the ureter relieved the 
conditions; and case 24 was one of definite nephritis. This tremendous 
preponderance in parous women is striking when one considers that we 
have in general as many non-parous as parous cases. In both of the cases 
in men there was evidence of nephritic change. In looking over Israel's cases 
we find that he had six men, seven married women, and one unmarried woman ; 
the latter had passed through a severe infectious disease. In one of our cases 
the trouble began after an attack of grippe. In another there had been a 
definite stone passed at one time. 



CLINICAL SYMPTOMS. 

We have already gone into the principal symptoms, which are blood in the 
urine, alone, or blood and pain in the kidney, or pain in the kidney. In the 
cases where blood alone is present, if it is in moderate quantities the patient 
may have little or no discomfort. . In some cases, as in case 2 of this series, the 
bleeding has kept up for almost 8 years, almost without cessation, and yet 
the woman is in fair condition and able to work actively. In other cases the 
hemorrhage may be severe and lead to marked anemia, the hemoglobin being as 
low as 45 per cent, in case 1, and 27 per cent, in case 15. As pointed out in 
Chapter VII, page 224, several cases of fatal hemorrhage in Bright's disease 
have been noted. As a general rule, however, the bleeding is not so great as 
to result in any serious impairment of health, and the most frequent note made 



6 ESSENTIAL HEMATURIA AND NEPHRALGIA, 

on the general condition has been, "the patient seems fairly strong and healthy- 
looking." 

The pain which is present in so many of these cases is in the form of 
attacks of colic resembling in every way that due to stone in the kidney and 
ureter. In most of the cases the pain has been in the back and radiates toward 
the bladder. In two cases the pain was in the ureter. As already pointed 
out, the hemorrhage may be either intermittent or continuous. There is rarely 
any disturbance from the bladder. Only one patient presented this symptom. 



DIAGNOSIS. 

Before making a diagnosis of idiopathic renal hematuria, every other cause 
of bleeding from the kidney must be excluded. This is often a difficult under- 
taking and must be carried out with great care and thoroughness. All the 
kinds of hematuria described imder Chapter VII should be thought of. One 
should be sure that there is neither poisoning nor infectious diseases and that 
the coagulability of the blood is normal. The presence of other elements than 
blood in the urine is of great importance. Pus and bacteria will indicate in- 
fectious diseases ; large numbers of casts and albumin, true nephritis. A stone 
should be found, if present, either by the wax-tipped catheter or the X-ray 
plate. Tuberculosis should be excluded by giving tuberculin in addition to 
examination for the organism in the urine. In case of renal tumor valuable aid 
is obtained by comparing the functional activity of the two sides. In essential 
hematuria the bleeding kidney is as active as the other one, whereas in case of 
neoplasm it is much more likely to be reduced in its function. Endocarditis 
should suggest an infarct. In all cases the careful clinical history is of great 
importance. In the essential hematuria and nephralgia there is no general 
disturbance ; the temperature and pulse are normal. In spite of all effort, how- 
ever, some cases will remain in doubt. A vsmall tumor of the kidney or its 
pelvis or an aneurism might cause identical symptoms and physical manifesta- 
tions. 

TREATMENT. 

After a diagnosis has been reached, it is justifiable to try an expectant 
and a medicinal treatment, providing the hemorrhage per se is not so great as 
to endanger the patient's life. In none of our cases have we had the misfor- 
tune to have the condition subsequently proved to be neoplasm. The results 



TREATMENT. 7 

of the expectant treatment, however, are not nearly so brilliant as of the 
operative. Out of ten eases treated medicinally, five were relieved, two re- 
lieved only after long periods in bed, and three not relieved. The patient 
should be put to bed and kept on a milk diet. In this way many cases of 
hemorrhage can be checked. In cases 12, 14, and 24 treatment of this kind 
was sufficient to check hemorrhage, which had persisted for months. In case 
16, where there was a pregnancy, it was likewise successful. Various styptics 
may be given in full doses by mouth. M. Freund (Centralbl. /. d. Ham- u. 
Sex.'Org., 1906, xvii, 204) recommends stypticin in full doses. Cases are 
on record where ergot has proved of value. Molnov reports the use of adrenalin 
by mouth, in 20-minim doses every four hours. Personally we have not seen 
very brilliant results from such drugs. In case 15 our associate. Dr. Russell, 
injected 15 c. c. of a 10 per cent, adrenalin solution with complete cure. Dr. 
Hugh Young of Baltimore recently reported a successful case of this kind. In 
Young's case there was a recurrence of the hemorrhage in the fall of the year, 
bat it persisted only a few days and then ceased. We think it quite likely 
that cases relieved in this way are due to some small varix in the pelvis of the 
kidney. Neither RusselPs nor Young's case was associated with colic. In a 
number of cases where we have tried adrenalin personally it has failed. With 
such marked results in other cases, however, it is a method that should be car- 
ried out in every case. Albarran (14/A Intemat, Congress of Med,, Madrid, 
1903) reported a case in 1903 where, as the result of a cystoscopic examina- 
tion, the hemorrhage ceased. He quotes a case of Picque and Reblaub (Rev. 
de chir., 1895, xv, 927), who diagnosed that the hemorrhage came from the 
bladder and did a suprapubic cystostomy, only to find that the bleeding was 
coming from one kidney. The patient was sent back to bed and an operation 
on the kidney planned for the next day. The bleeding, which had been long 
continued, stopped spontaneously, and no other operation was necessary. In 
one of our own cases the hemorrhage, as well as the colic, ceased for about 
three months after catheterizing the ureter (see case 13). When, in spite of 
these medicinal measures, the trouble still continues, an exploratory operation 
should be performed. 

The kidney is reached by the usual lumbar incision and should be de- 
livered through the incision. If it is found to be normal-looking it should be 
opened up in the plane of vascular cleavage by means of the silver wire meth- 
od. The pelvis, calices, and apices of the pyramids can by this means be 
explored. The kidney should then be sewn together if no disease is found, 
and the incision closed, with the exception of a small drain down to the kid- 
ney. The results of this procedure are most excellent We have employed it in 



8 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

nine cases. In two cases the hemorrhage did not cease at once, but was greatly 
decreased and ultimately ceased. The pain was relieved in all except one 
(case 22). Out of eleven cases Israel reports six relieved by nephrotomy, 
three temporarily relieved, and two not benefited. 

We have never found it necessary to leave the kidney open and let it heal 
by granulation, as suggested by Israel. Durham reports a case which contin- 
ued to bleed for two years after his nephrotomy. The condition was relieved 
by a nephrectomy. When the hemorrhage is of small amount and the pain 
marked and low down, suggesting a ureteral stone, we would advise an explora- 
tion of the ureter through a muscle-splitting incision. This can readily be ex- 
plored all the way from the kidney pelvis to the bladder. We did this operation 
in cases 18 and 20 with complete relief of the symptoms. It is possible to 
palpate tlie kidney through the incision made to explore the ureter. The 
nephrotomy is effectual when there is actual nephritis present, as shown by 
the presence of casts and albumin, as is evidenced in case 6 of our list. Ede- 
bohls (Med. Recordy 1901, Ix, 961) had secured a complete cure in the same 
kind of a case by decapsulation. In case 23 of our series decapsulation was 
performed with perfect relief. This patient did not have an ordinary form 
of nephritis, but there were adhesions between the fatty and the fibrous cap- 
sules. Harrison {Brit. Med. Jour., 1901, ii, 1,125) reports three cases 
successfully treated by renipuncture. Nephrectomy, which was carried out in 
a number of the early cases*, should never be done unless all other methods 
have failed and the patient continues to bleed to such an extent that life is in 
jeopardy. This must be a very rare condition. 



ILLUSTRATIVE CASES. 

Case 1,— Gynecological Number 11,393. Mrs. H. P. Age 37. White. 
Admitted July 7, 1904. Discharged August 1, 1904. Complaints: attacks 
of colic in right kidney, associated with hematuria of moderate degree. 

The family history was negative. The past history was that patient had al- 
ways been delicate, no definite disease of any kind. She was the mother of seven 
children. The youngest child five years old. Present illness, the patient had 
suffered from attacks of pain in the right side for five years, the attacks being 
frequently associated with small amounts of blood in the urine. The attacks 
of pain began in the kidney and radiated down toward the bladder. The at- 
tacks came every week or two and would last for an entire day. The patient 
had acquired the morphia habit. The general physical examination showed 



ILLUSTRATIVE CASES. 9 

a stout but well-nourished woman. No evidence of disease made out in the 
heart or lungs, temperature and pulse being normal; 78 per cent of hemo- 
globin; the leukocyte count 6,000. Neither kidney was palpable; the pelvic 
organs were normal ; the urine, except for an occasional blood cell, was normal. 
A wax-tipped catheter was passed into the right ureter up to the kidney, but 
no scratch mark was obtained. The X-ray picture also showed nothing. The 
right kidney was injected with sterile salt solution and its capacity found to 
be 8 c. c, A typical attack of the pain from which she was suffering was thus 
brought on. 

Operation: July 3, 1904. The right kidney was explored through a typi- 
cal lumbar incision. It was normal in shape and appearance. It was opened 
in the plane of vascular cleavage in the long axis. No alteration of any kind 
was found. The kidney was sewn up w^ith catgut sutures. 

Results: Except for a slight temperature after the operation for a few 
days there was no complication following this operation. The patient ceased 
having pain and has had none since then. Several careful examinations of 
the urine made three years later showed that it was perfectly normal. 

Case 2. —Mrs. N. G. Gynecological Number 9,370. Age 37. White. 
Admitted January 28, 1902; discharged February 2, 1902. 

The family and past history are entirely negative in this case. The patient 
had had no pain of any kind, but stated that she had been having blood in the 
urine for 2 J months. The general physical examination showed a fairly 
healthy-looking woman. Hemoglobin 78 per cent. 

Neither kidney was palpable. The pelvic organs were normal. The urine 
showed blood, but no casts or other abnormal elements. Cystoscopic examina- 
tion showed a normal bladder and bloody urine from right kidney. The 
amount of urine from the two kidneys was equal. This patient declined an 
operation. She was seen five and a half years later, in 1907, and reported 
that, with the exception of two intervals of about three weeks each, blood con- 
tinued to be present in the urine at all times. That the amount of blood 
varied greatly. At times there were small clots. There had been no pain of any 
kind. She had been hard at work. Cystoscopic examination made on June 20, 
1907, showed that the bladder was normal, that both ureteral orifices were 
normal Both kidneys were catheterized, the lengths of the ureters were equal, 
26 cm. in each case ; the right kidney was secreting a urine made red by blood 
while the left side was secreting normal, clear urine. In ten minutes the left 
kidney secreted 6 c. c. of urine and the right 6J. The polyuria test showed 
that both kidneys were equally active. The amount of urea was identical on 
die two sides. 



10 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

Case 3. — Mrs. L. S. Gynecological Xumber 1,371. Age 37. White. 
Admitted June 5, 1892; discharged July 22, 1892. 

The family history was negative. Had been married 17 years. Several 
children. Had never had any acute illnesses of any kind. The present trouble 
began two months after the birth of her last child, five years ago, when she 
for the first time noticed blood in the urine. This blood was only present for 
one day. It did not return again for six months. It, however, gradually 
became more frequent, coming every week or two, and for the past five weeks 
the urine had been continuously bloody. Patient had never had any pain what- 
ever in either kidneys or bladder. Physical examination showed a well-nour- 
ished woman, the heart, lungs, and the abdominal organs were normal on exam- 
ination. She was quite anemic. Hemoglobin 45 per cent Temperature and 
the pulse were normal. The urine was normal except for the presence of blood. 
The urine was examined for some days without ever finding a cast. Cysto- 
scopic examination showed a normal bladder and at first bleeding from both 
kidneys. Kepeated examinations, however, disclosed the fact that the bleeding 
was almost entirely from the right kidney. On July 2, 1892, the right kidney 
was explored. It was apparently normal in every way. It was opened in 
the plane of vascular cleavage longitudinally and the pelvis also explored. 
Kidney was sewn up. The patient made an uninterrupted convalescence, and 
went out of the hospital without any hemorrhage. The urine at that time was 
perfectly normal. Kesults: For three years after the operation, at intervals 
of several months, the patient had hemorrhages lasting a day or two, but in 
the twelve years following the first four years there was no return of hemor- 
rhage, so that this patient, we know, has been perfectly well for about four- 
teen years. 

Case 4. — Mrs. Z. Q. Gynecological Number 1,654. Age 36. White. Ad- 
mitted November 1, 1892 ; discharged November 29, 1892. 

The family and past history were entirely negative. The menstrual history 
was negative. The patient had had one child, nine years ago. The patient 
had been having blood in the urine for about a year. At times it was absent for 
a day or two; was never very great in quantity. The general condition of this 
patient was excellent. There was no evidence of disease outside of the urinary 
tract. The urine was normal except for the blood. The bladder on cystoscopic 
examination was found to be normal. On catheterizing the ureter both kidneys 
were found to be functionating, but the bleeding was entirely from the left 
side. On October 9, 1892, operation wns performed; left kidney was found 
perfectly normal-looking. Its pelvis was found to be normal-looking. A 
small piece of tissue removed at the time of operation proved to be normal. 



ILLUSTRATIVE CASES. 11 

The kidney was drained. Result: The patient ceased having hemorrhage, and 
for two years was perfectly well. She has been lost sight of since that time. 
Cases.— Mrs. H. C. Gynecological Number 11,282. Age 37. White. 
Admitted May 16, 1904; discharged June 18, 1904. 

The patient gave a family history of tuberculosis, but has always been well 
and strong herself. She had four normal pregnancies. She dated present ill- 
ness to an attack of renal colic nine years before she came to the hospital. She 
had frequency of menstruation at that time and passed a stone by the urethra. 
Three years later she passed another stone. From that time onward there 
was no trouble until three months earlier, when a dull pain began in the 
Jcft loin. Physical examination showed a healthy-looking woman. Temperature 
normal. Heart and lung examination normal. Neither kidney enlarged or 
tender. Neither kidney palpable. On cystoscopic examination bladder found 
xiormal. The bloody urine was found to bo coming entirely from the left kid- 
tiey. Both ureters were catheterized. The right kidney was found to be se- 
crreting in 8 minutes 6.4 c. c. of urine with a percentage of urea of .005. In 
-the same time the left kidney secreted 4.3 c. c. with a percentage of urea of 
^003. The wax-tipped catheter showed no scratch marks. The X-ray also 
-^rsLS negative. The urine contained no abnormal elements except blood. It 
^would seem from the urine examination here that the left kidney was really 
l)etter than the right. Unfortunately no subsequent studies were made. The 
operation was carried out on May 28, 1904. On cutting down on the kidney 
a perfectly healthy organ was found so far as external appearance was con- 
cerned. Longitudinal nephrotomy was done. Macroscopically the kidney 
parenchyma and pelvis looked normal. 

A small piece of tissue removed from the kidney proved on microscopical 
examination to be normal. Results : This patient made an uninterrupted con- 
valescence and has remained for six years without any recurrence whatso- 
ever of the hemorrhage. She has had a child in the interval without any 
bad effect. 

Case 6. — ^Mrs. N. B., Gynecological Number 13,605. Age 60. Date of 
admission February 18, 1907. 

The family history showed marked tuberculosis, but the patient had always 
been a healthy woman herself until about six years before, when, after an 
attack of la grippe, she had an attack of pain in the right kidney region, lasting 
for two hours, followed by the appearance of blood in the urine. At inter- 
valfl since then patient had had recurrence of attacks of hematuria lasting from 
erne to three days, sometimes without pain and sometimes associated with colic. 
Once or twice there had been severe attacks of pain. The patient in this case 



12 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

was a healthy-looking woman for her age. The heart and arteries were normaL 
There was no fever. On palpation hoth kidneys were tender and enlarged. 
The hladder on cystoscopic examination was normal. Both kidneys were 
catheterized. From both kidneys urine containing albumin, hyalin, and gran- 
ular casts was obtained. The urine from the left kidney was clear ; that in the 
right bloody. Functional tests from the two sides showed about equal secretory 
function from the two kidneys. Operation was carried out by the usual lum- 
bar incision. Rather large red kidney was found. Typical nephrotomy done. 
A piece of kidney removed for microscopical examination showed marked in- 
terstitial nephritis and proliferative glomerulitis. The patient made an unin- 
terrupted convalescence and the blood immediately ceased appearing in the 
urine. It has recurred, however, in small quantities since that time. 

Case 7. — Mrs. J. C, Gynecological Number 9,923. Age 46. Admitted 
October 30, 1902. Discharged January 7, 1903. 

The family history was negative. The menstrual history negative. The 
patient had had four children, the youngest eight years old. She had had no 
illnesses of any kind. Her trouble started six months before coming to the 
hospital, with slight attacks of pain, small amounts of blood in the urine. 
Since beginning the bleeding had been continuous, but the pain only came in 
attacks. It consisted in a slight attack of pain in the left kidney region. 
The general condition of this patient was rather poor. Temperature and 
pulse were normal. Hemoglobin 65 per cent. Neither kidney was enlarged 
or tender, and neither movable. The X-ray was negative. The tubercular 
reaction was also negative. Both ureters were catheterized. The urine from 
the left side^ was quite bloody. That from the right side normal. The opera- 
tion was performed on November 12, 1902, by the usual lumbar route. A 
perfectly normal-looking kidney found. Our usual nephrotomy was performed 
and on section the kidney looked normal. The kidney was sewn up and re- 
placed. While in the hospital the hemoglobin rose to 85 per cent. Since that 
time the patient has remained perfectly well and there has been no recurrence 
of blood in the urine. 

Case 8.— Dr. L. N. S., Sanatorium Number 234. October 15, 1895. 

The patient in this case was a physician. The hemorrhage was from the 
right kidney. The urine contained, in addition to albumin, blood, hyalin and 
granular casts. The bleeding was entirely from the right side. The condition 
was chronic interstitial nephritis. A nephrotomy performed on the right 
kidney in the usual manner immediately controlled hemorrhage. There was 
a cessation of hemorrhage in this case. Patient remained well until his death 
some years later. 



ILLUSTRATIVE CASES. 13 

Case 9. — Mrs. F. H. V., Sanatorium Number 850. Age 64. April 2, 1900. 
The family history was unimportant; also the past history. The present 
trouble had been in existence for about 15 weeks, and consisted in frequent 
recurring attacks of hematuria, associated with a marked stinging sensation 
in the bladder, but no pain referable to the kidneys. The patient was a delicate- 
looking woman. The temperature \vas normal, and there was no evidence of 
disease except the hematuria. The urine, except for the blood, was normal. 
Jfeither kidney was palpable or tender. On cystoscopic examination the blood 
iiras found coming entirely from the left kidney. Functional tests showed that 
the twro kidneys were equally active. The wax-tipped catheter was not scratched. 
X-ray was negative. The capacity of the renal pelves was normal. The patient 
in this case was kept quietly in bed for several weeks and the attacks ceased. 
She then went home, and the bleeding began to recur with attacks every six or 
geven days. She was almost confined to her bed. After six months the severity 
of the bleeding became less and the intervals greater. By the fall of 1901 they 
had entirely ceased. This patient, nearly 75 years old, is still living and has 
had no recurrence. 
Cem 10.— Mrs. A. B. Age 36. January 2, 1907. 

Family history tubercular. The patient, when about 17 years old, had a 
severe attack of hysteria, but has otherwise been well. Her trouble began 
in April, 1900, with a slight attack of renal colic on the right side, followed 
by hematuria. A month later she was operated on for extra-uterine pregnancy. 
In 1902 there was a severe attack of renal pain in the left side, lasting for half 
an hour. In September, 1905, she had a severe attack of colic in the left side, 
accompanied by marked hematuria. Since then every menstrual period has 
been preceded by a similar attack. Numerous X-ray pictures show nothing. 
In July, 1906, the uterus was suspended and adhesions about the site of old 
operation on the left side cut. The left ovary was also removed. The patient 
in this case was a healthy-looking woman. At the time I saw her, March 8, 
1897, the urine was perfectly normal. Both kidneys were catheterized. The 
nrine collected from each side was normal and equal. The left kidney was in- 
jected and the pelvis found to contain 7 c. c. of fluid. Following this injection 
and beginning a few hours later the patient had a severe hematuria, lasting 
several hours. 

Cue 11. — Mrs. S. B., Gynecological Number 9,357. Age 59. January 
23, 1902. 

Family history was unimportant. The patient had scarlet fever when a 
child, but no other illnesses. She was the mother of nine children. Her present 
trouble had been in existence for a month, and consisted of blood in the urine 



14 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

and some pain in the right kidney region. The patient was of small frame 
but well nourished. Temperature and pulse normal. There was a spot of red- 
dening in the base of the bladder. There were white and red blood-corpuscles 
in the urine. No organisms were found. The spot in the bladder cleared up 
promptly on treatment. She continued, however, to have pain in the right 
side, and there was bleeding from this kidney. The urines from the two 
kidneys were identical except that in the right there was blood, and in the left 
no blood. The amount of blood was rather small. Injection of the right kid- 
ney produced intense pain. The X-ray was negative and there were no scratch- 
marks. This patient declined operation, and a year and a half later was still 
having her symptoms. She has been lost sight of since then. 

Case 12. — ^Mrs. E. B., Gynecological Number 13,967. Age 20. July 2, 
1907. 

Family history was negative, also past history. The patient had one child 
three years old. For several months she had had severe pain in the right side 
associated with blood in the urine. Since its first appearance the blood contin- 
ued in rather large quantities. The patient was a rather slightly built woman ; 
heart, lungs, and temperature normal. The blood was coming entirely from the 
right kidney, which was secreting as much urine as the left. She remained in 
the hospital six days and the bleeding ceased, but the pain remained. Two 
years later she wrote that she had had no recurrence of the bleeding, but had 
had almost constant pain. The X-ray and the wax-tip gave negative results in 
this case. The patient refused all operative treatment. 

Case 13.— Mrs. A. S. G. Age 36. February 26, 1907. 

Family history and past history entirely negative in this case. Seven years 
before, her present trouble began with a severe attack of pain in the right kid- 
ney. There was aching in this side afterward for six months and it was asso- 
ciated with blood in the urine. In the fall of 1905, five years later, there was 
another attack of pain, which lasted several weeks. In the spring of 1906 
the next attack of pain occurred. This was followed by frequent attacks dur- 
ing the summer of 1906. In the fall of 1906 she began noticing blood in the 
urine. The attacks continued up to the time she came to us. Neither kidney 
was palpable or tender, and the patient^s general condition was excellent. This 
patient was examined first during an attack of bleeding. The hemorrhage 
was found to be coming slowly from the right kidney. The two kidneys were 
functioning equally. The bladder was normal. There were no abnormal con- 
stituents except blood in the urine. Injection of the right kidney reproduced 
the pain. Tuberculin was negative, as well as the X-ray and wax-tip cultures. 
Following the catheterization this patient remained well for several months. 



ILLUSTRATIVE CASES. 15 

Since then, however, there have been some recurrences. The amount of hemor- 
rhage is never great in this case. 

Case 14. — Mrs. M. S., Gynecological Number 11,321. Age 43. Admitted 
May 31, 1904. 

The family and past histories were negative. The patient had had five chil- 
dren. Her trouble consisted of blood in the urine. No pain. This blood had 
been present for two months. The amount of blood was not great. The general 
physical condition of this patient was excellent. Bladder examination showed 
that the bleeding was entirely from the left kidney. The two kidneys were 
secreting approximately equally. This patient was kept in bed and went home 
on June 16 entirely well. Six months later she was still well. Has been lost 
sight of. 

Ca»c 16. — ^Miss E. W., Gynecological Number 8,375. Age 47. Admitted 
December 10, 1900. 

The family history in this case was tubercular, but the patient had always 
been a healthy woman. She began bleeding in February, 1900. The only 
symptom was blood in the urine. This was constantly present. The urine 
except for the blood was normal. Both kidneys were very movable. The 
hemoglobin at the time of observation was only 27 per cent. The bladder ex- 
amination showed that the bloody urine was coming solely from the right kid- 
ney. The patient^s right kidney was catheterized by Dr. W. W. Russell, and 
15 c. c. of a 10 per cent, solution of adrenalin injected into its pelvis. The 
hleeJing stopped at once and never recurred. In March, 1901, hemoglobin 
had reached 80 per cent. 

Case 16. — Mrs. M. J., Gynecological Number 12,335. Age 32. Date of 
admission Septeinber 6, 1905. 

The family history negative, as well as the past history. The patient had 
had pain in the left kidney and blood in the urine for three months. The 
urine was otherwise normal. Neither kidney was palpable ; no evidence of 
any general disturbance. On cystoscopic examination the bladder was normal. 
The blood was found to be coming from the left kidney entirely. This patient 
was about five months pregnant. No operation was done, but by being kept 
partly in bed the bleeding entirely ceased, and the pain was better. This 
patient went home and has been lost sight of. 

Caie 17. — Mrs. L. L., Gynecological Number 11,818. Age 34. Admitted 
January 18, 1905. 

The family history in this case was markedly tubercular, and the patient's 

past history indicated pulmonary tuberculosis now healed. The patient had 

■ had several children. The present illness had been in existence for 14 



I 



16 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

years, and consisted of attacks of colic beginning in the region of the left 
kidney and radiating downward toward the bladder. There were no symptoms 
of bladder disturbances. The urine was perfectly normal. The general physi- 
cal examination showed a well-nourished woman. No evidence of the tubercu- 
losis could be found in her lungs. The left kidney was not palpable ; the right 
kidney was palpable, but apparently normal. On catheterizing them, both kid- 
neys found to be secreting actively. Injection of normal salt solution into pelvis 
of left kidney brought on attacks of pain similar to those with which the patient 
suffered. This patient was operated on, January 23, 1905; a kidney was ex- 
posed through the lumbar incision and found to be normal-looking. Its pelvis 
contained no stones. A nephrotomy was done. The incision of this operation 
healed promptly, and the i)atient was entirely relieved of her attacks of pain. 

Case 18.— Mrs. E. B., G:>Tiecological Number 13,522. Age 46. Admitted 
January 21, 1907. 

The family history as well as the past history was entirely negative, except 
that in January, 1905, she had an operation for fistula in ano. Her present 
illness dated from a fall ten years before, since when there had always been pain 
in the left kidney. This had been so severe as to confine her to the bed most of 
the time, and the pain was made much worse by the menstrual period. The 
patient was a well-nourished woman ; the urine contained a trace of albumin, 
but no other abnormal elements. The pelvic organs normal. Neither kidney 
palpable, but there was a slight tenderness in the region of the left. The 
bladder found normal. Both kidneys catheterized. Ten c. c. of fluid injected 
into the pelvis of the left kidney reproduced the pain. There was a trace of 
albumin in urine from both kidneys. The urine from each kidney was equal. 
Operation on January 23, 1907. The entire ureter explored and found nor- 
mal. The kidney examined and found normal; not movable. The incisions 
healed promptly in this case, and the patient went home entirely relieved. 

Case 19. — Mrs. J. B., Gynecological Number 7,948. Age 26. Admitted 
July 9, 1900. 

The family and past history were entirely negative. Present illness con- 
sisted of attacks of pain for about two years in the right kidney. The kidney 
was slightly movable. The urine contained blood cells and albumin. Catheter- 
ization and injection of the right kidney reproduced the pain. Operation per- 
formed July 11, 1900. The right kidney was explored; no stone foimd. The 
kidney was suspended. Patient made an uninterrupted convalescence, and six 
years later wrote that she had no return of pain. 

Case 20. — ^JMiss P. R., Sanatorium Number 2,504. Admitted June 17|^ 
1907. Age 16. 



ILLUSTRATIVE CASES. 17 

Family and past history negative. The patient in this case had had trouble 
for three years. Pain was constantly present hut was varied in intensity ; was 
gradually growing worse. Always increased at menstrual periods; not in- 
fluenced by posture. Began where left ureter crossed pelvic brim and radiated 
toward the leg on the left side. Once or twice there was blood noted in the 
urine. There was some frequency of urination during the day. The patient 
had had almost every variety of rest cure and medicinal treatment without re- 
lief. The general physical examination showed that the girl was quite healthy. 
X-ray picture of the kidney was negative. The kidney was not movable. The 
urine was perfeiqtly normal. Both kidneys found to be functioning equally and 
normally. Seven c. c. of fluid injected into the left kidney produced the pain 
that the patient complained of. Operation. Muscle-splitting incision at Mc- 
Bumey's point. The ureter was exposed from pelvic brim to kidney. No 
disease was found. This patient made an uninterrupted convalescence and 
has remained well. 

Case 21. — Miss A. W., Gynecological Number 10,365. Age 40. Admitted 
March 28, 1903. Discharged April 25, 1903. 

Family history in this case was markedly tubercular, but the patient had al- 
ways been well. Her present illness had lasted for ten years. The onset was 
intense pain in the back, nausea and vomiting, and frequency of micturition. 
The pain was constant, but also exacerbated in attacks. Physical examination 
showed the patient was rather poorly nourished. No evidence of diaease was 
evident elsewhere than in the kidney. The urine was perfectly normal. Neither 
kidney movable. The right kidney was catheterized and found to be secreting. 
Eight c. e. of fluid injected reproduced the pain. On April 3 incision was made 
down to the right kidney, which was found normal-looking. It was suspended 
with three silk sutures to the last rib. This patient subsequent to her operation 
was entirely relieved of her attacks of pain, but still had a dull aching. 
Case. 22. — Mrs. M. L. F., Sanatorium. Admitted June 1, 1900. 
The family history as well as past history negative. The patient had had 
backache for many years, and for three years had had severe dull aching pain in 
the right kidney regions. The pain also came in attacks and radiated through 
the leg. The right kidney had been suspended two years before without relief. 
The urine was normal. The patient was a healthy-looking woman. The right 
kidney was injected and brought on a typical attack of pain. In June, 1900, 
through an exploratory laparotomy the ureter was explored from bladder to 
kidney and found normal. The kidney was then explored from the lumbar 
region, was opened, and found normal. The incisions promptly healed in this 
case. The patient, however, was unrelieved of her pain. 



18 ESSENTIAL HEMATURIA AND NEPHRALGIA. 

Case 23.— Dr. N. H., Sanatorium Number 1,588. Age 65. 

Family history negative. Past history began 12 years ago in an attack of 
renal colic. Ko trouble from then until the present. Present illness began one 
year ago. At intervals of five to eight weeks had been having severe attacks 
of pain in the right kidney. The pain lasted from three to forty-eight hours. 
The pain began in the right kidney and radiated down toward the bladder. 
During the attack micturition was increased in frequency and the urine some- 
times contained blood. On physical examination the patient was a healthy- 
looking man. The urine was normal. The prostate gland was normal ; bladder 
normal. Both kidneys actively secreting. Operation October 13, 190*3. Lum- 
bar incision down to right kidney. The kidney was normal in size and shape. 
There were adhesions between the upper pole and the fatty capsule, and over 
the kidney at several places were noted thickenings of the capsule with depres* 
sions. The kidney was decapsulated. Small piece of kidney tissue was re- 
moved for examination. This proved to be quite normal. The incision healed 
promptly in this case ; the patient was relieved, and seven years later the report 
was brought of no recurrence. 

Case 24. — Miss L. C, Sanatorium Number 2,320. Age 48. 

Admitted January 14, 1907. Family history good. Past history good. 
The present illness consisted of attacks of pain in the right kidney region asso- 
ciated with frequency of micturition. The patient in this case was anemic-look- 
ing, hemoglobin 60 per cent. The urine contained albumin and hyalin and 
granular casts. The urine from the two kidneys was identical. Injection of 
the right kidney reproduced pain. On a milk diet, rest in bed, and water 
this patient was relieved of her pain, but there was no relief of the nephritis. 



CHAPTER XIX. 
TUBERCULOSIS OF THE KIDNEY. 

fflSTORY. 

Study of tuberculosis of the kidney is distinctly modem, for practically all 
present-day understanding of the condition has been elaborated during the past 
century, most of it during the past twenty years. The firsit recorded case is that 
of the celebrated pathologist, Morgagni ("De Sedibus et Causis Morborum," 
1767, iv, 336), who, while doing an autopsy, found that the left kidney was 
tuberculous through an extension of the process from a large mass of contiguous 
Ivmph glands. During the early years of the nineteenth century a number of 
isolated clinical studies and autopsy reports of tuberculous kidneys were made. 
Some of the old observers showed a keenness that stands in marked contrast to 
many of our reports at the present time. Howship ("A Practical Treatise on 
the Symptoms, Causes, Discrimination, and Treatment of Some of the Most 
Important Complaints that Affect the Secretion and Excretion of the Urine," 
1823) recounts the histories of two patients in a most thorough way, pointing 
out the frequency with which all the symptoms may arise from the bladder, 
while the kidney itself, the actual seat of disease, gives no indication of disorder. 
It is the one peculiarity of tuberculosis of the kidney which to this day confuses 
80 many physicians and leads to useless and harmful treatments of the bladder, 
through a failure to recognize that the kidney is at fault. 

Raver ("Traite des maladies des reins, etc.," 1841), making a full report 
of 16 cases, was the first to attempt a systematic investigation and classification 
of the condition. He made three subdivisions: 

(1) Those where the kidney is involved conjointly with a number of other 
organs, and no local symptoms develop from the kidney. 

(2) Those where the disease is limited to the kidney and its pelvis. 

(3) Those where the disease, in addition to involving the kidney, has also 
attacked the bladder alone or the bladder and the genital organs (urogenital 
tuberculosis). 

It is impossible to pass on without referring to the remarkable watercolor 

19 



20 TUBERCULOSIS OF THE KIDNEY. 

illustratione of tuberculous kidneys, pictured in Rayer's "Atlas^" These will 
always remain as models of illustrative work and give us a conception of how 
thorough his work was. In spite of this advanced investigation, little general 
interest was manifested in the disease for many years. Schmidtlein (Dtsche. 
Klinik, 1863, xv, 185 ; 264) described the two modes of the spreading of tuber- 
culosis in the urinary tract and laid the basis for the ideas of urogenital tuber- 
culosis which persist to this day. Up to 1890 practically all observers held that 
the so-called ascending tuberculosis, which began in the genital organs or bladder 
and involved the kidney by extension up the ureter, was the common method by 
which the kidney became infected. To-day we know that the kidney is prac- 
tically always infected through the blood, and the infection of the lower urinary 
organs is secondary to it. 

Only a very few autopsy reports, where tuberculosis was found limited to 
the kidney alone and the rest of the body clear, are found in the literature ; but 
Buch a condition was observed by Lancereaux, 1872. 

Surgical operations on tuberculous kidneys followed closely on Simon's 
demonstration (1869) that one kidney could be removed and its fellow carry 
on the necessary elimination of urine. 

Bryan (1870) removed a tuberculous pyonephrotic kidney without recog- 
nizing it to be sucL Peters (A^ Y. Med. J., 1872, xvi, 473), operating for 
what he thought was a calculous pyonephrosis, found the condition tuberculous, 
and removed the kidney. This was the first deliberate nephrectomy for renal 
tuberculosis. In 1885 Gross the younger was able to collect from the literature 
twenty cases of nephrectomy for renal tuberculosis with eight deaths immedi- 
ately following operation, and so many more occurred in a short time that 
eminent authors, such as Dickinson and Morris, openly questioned the pro- 
priety of ever removing a tuberculous kidney. 

Precise grouping of all the tuberculous diseases under one head was made 
possible by the discovery of Koch (1882), who isolated the tubercle bacillus and 
showed its relationship to scrofula, pulmonary consumption, white swelling, and 
the various other tuberculous manifestations with which we are so familiar. 

Babes (1883) demonstrated tubercle bacilli in the urine of a patient suffer- 
ing with a tuberculous kidney and advocated this now much used method of 
examination for help in diagnosis of the condition. 

But operative attempts at the treatment of kidney tuberculosis were desul- 
tory, indifferent, and half hearted until the nineties of the last century. In 
large measure lack of confidence arose from the belief that tuberculosis of the 
kidney was but the end stage of a tuberculosis of the entire urinary tract. The 
distinguished urologist, Guyon (Ann. d. mal. d. org. genito-vrin., 1888, vi, 577) 



THE OCCURRENCE OF KIDNEY TUBERCULOSIS. 21 

declares : "We do not know of a single case of renal tuberculosis primitive and 
unilateral without lesions of the same kind in the bladder, the seminal apparatus, 
or other organs." The valuable pathological work of Steinthal {Virchow^s 
Archiv, 1885, c, 81) was the first upset to this view. In a series of twenty-four 
autopsies upon patients suffering with genito-urinary tuberculosis he found the 
kidney involved in every case ; the lower tract in only 50 per cent, of the cases ; 
while in nine instances the kidney alone was involved. Prior to his report 
autopsy findings had already demonstrated that in one-half the cases of renal 
tuberculosis only one kidney was involved. Furthermore his investigations were 
presented with such directness and clearness that numerous pioneer surgeons 
boldly Ix^n removing the diseased organs. Between 1890 and 1900 the names 
of Israel, Albarran, Morris, Tufiier are inseparably connected with the mar- 
velous progress of surgery in treating this condition. During this period, too, 
were bom modem cystoscopy and catheterization of the ureters. This method 
of examination quickly showed that kidney tuberculosis was often unilateral, 
demonstrated which side was involved, and lent so much certainty to the surgical 
work that all disputes as to this question had almost di,ed out by 1900. It is 
of interest, in view of our present attitude, to consider the diatribes aimed at 
catheterization of the ureters by many of the leading men of that period. 



THE OCCURRENCE OF S3DNEY TUBERCULOSIS. 

Twenty years ago the surgical form of renal tuberculosis was considered 
rare. With our ability to recognize the disease and to disseminate widespread 
knowledge in regard to it, we now know how common an occurrence it is. 

The actual frequency, owing to incompleteness and inaccuracy of vital sta- 
tistics in the Health Departments of this country, cannot be stated. It is neces- 
sary, therefore, to fall back on the less representative autopsy records of general 
hospitals. Naturally, the frequency of the condition in these hospitals varied 
with the character of the patients admitted, much higher percentages being ob- 
served in those institutions freely admitting suiferers with pulmonary tubercu- 
losis than in those which excluded such patients. For this reason, it seems more 
systematic to consider the statistics of occurrence in a classified order, which we 
will do under seven headings : 

(1) The frequency of tuberculosis of the kidneys at autopsy without ref- 
erence to the class of subject admitted to hospital. 

(2) The frequency where there is active tuberculosis in some other 
part of the body. 



22 TUBERCULOSIS OF THE KIDNEY.' 

(3) The frequency of miliary tuberculosis. 

(4) The relative frequency of miliary and caseo-cavemous tuberculosis of 
the kidney. 

(5) The influence of age. 

(6) The proportion of unilateral to bilateral cases in caseo-cavernous tuber- 
culosis. 

(7) Renal tuberculosis without the disease being present elsewhere. 
Now, taking these questions categorically : 

(1) Frequency of Autopsies of Tnbercnlous Kidneys, Without Any Beference 
to Particular Class of Subject. — The combined statistics from five great hospitals 
show in 12,688 autopsies 603 tuberculous kidneys, or a proportion of 4.7 per 
cent. The individual percentages varied from 2.2 per cent, to 5.6 per cent. 
(General Hospital of Prague; Tilden Brown's Report, Presbyterian Hospital, 
New York; George Walker, Johns Hopkins Hospital Keport, 1904, xii, 455; 
Henry Morris' report, Middlesex Hospital, London, also ^'Surgical Diseases of 
the Kidney," Morris; and Posner's records, cited by Walker.) 

The statistics are : 



AtUopsies 

Prague Gen. Hosp 4,536 

Tilden Brown 567 

George Walker 1,369 

Henry Morris 3,331 

Posner 4,710 



(2) Frequency of Kidney Tuberculosis at Autopsy with Active Tubercu- 
losis Present in Other Organs. — The importance of information as to the num- 
ber of tuberculous patients admitted to a hospital in estimating the frequency 
of disease is well shown by the fact that in tuberculous patients the percentage^ 
of renal tuberculosis runs from 12 per cent, to 33 per cent, in the statistics o£ 
Posner, Brown, and Walker. These are as follows: 



Cases 

Posner 789 

Brown 68 

Walker 482 



Tuberculosis 




of Kidney 


Per Cei 


256 


5.0 


23 


4. 


61 


4.5 


74 


2.2 


189 


4. 



Tuberculosis 




of Kidney 


Per Ce\ 


189 


26 


23 


33 


50 


12 



THE OCCURRENCE OF KIDNEY TUBERCULOSIS. 23 

Combining the statistics of these authors, it is seen that 20.2 per cent, with 
pulmonary and other active forms of tuberculosis that oome to autopsy have 
tuberculosis of the kidney. 

(3) Frequency of Kidney InTolyement in Cases of Miliary Tnbercnlosis. 
— Just how many of the cases had miliary tuberculosis is even more important 
in c"<>nsidering the statistics, because, in almost every case of this form, there is 
involvement of the kidneys with the tubercles. Walker, for example, in thirty- 
six cases of miliary tuberculosis found both kidneys involved in every one. 
Morris, in twenty-nine, found bilateral involvement in twenty-eight, and one 
kidney involved in one case. 

(4) Relative Frequency of the Miliary and Caseo-cavemons Forms. — ^In 

adults acute miliary tulx*rculosis of the kidney occurs on the average about 

twice as frequently as the casco-cavernous form, but, as Dickinson pointed out, 

iu children the preponderance of the miliary form is much more marked, and 

tbis accounts for the greater frequency of renal tuberculosis in children. In 

adults the frequency is illustrated by the findings of Morris and Walker. 

Morris, in forty-nine cases of renal tuberculosis, had twenty-nine miliary and 

fifteen caseo-cavcrnous kidneys, while Walker, in forty-nine, had thirty-six 

miliary and twenty-three caseo-cavernous types. 

(5) Influence of Age on Frequency of Miliary and Caseo-cavernous Tuber- 
culosis. — The greater frequency of kidney tuberculosis in children is due to the 
fact of the more frequent occurrence of miliary tuberculosis among them. The 
surgical form of tuberculosis, however, is more commonly met with in adults. 
The voungest case we have ever had personally was sixteen years old. It is in- 
teresting to note that Morris in his large statistical studies has never met with 
a cai^e under ten years of age. 

S. M. Hamill (Iniernat. Med. Mag., 1895-6, iv, 881), however, has espe- 
cially investigated the occurrence of the caseo-cavernous form in children, and 
colleeted fifty-five cases out of the literature. Two were under one year, 
thirteen l>etween one and five, eleven between five and ten, and twenty be- 
tween ten and fourteen. Posner, again, who estimates that 25 per cent, of 
adnlts with active tuberculosis of the lungs or elsewhere have renal involve- 
ment, states that 40 i)er cent, of children show it. 

Tiarthez and Rilliet ("Traite clinique et pratique des maladies des enfants," 
1^84-01, iii, 852), in three hundred and twelve autopsies on children under 
twelve, found forty-nine cases of renal tuberculosis, making 15 per cent., which 
stands in marked contrast to the 4.7 per cent, occurring in adults. They 
found also, that in seventy-two active tuberculous cases, forty-nine, or sixty- 
eight per cent., showed involvement of the kidneys. As already stated, this 



24 TUBERCULOSIS OF THK KIDNF.Y. 

great increase in frequency in children is due to the relatively greater frequency 
of miliary tuberculosis. 

Vignard and Thenevot {J. d'uroL, 1912, i, 323) have recently reviewc<l 
this matter in a most interesting way, reporting 47 cases of surgical tubercu- 
losis in children. They mention the case of Bardenheuer, who saw the disease 
in an infant three months old, and note that the right side is more frequently 
involved than the left, that there is a slight percentage more in males than in 
females^ and that the disease is almost always unilateral. 

In small boys there is often associated involvement of one of the semi- 
nal vesicles and prostate. As in the adult, the principal symptoms are those 
from the bladder. In the early stages the frequent occurrence of nocturnal 
incontinence is quite pronounced. The diagnosis and treatment are the same 
as in the adult. Where the disease was unilateral 12 permanent cures followed 
nephrectomy. 

(6) Frequency of Unilateral Renal Tuberculosis of the Caseo-cayemoiu 
Form, in Proportion to the Bilateral Involvement. — From its very beginning the 
miliary form of tuberculosis is nearly always bilateral, but this is not true of 
the caseo-cavernous form, and on this fact the surgical treatment of the disease 
is largely based. We believe almost every case of caseo-cavernous tuberculosis 
begins as a unilateral disease, and that it remains so for a long time is amply 
shown in both autopsy and clinical studies. The influence of age and the influ- 
ence of active tuberculosis in other parts of the bo<ly have bearing here, also, 
in that children are more likely to have the bilateral form, and a patient suffer- 
ing with active pulmonary tuberculosis is more apt to have the bilateral 
form than one without such a lesion. One of the earliest authors to urge 
the frequency of unilateral involvement was Dickinson, his views being clearly 
set forth in his text-book on "Diseases of the Kidney.'' Authors who have 
particularly investigated autopsy findings with reference to this point are 
Fisher (These de Paris, 1802) ; Vigneron (These dc Paris, 1894) ; Halle and 
Motz (.'inn. d. mal. d. org. geniio-urin., lOOG, xxi, IGl). Combining their 
statistics, out of four hundred and fifty-nine autopsy subjects with caseo- 
cavernous tuberculosis, two hundred and fifty-three showed only one kidney 
involved, which gives a percentage of 55.1 per cent This means that even in 
extreme stages of the caseo-cavenious form more than half had only one kidney 
involved by the tuberculous process. 

Morris, emphasizing the difference between children and adults with caseo^ 
cavernous renal tuberculosis, notes, in twenty-eight children under twelve wh<^ 
came to autopsy from this disease, that one kidney was involved in only nin^ 
cases, making 32 per cent.; whereas, in fifty-seven over twelve years of age^ 



THE OCCURRENCE OF KIDNEY TUBERCULOSIS. 25 

twenty-nine, or 50.8 per cent., were unilateral. So the chances of both kidneys 
being involved in a child are almost twice as great as in an adult. 

A common autopsy finding is the total involvement of one kidney, and par- 
tial involvement of the other. Indeed, it is a rare exception to find the kidneys 
equally involved. The study of cases operated on adds to this finding, sug- 
gesting that at the earliest stage kidney tuberculosis of the caseo-cavemous type 
is probably nearly always unilateral. Most of the cases which come to opera- 
tion are in patients who have been suflFering for a long while. Israel estimates 
from his operative results and clinical findings that only 9 per cent, are bilat- 
eral ; in other words, that for every case of bilateral tuberculosis of this type 
there are nine unilateral, and a careful analysis of our own cases leads to the 
same conclusion. 

Taking first those cases where there has been no evidence of tuberculosis else- 
where in the body, and where the disease is limited to one kidney, we have 
bd thirty-four such patients. In every one, operation has seemingly produced 
a permanent cure. Some of them had been suffering from the disease for a 
considerable time, but the absence of bladder involvement justifies putting 
them among the early cases. Taking this series of early cases, we have 100 
per cent, of unilateral occurrence, but, in contrast with these, are sixty-four 
where there was marked involvement of the bladder at the time they came for 
treatment. Nineteen of these have remained well. 

The greater frequency of bilateral involvement in those cases where there 
is evident active tuberculosis in some other part of the body has been noted by 
Morris, who states that out of ten cases limited to the kidney alone, only one 
was bilateral, whereas in sixty-four with marked disease elsewhere twenty-one 
were bilateral. We have had thirty-nine cases with active tuberculosis present 
elsewhere in the body, most of them pulmonary, whose subsequent history has 
shown that fifteen were unilateral and three bilateral. Just as in autopsy find- 
ings, 80 in clinical, the presence of active tuberculosis of the lungs or of other 
parts of the body is shown to give greater chance of bilateral involvement. 

(7) Freqmency of Occurrence of Primary Eenal Tuberculosis Without Evi- 
lenoe of Tuberculosis Elsewhere in the Body. — Rayer was the first to suggest the 
possibility of tuberculosis limited to the kidney, though Hiss evidently assumed 
that such a condition might exist. The great frequency of healed foci of tuber- 
culosis in the bronchial glands, in the lungs and elsewhere makes it extremely 
difficult definitely to determine the tuberculous focus in the kidney the primary 
focus in the body. To explain such a lesion we have to assume that the tubercle 
bacillus has entered into the body and passed into the blood without localizing 
until it reaches the kidney. Clinically, primary renal tuberculosis cannot be 



26 TUBERCULOSIS OF THE KIDNEY. 

shown; our only source of information must be from autopsy studies. The 
necessary rarity of such a finding at post-mortem is understandable when we 
consider the progressive nature of the disease. A patient who dies with a 
tuberculosis limited to one kidney does not die primarily from this cause. 
Albarran has collected five instances from the literature. One is the much 
quoted case of Israel (Dtsche. mod, Wchschr., 1898, xxiv, 443), who reported 
the autopsy findings in a boy of eight years, where there was tuberculosis lim- 
ited to one kidney — a pathological rarity, for in the large statistical studies of 
Steinthal, Vigneron, Morris and Walker no such are described. 

It is not uncommon to find advanced tuberculosis of the kidney and only 
slight tuberculosis in some other part of the body. Walker's conclusion is that 
several of his cases must have been primary in the kidney. Steinthal in one 
case found only a small ulceration in the rectum with a cheesy bronchial gland. 

Taking the frequency of primary renal tuberculosis from the clinical stand- 
point, the figures are different. Hero primary renal tuberculosis is a disease in 
which there is renal tuberculosis, but no signs of tuberculosis in any part of 
the body and no history of such trouble. Israel, for example, found twenty- 
two out of thirty cases, or 73 per cent., to be cases of i)rimary renal tuberculosis. 
Out of our hundred cases the disease was limited to the kidneys or the kidneys 
and bladder in thirty-eight, or Gl per cent. In every caft3 of bladder tubercu- 
losis, with one i)ossible exception, as we show later, the disease was apparently 
primary in the kidney, and the bladder secondarily involved. In thirty-eight an 
operation was done, and all have now passed over more than six years without 
return or evidence of tuberculosis elsewhere. 

PORTAL OF ENTRY OF TUBERCLE BACILLUS TO THE KIDNEY. 

The essential cause of kidney tuberculosis, like that of tuberculosis every- 
where, is the tubercle bacillus. By what rgute the tubercle bacillus reaches 
the kidney and what determines its development when once it is there, are 
important questions. Three principal routes have been described, talked about 
and much discussed, while opinions as to their frequency have materially 
altered with time. 

(1) Through kidney capsule by direct invasion from an infected con- 
tiguous organ. 

(2) Through ureter. 

(3) Through arterial blood system. 

Before 1800 and Ix^fore SteinthaFs work, practically all kidney tubercu- 
loses were regarded as developing from an extension of the process in the blad- 



PORTAL OF ENTRY OF TUBERCLE BACILLUS TO THE KIDNEY. 27 

(ler up through the ureter, but we now recognize infection through the arterial 
vessels by means of tubercle bacilli carried in the blood, as the most frequent 
and iniix)rtant cause. Other routes suggested have but little experimental or 
autopsy evidence in their favor as to actual occurrence. Albarran pointed out 
a venous anastomosis between the two kidneys through the inferior diaphrag- 
matic veins and suggested it as transmitting infection from one kidney to the 
other, affording an additional reason for doing nephrectomy on the tuberculous 
kidney to save its healthy fellow. 

Many have suggested that the tubercle bacillus h carried into the kidney by 
means of lymph vessels, but against this is the fact that there are no lymph 
vessels passing from the outside into the kidney. All lymph vessels flow from 
the kidney outward, and, as we show later, infection by the tubercle bacillus 
rarely occurs against the stream. 

Taking in order the three recognized routes: 

(1) Infection of Kidney Capsule by Direct Invasion from an Infected Con- 
tignoiu Organ. — In practice we have never met with such a case, but there are 
many well-authenticated instances in the literature. Indeed, the first tuberculo- 
sis of the kidney on record, as already noted under history, was an extension 
from the lumbar lymph glands (Morgagni, 1767). Rayer reports two cases 
where involvement took place from an extension of the process from the verte- 
bral column. Xewman ("Lectures to Practitioners," also "Surgical Diseases of 
the Kidney") has described a case coming from a tuberculous empyema, J. 
Patoir (Med. moderne, 1897, viii, 629) describes most interestingly a case of 
a girl of nineteen where both kidneys were involved through an extension from 
a tuberculosis of the vertebral column. Tilden Brown has laid great emphasis 
upon the resistance of the capsule of the kidney to penetration by a tuberculous 
process on the outside; this is perhaps explained by the direction which the 
lymph vessels take. Brown urged that care be exercised in removing a kidney 
for perirenal tuberculosis when the urine is perfectly normal. Not a few of 
these perirenal tubercular abscesses take their origin from the adrenal glands, 
a fact of anatomical and pathological interest rather than of practical clinical 
importance, both because of the rarity of occurrence and because the other tuber- 
culous processes dominate the field. 

(2) Extension Through Ureter. — The importance of this mode of infection 
has been greatly reduced in the minds of urologists during the last ten years, 
not a few holding to-day that it never occurs. Most observers hold it extremely 
rare, and even its strongest advocates, notably Pousson, think it less frequent 
than extension through the blood. Yet at one time it was credited with being 
the road of infection in almost every case, a view which arose from the fact 



28 TUBERCULOSIS OF THE KIDNEY. 

that most cases of tuberculous kidney gave evidence of disease, first, by 
symptoms from the bladder. Most cases experience extreme vesical distress 
for a long time before there is any evidence whatever that the kidney is in- 
volved. Kidney tuberculosis was, therefore, for a long time believed to be 
merely a part of a urinary tuberculosis, the primary source being either in 
the bladder or in the genital organs and, as during the eighties of the last 
century practically all observers maintained this view, any operative work 
on tuberculous kidneys was discouraged. This view of extension up the ureter 
led to the use of the term ascending uro-genital tuberculosis, while that form 
which started in the kidney and spread to the bladder was called descending 
uro-genital tuberculosis. 

^ An interesting method of extension up the ureter to the kidney has been 
observed in a few cases. This consists in a perforation of the ureter by some 
focus of infection outside it. Bab had such a case, in which a tuberculosis of 
the prostate led to direct invasion of the ureter and extension up to the kidney, 
and Tuffier one where primary tuberculosis was in the spinal column, and 
thence, by rupture into the ureter, the kidney was involved. The ease with 
which such extension can occur is suggested by the frequency with which 
renal colic accompanies appendicitis, while Dr. Hugh Young has commented on 
obstructions of the ureter through inflammatory processes in the seminal vesicles. 
We consider this ascending form extremely rare and cannot recall such a case. 
The infrequency of this condition in women, who have tuberculosis of the 
kidney quite as frequently as men, indeed more frequently in our experience, 
is shown by the extreme rarity of vesical primary tuberculosis without tuber- 
culosis of the kidney. We have had only two cases of this description. In one 
both kidneys were explored in addition to an examination of the separate urines 
without finding any disease, in the other, the separate urines repeatedly exam- 
ined were always normal, and both patients were relieved by bladder operations 
alone. One of these patients we have since taken out of this class. She had had 
no symptoms from the kidney, and the urine from each side had been clear. 
Two years ago she came in for an investigation, her operation having been done 
in 1902. The urine was still clear, but an examination showed the functional 
capacity of the left kidney greatly reduced. The patient has been well at all 
times. This finding is interpreted as a healed tuberculosis of the left kidney 
and, if so, is a rather unique example of this kind of cure. 

In men tuberculosis of the bladder is much commoner, this being due to 
the close union between the urinary and genital organs. Contrary to the gen- 
erally accepted view, we consider genito-urinary tuberculosis, that is, involve- 
ment of both genital and urinary organs, about as frequent in women as in men, 



PORT^VL OF ENTRY OF TUBERCLE BACILLUS TO THE KIDNEY. 29 

but the association is not so intimate. Dr. George Walker has communicated 
an experiment on a dog, where by artificially producing a tuberculous ulcer in 
the bladder, he got an extension of the process to the left horn of the bicornuate 
uterus, which would seem to suggest an association between the two foci. 

In the male, renal tuberculosis and epididymal tuberculosis when they occur 
together are independent affections, a view which is now most generally ac- 
cepted and which we hold, contrary to the old one, that a tuberculosis either 
started in a kidney and extended to the bladder and from the bladder to the 
epididymis, or exactly the reverse. 

Take now the three lines in which observations have been carried on : The 
study of post-mortem specimens; Animal experimenta- 
tion; Clinical studies on the living. 

(1) Post-mortem Specimens. — So far as we are able to discover there 
is not a single case on record where tuberculosis has been found limited to the 
bladder and ureter. Such cases, if common, would have been recorded. Also, 
the majority of specimens studied show the tuberculous process in the kidney 
to be manifestly older than that found in the bladder. Again, there are many 
cases recorded with one tuberculous kidney and bladder tuberculosis, so exten- 
sive that the ureter of the sound side stands up in it like a foreign body, but 
with no involvement of either the ureter or its kidney. The mere frequency of 
one-sided renal tuberculosis in autopsy subjects, about 50 per cent., speaks 
against this mode of infection, especially when it is realized that the cases are 
usually chronic, the opportunity of infection long present, and the patient evi- 
dently susceptible to the disease. 

(2) Animal Experimentation. — The first investigator here was Albert 
Cayle (Thise de Paris, 1887), who injected a culture of tubercle bacillus di- 
rectly into the bladders of rabbits, or in some cases directly into the ureter 
after it had been tied off, an experiment which enabled him to produce tuber- 
enlosis of the bladder, but in no case an ascending tuberculosis involving the 
kidney. On the other hand, by injecting tubercle bacilli directly into the kid- 
ney, he not only produced renal tuberculosis, but found the process extended 
downward to the bladder. Therefore, Cohnheim's view that genito-urinary 
tuberculosis is essentially a disease of excretion, and that infection follows the 
same course as the excretion, had his warm support. Baumgarten (Arch. f. 
Win. Chir., 1901, Ixiii, 1019) repeated and extended Cayle's experiments, not 
only confirming his statement so far as the kidney was concerned, but further 
demonstrating that tuberculosis did not pass from the prostate gland and blad- 
der to the epididymis, but by infecting the latter caused the prostate gland and 
Uadder to be secondarily infected. In other words, in the genital system, just 



30 TUBERCULOSIS OF THE KIDNEY. 

as in tho urinary, the infection followed the course of excretion. He also prove<l, 
by injecting tubercle bacilli into the urethra of rabbits, that tuberculosis of the 
prostatic gland and bladder could be produced. Albarran (1901) was able to 
produce an ascending tuberculosis of the kidney by tying off the ureter and 
injecting tubercle bacilli into it above the ligatures. Kovsing was able to get 
an ascending tuberculosis of the kidney from the bladder of a dog in one case 
by first seriously injuring the bladder, then injecting tubercle bacilli and pro- 
ducing a twenty-four-hour retention of urine in the bladder, but he only suc- 
ceeded in doing this in one out of a number of trials. In addition to rabbits 
and dogs, goats and guinea pigs have been experimented on and all with nega- 
tive result. The failure to produce this ascension of infection in rabbits is 
particularly interesting, in view of the work of Loewen and Goldschmidt, who 
wished apparently to demonstrate reflux from the bladder up the ureters as 
occurring fairly often in this animal. By far the most complete and inter- 
esting work in this connection has been done by Dr. George Walker, in his 
studies in the experimental production of tuberculosis in the genito-urinary 
organs {Johns Hopkins Ilosintal Reports, 1911, xvi, 1), to which the reader is 
referred. 

(.*5) Clinical Studies. — The efficient use of the cystoscope, the catheteriza- 
tion of ureters, and the studying of patients upon whom nephrectomy has been 
performed have done much to show the in frequency of ascending renal tubercu- 
losis. The facts that militate against its occurrence are : firstly, the numerous 
cases of renal tuberculosis where cystoscopic examination shows a perfectly nor- 
mal bladder: secondly, the marked and advanced disease of the kidney witli in- 
volvement of the lower end of the ureter, with only a slight amount of fresh- 
looking bladder tuberculosis located principally around the orifice of the affected 
kidney ; and, thirdly, the absence of all cases of normal kidneys with tubercular 
bladders and thickened, diseased ureters. 

Clearly, then, infection of the kidney through the ureter is rare. But 
should it be entirely excluded ? Those who believe in a direct extension now 
hold that with a normal ureteral orifice this extension can not occur, because 
normally there is no reflux from the bladder into the ureter. It is held, how- 
ever, that changes result in the end of the ureter which harden it and prevent 
the normal valve-like closure. That such changes take place has l)een made 
evident to us in several cases. One of us, Kelly, removed a kidney, and there 
was a backflow regularly through the ureter which was left in. Again, in a 
case with double pyelitis and severe cystitis, any overdistention of the bladder 
would result in a backflow into the ureters, which could be easily demonstrated 
by:filli|)githe bladder with a solution colored with methylene blue. This con- 



PATHOLOGY. 31 

(lition was demonstrated by Dr. John A. Sampson, then resident gynecologist at 
the Johns Hopkins Hospital. 

The method of extension to the kidney through the ureter has been ascribed 
to direct i)rogress of the disease, first, by orawling up the ureter, and, second, 
by being carried up in a reflux as already suggested. 

(3) Infection Through Arterial Blood System. — This is by far the com- 
monest and most important route by which the tubercle bacillus gets entrance 
to the kidney. This fact is confirmed by autopsy findings, experimental work, 
and bv clinical experience. All cases met with were due to this source of infec- 
tion. The organism comes, as a rule, from some other focus of infection in the 
body, although in very many cases met with in clinics this focus may be entirely 
hidden. In one hundred cases of our own, seventy-one apparently belonged to 
what might be called clinical primary tuberculosis, and in only thirty-nine was 
there any evidence or history of other tuberculosis. In the thirty-nine cases 
eighteen had foci in the lungs, eight in the Fallopian tubes, six in lymph glands, 
and six in bones. It must be kept in mind, however, that tuberculous infection 
is very common, so common that the great German pathologist, Virchow, stated 
that "Everybody has a little tuberculosis." It is very easy for an infection to 
escape the notice of both patient and examining physician. Walker gives the 
commonest primary origin as the lymph glands. It has been shown by many 
experiments that the tubercle bacillus can pass through the mucous membrane 
without leaving any trace of its passage. The best illustration is gained by 
feeding animals on tubercle bacilli, and developing infection in the retroperi- 
toneal lymph glands, leaving the mucosa of the bowel perfectly normal. We 
mention only a few of the very numerous experimenters who have dealt with 
this subject. Practically all the work that has lieen done is confirmatory and 
adds little to that of Durand-Fardel (1885), who injected a culture of the 
tubercle bacillus into the renal artery and thereby produced an acute miliary 
tuberculosis of the kidney similar in all respects to that found at autopsy. 
Pels-Leusden (1905) has had the same results in goats. Asch (Centrlbl. /. 
Ham.- u. Sex.'Org., 1903, xiv, 183) had exactly similar results in dogs. 



PATHOLOGY. 

The tubercle bacillus after reaching the kidney sets up two distinct kinds 
of reaction: the formation of tubercles and the formation of fibrous tissue. This 
corresponds with the action of the tubercle bacillus and its toxin in other parts 
of the body. Depending upon the site of the tuberculosis and its development, 



32 TUBERCULOSIS OF THE KIDNEY. 

various gross pathological conditions develop which have been described, such as 
massive degeneration, nodular tuberculosis, papillary tuberculosis, pyonephrosis 
with tuberculosis of the kidney, etc. Before taking up and considering these 
various forms separately, let us follow the tubercle bacillus after it enters the 
kidney to determine its fate. There seems little or no doubt that it can, under 
certain conditions, pass through the kidney without causing any determinable 
lesions. This is exactly analogous to its passing through the mucous membrane 
of the intestine without leaving any trace of its passage. The evidence that it 
can so go through the kidney without leaving any lesion has been furnished 
by a number of investigators. Hugh Walsham {Lancet, 1901, ii, 311) first 
drew attention decidedly to this fact by showing that tubercle bacilli could be 
demonstrated in the glomeruli, in the uriniferous tubules and in the urine of 
cases of acute miliary tuberculosis, without any tubercles or other change in the 
kidney. Foulerton and Hillier (Brit. Med. J., 1901, ii, 774) examined the 
urines of twenty-five patients suffering with pulmonary tuberculosis, and found 
tubercle bacilli present in only one. In doing this they used only the ordinary 
staining method. On the other hand, they injected guinea pigs from eighteen 
of these cases and of these eighteen nine developed tuberculosis. Three of the 
nine subsequently died of tuberculosis, but post-mortem examinations of the 
kidneys fail to show any evidence of the disease. Fournier and Beaufume 
(Comp. rend. heb. d. seances et mem. d. I. soc. d. biol., 1902, No. 15, 1239) 
were able to find tubercle bacilli in almost every case of pulmonary tuberculosis 
by inoculating the urine into guinea pigs. The fact that even at autopsies only 
25 per cent, of subjects with pulmonary tuberculosis show kidney tuberculosis 
also affords definite proof of the frequency of the passage of the organism 
without producing lesions. 

The bacillus may locate and develop at any level or in any part of the kid- 
ney, but the common site of selection seems to be those glomeruli situated next 
to the medulla. The experimental production of miliary tuberculosis by 
Durand-Fardel, Cayle, Borel, Baumgarten, and Walsham indicates the 
glomerulus as the favorite seat of onset, the apparent reason being that the 
blood current is so slow at this point as to afford consequent increased growth 
and ease of implantation. The earliest change is a hyperplasia of the endothe- 
lial cells lining the blood-vessels. The bacilli pass out of the blood-vessels be- 
tween these cells into the connective tissue, where are formed small masses of 
lymphoid cells which soon become epithelioid cells. These, however, as already 
indicated, are rarely involved without definite involvement of the kidney. 

When a tubercle is started in the tissues around the blood-vessels there is 
distinct degeneration of the epithelial structures and tubules of the kidney 



PATnOLOGY, 



» 



xeo 



xlO 



x60 



lying nearbjj and not infreqiientiy a marked round celt infiltration of the 

snrmundiug tissues (Fig, 275). TLe process may be general, or localized 

at one point, and the size of the individinil tnmor 

masses 18 determined by the number of tviberclea 

present (Fig. 270). In plaeca large nnmbers of 

tubercles fuse together to fonn noJnlca which soften 

in the center by caseation and fonii Citvities (Fig. 

77). Sometimes the cavity oceupies a hirge part of 
kidney, and in many cases these cavities communi- 
cating or not communicating with the pelvis may be 
larger than the original kidney. In addition to the 
formation of distinct tubercles with giant, ei>itheUoid, 
or lymphoid cells, there is frequently a diffuse tuber- 

tilotid process. Many of the latter kind are scattered 
tigh the tissue, and these seem to un<k*rgo a kind of 
[Oration, not to be confused, however, with the 

broua change so freqnently found in kidneys the seat 
of tul>erculosis, w^liieh change is apparently duo to the 
toxin excreted hy the tulx^rcle haei litis* Praetiealiy all 
these cases show marked interstitial nephritis of a focal 
nature. In parts the kidney may appear almost normal, 
but in others there is a marked change, Tt is of great 
interest that Rayer thought 40 per cent, of all cases of 
tuberculosis were associated with nephritis^ and that 
aueh frequency has been also dwelt on by Coffin, Albar- 
ran, and many others. We give some other authors, 
encb asG, Salus {Berl kJin, Wrhusrh., VMK% xl, 1150), 

ho, in twenty-seven cases of pulmonary tuberculosis, 
ftnmd 44 per cent, albnmin and 51 per cent, casts. 
Then Lecorche and Talamon ('^Traite de ralbuminurie 
el du mal de Bright," 1888) found albumin in 3*1 per 
ecnt, of all cases with pulmonary tuberculosis examined 
by them, while Bright, the original worker on kidney 

iseases, noted this frequently. These changes, it would 
seem, are probably due to toxins formed by the tubercle 
Imcilli passing through the kidney. Numerous experi- 
ments on animals have demonstrated that tuberculin, 

when injected subcutaneously and ropeatcdly m hirgc* doses, leads to a paren- 
chymous degeneration of kidney cells. An ctlji^r extract of tubercle bacilli 



Fig, 275. — Microscop- 
icAL Section of 

Tl BKRCUL.\R KmNEY. 

Magnitieations indi- 
cated under drawings. 
The larger drawng 
to the left shows the 
cortex and the very 
beginning of the 
medulla. Ths small 
squares show parts of 
section whicti are more 
highly magnified in 
drawing to the right. 
Note iu addition to 
typical tubercles the 
wides pread i n fi 1 1 ration 
with small round and 
polymorphonuclear 
cells. The degree o 
this infiltration varies 
greatly with the case. 



Fio. 276. — Section of Kidney from Papilla to Surface. Note wide extent of tuber- 
cular process which in this case is of the nodular fibrous variety. In contradistinction 
to the type shown in the preceding figure, there is marked cortical involvement. The 
large nodules result from a confluence of tubercles. Note typical tuberculous struc- 
tures as indicated by giant cells. There is still considerable renal tissue present, both 
glomeruli and tubules. The amount of sclerosis due to fibrous tissue formation varies 
widely according to the case. 



34 



Fio. 277. — Tubercular Process in Upper Pole of Kidnet. Lower figure. The diadfld 
surface indicated by arrow shows the block from which the section shown in upper 
drawing was taken. The upper drawing is low-power, five times magnified. To 
the right is shown a cavity lined by thick, fibrous tissue. This is an endneitage of ( 
cavernous transformation. To the left, note transformation of medulla into 
material; some of the large collecting tubules still persist. The cortex above is 
pressed, the tubules are for the most part occludcxi; many glomeruli are still intact 
and apparently functionating. Others show hyaline transformation. Note greatly 
thickened and sclerotic blood vessels. Note also great thickening of capsula innopria 
of the kidney. 




36 



38 TUBERCULOSIS OF THE KIDNEY. 

injected into a living organ produces tubercles which rapidly caseate, while, 
on the other hand, a chloroform extract produces tubercles which show no sign 
of caseation, but are finally absorbed and replaced by fibrous tissue. Bernard 
and Salomon {J, de physiol. et de j}ath. gen,, 11)05, vii, 303) were the first to 
demonstrate this most interesting fact, their experiments seeming to point to 
two toxins at work producing quite different results. 

An extensive study of the kidneys of those dying of pulmonary tuberculosis 
has been made by Arthur Heyn (Inaugural Dissertation, Berlin, 1901), who 
found a focal nephritis, often manifest as little whitish areas resembling in- 
farcts on the surface, to be also present in all parts of the kidney. Such lesions 
were frequently present along with positive tuberculous lesions, but also, in 
some cases, quite independent of them. These findings were confirmed by 
D'Arrigo. Examination of our own specimens convinced us of the very fre- 
quent occurrence of these areas of focal interstitial nephritis; not only every 
specimen, but in some cases almost every section shows them. Whether they 
are due to toxic action or the bacillus is, of course, not answerable. We have 
not been able to demonstrate tubercle bacilli in any of these areas, but that 
does not exclude the fact that they might at one time have been there. Some 
specimens, however, show very little change, and definite tubercles are met 
lying in among normal-looking tubules, which goes to show that in some cases 
the tubercle bacillus is more capable of producing toxins than in others; and 
where there is simply caseation without fibrous reaction, the assumption that 
we are dealing with a toxin similar to that obtained by ether extracts of the 
tubercle bacillus is suggested. 

The process may long remain confined to one part only of the kidney, and 
the rest continue fairly normal and actively secreting. Here is a case: 

Miss A. E. This patient had symptoms pointing to kidney tuberculosis for 
thirteen years. After removal, the kidney cavities were found occupying both 
poles, but the middle portion was well preserved and showed that active secre- 
tion was going on. 

Infection of the kidney pelvis and the ureters in most cases would seem to 
be by the urine. The tulx^rcle bacilli implanted on the mucous surface pass 
through the epithelium, and Ix^gin to produce typical tuberculous lesions in the 
layer of the mucosa immediately under the surface epithelium. 

Gross Types of Kidney Tuberculosis. — Location of kidney; rapidity and ex- 
tension 'of the ^process ; condition of ureter ; and presence of secondary infect- 
ing organisms may cause the appearance of a tuberculous kidney to vary im- 
mensely. • 

Firsf^as to occurrence of cavities. A large percentage of 



40 



TUBERCULOSIS OF THE KIDNEY. 




In our series no less than 27 specimens showed involvement of the apices of 
the pyramids. In only 1 case, however, was there solitary involvement of this 
part of the kidney. The clinical symptoms were marked hematuria. The con- 
dition is pictured in Figure 292. 

Tuberculous kidneys are, as a rule, enlarged, the only exceptions being 
where they are so diseased that the kidney is replaced with fibro-fatty 
tissue which may contract and produce a very small organ. We ob- 
served four such specimens out of fifty-five, and three others in which there 
was no kidney enlargement 

Looking to the possibility of conservative BorgBrj^ 
it is of interest that in only seven was the cliaeiM 
limited to one pole, in four of which the i^lvh and 
ureter were involved. Thus, out of fifty-five spesci* 
mens only three e\ddenced that a resection eonlil 
have entirely removed the disease. An excellml 
illustration of a condition where conservative tar- 
gery might be thought of is shown in Figtn^ 281. 
Here is a double kidney with double pelvis and 
double blood supply, and the disease limited to one 
pole. 

Closed Ureters. Concemi ii^ the in tlueiice 
of the closure of the ureter upon the derelopmeul of 
the process in the kidney much has been written. 
Eleven of our specimens showed a closed ureter^ in 
every case with enlarged kidney, and the largest we 
have belonged to this group. It showed the onnplete 
transformation of the kidney into a multilocalar 
thick-walled sac filled with caseo-gelatinous material, the soH^alled massive 
degeneration of Tuffier (Fig. 283). Some of the other specimens showed 
cavity formation and caseation; one diffuse infiltration with tuberculosis; 
another a small fibro-fatty kidney, the entire renal structure being replaced 
by this tissue, showing this transformation also possible with a closed ureter. 
Several of these latter specimens, examined microscopically, showed apparently 
good functional tissue in the kidney, the tubules and glomeruli being well pre- 
served. In one there was a peculiar cystic transformation of the kidney, its 
entire surface being covered with cysts, with clear, thin walls and filled with 
clear fluid. The closure of the ureter seems to have no effect in producing 
perirenal involvement. Out of ten cases with marked perirenal ahaoesses, five 
had open and five had closed ureters. 



Fig. 279. — Diagraioiatic 
Repbesentation of 
Upper Pole of Kidney 
Shown in Last Figure. 
Note how destruction of 
papilla occurs not only 
from surface but in its 
interior, as shown in two 
little cavities indicated in 
shaded areas. 



PATHOLOGY. 



41 



Open Ureters, Not less important than transformafioTis possible with 
R closed ureter are those possilile with an open one. We had five cases which 
showed complete destruction of the kidney^ one of these being a typical massive 
je^neration of Tuffier (Fig. 283); two others were greatly enlarged, hut two 




Flo, 280.— Large Tiberci lar Kidyey. The drawing to the left shows the anterior 
surfarr; that on the right b a fross sortioii. Note in the suixrficial \4ew the extensive 
<: [i of the tubercles, surrounde<! by ecch>'raosea. The distended pelvis is filled 

v^ *: .. , . lL Note that the upper antl lower i>oles of the kidney arc apparently healthy, 
except for a few isolated tubercles, which, however, would, rcrnder nugatory any con- 
servative operation. (Ruark, patient of Dr. Ilunner's, V» natural size.) 

smaller than nomiah Thirty-three specimens showed an open ureter, 
id clinical studies before operation showed the kidneys were secreting 
rough the ureters. Twenty-six were cnhirgcd kidneys, three normal, three 
father below normal. The type of involvement was always of the caseo- 
cav^^mons or of the diffuse form; none showed the massive degeneration of 
TdBer. 

Oroea types, therefore, would seem to be dependent upon the original die- 






!• 282. — ^TuBERCULOsis OF LErr Kidney. At one point, a, the rtulKTukr process has 
broken through the capsule of the kidnej^ and unites tiie pchm with a perirenal abscess. 
Thr medulla is ^•o^lparati^'ely inueli oKiie invohed than tlie cortex. Ilils type of in- 
voh^frment wa.s fonnerly explained on the grourids that the infection tjf the kidney came 
ffom ifie bladder by ascending the nreter. The destroyed pelvis and calices, with the 
immediately contiguous parench>ina, is eoniposed of caseous nmtter, and is shown in 
drawing a>» pale zone, c. A tubercuhir ^land in the hiluni of the kidney is indicated by 
I. lATrc. M .Tu,t.. t.' V\a] J H. H.; natural sizej 



44 



TUBERCLXOSIS OF THE KIDNEY. 



we have seen beautifully illustrated in many sijeeimeiis. There is a distlnet 
danger of perirenal abscess, and of complete destruction of the kidney as a 

result of secondary infection hi coiiiliiimtion Tvifh a clr^sed nreter. Among the 
types of involvement which have !>een described are: Tiiffier*a massive degcn- 



Fia. 283. — Massive Tuberculosis of toe Kidney. Complete traiisfomiation of paren- 
ch>Tiia into caseous material. Olillteration of ureter, Cireat thiL-kenini; of capsule. 
Fat of sinus renalis transfonnt^d into liard, j^laj^^y fil>roujs niatfjTial. Note larj^e tul>er- 
cular lymph giand.^ at hilum. »Selerotie renal artery. Note likewise large size of kidney. 
This is the well-known missive degeneration of Tuffier. It is usually, though not always, 
associated with closed ureter. (Autopsy, 1553, J. H. H*) 



eration; fatty seleroticj pyonephroticj bydronephrotic; cystic kidney ; involve- 
ment of one part of a double kidnt^y; radial involvement along the blood- 
vessels, or of one apex of a kidney pyramid* 

Tuffier's massive degeneration (Fig. 283) represents to 
end stage uf kidney tnlx^rculosis. The ureter may be open or closed, but if open 
there is sure to be some bk>cking within the jxdvis* This form is not found 
where there is active set»retion from the kidney. A kidney undergoinj^ massive 
degeneration presents a lobulated appearance, similar to a cystic kidney, but 



PATHOLOGY. 45 

the walls are thick, dense, opaque, with average thickness of ^ cm. There are 
extensive adhesions, as a rule, to the fatty capsule, and the kidneys are from 
three to five times the normal size. 

Fatty sclerotic kidney represents another end transformation of 
tuberculosis, the kidney being entirely destroyed, shriveled up, frequently cal- 
cified and in some cases entirely transformed into a calcareous mass, while the 
capsule is adherent but rarely shows marked change, except in diminution of 
size. Palpated from the abdomen, these fatty, sclerotic kidneys may give a false 
idea that tlie kidney is normal. We have palpated such, in which the total mass 
of kidney and fatty capsule entirely approximated that of a normal kidney, 
and ezaedy agreed with it in shape. 

Willt do0UTe of the ureter tremendous pyonephrotic processes 
may dovdop in the kidneys, either with or without secondary infection. In 
eaaea vlieve aeoondary infection is present, however, the kidneys attain a greater 
nae and produce more pronounced symptoms. Pyonephrosis is usually asso- 
datad "with extensive abscess formation in the parenchyma of the kidney, and 
with m large pyonephrotic pelvis in communication with the abscess in the 
eotliez (^S* 284). The entire kidney may be destroyed in this way, all the 
eantiaa upening together, or the disease may result in a rupture of the capsule, 
with large perirenal abscesses in addition to the pyonephrosis. 

A large hydronephrosis, due to tuberculosis of the kidney, is rare, 
but our specimens show a few cases of a mild form, where the disease was in 
in early stage with tuberculous involvement of the ureter. One came to us 
some years ago from Dr. Vineberg, of New York, who later operated upon it. 
Tuffier and Kippel have described large sacculated kidneys filled with clear 
fluid, attributed to a preceding caseous destruction of the kidney, with a wash- 
ing out of all caseous matter through the ureter, and then a blocking of the 
same, filling the kidney pelvis with clear fluid. 

Cystic kidney may result from an involvement and closure of collect- 
ing tubules near the apices. F. Curtis and V. Carlier give an interesting case 
(inn. d. mah d. org. genito-nrin., 1906, xxi, 1) in which there was a cavity 
in the upper pole of the kidney, the apices of the lower pyramids being involved 
in such a way that there resulted a cystic transformation of the entire lower 
pole. The cysts varied in size from 2 to 3 cm. in diameter, the entire kidney 
presenting the appearance of one congenitally cystic. We quote one from our 
own records (Fig. 285) : 

C. N., aged forty-nine, had had throbbing attacks of pain in the right side 

and back for four years, some increase and frequency of micturition, and some 

pain on voiding. Urine normal, except for a trace of albumin and some casts. 



Fig. 284.— Tuberculosis of Kidney and Ureter. T>7)ical complete destruction of 
kidney and its transformation into caseous masses and broken-down caseous material 
forming caverns. The condition of the ureter is indicated by the transveise section. 
The upper three show lumen filled with caseous material except for a narrow slit near 
center. In lower four there is partial fibrous transformation; in some cases this leads 
to transformation of ureter into a solid cord. This type of unjt<»r is mostly associated 
with early destruction of the kidney. In this case, liowever, the contents of cavema 
must have washed down before closure. (Miss K., May 25, 1906; ^5 natural size.) 



48 



TUBERCULOSIS OF THE KIDNEY. 



Ureter of right side clo^erl, left side doing all the work. Operation 
revealed a cystic kidney, so cloBply reaeinbliiig a cougenital cystic kidney that, 
before removing it, we explored down to the other kidney and found this normal 
in aize and shape* The entire kidney cortex was stndded with cysts, varying 



#7 f/ 



Fig, 286. — ^Tubercuujsis of the Kidnby with Cystic Teansformatiok of Upper Pole. 

Caseo-cavemous degeneration of middlo j>ortion and iinrnml lower pcile. The drawing 
to left ahows the appearance of posterior asjjcct uf kidney. The dra\iing to the right 
shows loniijitudiniil section. The cysts at upper pole were filled with clear fluid. (C., 
Dec. 31, 1898, natural siise.) 



in size from a pinhend to 4 cm. in diameter; a couf?iderahle niciliillary por- 
tion of kidney apparently normal still intact. IVdvis waa dilated, one of the 
cavities communicated with it, but moat of the cysts were entirely separate 
from the pelvis. Cysts thin-walled and filled with clear fluid. On exam- 
ination, definite tuberculous pnK-essea fonnd in walls of some cj^ts, and 
cyst wall apparently nuide up of new-furnied fibrous and conjprcssed renal 
tissue. 



PATHOLOGY. 49 

Tubercular Kidneys with Double Ureters. This division 
is of great interest and demands special attention. We had a good case where 
the patient had a normal second kidney, the tuberculous one being double, with 
an entirely different blood-supply as well as a double ureter and pelvis. The 
upper half was completely destroyed by an infiltrating fonn of tuberculosis, its 
ureter being closed, while the lower portion showed a normal kidney and a 
normal ureter. Such a case would lend itself admirably to an attempt at resec- 
tion of the kidney (Fig. 281). Albarran reports an autopsy finding where 
one-half of the kidney, one ureter, and the bladder were tuberculous, the other 
half of the kidney and the other ureter being seemingly normal, and Lennander 
has operated on a horseshoe kidney where tuberculosis was limited to one pole. 

Cnrioiis forms of distribution of tubercles along the course 
of a given blood-vessel are sometimes observed. Tilden Brown has 
exteoaivelj described a case showing this. 

Somewliat similar are cases where, with two poles comparatively normal, 
a hraad bud of tuberculosis is present along the middle of the kidney, pro- 
doci^g; a kind of girdle, well defined as the girdled or belted kidney 
(Fig. 395). 

We liave said it is not unusual to find the apices of the pyramid involved, 
leading to eactensive hemorrhage. There was definite destruction of the apex 
of (me o£ the npper pyramids in one of our cases, and similar cases have been 
described by Israel and others (Fig. 292). 

I&Tiihmient of Ureter in Tnberonlons Kidney. — Of course, as will be pointed 
oat later, it is possible for a thickened ureter to be present and the thickening 
not to be due to tuberculosis, though in no less than fifty-two specimens out of 
fifty-three of which we have accurate notes, this thickening of the 
lower end of the ureter was present. The tuberculosis is usually diffuse, in- 
volving the entire length of ureter, but the most important parts of it which 
suffer particularly are: first, the vesical, and, second, the pelvic end. Thirty- 
one specimens, in which we have the ureters as well as the kidneys, all showed 
tuberculosis of the lower end, and out of these, fifteen had tuberculosis dis- 
tributed all through the course of the ureter, while in eight there were only 
a few tubercles here and there. 

In addition to definite tuberculous change, there is an inflammatory reac- 
tion of an interesting nature, limited to the mucous membrane. In nearly 
every case of tuberculous kidney there is a marked round-celled infiltration of 
the tissue immediately underlying the epithelium of the mucosa of the ureter, 
a change frequently present when there is no sign whatever of either tubercle 
bacilli or of tubercles, and which, in many cases, has been diagnosed as chronic 



Fig. 286. — Tuberculosis op Kidi^^et and Ureter. Note wide lumen of lower part of 
ureter and choked condition alwvc. Note extensive involvement of calices and pelvis, 
where disease seems more advanced than in cortex. At lower pole there is still a little 
nonnal cortex. The wide-lumcned ureter is due to the fact that after caseation of 
its inner coats, the down-pouring urine washes out a channel. If the renal parenchyma 
holds out long enough, the entire ureter may thus be opened. For such a condition 
a secretory kidney is essential. (Miss G., May 1, 1906; 3i natural size.) 



51 



im'M''' 



52 



TUBERCULOSIS OV TUVl KIDNEY. 



ureteritis by the patliologi^t. It scenia to l>e due to the irrittitiou of ftome 
toxin present in the urine, derived from the tiil^erele baeilkis itself or from 
the altered kidney tissue. The blood vessels in »he nnieou^ niefnbnme are usually 
dilated, with oeeasiunal polyniorphomudear leukorytivs and nnind cells in the 
stroma* This change h met with in pnre tuberculosis without any secondary 
infeeting organisms. When tiibereles develnji, they always l>c»gin in this same 
layer and involve first the mm-usa nnd then the luuseiilaris of the ureter, also 
tliere is usually present a periureteral inllaniinatitm which results in the adher- 
ence of the ureteral sbealh t<» the ureter. 

The process, lieginning widi miliary tul)crcle3» 
which increase in number, fuse to^retber, and eus^'- 
ate, generally continues on to the formation of 
ulcers alon^ the ureter, with stricture as a not un* 
common result, espeifially at its lower end. In 
other cases the ureteral lumen may In? actually 
plugi>ed with easeo'us nuitter* a likely happening 
if the kidney is destroyed above and fuuetionleas. 
With an actively secreting kidney above, the debris 
is likely to be washed thrnu^irh ; then ensues such 
destruction of the ureter that all normal coats are 
destroyed, the fibrous sheath practical ly f firming a 
ureter, with a very widely dilated lumen ( Fi^ 
2Si\ and 200), These giant ureters, aeeording to 
Halle and Motz, are particularly likely to ix*eur 
where there is secondary infection. That small 
ureters do not ix'cur in cases with marked secondary infection confonns 
with our experience. 

Four stages are given by Halle and Motz (Ann, d. mnL d. org. genito'tirin,, 
HIOC, i, 162; 241): (1) The mucosa alone is infected, the ureter always a 
little dilates] ; (2) The lumen is filled with tuWcular and caseous material; 
(Z) A new lumen is made l>y the breaking down and washing out of tissue; 
(4) A transfomiation of entire ureter into a fibrous cord (an unusual and 
very late change presented by only one of our specimens). The type& of 
ureteral changes are beautifully shown in Figures 284, 286, 287, 288, 289, 
200 and 201. 

It is through the urine that the tubercle bacillus involve the ureter in the 
majority of cases. It is carried down fnim the kidney and implants itself 
directly on the mucous membrane, and there produces its typical change. 



Fio, 287*— Transverse Sec- 
tion OF THE I'rETER. TllG 
thieknci<.s4*H of llu* «i'ViTal 
coats arc in ttie jiroportiona 
shown. Note fihro-fatty en- 
velope, MagnifietJ 6 timt*s. 




SYMPTOMATOLOGY. 



53 



SYMPTOMATOLOGY. 

itially ii cliroTiie disoase, witli the exception of the miliary form, tuber- 
of the kidney may run a eoiirse of many years if not interrupted by 



x6 



x30- 



Flo 288. — Early TuBERcrLosis of the ITre'"zr Due to TitaEauLrMisii^; op TitE KiD?fEY, 
Drawing to the left n^prestnits transvLTwe Heetiuu of the ureter niaginfieil .^^ix times. 
The transverse diameter of the ureter Is of normal length. The muscular and fibrous 
coats arc normah The Imnen is somewhat narrowed^ due to tliirkness of nmcowa which 
ta tubercular. The little square marked l>y arrow is magnified 30 times in drawing to 
ri^i. Note that surface epithelium is destro.yed. Two tubercles with giant -celled 
centers are shown. Note marked infiltration uith small round and poI>Tiiorphonuelear 
cells, ill this c m extending through muscular coats and to a lesser degree through the 
fibrous coat. 



iOfipcal tTetitnient. A few cases, to wliicli we will return later, heal spon- 
taneotiiily after ef>mplete flestrnetion of tlie kidney involved by occlusion of 
the tireler. A good illustratifm of the ebronieity of the disease is the fact that 
the avera^* s^^upto^latic period in our own cases is three and a half years. 

In Bomc ea,^e& the process moves far more rapidly : within a few months after 
ilj- first onset of symptoms, the entire kidney may be destroyed, the other one 
po^^rl-Jy diseased, and the bladder thoroughly so. This rapid course was w*ell 
illustrated in one of our eases. 



54 



TUBERCULOSIS OF THh: KIDNEY, 



G, B,, an unmarried wonmii of 24, consulted ns in September, 1905, baling 
had for a few inojiths mild .syniploins sugges^tivc of cystitifl. Tulx?rcle bacilli 
W€*re discovered in urine from right kidney. The resident at the Johns Hop- 
kins liospital, planiiiniT ti> do n m^phreetumy, ex(>n.<etl I lie kidney but found it so 



Thickened 
fibrouft shtafh 




Infiltrated macohm 
Wiih Tiitmtreuf, 
tubtrelcft 



^ 



\ 



f 



inf:Itra1ci 
muscle 



x6 



Fig, 289. — More Advanled Stage of TuBERcLM^i^is r»F the I'ueter. Entire mucofll 
dcatroycHl. Most of the nuisele coats destroyed and replaced by caaeoas material. 
The lumen of urc^ter is filled with same materiah The deeper mtisele layers are in- 
filtrated uitli t> picid tulpereli^s. The fibro-fatty «lieiith liajs become densely adherent 
to ureter anil forms, as it were» itj^ outer coat. It is the addition uf this coat which 
gives the great increase in thickness of ureter. 

normal in appearatiee that be did ncphrntomy, and fonnd no cvitlenee whatever 
of disease. His ojjeration ^ave no relief nml the symptoms increased in severity. 
She returned six mnnfhs Infer, the kidney was removed, and there was not the 
slightest amMiint of aetivi^ renal tissm- left, us slmw!i by miemseopie examina- 
tions of the retnoved orfi^nn. Note, t<x>, thnt this destrnetion wha aeeotnplished 
by the unaided inflnenee of the Inlx'rele baeillns, ff>r the baeteriologic cxamina* 
tion showed w*e were dealing with a jnire tub(*r(*ulnns infection, 

Svmiptonis arising from tnbereulosi.s of the kidney are varionj?. It is eon- 
v(*nient to classify them into several groups; (1) General manife&tationSj such 
as loss of weighty, chills, sweats, fevers, etc. 




Fte, 291. — Healed Tobeiu'UU>sis of- the Ureter, Thia repnvsoriLs a still more? advanced 

tstagie than the preccnling figure. The fibruus shMih has shruoken and the liiinen been 
obliterated by fibrous tissue. No e\idence of original tubercular process appears. 
(3) Disturbance of bladder; frequency of and pain in uucturition ; inconti- 
oence of urine, Btrangnry, etc. 



56 TUBERCULOSIS OF THE KIDNEY. 

(4) Alteration in character of urine, caused by the appearance of pus, 
blood, or cloudiness; malodors are occasionally complained of by patient. 

General Symptoms. — Just a word on general symptoms before taking these 
groups up in order. It is striking how, with severe renal tuberculosis, the gen- 
eral condition of a patient may for a long time be unaffected. Only recently 
this was shown in the case of a minister, a man of fifty years of age, who came 
to us, as the operation disclosed, with congenital absence of the left, and ad- 
vanced tuberculosis of the right kidney, associated with stones in its pelvis. 
With marked vesical distress, and kidney symptoms for many years, he was 
yet in an active state of health, and stated that he had lost no weight. So good 
was his general condition that it was difficult to believe that he had only one 
kidney and that tuberculous. 

Out of one hundred cases only twenty-five of our patients were in pro- 
nouncedly bad condition as far as nourishment and strength went In 30 per 
cent, of these patients the condition was noted as robust; in 40 per cent, as only 
fair. Forty-two per cent, gave a history of chills, fevers, and sweats ; the other 
60 per cent, had had none of these symptoms. We found those cases presenting 
most marked evidence of general ravage from disease to be those with pyone- 
phrosis, either of the pure tuberculous type or with secondary infection. In the 
presence of such large abscesses, the sufferers have high fever, exhausting sweats, 
and rapidly lose fle.^h. Such patients often come into the clinic apparently 
almost in extremis. It is wonderful how rapidly they pick up after the drain- 
age of the abscess by nephrotomy. Most patients with tuberculosis of the kid- 
ney show elevation of temperature. This was observed in 70 per cent, of our 
list. Where the ureter is open and consequently there is damming back of 
infecting matter, the temperature is usually only a degree or two above normal 
in the afternoon, but not always, for fever in kidney tuberculosis is very irreg- 
ular. Unless secondary infection is present, this fever is not accompanied by 
increased polymorphonuclear leukocytes in the blood. But with secondary 
infection there may be marked leukocytosis. While the temperature in some 
cases is almost continuous, in others there is sometimes a morning rise and an 
evening fall. 

Anemia is a frequent though not striking complication. In one of our 
cases the hemoglobin was only 33 jx^r cent. The average hemoglobin, however, 
was 75 per cent., almost average adult normal. 

Symptoms deferable to Kidney. — A striking characteristic of kidney tuber- 
culosis is the frequent absence of local symptoms referable to the kidney itself. 
In this it stands in c*ontrast to most other renal affections. 

Tumor. — We have never had a patient come in complaining of a mass in 



SYMPTOMATOLOGY. 67 

the side as her chief symptom, although in twenty-two the kidney has been so 
much enlarged that palpation readily demonstrated such a mass. That tumor, 
however, can occasionally occur as the only symptom and the cause of the 
patient's consulting the physician is well recognized. Viannay {Independance 
med., 1901, Nr. 18) gives an excellent example. Without any previous symp- 
toms a tumor developed in a patient's side and reached the size of a man's head. 
Its api>earance, the absence of all symptoms from the urinary tract, and the 
negative findings on examination of the urine, led him to diagnose a pancreatic 
cyst, but the operation disclosed a tuberculous kidney containing 400 c. c. of pus. 

Pain in the Kidney. — Pain occasionally occurs as the only, and frequently 
as the principal symptom of tuberculosis of the kidney. It varies markedly in 
its character. In some cases it is merely a dull ache in the lumbar region, in 
others it comes in paroxysmal attacks of renal colic, in no way differing from 
those occasioned by the passage of a stone down the ureter. 

As to the frequency of pain in comparison with the other symptoms and its 
inijMDrtance, we quote concerning sixty-two cases: In only six was the sole 
symptom of the disease pain in the kidney. In twenty-two, from beginning to 
end, the symptoms were those of cystitis, and the patient was not in the least 
conscious of any kidney disturbance. In sixteen, associated with marked irri- 
tability of bladder, there was a dragging, distressing sensation in the kidney 
region; and in seventeen, with bladder disturbance, a history of paroxysmal 
attacks of renal colic. These cases with occasional attacks of pain are frequent, 
and often give a history of several years' duration. It is worthy of note that 
of the six cases where the sole symptom was pain, the pain was paroxysmal 
in four and in two a constant dull ache. As already pointed out, pain with 
kidney tuberculosis usually starts in the kidney, and though in most cases 
it does not radiate, it may run along the course of the ureter, and we have had 
instances where there was radiation to the opposite kidney, or to the shoulder- 
blade. * 

The attacks of colic are rarely so severe as those which accompany stone in 
the ureter, and in the early staged are dependent, no doubt, upon swelling of 
the mucous membrane of the kidney pelvis and the ureter from inflammatory 
reactions. In the later stages such attacks can be brought about by the passage 
of bits of caseous matter or blood clots through the ureter, and, not infre- 
quently, by the passage of pieces of calculus, for, as will be shown a little 
later, the concurrence of tuberculosis and renal calculus is common. 

Bladder Symptoms. — It is of the highest importance that we should recog- 
nize marked vesical disturbance as the commonest, in fact almost the charac- 
teristic, symptom of renal tuberculosis. As stated in the introduction, Howship 



58 TUBERCULOSIS OF THE KIDNEY. 

(1823) saw this, and almost every writer on kidney tuberculosis has referred 
to it. It is this vesical irritability, as either the sole or the predominating 
symptom in the clinical picture, which so frequently leads the practitioner 
astray and involves the patient in a long course of painful bladder treatments 
yielding no result. 

The importance of irritability of the bladder as a symptom of kidney tuber- 
culosis cannot be overestimated. At least 90 per cent, of our cases presented it 
alone or in combination with other symptoms, while in 70 per cent, it was the 
initial symptom. 

Cause of Vesical Symptoms. — In many cases frequency of micturi- 
tion and painful micturition associated with tuberculosis of the kidney are 
due to involvement of the bladder by the tuberculous process. In many in- 
stances, however, marked vesical distress is met with where cystoscopic exam- 
ination shows a healthy looking bladder. Many explanations have been offered 
to account for this, the commonest being perhaps that of a reflex nervous 
phenomenon. This reasoning seems weighty from the fact that disturbances of 
the bladder are so frequently associated with kidney colic and with diseases of 
the rectum. We have noted in several patients that this irritability occurred 
when the ureter was completely closed, the kidney functionless, and the blad- 
der normal. In spite of this, we incline to the view that the chief reason lies 
in irritation caused by the urine. Reddening and irritation of the bladder are 
frequently observed where there is a tuberculous kidney, which immediately 
disappear when nephrectomy is done. This irritating character of the urine 
has been noted in describing the pathology of tuberculosis of the ureter. It is 
well to bear in mind, however, that these vesical symptoms without involve- 
ment of the bladder do not compare in severity with those present when the 
bladder also is involved in the disease. 

Incontinence. — The first bladder symptom is urgency in voiding. This 
may at first occur only during the working hours, but is soon felt at night 
Georges Constant! nesco {Jour, d'urol., 1912, i, 611) has drawn particular atten- 
tion to the frequency of incontinence of urine and notices that it may be 
associated with either unilateral or bilateral tuberculosis and is mostly noc- 
turnal. 

In extreme cases the patient is compelled to pass urine almost continuously. 
We have had many who have slept with bed-pans and other arrangements as 
necessities. 

Pain. — The accompanying pain develops later and is usually most severe 
at the time of voiding. Sometimes it is described as following micturition, 
but generally it precedes or accompanies it. This pain is variable in inten- 



SYMPTOMATOLOGY. 59 

sity, it may be a mere tickling sensation scarcely noticeable, or an extreme 
strangury. It is no unusual sight to meet with a patient who actually screams 
with pain at every voiding, a condition well understood when one realizes that 
the voiding may occur every hour and take fifteen minutes. In addition to 
the pain on micturition there is frequently marked constant pain in the bladder. 
It is common in the male subject, where the prostate gland is involved, to have 
severe pains in the perineum and in the urethra, especially at its end; also 
burning pain at the end of the urethra which follows micturition and which is 
so common with stone in the ureter. It is much more uncommon to have pain 
in and around the perineum in women, but we have seen one case where there 
were severe attacks. 

Immunity of the Bladder. — That it is possible for the bladder to remain 
free from tuberculosis even when considerable amoimts of blood and tubercle 
bacilli are passing over it, is well illustrated by one of our cases in which the 
principal symptom was marked hematuria. In this instance there was pul- 
monary tuberculosis with neither bladder nor local kidney symptoms. The 
catheterization of one kidney showed that tubercle bacilli, as well as blood, were 
coming down in large numbers. The kidney removed by operation 3howed the 
tuberculosis to be limited to the apex of one of the pyramids coming from the 
upper pole, and the rest of the kidney was normal (Fig. 202). 

Polynria. — Polyuria, noted as present in the early stages of the disease, and 
especially urged as characteristic by Tilden Brown and by Guyon, seems, never- 
theless, to have no particular significance as a symptom, and certainly is not 
present in the majority of cases. It is often pronounced in miliary tubercu- 
losis, and the idea of its frequency is no doubt accentuated by the accompany- 
ing urgency of micturition. The underlying cause is not clear; it may pos- 
sibly be due to interstitial nephritis set up by the disease, which is a constant 
accompaniment of tuberculosis (see Pathology'). Cystoscopic studies have im- 
pressed us with the frequency with which the tuberculous kidney can secrete a 
greater volume of fluid than its healthy fellow, although in these cases it must 
be borne in mind that the total amount of solids is less from the diseased than 
from the normal kidney. 

Changes in Urine. — In describing a case of hematuria we pointed out 
that blood may be the first and potent cause of a patient's coming to a physi- 
cian, and it is not an infrequent accompaniment of other symptoms. Out of 
one himdred cases 25 per cent, complained of having passed blood. In only 
two, one of which was the case quoted, was the amount of hemorrhage great. 
The patient will generally say she has noted small amounts of blood in the 
urine for a few days, and then comparative clearness for quite a period. Cer- 



60 TUBERCULOSIS OF THE KIDNEY. 

tain authors have noted that cases with marked hematuria are associated with 
disease in the apex of a pyramid. The reason for the hemorrhage in these 
cases is readily understood by remembering that the pyramid is surroimded by 
a vascular network of anastomosing veins, which would readily be opened by 
marked disease in the papilla (Fig. 209). But extensive hematurias occur 
when the disease is located in other parts of the kidney, of which Tuffier 
(Comp. rend, Soc. biol. de Paris, 1892, iv, 511) reported a good case in 
1892, the tuberculous foci consisting of six cavities in the parenchyma. Schles- 
inger also gives one of severe hemorrhage in a patient who died of pulmonary 
tuberculosis, where the autopsy showed nothing save a few tubercles situated 
in the kidney pelvis. This case would seemingly need to be classed with essen- 
tial hematurias, and perha])s depended upon some focal interstitial nephritic 
change. This hemorrhagic form has been described by Israel, Pousson, Albap- 
ran and others. 

Only less marked in its influence on the patient is turbidity. Very 
turbid urine may be constantly present, or only attract attention now and again, 
but it is rare for no change whatever to be noted. 

F. II., a woman of 47, came to us complaining of throbbing attacks of pain 
in right side and back, which had been present for four years. Urinary exam- 
ination showed merely a trace of albumin and a few hyalin casts; palpation dis- 
closed a body in right side which felt like a cyst. Cystoscopic examination 
revealed one ureter secreting normal urine, the other none whatever. Bladder 
normal. Operation disclosed a cystic kidney, described fully under Pathology. 

It is not uncommon also for the urine to be normal for a certain period, due 
to temporary occlusion of the foci of disease, but this point will be better dealt 
with imder the section Examination for Pus. 

Summary. — To sum up, in an average case, there are: 

(1) Vesical distress, possibly some pain in the side; 

(2) Occasional fever; 

(3) General condition fair; 

(4) Blood and perhaps turbidity in the urine. 

There are, as said, exceptions. Tuffier recently reported a series of cases 
where marked pain in the kidney was the characteristic symptom. 

Rafin (Jour. d'uroL, 1912, i, 779) has studied the initial symptoms in 160 
cases with the following result: 

Vesical symptoms, 61.87 per cent ; 
Kidney symptoms, 19.37 per cent. ; 
Hematuria, 5 per cent. ; 
Turbidity of urine, 2.5 per cent.; 



DIAGNOSIS. 61 



Albumin, 1.8 per cent. ; 
Eenal pain and hematuria, 2.62 per cent.; 
Vesical pain and hematuria, 1.87 per cent. ; 
Loss of general strength, 2^ per cent.; 
Indeterminate, 4 per cent 



DIAGNOSIS. 

A careful clinical history is the first indispensable step to correct diagnosis. 
Every patient complaining of bladder symptoms should be carefully interro- 
gated with the possibility of tuberculosis of the kidneys in mind. The physi- 
cian must first determine whether the condition is tuberculosis, and, having 
determined this, must then find out its location and extent. Is one or are both 
kidneys involved? Is the bladder involved? Is there tuberculosis in other 
parts of the body ? If the tuberculous process is limited to one kidney, is the 
other kidney perfectly healthy? While diagnosis is comparatively simple in 
those cases with blood, pus, and tubercle bacilli in the urine, it may be extremely 
difficult in early cases where none of these abnormal elements are demonstrable. 

The first step is to demonstrate that tuberculosis of the urinary system 
exists, and the one positive proof is the presence of the tubercle bacillus in the 
urine. Bear in mind that there are other findings which render the probability 
of tuberculosis very great and which in some cases form the basis of complete 
diagnosis : e. g., a chronic acid cystitis which has started insidiously and resists 
all ordinary medicaments is highly suggestive of kidney tuberculosis, still more 
so when there is evidence of tuberculosis elsewhere in the body. In our series 
of eases there was evidence of tuberculosis elsewhere in only 30 per cent. ; of 
these, 50 per cent, showed pulmonary involvement, 20 per cent, involvement 
of the genital organs, 15 per cent, of the lymph glands, 15 per cent, of the 
joints and bones. 

Palpability of Kidney and Ureter. — ^Added to careful observation of the 
temperature curve and of the leukocytosis, palpation of the abdomen in tubercu- 
lous kidney is of importance. From what has been said of the frequency of 
kidney enlargem.ent, it is evident that tuberculous kidneys are far more fre- 
quently felt to be enlarged than those in patients who have no tuberculosis. In 
cases where pyonephrosis has developed or perirenal abscess, there may be 
great masses in the kidney region, but in the majority the kidney, while en- 
larged, is not sufficiently so to be found by ordinary abdominal examination. 
(Other methods are described under the general chapter on Examination.) 



62 TUBERCULOSIS OF THE KIDNEY. 

Only 35 per cent, of our cases had palpable or enlarged kidneys. When the 
kidney is palpable, as in a recent case of movable kidney associated with tuber- 
culosis, the irregular form was readily made out The tuberculosis was limited 
— as shown by examination of specimen after operation — to the middle zone 
of the kidney. This resulted in an irregular shaped nodular mass, not at all 
corresponding to the usual bean sha{)e of a normal kidney. It is uncommon 
to produce the so-called ^'kidney bladder reflex" by palpating tuberculous kid- 
neys, but occasionally forcible palpation of a tuberculous kidney will produce 
a pain which radiates down from the kidney along the course of the ureter. 

Thickened Ureter. — A sign which we have found of the greatest assistance 
in diagnosis is the discover; of a thickened, tender ureter by vaginal examina- 
tion. The technique of examination is shown in Figure 115. The index 
finger can feel the enlarged ureter passing through the parametrium. The 
ureter in some cases may be simply hardened and about the shape of a lead 
pencil; in others it is actually nodular, and the reflex described by Bazy 
(pressure on the ureter causing a desire to empty the bladder) is almost in- 
variably present. 

TJiickening of the lower end of the ureter is a most common accompaniment 
of renal tuberculosis, occurring in 75 per cent, of our cases. Similar thicken- 
ings are present with stones in the lower end of the ureter, and with strictures 
due to ordinary infections. The mere discovery, therefore, of a thickened 
ureter is only highly suggestive. In some cases a thickening of the ureter does 
not mean tuberculosis of the kidney, even where there is an actual tuberculosis 
of the urinary tract. We have had two patients in whom, with tuberculosis in 
one kidney and simple pyelitis in the other, the pyelitic ureter was as thickened 
as the tul)erculou3. 

A discovery of tubercle bacilli in the urine and a thickened ureter on on© 
side, with a normal feeling ureter on the other is in most cases sufficient to 
justify the removal of the kidney with the thickened ureter, but that this may 
lead to evil consequences is certain. The following case illustrates this point z 

^[. F., a woman aged 26, had a small, contracted, and completely tuberca— 
lous bladder. Right ureter not palpable, but left thickened and tender. I^ 
was found impossible to catheterize the ureters. An exploratory laparotomy" 
showed what appeared to be a right kidney of normal size, but a greatly enlarge«3^ 
left ona The left kidney w^as, therefore, removed, and this patient died o:f 
complete anuria. A pathological examination showed the kidney removed to 
be a compensatorily hypi^rtrophied one, with acute miliary abscesses of py(^ni<3 
origin scattered throughout its entire cortex, while the other was a fibro-scl^5- 
rutic tuWn'ulous mass from whi(*h all renal tissue had disappeared. The normsB-l 



DIAGNOSIS. 63 

shape and size felt by the laparotomy were given to the kidney by its fatty 

capsule. 

Tuberculin. — Tuberculin is of distinct value in the diagnosis of kidney 

tuberculosis. Carefully employed it is without danger and frequently gives 

positive evidence of the disease not obtainable without it. The skin and oph- 
thalmic reactions are of much less value than the old hypodermic method, be- 
cause, even when positive, they do not point definitely enough to the kidney. 
Tbey are also frequently negative, when there is tuberculosis of the kidney. 
By the hypodermic method, although it also fails to react in some cases posi- 
tively tuberculous, the results are more satisfactory. We are in the habit of 
taking the temperature every two hours for twenty-four hours, and then giving 
tbe patient one milligram of diagnostic tuberculin. If there is no reaction to 
this, the next night a dose of three milligrams is given. The temperature 
should then be taken every two hours for thirty-six hours. When positive, there 
is a distinct rise in temperature, usually at the end of eighteen hours, and the 
patient is likely to feel badly for a day or two, with general malaise. We have 
observed no permanent ill results, however, from such doses. Frequently, in 
addition to causing pyrexia, it will set up pain in the affected kidney and irri- 
tation of the bladder. Often, where they have not been demonstrable before, 
there is a throwing down of tubercle bacilli in the urine during a positive 
tuberculin reaction. 

Vrinary Examination. — Under Pyuria the significance of pus in the urine 
without any vesical symptoms has been discussed at length, such pus almost 
always coming from one or both kidneys. Exactly the same thing is true of 
blood. It must be remembered, however, that the presence of vesical symptoms 
does not necessarily mean that the abnormal element comes from the bladder, 
for, as said before, a tul)erculous kidney may create a great deal of vesical pain 
and irritation without there being any bladder tuberculosis. The first and most 
important step in a suspicious case is the demonstration of tubercle bacilli in 
the mixed urine. 

The Tubebcle Bacillus in the Urine. — The demonstration of the tuber- 
de bacillus in the urine clinches the diagnosis of urinary tuberculosis, and, 
from what we have already said as to the character of urinary tuberculosis, it 
is positive evidence that one or both kidneys are involved. Owing to the fact 
that the smegma bacillus takes the same stains as the tubercle bacillus, it is 
useless to examine voided urines. It is always imperative to obtain catheterized 
specimens. This simple point in technique is frequently overlooked and very 
often leads to serious diagnostic errors. Hardly a season passes without a case 
or two being brought in to us with a positive diagnosis of tuberculosis of the 



64 TUBERCULOSIS OF THE KIDNEY. 

kidney when the real cause is something else, the smegma bacillus having con- 
fused the examiner. The finding of tubercle bacilli in the urine means both 
kidney and bladder involvement in some cases; in others, kidney alone. A com- 
plete diagnosis is only reached by catheterization of the ureters and examina- 
tion of the urine of each kidney separately. 

The methods of demonstrating the tubercle bacillus in the urine are similar 
to those used for other fluids. They are either demonstration of the organism 
on smears or the production of the tuberculous process in guinea pigs by inject- 
ing the suspected urine into their subcutaneous or peritoneal tissues. 

Smears. — ^As staining reagents, nothing is superior to the well-known 
saturated aqueous solution of carbol fuchsin and Gabbot's methylene blue. The 
smear, which has been dried in the air, is fixed by passing it through the flame 
of a Bunsen burner. The carbol-fuchsin is added and allowed to steam for tw(^ 
minutes, the fuchsin is then washed off in running water, and Gcbbot's methy- 
lene blue added until all the red color has disappeared, one minute as a rule 
sufficing for this. When present the tubercle bacillus will be shown as a red 
staining body, slender and usually in clumps. The staining is a little irregular, 
giving the organisms a beaded appearance. The pus present, as well as con- 
taminating organisms, will be stained blue in these preparations. 

Recently marked improvement has been made in the method of centrifugal- 
izing the specimens from which the smears are made. Our own technique for 
years has been to take a well shaken-up specimen, thoroughly centrifugalize it, 
and make smears from the deposits in the bottom of the centrifugal tubes — the 
pus present serves as a fixative on the slide. This method is of no value m 
cases of excretion of tubercle bacilli through healthy kidneys, for the tubercle 
bacillus is of less specific gravity than the urine and will not sedimentize. Itm. 
such examinations better results should be obtained by employing Loeffler*^ 
method, which consists in adding chloroform to the urine, shaking up well, and 
centrifugalizing. The chloroform combines with the tubercle bacillus and. 
greatly adds to its weight. The smear is made from the stratum of urine whicl:m 
lies just above the chlorofomu In very purulent urines,' especially where othe*^ 
organisms are present, it is of advantage to employ the full Loeffler method 9 
which is, to add antiformin to the urine, thus dissolving the pus an^l 
formed elements with the exception of the tubercle bacillus, after which th.^ 
urine is mixed with the chloroform, as already described. O. H. Forsell ha.^ 
described a method by which he is able to centrifugalize very large amounts c^:^ 
urine, even twenty-four-hour quantities, and believes that he discovers orgar"m.- 
isms if they are present. Undoubtedly some cases of surgical tuberculosi ^ 
where abscesses are inclosed in the cortex are not associated with tubercle 



DIAGNOSIS. 65 

bacilli in the urine; such, however, are certainly exceptional. In 62 cases, 
where carefully looked for, we found tubercle bacilli 34 times. It is of ad- 
vantage to look for the organisms repeatedly and in different specimens; it 
may happen that they are absent from the urine one day and appear the next. 
The Guinea Pig Method. — This procedure is very delicate for 
urines which contain no pus. It is with difficulty applicable to urines contain- 
ing secondary infecting bacteria, because the animal is so likely to die from 
ibe pyogenic infection. In cases of pure tuberculous infection it is very delicate 
but has the disadvantages of costliness and slowness in development. 

A healthy animal should be obtained and always preliminarily tested with 
tuberculin. We have obtained our best results by subcutaneous injection, al- 
though many prefer intraperitoneal. The abdomen should be shaved and 
cleaned and three or four c. c. of the suspected fluid injected with an ordinary 
hypodermic syringe. In from two to three weeks there will develop definite 
tuberculous tissue, both at the point of inoculation and in the contiguous lymph 
glands. Considerably more certainty is added to the glandular involvement by 
traumatizing the inguinal and axillary region at the time of the injection. This 
can be done by pinching and bruising them. A satisfactory method of demon- 
strating the disease is to grind up the tissue, treat with antiformin until di- 
gested, then to centrifugalize and stain the sediment for tubercle bacilli. 

Other Pathological Elements. — In addition to the specific organism, 
pus and blood are almost constantly present in the urine, and in many cases 
other bacteria and frequently casts, as well as epithelial cells. 

Pus in Urine. — ^This can be reckoned on as always present, although 
the amount may vary enormously, and we have found it in 98 per cent. The 
cells are mostly polymorphonuclear, that is, 90 to 95 per cent, are so, while 5 to 
10 per cent, are mononuclear. Many efforts have been made to diagnose tuber- 
culosis by the character of these cells, and one of the most recent workers in 
this direction, S. Colombino, observed in a series of cases with tuberculosis 
that the leukocytes were extremely irregular in shape and size, and the nuclei 
were not so clearly stained as when they arose from some other pathological 
process than tuberculosis. He noted, too, that the nuclei are often found out- 
side the cells. J. Moscou (Presse med,, 1907, xii, 9) has more or less con- 
firmed the work of Colombino. Since the publication of Colombino's work 
(Ann, d, mal. des org. genito-vrin., 1906, xxi, 81) in January, 1906, we have 
attempted substantiation, but have not been successful. In our experience the 
cells are just as normal and as well preserved in tuberculous genito-urinary 
cases as in those due to other organisms. The irregular cells which he describes 
do sometimes occur with chronic tuberculous conditions of the bladder and 



66 



TUBERClfLOSlS OF THE KIDNEY. 






Ttib«rrulmr pApllla 
(solltAry focuH) 

Fig. 292. — TrijERct i.\a Kidney. 
Disease lioiited to solitary focua 
in lowermost |>apilla. Hematuria 
was the ijrimary and character- 
istic s>Tn|Hom of thU case^ due 
to injury of numerous vaao-reeti, 
after destruction of papilla. (S., 
Nov. 23, 1890; natural size.) 



kidneys, but are also met with in other ehronie alTet*tions. Maiij text-books 
state that a large number of nuumnuelear cells are eharucteristic of tubereulosis, 
but this is not in aecordanee with our findings. VH 

K e d B I o o d C e 1 1 s. — In assoeiatiori " 

with pus red blood eclls are nearly always 
present, usually in niiercseopic amount, but 
not infrec[ueiitly beninrrhage is extremely 
abimdant niid inny Ik' the most nnirkiHl sym[>- 
tom. ^nrh wart the ease of Mhs S,, a |jatit'i»t 
who had II tubereulous process loeatcnl in the 
a]»ex of ouv [Kifiilla of the up]»er part of the 
kidney (Fig. 21»2). 

Ijider Symptoms we have jwiinted out 
that mae rosea pica! lif blood was observed iii 
only 40 pt^r ecrit. of eas(\s ; but it was found 
tnkrosi-opicaUi/ in practically every case 
where pus w^as present. 

Secondary Organism s. — Involve- 
ment of the bladder and kiduoy by other or- 
ganinmH tlian the tulnTcle barillus 18 liable to 
take ]daee at any time in ibe course of the 
disease, thout»h not so fre»pu/ntly as some 
would lead us to believe. In our series ouly 
17 per cent» showed secondary infection, the 
organism in every case Ix^ing the colon bacil- 
lus. There is no reason, of course, why other 
pus formers should not be associated, and 
such cases have been described rei>eatedly in 
other case reports. The presence of the sec- 
ondary organism in no way changes the 
sytnptoms, although pyoneph roses are more 
liable to develop, a fact likely to complicate diagnosis eonsitlerably, for the 
tubercle bacilli were denmnstrated in only *30 per cent, of this group of cases. 
The amount of pus with a pure tnl>ereulous infection may be tpiite as great as 
that with a mixed infection. The presence of si^condary organisms can be 
demonstrated on the slide with catheterized urine, and their exact nature is 
best worked out by getting a culture of the bhidder urine. 

Casts and Albumin. — ^The great frequency of these in the urine is 
easily understood in face of the pathological processes induced by tubercle 



DIAGNOSIS. 67 

bacilli. We refer to the focal interstitial iiephritides. Many sections of tuber- 
culous kidney show hyalin and sometimes granular casts lying within the 
tubules, and it is not uncommon to observe these in the urine during life, while 
a kidney which is not tuberculous may be the source of some casts (see Indi- 
cations for Operation). Five of our cases showed no tuberculous process, but 
casts and albumin were in the one kidney and tuberculosis in the other. With 
tuberculous kidney there is frequently an excessive amount of albumin in the 
urine, but this subject comes under the chapter on Urinary Analysis. 

Cultural Metjiod of Diagnosis. — ^When urine contains a large amount of 
pus and neither on cover slip nor on agar culture any bacteria are found, the 
probability is greatly in favor of the disease being tuberculosis. A small 
amount of pus, however, simply indicates a gonorrheal infection. These gono- 
cocei, like tubercle bacilli, are difficult to demonstrate and do not grow at all in 
the ordinary cultures. Very occasionally, also, pyurias are due, as in one of 
our cases, to an anaerobic organism which does not grow on ordinary media ; 
the distinction from tuberculosis, however, is clear, as the cover slip shows 
this organism in the urine in large numbers. Out of forty-eight consecutive 
cases in which we took cultures, thirty-seven showed no growth on agar. An 
abundant acid pyuria without any organisms discoverable is, therefore, one of 
the most suggestive signs of tuberculosis we have. 

Cystoscopy. — The methods of examination hitherto described are such as 
8erve to establish a tuberculosis of the urinary tract, but do not show us just 
what is its location, nor distinguish between bladder and kidney tuberculosis, 
nor show if either kidney is healthy. It is possible, however, in many cases, 
by a consideration of the hi^ory, by the feeling of the ureters, and by tuber- 
culin results to locate the disease in one side or the other, a decision finally and 
exactly arrived at by cystoscopic examination, catheterization of the ureters, 
and examination of tlie separated urines. The cystoscope at once reveals the 
bladder as involved or not so ; and also shows the site of involvement The 
appearance of marked tuberculosis around one ureteral orifice while the rest of 
the bladder is normal suggests very strongly a diseased kidney above it, and 
such a finding is quite common. In 50 per cent, of our series there was marked 
tuberculosis about the ureteral orifices; in 15 per cent, the disease was about 
both orifices, but in half of these, as subsequently shown, the disease was limited 
to one side. In eleven, where there was only slight tuberculosis around a single 
orifice, this orifice was invariably that of the diseased side. Exceptions to this, 
iowerer, are met with, and a ease from the late Wm. Pryor aptly illustrates 
this point. He found on cystoscopic examination of one case a left ureter sur- 
ronnded by tubercles, with an apparently normal right ureteral orifice. On 



68 TUBERCULOSIS OP THE KIDNEY. 

catheterizing the right side, however, he found no urine being secreted, and 
a totally destroyed right kidney, with what was apparently an incipient tuber- 
culosis of the left side. Note well that in certain chronic cases of cystitis, 
little yellowish nodules may be seen on the trigonum somewhat resembling 
miliary tubercles, though generally readily distinguishable from them. Blad- 
der tuberculosis, as shown later, may be miliary or ulcerous, the latter being 
a later stage. 

In addition to definite tubercles, retraction of the ureter is frequently met 
with, this so-called golf-hole or funnel-shaped ureter being frequently an accom- 
paniment of the thickened ureter, and due to a shortening of the ureter de- 
pendent upon the tuberculous process. Hurry Fenwick reasons that within the 
first two years of the disease a golf-hole ureter means that the upper and lower 
calices of the kidney are the parts involved, the middle portion of the kidney 
remaining normal. He explains that it means a strictured ureter and there- 
fore a dilatation of the pelvis; such dilatation, on account of the anatomical 
relations, meaning that the greatest injury is brought to bear on the upper and 
lower poles. The golf-hole or retracted ureter, like the tubercles around the 
orifice, forms a very valuable index but not a positive one, as well illustrated 
in one of two cases of primary bladder tuberculosis which we have had, where 
one orifice was indrawn and the other slightly puflFy. Believing that the in- 
drawn orifice signified tuberculosis of that side, we explored the kidney, bnt 
found a healthy organ. A nephrotomy on the second kidney showed it likewise 
to be normal. In neither case was there any apparent kidney involvement* 
After three years this patient still has two actively functioning kidneys with- 
out any evidence of tuberculosis. 

Catheterization of Ureter. — To determine finally the involvement of one or 
both kidneys, the ureters should be catheterized. For the purpose of estimat- 
ing the functional activity of each side it is enough to catheterize one ureter 
and collect the urine secreted by the other from the bladder. The transvesical! 
method of collecting urine (described under Examination) we employ cor^- 
stantly. In addition to obtaining urine from each side the catheters are able 
to give information on points other than tuberculosis. Strictures of the ureter, 
which are often present, can be detected, the stricture most frequently found 
at the vesical end of the ureter being occasionally situated higher up, its fre- 
quency being manifested by the fact that out of thirty-nine cases where we 
have looked for it, it was present in twenty-one. The extent of such a stricture 
may be carefully calibrated by means of a series of graded catheters, and its bite 
may be tested by means of a spring with a pulley. The occurrence of a stricture 
at the lower end of the ureter is occasionally a very early manifestation of 



DIAGNOSIS. 



tuberculosU. Two of <nir eases hud urines^ apparently normal, but catheter- 
iring showed a slight hydronephrofciis mid a strictureJ iireter of one side. They 
cfime to our cliHie ^imw year'^ before the use of tubereiiliii and functional teats, 
and, nothing whatever being foniid except stricture of the ureter, they were 
^sent out with this diagnosis. Both developed later marked kidney tuberculosis. 
In two or three cases by means of the catheter we have removed from Ureters 
whose lumina w^ere plujrged with caseous matter small amounts of this sub- 
stance, and have shown the disease to be deHuitely tuberculous by uuikin^ 
■ smears on slides. Secondary infect iun apparently has no influence in the pro- 
ducing of such strictures; it was present in four out of eleven cases of this kind 
I where other organisms beside tubercle bacilli were found in the urine. 
Let there be a very definite procedure in catheterizing the ureters, owing 
to the poeaibility of carrying infcetiou into a healthy kidney. If the bladder 
is not at all involved, cntheterize that ureter which has excited suspicion, then 
wash out the bladder carefully and gather what has aecuniukted in it. The 
urine ia thus collected from the two sides. When the blad^ler is involved and 

I the disease is around one ureteral orilice, cathetcrize that ureter, wash out the 
bladder, and collect the urine from both sitles, one through the ureteral catheter, 
the other transve.sically* In very except iiujal cases it nuiy be necessary to 
catheterize both sides. A bladder thorougldy washed will show iirine from a 
healthy kidney to be. almost normal, even though it comes over a diseased blad- 
der. The urine should l:»e collected continuously froui the two kidneys for a 
period of not less than an hour, and should be submitted to the bacteriological 
and chemical tests already noted. 

Very confusing results are oi*casionally met with where two ureters come 
down froni one kiilney. In such a condition onedialf nuiy he discharging pus 
and tubercle hacilli, while the other jKJurs out practically clear urine. It ia 
poasible, therefore, to cathetcrize the ureters on both sides, getting clear urine 
from each side, and still have tuberculosis of the kidney. An interesting ease 
of thi^ kind has been descriW'd hy Ileymann (Zlschr, /. UroL, 1^112, vi, 473), 
in which a separator seemed to show tuberculosis of the left kidney and a nor- 
mal right kiilney, while catheteriziition of the ureters seemed to show that Wvlh 
tidneys w*ere normal. Nefdircctomy, left, disclosed the fact that the condition 
[waa a double kidney, oueduilf of which was tuberculous. 

Examination of the Other Kidney. — The exact state of the kidney which 

ffo not tubrrctdous must always In* ascertainetl : Tt uuiy be normal, it may 

»w nephritis, or there may be a pyelitis present within its pelvis. Having 

dncd the urine, one can compare the secretory power of the two sides. As 

itated, we have found albumin and casts present several times in the opposite 




70 



TUBERCULOSIS OF TIIK KlllNKY, 



kidney, and in several cases a definite colon pyelitis of the opposite side. In 
cases wheTC a tiilim*iili«iis kidney is doing a great deal of work, it becomes a 
qneation whether the other kidney can keep np the h^ij economy on removal 
of the tnheri'uloiis one. 

FTinctional Tests.- — For the technique and value of the functional tests the 
reader is referred to Chapter XL In every ease oi tuhcreulous kidney it is 
most inipnrtaiit to do everything pDssihle to gain an idea as to both 
the lulal and the comparative fuuctinii of each kidney. It should be bonic 
in mind tliiit the interstitial changes so common in tubcrcidona as well 
as in non-tubcrculmis kidneys in this class of cases will interfere considerably 
with the excretion of the dyes. One finds in comparing the tuliercnlons with 
its fellow ki<lney all the variations from total inactivity to u^ great or greater 
activity than the healthy side. In cases showing general renal insnfficieney it 
is a much graver procednre to remove an ac*tively secr(*tiug tnhercnlous kidney 
than one which is not secreting at all. It shoidd be Wjrne in mind, to<i, that 
the deaths from renal insnfficieney, due to nephritis^ may not occur immediately 
after the operation, but within a year or so. A factor to be considered, too, is 
that the second kidney, which is sidjjeet to a toxic nephritis, often improves 
after the removal nf the tidierenlons sitle. Eight eases wbere casts isml uUm- 
min were present before the operation, all except one remained well afterwards, 
and there was complete clearing of the urine. The ]iresenee of simple pyelitis 
in the second kidney is no contraindicatiori to nephreetomy, as w^e have flemon- 
strated in several cas(»s. After removing the tnbercnlons kidney the infection 
can hi' cleaned on the opposite side. 

Tlie X-ray.^ — In a pt^rfect X-ray plate, showing the kidney outline, which 
can always be secured by care in the preparation of the patient and the pho- 
tographing, the outlines and increase*! size of the kidney can be shown. Fre- 
quently, too, in these tuberculous kidneys shadows due to spots of calcification 
may he seen* Areas of caseation somelimes show. 

Lichtenberg and Diitlcn (Miff. a. rf. Grenz, d* Med. u, Chir,^ 1011, xxiii, 
739) have recently rejiorted the skiagraphic findings in eleven cases of tubercu- 
losis of the kidney studied by injecting eollargol solution. The destnictinn fif 
the papilla* and tlie irreguhir and ragged extensions into the kidney of the pel- 
vic cavity they consider eharactcristic. 

The use of eollargol will demonstrate any cortical abscesses communicating 
with the pelvis and neatly outline dilatations of the ureter; it will also, if stric- 
tures are present, show their Im-tition. We have noted in tuberculosis that not 
much is added to the nmlerstandiiig of the case by the eollargol pictures. It is, 
in our opinion, especially bad practice to inject both kidneys with eollargol, as 




PROGNOSIS. 71 



it undoubtedly lowers the resistance of the organs and would tend to spread a 
beginning tuberculosis in a kidney which could not be removed, as is the case 
in bilateral involvempnt. lodid of silver, two per cent., gives good results. 



PROGNOSIS. 

An essentially chronic disease, lasting for years, tuberculosis of the kidney 
in the majority of cases involves the bladder also, in its course, and, in fifty 
|)er cent., the second kidney. Efforts to estimate the actual duration of dis- 
ease are difficult ; Senator considers five years the time ; Albarran, on the other 
hand, has given three. We personally would give at least five, but it is 
extremely difficult to say just what its duration will be in the individual case, 
for there are very great variations. Two years from the onset of symptoms 
there will usually be tuberculosis in the bladder, but certain cases will not show 
thi?. In one of our i)atients. Miss A. E., age 42, there had been symptoms 
for thirteen years, and the kidney removed showed cavities at both poles, with 
a healthy middle portion and no vesical involvement. On the other hand, in 
certain cases, the entire kidney was destroyed when the symptoms had been 
present for only a year. What determines the destructive power of the 
bacillus? It must be the individual resistance of a patient. The presence of 
secondary infection is not in our experience so important as indicated by some 
authors. In one case, ^liss J. T., there had been a definite tuberculous and 
colon bacillus infection for eight years, and yet examinations showed active 
tissue still present. On the contrary, in other cases, such as Mrs. C. J. D., 
age 62, there was only moderate involvement of the kidney, though the bladder 
was very extensively diseased. This patient had only been having symptoms 
for six months. While the disease is chronic, the patient may have little dis- 
comfort and apparently enjoy robust health before involvement of the bladder, 
provided the ureter is open. The situation is very different when there is a 
definite involvement of the bladder. Such patients suffer from frequent mic- 
turition accompanied by burning; they have also a great deal of pain, and are 
among the most wretched people imaginable. Men, however, suffer more than 
women, owing to the involvement of the prostate gland as well as the bladder. 
Very valuable studies as to the duration of life with untreated tuberculosis 
of the kidney have been made by Rafin, Ilottinger, Wildbolz, Ekehorn, and 
Blum. 

A full review of this work is found in the excellent paper of Rafin (Jour. 
d'uroL, 1912, ii, 517), who finds that the average duration of life in the 



72 TUBERCULOSIS OF THE KIDNEY. 

patients who have died within ten years is four years and six months. No less 
than 16 per cent, of the patients who have survived five years die between the 
5th and 10th years of the disease. About 2 per cent, survive ten years. 

Eochet, quoted by Eafin, has noted some cases remarkable for their 
chronicity. Among seven cases of bilateral tuberculosis one lived for ten years. 
Many observers regard the prognosis, so far as duration of life is concerned, 
as much better in women than in men. 

Spontaneous Healing. — ^What is the expectation of renal tuberculosis healing 
spontaneously or by medicinal treatment? We are all familiar with the heal- 
ing of gland, bone, and lung tuberculosis under favorable conditions, but a 
study of our specimens does not disclose any definite healing process in kidney 
tuberculosis, as pointed out under Pathology. The only healing definitely 
known is where a kidney is entirely destroyed and its ureter occluded. Such 
cases, however, are rare, and there is always the possibility of a re-lightiiig 
of the infection. Albarran, examining one hundred and three specimens in the 
Necker Museum, found sixteen of complete ureteral closure. Le Fur {Ann. 
d. mal. d. org. genitcMirin,, 1903, xxi, 1734) has reported four which remained 
well for seven, four, three, and two years after this nature healing. A large 
number of our patients had been treated medicinally before coming to us, and 
in some of the earlier cases the effects of fresh air, feeding, and other usual 
means to relieve pulmonary tuberculosis were faithfully tried. Miss C. C, 
age 25, is an example of this. The patient apparently had a large amount of 
secreting kidney tissue, as shown by catheterization of the ureter of the kidney 
involved. She was so situated that every form of nursing could be secured 
without taxing her resources, and she was treated for a year, but grew steadily 
worse, in spite of the fact that her gereral physique improved. In another 
case. Miss W. W., age 23, the same treatment was tried with the result that 
the bladder became involved in six months. 

From what has been said about the excretion of tubercle bacilli in cases of 
pulmonary tuberculosis, it can be readily understood that the mere appearance 
of tubercle bacilli in the urine, without symptoms, pus, or blood, may occur 
without kidney involvement. Seven eases are reported by M. Pechere (Bull. 
8oc. roy. d. s. med. ei nat, de Bnix., 1905, Ixiii, 40), in which a cure appar- 
ently followed medicinal treatment, but no careful urinary notes are on record 
regarding them. They probably belonged to the class named. Max Schiiller 
{Mitt. au8 den Grenzgeb. d. Med. und Chir., 1906, xv, 208) gives a 
case of a man forty years old, with tuberculosis of the lungs, bladder, kidney, 
and testicles, who was treated for a year with guaiacol administered in doses 
of from twelve to twenty drops in water three times a day; thirteen years 



TREATMENT. 73 

afterward he was reported to be well. A somewhat similar case is reported 
in the Wiiritemburg Correspondenzblatt, July 9, 1904, where tuberculin was 
given. 

We have never personally observed — and this is the experience of prac- 
tically all surgeons dealing extensively with tuberculosis of the kidney — any 
healing in tuberculosis of the kidney, with the exception of cases where the 
ureter is closed, nor does the study of the pathological specimens encourage 
such belief. It must be rememl)ered, however, that the disease is sometimes 
very chronic, and that even with a single kidney, and that tuberculous, a 
patient can remain in an excellent stat^of health for a long time. It is inter- 
esting to see how a run-down patient with a pyonephrosis of one side and a 
tuberculous kidney on the other will pick up in general condition after re- 
moval of the pyonephrotic kidney. One such case is now under our observa- 
tion where tubercle bacilli are occasionally present in the urine of one side, 
yet the patient seems to be in very good condition ; the vast majority of cases 
of tuberculous kidney, however, mean infection of the bladder, a painful, se- 
rious disease, lasting several years and resulting in death. 

Besnlts of Medical Treatment. — The results of medical treatment stand in 
marked contrast to those of operative surgery. The medical procedures are 
those used for pulmonary tuberculosis, with which the profession is so fa- 
miliar, and consist of feeding, fresh air, and the employment of therapeutic 
doses of tuberculin. 

As already stated, we have had one case in which there is evidence of healed 
renal tuberculosis. Healing here is not definitely established, because it is 
conceivable that the reduced function present in the left kidney is due to some 
other cause than tuberculosis ; it is, nevertheless, highly suggestive. 



TREATMENT. 

The only satisfactory treatment of renal tuberculosis is operative, and 
should be carried out just so soon as a positive and complete diagnosis is made. 
The operation par excellence is nephrectomy, though occasionally a preliminary 
nephrotomy should precede it. There is a limited and still experimental field 
for partial nephrectomy in certain cases. Compared to the medical and expec- 
tant treatment, surgery has nowhere gained a more striking victory than in the 
treatment of renal tuberculosis. The reasons for early operation are as con- 
vincing as those for operating at all, for patients treated while the disease is 
limited to one kidney, in our experience, almost invariably get well. The re- 



74 TUBERCULOSIS OF THE KIDNEY. 

suits with extensive involvement of the bladder are not so bright; for, while 
many cases are rescued, some are not bettered. The primary mortality is prin- 
cipally in this group. When speaking of early and late cases wc do not mean 
in time of symi)t()ins, but in measure of the extension of the process. After 
five years one case may be early, and in six months another may be late. 

Historical Considerations. — In the early days of surgery for tul)erciilou8 
kidneys, nephrotomy, which usually meant incision and drainage of a tubercu- 
lous pus kidney, was considore<l as a serious rival for nephrectcmiy. This was 
largely due to the incomplete methods available for diagnosis and to the in- 
ferior techni(pie of nephrectniny. Vigneron (These do. Pans, 1892) found the 
primary mortality in IJiO ne])hrectomies for tulx»rculosis f the kidney 38.4 
per cent. On the other hand the primary mortality fron ne])hrotoniies was 
only 12.7 per cent. It soon Ix^came evident, how(»ver, hat many of the 
nephrotomy ons(\s died in the months immediately following ojx?ratioii, 
and that few permam^nt cures resulted. Pousson (Ccnirlhl. /. Chir,, 1901, 
xxviii, 82) estimated that out of ()*) nephrotomies, 39 died within a year. 
In Pousson's collection of ICl nephrectomies, the primary mortality was 11.6 
per cent., and the commonest cause of death was uremia. With the develop- 
ment of modern operative and examination methods the death rate, both pri- 
mary and secondary, in n(»phr(»ctomy for tuberculosis of the kidney has stead- 
ily fallen. Legueu ("Traite chirurgical d'urologie"), in G80 cases from Euro- 
pean surgeons, finds a primary mortality of about 7 per cent. In the case of 
Albarran — 118 cases — the rate was less than 4 j>er cent. W. F. Braasch, re- 
porting a series of 203 n('j)hrectomics for tuberculosis from the Mayo Clinic a-t. 
Rochester, Minn., lecords a primary death rate of only 2.9 per cent. Ourowxm 
death rate (mostly Kelly's operations) has been 4 per cent, in 100 cases. 

Although the primary death rate has been small, there are very few statis- 
tical records in regard to the ultimate outcome. This depends so much upoxn 
the character of the case and the complication in other organs that statistics ane 
rather dubious. 

Braasch could only obtain reports from 70 per cent, of his cases which had 
been operated on more than a year previously, and of this number no less than 
18 per cent, were dead. In our own series the secondary death rate in a period 
of over a year, and running back to cases operated on nearly twenty years ago, 
has been 10.9 per cent. We have ke])t records of all. Kronlein' (Folia Vro- 
logica, 1908, iii, 245) followed 71 cases from 1890 to 1908; of these 71, 18 
died; 14 in the first year and 4 others in from four to six years after operation. 
Albarran, who followed 39 cases, found that 5 died from the infection within 
3 years after the oi)eration, the other 34 apparently remained well. Our own 



TREATMENT. 75 

rate of cure has been 81.9 per cent., the death rate 18.1 per cent., and we 
would repeat that where the disease is limited to the kidney the primary and 
secondary death rate is almost nil. 

On the other hand, taking cases with advanced vesical tuberculosis as well 
as tuberculosis elsewhere in the body, the death rate, both primary and sec- 
ondary, will be much greater. In this class nephrectomy is but the beginning 
of treatment. It must be followed by treatments of the bladder and perhaps 
operations upon it, extending over a period of several years. This will be 
treated under Tuberculosis of the Bladder. 

The prepuce of tuberculosis in other parts of the body is not a contra- 
indication to nephrectomy. We find the association between tuberculosis 
of the kidney and tuberculosis of the genital organs in woman is almost 
as common as in man, and patients with active pulmonary tuberculosis, but 
with the most aggravated symptoms from the kidney, are often benefited by 
^ nephrectomy. 

I So far as our own cases are concerned the relative results in the different 

f groups have been as follows: 

i First, in 30 per cent, the tuberculosis was clinically limited to the kidneys. 

I There have been no primary or secondary deaths. 

I Second, in 56Vi> per cent, there was extensive involvement of the bladder 

as well as of the kidney. The primary death rate has been 11.5 per cent 
Within one year after operation the death rate in this group has been 26 per 
cent. ; the percentage of absolute cures about 60 per cent. 

Third, 8 per cent, had pulmonary tuberculosis in addition to the renal. 
The total death rate, primary and secondary, has been 20 per cent, and 80 
per cent, are apparently cured. 

Fourth, 8 per cent, have been associated with tuberculosis of the tubes and 
ovaries. In this group there has been no primary death from operation, but 
20 per cent secondary deaths. In these cases the affected genital organs were 
removed as well as the kidneys. 

Causes of Death After Nephrectomy for Tuberculosis. — O. G. Eamsay (Aiin. 
Surg., 1900, xxxii, 461) has collected the causes of death in 37 cases occur- 
ring after 191 nephrectomies. Fourteen were due to disease of the opposite 
kidney and in only three of these was the cause an active tuberculosis. Among 
other causes were collapse, peritonitis, septicemia, hemorrhage, exhaustion, 
necrosis of the bowel, etc. An unusual case is that of Jenckel {Dtsche. 
ZUckr. /. Chir., 1905, Ixxviii, 593) where, after a nephrectomy, the patient 
died on the fifth day with complete anuria. The autopsy showed a perfectly 
normal-appearing kidney. 



/ 



76 



TUBERCUT^OSIS OF THE KIDNEY. 



Bransnh i«tatc*8 that tiie cases eiKliiig fatally in his series showed at autopsy 
general nuliary tiibGreulosis, and we ourselves bad one such case. Deaths from 
tuberculous meningilis are also on record, but the large majority of primary 
deaths are due to iTisufficieuey of the kidnr-v left in situ. 

Technique of Nephrectomy. — ^The lumbar or exfraperitoneal method i» ap- 
plicable to, and should be employed in, all cases. The posture of patient is, as 
shown in Figure 173^ upon an l*Mebohl8 air bag, 80 that the space lK*tween the 
lowest rib and the crest of the ilium is exiciided to its maximum, ilake the 
incision (Fig. 183) from four to five eentiuieters in front of Pctit's triangle, 
and extend it from the angle of ihe twelfth rib above, w*ell around to the crest 
of the ilium below* Tt is Ix^lter always to cut the umscles and not to attempt 
muscle separation, as done in eases of movable kidney. Sjiecially take eare to 
avoid injury of the first lumlmr and the last dorsal nerves. If the perirenal fat 
is not involved, an incision of this kind will suffice to get the kidney out, but if 
the kidney is very large and very adherent, a lateral extension can be made 
across the alKlonnnal muscle beginning about its middle (Fig. lUO), which gives 
the so-called frying-|>fln incision. This affords a wide* exposure, and makes pos- 
sible an easy dissection of the kidney from its surroundings. It is rarely 
necessary to lireak or to excise the twelfth rib, though it may have to be done 
oeeasionally, when the upper pole of the kidney is deiihely adliereut. It should 
be avoided wdienever possible, as infection of the rib with a tuberculous process 
may result. Note well, in selecting the |ilace of incision, that the larger 
the mass the farther antet'ior should the incision be made. In very large kid- 
neys (Operations on Tumors of Kidney) an actual anterior incision is best, 
but, whichever is made, take every care to avoid injuring the peritoneum. 
Equally important is it, in removing tuberculous kidneys, to keep in mind that 
thorough mohili nation should Ik* secun*d Ijcfore attemt>ting to tie otT the pedicle, 
otherwise serious accidents may result* After making the incision down to 
Gerota's capsule, ]ierforate this and so expose the perirenal fat. When this is 
evidently not involved, the kidney can be partly pulled down by means of it, a 
number of clamps lieiug applied in the method which we have described under 
suspension of the kidney. 

Going through the perirenal fat, free the kidney everywhere gradually by 
working the hand through the adhesions. Wheij entirely free, the kidney is 
delivered. 

The next step is the tying off of the vascular pedicle. This can generally 
be attacked in one of two ways, the choice to he determined by the operator 
while he is working. Sometimes it is more convenient to Ix^gin tying off above 
(Figs. 293 and 294), going through the pedicle step by step. One strong cat- 





Fto. 29'L— l*^K<*f)N'D Stei" iN Nhiiinr.^ ihmv from ABfnE DfJWNWAia* ton Ti iu-ut i L+>isii 
nK THE KiT>NKV. The iippermust vi'ascl hns heoii doiihly lied and cut Ictween, as showQ 
The iic^xt li^!iturt* is l>emj; wt witli aneurysm nf^^cile. Instead of ligation on tii<? reii| 
Bide, it iii frequently more eonveiiient to employ clamps* 




Fig* 295.^ — Nephrectomy from Below Upward for Tltbercitlosis of the Kidnbt. 

I The first step is, as shown by arrow 1, the severance of the ureter near its pelvic jtmo- 
tion and the stenlixation of the cut encis. The stripping up of the ureter makes ao- 
eeofltblc the vascular rena! pedicle, which is tied off in progressive steps, from below 
%ip. This is the reverse of the method from alcove downward, and the same precau- 
tions should be observed. Thb? procf?<iure is adapted to those cases where the lower 
pole is more readily delivered than the upper pole. The operator will often have to 
decide after trying as to which method is to be preferred^ 



79 




TUBERCULOSIS OF THE KIDNEY. 

After getting all the way through the pedicle the ureter may he ligated ud 
cut through with a cautery knife and the kidney removed. 

But note that just the reverse proceihire may l>c the most applicable. The 
ureter is cut through first, the lower pole turned up (Fig. 21)5), and the pedicle 
ligated from helow upward with catgut. It la highly imjxirtant in going 
through the pedicle to ligate the vessels separately, and this can be greatly 

facilitated by dissecting off 



1^ 4 



f? 



■^<; 




the fat. A convenient method 
of doing this is by means af 
a small, flat, crenated dia^ 

sector. Special care should 
he taken in reference to tie 
right renal veia, adheaiona to 
the liver must be dealt with 
most carefully, and, if at any 
point in the operation bleed- 
ing is profuse, do not clamp 
hastily, but stop the bleeding 
by pressure, and then care- 
fully clamp. Occasionally it 
18 impossible to apply liga- 
tures to the pedicle. Under 
such conditions one can apply- 
clamps and leave them on fot 
several days (Fig. 296), bu^ 
this is a risky procedure. 

Exceeding care is nece^^ 
aary in removing the peri- 
toneum from the anterior 
surface of the kidney. Not infrequently there are dense adhesions in tkis 
direction, and the intestine may be injured, especially on the right aide, 
while a dufxlcnal fistula is not an easy complication to face. Removal of tte 
perirenal fat is best done after the removal of the kidney, and even if this is 
not done, the case will do %ery well. Lymphatie glands manifestly enla 
at the pelvis certainly call for excision. 

What to do with the ureter after removal of the kidney is a problem whicl 
will confront every surgeon. Our first complete ureterectomy was in 189®^ 
since when we have done it in many cases. Wlien to perform it must be decidecS^ 
by the operator. Our o^vti views we will take up a little later j just now wa 



^>f 



Fig. 296. — Ripm Removal of Kidney, Ceamp 
Method. To be used wlicn great haiste is neces- 
earj'i especially when one of the renal veins has 
been torn. 



JJ0 MS 

irra^ 
rhicfi" 




will consider the method of re- 
moval. In the earlier cases we 
extended the incision made to 
remove the Tcidney around the 
abdomen, after the iiuiiiijer 
employed by Israel, almost 
cutting the patient in half. 
Later, after freeing the kidney 
from its pedick* and all its 
att^tchments except the iireter, 
we made a second ineision, 
about fonr inches long, pa- 
rallel to Pon part's li^atuent 
(Figs, 192 and 193), and 
pnshed tlie kidney down to 
this underneath the perito- 
neum^ thus removing it and 
the ureter in a single piece; 
now w© cut the ureter in two 
near its junction with the pel- 
via of the kidney and sterilize 
il by means of a cautery. 

The ureter may be thus iso- 
lated; drawn under the bridge 
of the abdominal wall, and 
freed down to tlie !*1 adder a 
simple procedure in the nuile, 
but complicated in the female 
by the passage nf the ureter 
:>ugh the broail ligament. 
first we regularly cut the 
Uterine artery in order to get 
to the ureter, hut later found 
tfaU not nocf^ssary, for tbe ar- 
tery could be lifted up, the 
ureter freed, and a cone of 
bl0<]der pulled bat^k under- 
neath the artery (Fig. lUr*). 
It is possible to excise that 



Fig. 297.— KmNEY, Ure'tcr and Part or the Blad- 
der Inciading Ureteral Orifice Removed in 
One Piece for Tiberculosis of Parts Con- 
cerned. The tubercular process is shown on the sur- 
face of the lower pole of the kidney, and throughout 
ttie ureter J esi3ecially its vei^ieal end, by great thick- 
UQSs, and in the interior of the bladder by golf -hole 
ureteral oriBcc and tubercular patches. (Mrs* M.) 



82 TUBERCULOSIS OF THE laONEY. 

part of the bladder immediately aroimd the ureteral orifice in the bladder, and 
to turn in the bladder with catgut sutures (Figs, 297 and 298). In soino cases 
where the lower end of the ureter is manifestly healthy this is not necessary, 



¥lQ, 298. — View of the Abdomen Showing Position and Extent of Incisions Neces- 
sary FOR Hlmoval of Specimen Shouts jn Precedino Ficire. There were two 
incisions through the abdominal wall, one the usual hinibiir inciniou through which 
the kidney was severed from its vascuJar pedicle, being theu puslied down and brought 
into the peritoneal cavity, through the incision showTi in f>el\ic brim. The ovariao 
vessels left intact. Ureter and bladder exijosi^ by inrision ahowTi anterior to tube. 
The uterine artery was saciificed on this side. (Mrs. McH.) 

but the ureter is tied oflF with catgut and simply buried after cauterization of 
its end. When the entire ureter is left in, we prefer, as a rule, to bury it^ 
rather than sew it into the incision, 

IntracapsElar Hephrectomy. — ^Intracapsular nephrectomy is of great value 




1 



TREATMENT. 83 

in the large pyonephrotic tuberculous kidneys, and is usually secondary to a 
nephrotomy, its results, in our experience, being remarkably satisfactory. The 
sinus in the back persists longer than after an ordinary nephrectomy, but that 
will heal up. Out of eight such cases one closed in six months, one in a year, 
one in two years, one in three years, one in thirty months, and three are still 
open. 

As to operation, it is done after the following manner : Incision is made 

through the capsule; the hand is worked around between the capsule and the 

kidney, which is rapidly delivered, in some cases being taken out in pieces. 

As it is pulled up, the forceps are applied to the pedicle, which comes nicely 

into view. Very little hemorrhage follows, as this method is usually employed 

in those cases where there has been most extensive kidney destruction, and 

consequent interference with the blood supply (Figs. 401, 402, and 403). As 

the kidney is removed in pieces, and the clamps applied, we have at the con- 

cluaion the condition shown in Figure 404. The clamps are then carefully 

replaced from above downward, by catgut sutures, thus thoroughly controlling 

hemorrhage. The whole operation need take but a few minutes and can well be 

done under gas anesthesia. The incision is drained with iodoform gauze, and 

we find it extremely valuable to inject an oil mixture of iodoform emulsion. 

Before taking up the results of nephrectomy and the post-operative compli- 
cations, let us consider nephrotomy. 

lephiotemy and Beseotion of Kidney. — Nephrotomy is now limited to the 
opening of large abscesses and employed merely as a palliative measure, or pre- 
paratory to a later nephrectomy ; it is in no way to be considered a substitute 
for it The old method of opening tuberculous kidneys, with an idea of heal- 
ing, similar to the mere opening of tuberculous foci anywhere else in the body, 
has proved inefficient. 

Ifephrotomy, being limited to abscess cases, is very simply done. An incision 
is made over the most prominent part of the mass down to the kidney ; this is 
reached by means of a blunt clamp, the kidney is opened freely, and the pus 
evacuated. After emptying, it is best to put in a large gauze drain. It is truly 
remarkable how rapidly patients who have even reached a stage of extreme 
exhaustion recover after this operation. Patients who seem to be inevitably 
subjects for death are frequently saved in a manner almost startling. Neph- 
rotomy is occasionally the only operation possible, that is, when there is only 
one kidney, or occasionally when both kidneys are involved and one is pyo- 
nephrotic. Our own experience with nephrotomy where both kidneys are 
involved is not very satisfactory, for in four cases where we employed it, all 
died within two months after operation; all were distressed with fistula in the 



TUBERCULOSIS OF TUE KIDNEY. 

side, and nil received do benefit whatever. However, cases are recorded in the 
literature where benefit apparently followed. Pousson quotes a most intereating 
one, with normal urine, where the tuberculosis, of the easeo-eavernous type, w$b 
located entirely in the kidney cortex. He did a nephrotomy with extensive 
removal of the diseased parts, and, although the urine continued normal from 
that kidney, the fistula persisted in the side, and sixteen months later be found 
a nephreetoTuv neef^ssary, wliich disfdnned an active tuberculosis of the organ. 

Conservative Operations on Kidney.— When one kidney 13 perfectly sonnd 
conservative operation upon the other is not indicated; a nephrectomy is better. 
On the other hand, in eases where both kidneys are involved, it is justifiable, in 
the present state of our kiiowliMlcre, tu attempt eou>ervative operation to cure the 
one, for, if it can be so cured, then the other may be likewise treated or actuallj 
removed. Our personal experience with this method of operating is not very 
encouraging. In one case, although the urinary examination showed tubercu- 
losis to bo definitely present, it was quite difficult to find it on exposing the kid- 
ney, and required considerable manipulation of the organ; finally a small fo<'U3 
the size of a hazel-nut was removed from the upper pole. This was in reality 
the better kidney, although the other was actively secreting. The patient recov- 
ered, but continued to have marked tuberculous symptoms, and died six montJii- 
later of complete anuria, having sulTered with a remarkable form of hematuria^ 
from the kidney, in which she passed entire easts of the ureter. Autopsy^ 
showed the kidney o])erated upon to be almost destroyed by tnl>erculosis. 

Another of my own cases illustrates the deleterious influence of manipular— ^ 
tion upon a tuberculous kidney: 

Miss B. D., admitted to the Johns Hopkins Hospital Sept. 5, 1905, ^ 
tubercle bacilli and pus coming from right kidney. The resident explore^3i 
the kidney, but found a nornuil looking organ, and even after doing a nepl]i, 
rotomy he could see no evidence of tuberculosis. The kidney was therefo^*^ 
sewed up. Six months later, on April 2, 1000, the symptoms having increase<J^ 
this patient returned, and we removed the kidney, which was found to l>e 
entirely destroyed by tutxtrculosis. 

Seven such cases are rept^rted by Morris in his ^^Diseases of the Kidney aud 
Ureter," and three had to undergo a substHjuent nephrectomy. One was well 
four, another three, years after o[)eration. To quote again: Morris removed 
the upper third of a solitary tuberculous kidney, and four years after this opert^ 
tion the patient was in apparently perfectly good health* Israel, in 18!)6, did 
a partial nephrectomy tipon a pntient wlio enj(»yed seemingly gtx>d health for 
four years afterwards. The symptoms returned fidlowi ug a pregnancy, and it 
was necessary to do a nephrectomy* Kramer reports several successful cases 



TUBERCULOSIS OF THE URETERS. 



85 



I 



operated upon by Bardenheuer, while Dr. Christian Fengerj a pioneer in this 
field, attempted several cases, but by private eommunication some time before 
his death told me that all of them had relapsed. Dr. Francis Watson, of Bos- 
ton, also tells us of a similar experience. Dr. Henry T. Williams, of Roehes- 
ter, N. Y.J had a male ca.se where tho man was apparently well four or five 
years after operation, and the late Professor Lennander, of Upsala, reported 
the successful removal of a double kidney. 

To illustrate the possibilities of this form of surgery I quote the case of Mrs. 
S, (Fig. 281): The patient had a double blood supply and a double pelvis 
to the tuberculous kidney, the two kidneys being thus anatomically disasso- 
ciated. The tulterculosis, as shown^ was so limited that tlie upper pole was 
entirely destroyed by the tuberculous process, whereas .the lower one was nor- 
maL The upper kidney was not secreting at all, and the lower one excreted 
normal urine. In such a case it would have been very simple to have cut 
directly across and resected the kidney, an operati(*n occflsionrJIy possible, as 
shown by what we have found in our studies of specimens with regard to locat- 
ing the disease (see Pathology)* It is always a temptation, %vhere there is 
bilateral renal tuberculosis, to attempt some sucli operation when the almost 
certain progress of the disease when left alone is c<msidered, but we think that 
it is best to limit the operation to this group of cases, owing to the excellent 
results obtained by nephrectomy* 

Complications of Operation. — Most patients do well after operation^ and 
our four primary deaths were due in two cases to anuria, in one to peritonitis, 
and in one to general infection. The commonest complication is a persistent 
sinos in the side. This occurs most commonly when there is perirenal infec- 
tion, and may persist for years, though in most cases it finally closes. In many 
of the patients there may be vesical distress^ either with or without tuberculosis 
of the bladder, for long periods of time, 

rThe pathology and occurrence of ureteral tuJ>erculnsis have already been 
deecribed. In most cases the treatment is removal of the kidney above. It is 
rarely necessary to perform the operation shown in Figures 104-106. In 
some eases, however, there is no relief of vesical symptoms until the ureter is 
removed, and in not a few there may be attacks of colic in the affected organ 
even when the kidney is gone. If, after a prolongtMl period of waiting, these 
symptoms persist, the proper treatment is to remove the ureter, as shown in 
Tigures 194-196. 



I 
I 



TUBERCULOSIS OF THE URETERS. 




86 



TUBERCULOSIS OF TEE KIDNEY- 



TUBERCULOSIS OF THE BLADDER. 



Tuberculosis of the bladder is said to occur as a primary disease in a small 
percentage of cases of urinary tuberculosis. Id two patients we have observed 
bladder tuberculosis without any evidence of renal trouble. Both of them were 
women, and both were relieved, after extenaive Iwal treatments, by removal of 
the affected parts of the bladder through suprajmbic openings. Casper {Dlsche. 
med, Wchnschr., 11)00, xxvi, 661; 673) describes three cases of apparently 
priniary bladder tuberculosis. It is said to be commoner in male^ than in 
females. 

As a rule, and, indeed, almost without exception, tuberculosis of the bladder 
IB a woman means tuberculosis of the kidneys. In the male^ on the other band, 
there is frequently a bladder tuWrculosis which is secondary to tuberculosis of 
the genital organs, particularly t\i the prostate gland and of the seminal vesicles. 
We have ne%*er observed a bladder tuberculosis following tuberculosis of the 
tubes in a woman. 

Patholog:y* —The most thorough and comprehensive report in existence in 
regard to tuberculosis of the bladder is that of Halle and ilotsc {Ann. d, mal, 
d, org, geniio'iirin,, 1004, xxii, IGl). They divide the stages into several 

steps: in tlie tirst there is 
simple dissenniuited tuber- 
cle Innnation with c^cca- 
sional supcrtieial ulcera- 
tion aufl the disc^ase is 
limited to the mucosa. In 
til** second stage* the nicer* 
ations are deep and there 
are frcfpient extensions 
into the muscle layers. In 
the third the entire blad- 
der wall may be destroyed, 
and in the fourth extensive 
involvement occurs in the 
perivesical tissues. ^Vhi!e 
these extensive processes are met with in autopsy specimens they are rarely 
seen in life. In most of our patients the disease has been limited to certain 
parts of tlie bladder. This is often around the orifice (Fig. 291)) of the affected 
ureter, but it may be anywhere (Fig. 300). In addition to tubercle formations 



Fig. 2!j'J, t v>i*'-i dPic View of Rigut ant> Left 
Ureteral Orifices; Tubkrculosis of Left Ktd- 
NEY- Note corona of tubercles, around left orifice, 
and normal right orifice. (Miss M. D., March 16, 
1908,) 



TUBERCULOSIS OF THE BLADDER. 



87 



BPe is often a marked infliimmatory reaction, due perhaps to toxins, and 
ribed under Tuberculosis of the ITreter. In the prolonged and advanced 
there is usually marked contraction of the* bhidder. This is due in part 
tothe tuberculous process* but also to the almost eoiitiniioiis spasm of the organ 
due to irritation. The cjstoscopie appearances as well as the s;>Tnptoms occa- 
rioned by tuberculosis of the bladder have already been described. 

Fro^oftis. — A few years ago tuberculosis of the bladder was regarded as 
incurable disease* Its mere presence was CTiongh to enntraindieate opera- 
It is perfectly certain now that, provided thr primary cause is removed, 
(mimy patients suffering with bladder tuberculosis can be 
rured. The lighter the condition and the less extensive the 
process the surer this result. Our (experience in this con- 
nw'tioa has been confined almost entirely to women. Pro- 
vided, however, there is no associated genital tubercuiosig 
we believe that the course uf the diseast* in the two sexes is 
identical In cases where the affected kidney becomes shut 
off by occlusion of its ureter, there might be spontaneous 
healin^r, but such a result must be e-xtremely rare. In our 
opinion, without the removal of the primary cause, such 
patients inevitalily go from bad to iivorse. 

Treatment. — The first step in treatment is the removal 
of the primary cause, and in the female this is the kidney. 
In the milder cases removal of the kidney alone often 
mflier^ to cause a cure. If^ after removal of the kidney, 
the ineneral and local measures to be described fail, the 
next step to take is to form a vesico-vaginal fistula. The technique of this 
(operation is shown in Figures 557 and 558. It is carried out by intrndncing a 
mmi into the bladder, pressing down the trigonum between the urethral ori- 
fices, and incising from the vagina into the bladder. The opening should be 
fide, and, to prevent spontaneous closing, it is most important to bring the 
mical mucous membrane to the vaginal by suturing. Having formed such a 
fistnla it should be left open for six months or longer. From time to time 
C}itoK!«pic examinations will show progress. When the healing is complete 
the fistula can bo closed and, by gradual dilatations, the capacity of the con- 
tTRcted bladder restored. After such treatment, in many of these cases, the 
disease is found to be limited! to a single spot in the blad<ler ; indeed, the tuber- 
cnlona process may have disappeared and nothing remain except a reddened 
inflimed area which, however, keeps up tlie irritation to such an extent that 
the patient feels no relief. We have frequently had bladders which could be 



Fig, 3(KK — CysTO- 
scopic View of 
Patch of Dis- 
crete TlBBHCLES 
on Mucous Mem- 
brane of BLAOnEK. 
(Noriiiski, Nov. 12, 
1906. Cystoscopic 
Clime.) 



88 



TUBERCULOSIS OF THE KIDNEY, 



dilated to 300 c. c, and yet the patients were voiding every hour or so, night 
and day. 

In such cases there is rarely any relief from IcK'al applications through the 
urethra, and the best results have been obtained by following a plan deviled 
by one of us (Kelly), which has proved suceessfiil in a number of cases. This 
is to open the bladder by the suprapubic route and make a transverse incision 
through skin, fat, and fascia parallel to the pubes. The muscles are opened 
in the middle line, A catheter introduced into the bladder through the urethra 
affords a means of distending it with air. The peritoneal reflexion is pushed 
down and the bladder widely opened in a transverse direction. With the patient 
in a high Trendelenburg posture there is perfect exposure of the interior of the 
bladder. The spot is excised and the defect in the bladder wall closed with 
a triple o chromic catgut suture threaded on a fine staphylorrhaphy needle. No 
suture appears in the bladder, w^hich is then closed with the same suture 
material. The best stitch is a continuous one, and care should be taken that 
the sntnre does not present in the bladder and that the fascia covering the 
bladder is brought together. The incision may then be closed in any desired 
way, and it is \vell to put a small drain down to the prevesical space. The 
steps of this procedure are ahowTi in Figures 598-002. The results have been 
most satisfactory. 

Excision of the Bladder for Incurable Toherculosis.— There are occasional 
cases, particularly in the male, where, in spite of removal of the diseased kidney 
and drainage of the bladder, the vesical tuberculosis persists and gives rise to 
unbearable suffering. There are four or five reports in the literature where the 
entire bladder has been removed for this condition and the ureter implanted 
into the bowel. The death rate in these cases has been alxjut 50 per cent. 

A much simpler procedure is the cutting off of the ureter from the bladder 
and its implantation into the skin or into the bowel. The second procedure is 
inferior to the former owing to the rather high death rate from ascending 
renal infection, 

Andre Boeckl {Jour. d'uroL, 1912, i, 345) has reported the literature of 
this subject The patients may be given a number of years of comparative 
comfort by means of this procedure. In the cases where the implantation has 
been on the skin convenient apparatus may be employed to collect the urine. 
The treatnientj however, is only palliative, as most of these patients die of 
their disease within a few years. Where there is a pyonephrosis of the remain- 
ing kidney it h lietter to do a nephrotomy than ureterotomy. 

Medical Treatment of Bladder Tuberculosis. — ^It must be emphasized that 
treatment will be of little avail until the source of the disease, the infected 



TUBERCULOSIS OF THE BLADDER. 89 

kidney, is removed. Other things being equal, there can be no question of the 
value of fresh air and nourishing food. 

J. G. Pardoe (Lancet, 1905, ii, 1766) has reported extremely valuable re- 
sults from the therapeutic use of tuberculin. An interesting report along this 
line has also been made by Dr. J. Pedersen (New York Med. J., 1911, xciii, 
371). In two cases he saw complete clearing up of the urine, of both tubercle 
bacilli and pus. We have been observing a number of cases of tuberculin treat- 
ment, but have not been convinced of its value. However, it certainly does no 
liann. 

The best topical application is carbolic acid, which was first advocated by 
Professor Rovsing of Copenhagen. Our experiences with the 5 per cent, solu- 
tion advocated by Rovsing have not been entirely favorable. On the other hand, 
^th ^ and 1 per cent, solutions there have been apparently marked im- 
provements in many patients. Carbolic acid of this strength has a marked 
anesthetic action, and is one of the best fluids for dilating a contracted bladder. 
After a nephrectomy all of these measures should be put to trial before resort- 
iBg to any of the operative procedures advocated. 



CHAPTER XX. 

RENAL AND URETERAL STONES. 

Nephrolithiasis is the term employed to designate the condition of stones 
in the kidney. Xot only the kidney, but every part of the urinary tract maybe 
the initial location of stone formation. The migration of stones from the 
upper part of the tract to the lower segments is a common occurrence. A stone 
originating in one of the kidney calices may remain there, or it may pass to the 
renal pelvis to develop further, or, passing onward, enter and lodge in the 
ureter, from which it may escape, to form the nucleus of a bladder stone. The 
injuries which a kidney may suffer from the presence of stone in it are mani- 
fold : obstruction leads to hydronephrosis, infection to pyonephrosis, and the 
mere presence of the stone, through mechanical irritation, to various degenert- 
tive changes. 

HISTORY. 

Stone kidney is one of the oldest diseases known to medicine. Hippocratei 
not only records the condition with accuracy and in detail but describes surgical 
procedures for the removal of stones from pyonephrotic kidneys. 

Serapion, a Damascus physician of the ninth or tenth century, makes men- 
tion of operations for stones in the kidney. Avicenna, in the eleventh cen- 
tury, also speaks of operations through the back and loin, but expresses the 
belief that they are unjustifiable. Subsequent to Avicenna, who not only de- 
scribes the operation but also speaks of perirenal abscesses and the difficulty 
of healing them, a number of centuries elapsed before any new mention was 
made of the subject. Guy do Chauliac holds that the stones are formed in 
the kidney from kidney sand, and offers a number of medicinal methods of dis- 
solving the stones, saying that, if these are unsatisfactory, the stones may be 
removed from the bladder by operation. From the fifteenth century on can he 
found numerous accounts of successful stone removals, in French, German, and 
English literature. Tlayer quotes "Les chroniqiies de Jean do Troy es," in which 
is given an account of the death of Louis XL This account, however, is 

90 



raSTORY. 91 

nore or less apocryphal, and it is diflScult to determine whether the stone 
iras really removed from the kidney or from the bladder, and whether it was 
in the time of Louis XI or Charles VII. Riolan, in his work on anatomy, 
describes cases in which stones are present in the pelvis of the kidney and in 
the ureter. He gives an excellent description of the ordinary coral stone 
and goes so far as to advise operation to remove these stones. His publica- 
tion was in 1649. In 1670, in an endeavor to throw some light on this sub- 
ject, the Italian Zambeccari wrote to Fradi in the "Nova Acta Eruditorum," 
describing some experiments on animals, among others nephrotomies on dogs. 
BUnkaart, in 1690, suggests the removal by nephrectomy of the stone kid- 
Bey, although he does not say that he ever did it. Peter von Forrest, in the 
ieyenteenth century, advises against opening kidney abscesses, citing two cases 
that died within a short time after operation ; also another case in which there 
was present a renal sinus. The famous Nicholas Tulp, whom Rembrandt 
immortalized, gives excellent pathological descriptions of stone kidneys. He 
opposes the attempt to remove stones from the kidney, because it would cause 
guch a tearing of the kidney to get them out. One of the most remarkable 
descriptions of a nephrotomy for stone in the old literature comes to us from 
Charles Bernard, and concerns a certain Hobson who was the English Consul at 
Venice. He went to the famous Italian physician, Dominico de Marchetti, 
and demanded an operation upon his kidney. The physician advised against 
operation, but the obstinate insistence of the Englishman ultimately overruled 
his objections and he operated. With a knife he cut through the various layers 
of the abdominal wall to the kidney. On account of the extreme bleeding, how- 
ever, he packed the wound after reaching the kidney, and at a second operation 
opened the kidney and removed several stones. This patient had a fistula in 
the side for some time, but this finally closed, and a number of years later Dr. 
Downs, who saw him in England, as did also Tyson and Bernard, found that he 
was in splendid condition in every way. This case is the first absolutely authen- 
tic nephrotomy that we know of in literature. Schurig was the first to give the 
name of nephrolithotomy to the operation ; the older operators called it simply 
nephrotomy. 

During the entire eighteenth century there was great discussion whether 
to open a kidney abscess with a knife, with cautery, or to let it alone. Pass- 
ing rapidly over the work of the early eighteenth century, we come to the 
great father of kidney pathology, Kayer, whose work dates from 1841. He 
noted that the kidney stones were practically always in the pelvis of the kidney, 
fiie says that, if there is no swelling in the side, and if the strength of the 
Mtient is uninfluenced, no operation should be thought of. He speaks of the 



92 RENAL AND URETERAL STONES. 

folly of doing a nephrectomy in such cases, although granting, as he himself 
has proven, that it caii be done on animals, without bad reanlts. Comhaire, in 
1803, had also operated on dogs, and showed beyond any question that a kidney 
could be removed without impairing the urine-secreting function. At the eud 
of the sixth decade of the last century Tliomas Smith recommended the freeing 
and delivering of the kidney, when there was no abscess present, and the pal- 
pation slioweJ stones. Reidner and Maunder performed such procedures on 
the cadaver with success. 

Unfortunately for those who followed Smith's advice, among whom were 
Durham, Gunn^ Barber, and others, the then existing methods of diagnosis 
were so incomplete ihnt kidneys removed for calculus, in spite of a normal 
appearancCj proved to contain no stones. The first nephrotomy carried out 
on an apparently normal kidney wag that of Morris, 1880. During the next 
year Czeriiy removed a stone from the pelvis of the kidney by pyelotomy. For 
some years pyelotomy was the operation of preference. It yielded place to 
nephrotomy for a great nunilier of years, but is now once more coming to the 
front as the operation of choice. 

ETIOLOGY. 

The essential conditions which lead to stone formation in the kidneys are 
imperfectly underi^tomL Race, age, sex, habits, diet, none of them seem to play 
E great part. The stones which are found in the kidney are composed of sub- 
stances normally present in the urine. The problem to determine is, why these 
salts are precipitated into stones in some cases and not in others* Before past- 
ing to this point, however, we will note the character of stones which form in 
this region. 

Character of Kidney Stones. — A few stones are composed of one salt; most are 
made up of a great mixture of salts. They vary immensely in size, shape, and 
nuniber. The frontispiece shows thirty kidneys and bladder stones from our 
collection and that of Dr. Hugh H. Young, wdiich have been chemically 
investigated by Dr, G. L. Gordon, of Vancouver, B. C. His notes a9 
to the chemical composition and the physical structure are as 
follows : 

1, A urate stone of the sedentary period of life, the outer layers of which 
are infiltrated %vith triple phosphates from infectiom 

2. A urate conerement the matrix <if which has not been invaded, although 
the entire surface is coated with triple phosphates. 

8. An oxalate center surrounded by a urate layer, which, on the periphery, 




ETIOLOGY. 93 

has become infected so as to admit of infiltration with triple phosphates and 
oxalates. 

4. A urate, the outer layer of which has become infected and infiltrated 
with triple phosphates. 

5. The urate of infarct origin. The outer part of this has been infiltrated 
with triple phosphates and oxalates and the whole periphery coated with these 
Baits. 

6. A pure urate stone under the surfaces; a lamina was added while 
methylene blue was in the urine. 

7. The center of urate, the next layer urate, oxalates, and bone earth. 
The next layer urates only. The outermost layer is urate infiltrated with 
triple phosphates. 

8. Twin agglutinated urate centers of infarct origin, the outer layers are 
infiltrated with triple phosphates. 

9. Amorphous phosphates in nucleus. These are surrounded by oxalates 
adulterated with bone earth. The whole is then covered with triple phosphates. 

10. Pure urate. 

11. Urate oxalate coated with triple phosphate. 

12. A jack stone with oxalate center, over which are applied alternating 
layers of urates and oxalates. 

13. Urate, oxalate, and triple phosphate throughout. 

14. Urate nucleus with triple phosphate covering. 

15. Oxalate surrounded by triple phosphates. 

16. Urate of infarct origin, which has been covered with blood clot, and 
the blood clot infiltrated with calcium oxalate. 

17. Shows a broken catheter end surrounded by triple phosphates. 

18. Equally composed of uric urates and oxalates. 

19. Triple phosphates pure. 

20. Pure cystin. Note the character of the striation, which is radial 
rather than concentric. This is characteristic of this type of stone. 

21. The nucleus is composed of a bit of tissue, containing diplococci and 
1 few bacilli. This nucleus is covered with a layer of triple phosphate. 

22. Shows a pin-headed urate center surrounded by laminse of oxalates 
contaminated with bone earth. 

23. Amorphous phosphates in powder form covered with a thick layer of 
triple phosphates. 

24. Pure oxalate jackstone. This stone may take its origin from 
the elongation of the protuberances of the mulberry-shaped stone. It is 

poeaible that the growth of the protuberances is due to blood, occasioned 



u 



REKAL AND URETEEAL STOKES. 



by trauma of the bladder and collected upon thfm, in which oxalates are 
deposited. 

25. An absorbent cotton micleiis with triple phosphate coat. 

2(>, A hair nucleiis, triple jjbosphote coat. 

27, A pure bone earth ealcnins. 

28. Shows a center of tUx^r snrromidcd by a shell of oxalates. 
20, A pure oxalate from the nreter. 

30, An oxalate booji>-secd center with flakes of triple pho&phate. 
When the nuclei of the stones are studied it is evident that iiric acid and 

urate stones are the nio.st frequent. Tliia couforniB with the view of Ebstein, 
and is certainly true so far as the structure of atones, which are spontaneously 
passed, is concerned. It is equally ajipareut that in mixed stones the phos- 
phates ultimately predominate. In Ih. (tordon's series (frontispiece) the 
nucleus of the stone was eleven times uric acid and urates, eight times phos- 
phates, seven times oxalates, and four times mixetl. Israel found phosphates 
in 42,8 per cent., oxalates in l\2Xt per cent., urates and uric acid in 20.4 per 
cent, and sulphur and xauthin in 2 per cent of his cases. 

The ^eat van* 
at ion in size, shape, 
and ap}H?a ranee of 
kiihiey stones is to 
be expected when 
one considers the 
variety of constitu- 
tion. 

The uric acid 
and urate stones, if 
pnre» rarely grow 
larger than a cherry 
stone, are of a dull 
grayish color, some- 
times reddish, have 
a smooth surface, 
and are quite hard. This is a stone peculiarly adapted to passing through the 
ureter during attacks of kidney colic. 

The oxalate stones are hard, showing a crystalline, rough surface, which 
gives them the appearance of a nmlberry. It is this type of stone which de- 
velops into the occasional and interesting jackstone. The phosphate stones may 
be composed of either calcium phosphate, or the trial phosphates of ammonium 



m 



*.x\^ 



Fig. ,S01.— 'Coral Calculi Chokino Pelvis and Calicbs op 
Kjpney. Note fracture at juiH'tion of upjKT major ralyx 
and f»elvis. Some parent'hyma still rt mains; catheterization 
of the kidney had shown, liowevcr, that it was dead. The 
riglit kitlriey showed compensator)^ hypertrophy, and chains 
of calcareous deposits in the parenchjrma. Specimen ol>- 
tainiMi at autopsy. 14 natural size, {Miss A* C. T., Gyn, 
No. 7ti48, Autopsy No. 4520. See Fig. 339.) 



ETIOLOGY. 



S5 



^ 



y^ 



u 



y 



f -^ 



fK 302.— Large Coral Stone 
IN Pblvi8 op Kidney, Ex- 
TKXDiNa INTO Calices. As- 
sociated with a dilated pelvis 
containing 50 c. c. of Ruid in 
addition to the stones. The 
pnretichyma was entirely de- 
fitroyed and the kidney func- 
tionless. The only Hjmptora 
was a slight aching in the af- 
fected side which had been 
present but six months. Thia 
specimen was obtained by oi>- 
eration. The opposite? kidney 
was normal and the patient 
\m remained well since opera- 
tiotL (Mrs. E. H.. Gyn. No. 
720O, Sept. 18, 1899.) 






m 



\ 



H 



FiQ. 303.— Immense Stones Filling Lower 
Half of Kidney, with Xorwal Ufi'ER 
Half. Note nephrotomy scar from pre- 
vious op(^ration, also large polished facets 
between the two larger stones, due to the 
fixation of the lower |>ok' while the upper 
movtHl in respiration. The nephrotomy 
scar noted was mai^le July 15, 1898, by 
J. Bloodgood, who found 200 c.c. of 
punilent fluid, but no stones in lower 
poll* of kidney. In August, 1898, the 
patient pai^^sed three calculi spontane- 
ously. In March. 1896, the X-ray 
showed no stones. (Mr. (?. K., Ch. H. 
and Inf., Nov. 23, 1910. From Thos, S. 
CuUen.) 



and magnesjum. Piiro cnlciimi phosphate stones are rather rare. Phosphate 
stones are frec|ueiitly faceted, and are often multiple. The hiigo coral stones 
ire for the most part made up of phospliates. The imusiuil cystin stone, one 
of which is shown in the frontispieee, is of a dirty yellowish color, and in 
Jaee of the usual laminated concentric stria tion shows a distinct radial stria- 




96 



EENAL AND URETERAL STONES. 



Among the unusual etcmea must be classified those found in one of our 
cases. This patient had had repeated attacks of renal eolie, and the function 
of the kidney had become greatly impaired^ f^o that a nephre<-toniy was done. 
The kidney pelvis and ealiees were found choked with browni.shj smooth Ixxlies, 
more tlian 150 in number, varying in size from a small pea to a bean, with a 
distinct concentric lamination. These structures were very soft, and crushed 



l^k 



Wf 



M 



V^ 



-*^^^^'" 



:^ 4 



YA 



§k 



^*<w. 



}W^ 



"^ 



Fig. 304. — Large BilateRx^l Coral Stones Filling Pelveb and Calices of Both 

KtDNEYs, ANiJ Makinij Pkrfkct Castb OF Them. Notu fracture of tho stones at junc- 
tion of upper Jiuijor ealiccs with jxVlvis. This is quite eliaractcristir and is fount! in 
ne^irly all coral stoiit\s. It may be due to bemlin^ of kidney l\v rciipiraU>ry movements. 
Not the normal looking kidney pareoclmna H natural size* (K.j J* IL H*, Autopsy, 
Aug, 17, 1900.) 

easily between the fingers. This type of stime lias been fully de^ribod 
hv llntiier (iage and Ilnward Heal (Ann, Stir*, 1908, xlviii, 37^), In 
their artick* is fuiniJ a nmst ii)terestin»i: review of the pertinent literatnra 
Their patient died 1\vn years after operation. Our own is still living nine 
years after operation, never having iiad any troublo with the remalniiig 
kidney. 

So far as size is eoneernedj stones may vary from sand to imnnense stmc- 
tures. The very large stones are, as a rule, situated in the pelvis of the kidney. 
Some of our hirgest are show^i in Figures 301, ?i02, 303, also 323, 351, and 359, 
Some immense stones have lieen deseriW*d in the literature. TsraePg largest 
stone was 17 em. long and 9 em. in eircumferenee. Kovsing states that he has 




ETIOLOGY. 



97 



kd stones weighing 148 grams. Juliiiesen (Bert Min. Wchn^chn, 1906, xliii, 
1623) reports a stone 14.1 em. loug, its longest circumference 33.5 cm,, and 
il* smallest cireiirafereiice 28,5 cm. The ^tone weigbeJ 330 gr. J. Kamsay 
[Intercolonial Mvd, of Ausfrahtsia, 1*J02, vii, 342) reeords a very large stone, 
and refers to the case of T. IL Jessop, where the stone weighed over 11 ounces; 
■ he also quotes Polil (AUbntt's ''System of Medicine/' 1897, v, 440) as remov- 
ing at poet-mortem a stone weighing five ponnds. 

The sfiape of stones is largely determined by the factors of pressure and 
gnrroiindings. This is well shown in the faceting of the rnultipb stones (Fig. 
i03), in the long, narrow stones sometimes found in the ureter (Fig. 317), and, 




iFiG. 305. — Urbter.\l 
Cxucvhus Present- 
ing A Smooth and 
HiGHLr Polished 
H SiTHPACE. Its color 
B was the dark reddish 
brown of cliocolate. 
(From Harvey Cush- 
iag, Sept., 1905.) 




Fig. 306. — Ureteral 
Stone with diinovED 
Passage foh Urine. 
Transverse section in 
up|XT fif^ure, (P. F. 
Mundi^, Yak M. J., 
Nov., 1809.) 



Fig, 307. — Ureteral 
Calculus Forming a 
Hollow Shell that 
IS (jBviousLY No Ob- 

fiTACLE TO THE EXCRE- 
TION OF Urine. (From 
J. W. Bovee.) 



above all, in the wonderful coral stones (Figa. 304 and 359) which make such 
perfect moulds of the kidney pelvis and its calices. A stone of unusual appear- 
ance is that showTi in Figure 305, Many ureteral stones become lodged und 
fixd and then grooved or hollowed out so as to allow free passage of the nriuSp 
Unique examples are shown in the speeimens loaned us by Drs* Bovee and 
Mttude (Figs, 306 and 307), 

lu analyzing our cases to determine the frerpieney of single, of mul- 
tiple, of unilateral, of bilateral, of r i g h t - s i d e d , and of 
left*sided stones we were astonished to observe bow closely our results 
agreed with those of other observers. To nearly half of the cases a solitary 
stnnc exists. Unilateral involvement is far comTUoner than bilaterab The right 
kitbey is more often affected than ihe left. In otir series a single stone was 
found in a little more than 47 per cent, of the cases. In over 44 per cent, of 



gS RENAL AND URETERAL STONES. 

our cases the stones were multiple, and in 9 per cent. 2 were found. Israel, 
in a series of 48 cases, found solitary stones in a little less than 46 per cent of 
the cases ; multiple stones in 54 per cent. The largest number of stones in any 
one of our series was 150. These were of the fibrinous character already re- 
ferred to, but Gee has reported finding 1,000 stones in one kidney. In our 
series the stones were limited to one kidney in 79 per cent, of the cases. In 
764 cases Kiister found unilateral stones in almost 89 per cent. His cases 
were collected from the literature, and it is quite possible that some of those 
recorded as single were really bilateral. In his series, where the stones were 
limited to one side, the right kidney was involved in 57 per cent., and the 
left in 43 per cent. In our own, the right kidney was involved in 56.9 per cent, 
and the left kidney in 43.1 per cent, the figures thus being almost identical 

Heinrich Grau ("Die Haufigkeit der Nieren und Blasensteine," Inaugural 
Dissertation, Munich, 1904) has furnished a valuable statistical study from the 
Pathological Institute in Munich. During the period between January, 1896, 
and January, 1904, 90 cases were found of kidney and ureteral stones. In 16.6 
per cent, the stones were bilateral, and in 83.4 per cent, unilateral. 

The relation of stones to sex, age, race, and habits has constituted the prin- 
cipal part of several studies. 

Sex. — There is no great difference in frequency of occurrence between the 
two sexes. Kiister found stones in 368 males and 345 females ; Kiimmel, in 60 
males and 41 females; Grau, in 52 males and 27 females. Our own statistics 
show 88 females and 7 males. Israel found 59 per cent of his cases were 
women. Our own series does not form a basis of comparison, because we see 
far more women than men as patients. Grau, who calculated the proportion of 
stone cases in males and females in proportion to the total number of autopsies 
in each sex, found the percentage of occurrence in men was 1.32 per cent and 
in women 8 per cent 

Age. — Unquestionably middle life is the time when most of the cases that 
come to operation occur. This is just contrary to the old idea that childhood 
and old age are the common periods for this condition. By far the commonest 
period, according to the combined statistics of Israel, Kiister, and Kiimmel, is 
between the ages of 20 and 40 years. In our series there were no cases under 
10 years ; 5 cases between 10 and 20 ; 18 between 20 and 30 ; 27 between 30 and 
40, and 22 between 40 and 50, with 20 over 50. Grau found tlie commonest 
period in his cases was between 45 and 60. As his statistics were taken from 
autopsies, this is not surprising, and it gives us, in a sense, an idea of the ave- 
rage of life in this condition. It is of interest that the adult males in his scries 
ranged in age from 15 to 94, and the adult females from 35 to 79. In 11 of his 



ETIOLOGY. 99 

stone cases, constituting more than 12 per cent, of the total, the stones were 
found in children. The percentage of occurrence in children in proportion to 
the total number of autopsies was .74 per cent. Ko less than 8 of these children 
were under one year of age, and the question arises as to whether he was dealing 
with infarcts or definite stones. Monsseaux {Bull, vied., Paris, 1904, xviii, 
301) reports from the literature 77 cases of kidney stones in children between 
the ages of 1 and 15 years. In 90 cases Grau found ureteral stones 20 times 
(22 per cent.). We found ureteral stones 20 times in 95 cases (about 21 per 
cent.). 

Ckographical Locality. — That certain localities favor stone formation in the 
kidneys has long been believed. In this country no statistics are available. 
Ilirsoh finds that, in Europe, Middle Russia, Holland, Italy, Hungary, eastern 
England, and western France furnish a larger proportion of cases than other 
portions of the continent. There is no question that the disease is very common 
in America, much more so than operative statistics would indicate. There is 
no definite evidence which points to any influence of atmosphere, soil, or water 
in causing stone. 

Bace. — Kiister believes that the Jews are more liable to stone kidney 
than oth(;r races. Our own experience does not confirm his view, but the num- 
ber of cases is too limited to draw any real conclusions. It is of interest to note 
that, in spite of the large negro population in Baltimore, and the fact that wo 
have a number of negroes as patients in the clinic at the Johns Hopkins Hos- 
pital, not one of them has ever shown stone in the kidney. 

Determining Factors. — The question as to what determines the formation 
of stones in the kidney cannot be answered at the present time. It has been 
suggested again and again that foreign elements in the urine, such as bac- 
teria, blood clots, or shreds of tissue, may furnish the nuclei upon which stones 
are built. The reasoning is from analog\' based upon the well-known fact that, 
if a foreign body gains entrance to and remains in the bladder for a long time, 
it becomes covered with an incrustation of salts, and forms a stone. Numerous 
cases are on record where bacteria, blood clots, shreds of tissue, parasites, such 
as the schistosoma hematobium, and filaria sanguinis hominis, have been found 
in the nuclei of stones. Nevertheless, such findings are the exception. Dr. 
Thomas R. Brovm {J. Am. Med. Ass., 1901, xxxvi, 1395), reporting seven 
cases of stone and infection in which he found bacteria in the nuclei of the 
stones, points out the frequency of stone formation when the infection is with 
organisms which split urea and cause alkaline urine. He notes also that the 
stones associated with infection are made up of phosphates and carbonates. In 
one of the stones worked up by Dr. Gordon gonococci were found in the nucleus. 




Fig, 3QR.— Htdronephrosts and Hydroureteh op HirsHT Kibney Due to OBsrarcnow 
OF Urkter by Stone about JO cm, from Vesical OniFirK, The capacity of the pelvis 
and urot'cr in tfiis ca.se wai? fKJ e. c, as measured by inject ion l>effirc operation. The 
drawing to the left shows extc-mal appearance. The tortuous course is characteristic 
of all distended ureters, and is due to increased length, with variahle rapacity for disteii- 
tion in different parts of the ureter. On palpation the calculus was felt as a hani body. 
Owing to thickening and inflaoimation aijout it^ the stone seemed to Ix? three times as 
large as it really proved. The drawing to the right shows the condition in section. 
The synifitoms consisted of attacks of pain in the right side lasting for three j'eam. 
Stone demonstrated by gouges on wax-tipfx^d catheter. Function of kidney practically 
normal. Treatment: first o[>erationp nephro-uretero*omy; removal of stone; dilatation 
of stricture througli extra-j)eritaneal incision. Two months* relief. Second operation^ 
nephro-uretcrectomy, with complete and permanent rehef, (Mrs. N. 8., age 28. Gyn" 
Nos. 13453 and 13577. Dec. 13, 1907.) 



ETIOLOGY. 



101 



There is no question that infection does favor stone formation ; but there are 
many cases where infection has persisted for years and yet no stone formation 
has taken place; and likewise, in the large majority of stone cases, the nuclei 
do not contain bacteria, blood, or tissue. 

Following Meckel's suggestion, that a catarrh of the urinary passages was 




Fig. 309. — Chain of Pocketed Stones Extending Several Inches down Ureter. 
The large stone prevents the passage of the smaller ones above it. (From J. Deland.) 

at the basis of stone formation, Ebstein demonstrated that in every stone, in 
addition to the crystalline part, there is a framework of albuminous nature. 
For some time after the publication of these studies his conclusions were given 
full credence. Later, however, the investigations of ^Moritz, ^fendelsohn, and 
others proved that all precipitates in the urine contained an albuminous frame- 
work, thus robbing Ebstein's explanation of most of its interest. Since 



Fig. 310. — ^Enormous Hydronephrosis and Htdroureter with 47 Stones in Vesical 
End op Ureter. The symptoms were attacks of renal colic and intermittent hy(ln>- 
nephrosis, extending over a period of more than 9 years. There were no symptoms 
referable to the bladder nor abnormal elements in the urine. Complete recover}' fol- 
lowed operation. Note the grooved lowermost stone, caught in the vesical orifice, 
with one end projecting into the bladder and the other in the ureter. This prevents 
the passage of the stone itself and dams back the other stones, though it pcniiits tlie 
percolation of urine into tlie bladder. (Mr. J W. B., age 44, Feb. 25, 1905. From 
J. G. Sherrill and J. W. Long.) 



102 



104 



RENAL AND URETERAL STONES. 



.»-Ni»* 



% 



^^^ 



BramaDH, 181)1, pohitocl out the froqiieiiej of stone formation in the kidnej in 
cases of injury of the vertebral cohnnn, numerous confirmatory reports, as thit 
of G. Sootisch {Dfsch, Ztschr. /, Chin, 1908, xciv, 42(i), have Ix^eu made* II 
would seem that this stone formation occurs indepcnflently of infection, which 

invariably follows in the uri- 
nary system from injuries to 
the spinal cord. Rovsing hat 
snjLr.4i:ested that there may be i 
congenital or acquired diathe- 
BIS in which an excessive 
anifjunt of certain salts is ex- 
creted. It has botm suggesti?d 
in other quarters that food has 
an inHuenee and that certain 
alkaline substances, particu- 
larly alkaline waters, predi** 
pose to phosphaturia; that 
grapes and tomatoes t«id to 
produce oxaluria. Rheuma- 
ti«ni and gout are said to pre* 
dispose to the condition, 
R^jsenbach (Dfsch, Xlschr. /, 
CJiir., 1011, cxi, 556) has pro- 
duced stones in the kidney of 
rabbits and dogs by feeding 
them on oxauiid, and shows 
that tying the ureter, cutting 
off the nerve supply, tying ar- 
teries, and putting foreigu bodies in the kidney all markedly favor stane 
production. 

In sunmiing up, however, it nmst be cnnfes8ed that but little is kiiown re- 
garding the iafluence of these factors on stone formation. 



PATHOLOGICAL CHANGES IN THE KEDNEY PRODUCED BY STONE, 

Under exceptional eircunistaneeei a stone, even a very large one, may remain 
for a long time in the kidney and produce but slight alteration in its anatoraicAl 
structure, as well as little influence on its functional activity. Sooner or later, 



Fig. 311. — Stones in KmNEY Associated wrre Dis- 
TKNDEn Pelvis and Calices. In the pelvis are 
one large egg-shaped Btmm and two smaller ones; 
one small stone shows in upper calyx. Note ex- 
cellent pre8er\^ation of cortex and marked peri- 
pelvic fat layer. K natural size. (From J. Ernest 
Stokes.) 



IPATHOLOGICAL CHANGES IN THE KIDNEY PRODUCED BY STONE. 105 

^lioweTer, destructive changes of one kind or another are sure to set in. Obstruc- 

ions to the outflow of urine lead to byJronophrosis (Figs, 308^ 309, 310^ and 

311), a condition observed in aliout 20 per vahiL uf our eases. Iloinrich Grau 

loted hydronephrosiis in 14 out of 74 eases at autopsy. The dilatation varies 

rfrom E slight dilatation of the rnual pelvis to euorinous disreution. Not only 
the stone, but more frequently the pathological proeess it gives rise to, leads to 
rhe hydronephrosis. A very small stone in the ureter may lead to complete 
Iransformation of the kidney in this way (Figs. 312 and 313). 



\ 



o 






I 



Fia, 312. — Mabsive HrDRONBPHRosis Doe to Stone in Uppeh End of Uretgb. 

(Wm. Osier,) 

Frequently a stone kidney will he found eonsiderahly enlarprerl, owini;: to a 
marke^l inerease in its eonneetive tissue^ producing an lulerstitial nephritis. 
When this fibrous transformation has progressed further the kidney usually 
becomes smaller than normal. The condition of ehrouie interstitial nephritis 
in this conneetlon is a very common one. Grau note<l it in 3D cfises out of 74 
of those which he studied. 

Israel has pointed out the fibrous fatty change whieh takes place in the 
capsule of the kidney and the surrounding fat. It is not nu uncommon occur- 
rence for the kidney to undergo eomplete degeuerntioii and to he entirely re- 
placed by a fibrous fatty tissue (Fig. 314). 

One other change which is oeeasionally met with is cyst formation following 
the obstr\iction of a single calyx. Such a kidney is showni in Figure 285, 
exwpt that, in place of stone, a tuborerdous process represents the obstructive 
(actor. The same condition was found in the specimen shown in Figure 315. 



106 



RENAL AKD URETERAL STONES, 



^Wft^ •' 



In addition to these changes, which occur when there is no infection^ it is to 
he rememhered that the presence of stone eontinnonsly predispoees to bact^riil 
attack, a common and a serious coniplicalion. A higher percentage of infection 
18 found in stone kidneys operated on tlian in those discovered hy accident du^ 

ing pot^t-niorteni examiuatiotis. 
For instance, Crau found infec- 
tion in 20 out of 74 eadc*3- la 
our scries there wore 73 infected 
cases out of l>9. The infecting 
or<ranisni nniy be any of the pia 
formers, and is not uncommoDly 
the tubercle bacillus. When in- 
fection has once set in, any 
chanji^e from a mild pyelitis to 
complete destruction of the organ 
may take place. 

Pyoneph roses and large peri- 
renal abscesses are very common 

(Figs. ;iir. and :^r>j)). 

Changes in the opposite kid- 
ney not in%'olved by tlie stone 
process are common. T^gnm 
states that, in 38 eases where 
stones were present in ono kid- 



^ . 



Fig. 313.— Section through Kidney Shown in 
Last Figure, Showing Size and Site of 
Stones. Note complete destruction of kidney 
parenchyma, }4 natural size. 



ney, in only 4 w^as the si*oond 



kidney absolutely nonnal. In 
uur own series of 55 cases, even 
when there was infection of the 

one kidney, the other w^as apparently absolutely healthy in 23* One of the 
common changes in the second kidney, as the first one undergoes destruction, 
is a compensatory hypertrophy. 



SYMPTOMS OF STONE IN THE KIDNEX 



I 



To the uninitiated, stone in the kidney invariably suggests attacks of pain 
in the side and the passage of blood in the urine. They are the well-known 
symptoms associated w^ith kidney eolic. We know, however, that they arise 
from many pathological conditr<nis of the kidney lx*side stone, and timt in manv- 
cases of stone they never occur. There are fe^v kidney diseases in w*hich 8U< 



SYMPTOMS OF STONE IN THE KIDKEY. 

rariable eymptomfl arise as stone, but there are many cases of renal stone which 
never give rise to sjmptoms at all. On the other hand, there are cases in which 
some complication creates the .symptoms, the case presenting the picture of a 
pyelitis, or of a pyonephro^^is, or, occasionally, of a tuberculosis of the kidney. 
As ihe symptoms arising from sueh troubles, pain, fever, tumor, pyuria, in- 
CTemae of the leukocytes in tlie blood, are fully deseril^ed in the chapters devoted 
to tlie$e subjects, they will not be gone into here. It seems the most simple plan 




Fio. 314.^ — Labgb BTOiiB m Pelvis of Kidney and Calicbs with Comflbte Dbstruo- 
Tiox or TH8 KiDNBV. The parenchyma lia:* beeti Izirgcly replnced by fatty tissue. 
The stone is fragmented as xisual. Note that the large piece in ttie middle has ttio 
ah&pe of a p^lvns, while the piece above it probably originated in the upper calyx, now 
repredented by a band of scar tissue, (From Hugh H, Young, Nov. 28, 1902.) 



to consider the topics: renal colic, pains r^ilicr than colic, hematuria, and anuria* 

Renal Colic. — The colic due to stone in the kidney does not differ from that 

issoeiated with other pathological conditions of the organ, and cannot be dis- 

tinpii^hed, cither by severity, location, or radiation. It varies from a slight 

Jiscomfort to veritable agony, which cannot be controlled by morphia. The 

duration of the pain varies from a few minutes to honrs. The commonest 

type is that in which the pain ljegin?i in the loin and radiates downward along 

jk course of the nreter toward the Itladder, often to the ileum, sometimes to 

}\%, sometimes to the ovary or testicle. In moro unusual forma the pain 

liites toward the Bhouldcr bladt*, or over to the opposite kidney. In some 

tscs the pain remains localized in the kidney, and does not radiate at all. 

How many cases exhibit renal colic ? Roughly sj^eaking, about 50 per cent. 




Fig. 316, — Stone in the Pelvib of the Kidney. Pyonephrosis of the lower pole ao 
calices; cystic Iransfonuation of the upper i>ole, due to closure of the nei'k of the inftj< 
calyx by scar possibly irnluc-od by friction of rah-uUts, Only syniptoiii, shght dmgg^ 
pains in left side when on feet. Duratirjo, one year. The right kidney was perfecti 
normal. Natural size, (Mrs. J. 1\ K., Sau. No,^ 21'JG, May 28, 19iM3. \\ge a6.) 




SYMPTOMS OF STONE IN THE KIDNEY. 109 

of a month, show a continuous pain and no further attacks of colic. Just 
as the duration of the colic is a variable symptom, so is the frequency of the 
attacks. Sometimes months elapse, even years, between the single attacks. In 
other cases they may be of almost daily occurrence. It is well known that the 
passage of a stone down the ureter occasions kidney colic. On the other hand, 
a stone may exist in the ureter, as is shown in 5 of our cases, and yet never 
occasion attacks of pain. In many of our cases of stone in the pelvis of the kid- 
ney the pain has been present only in attacks ; the proportion of pain in attacks, 
however, is considerably greater in ureteral than in kidney stones. Many cases 
where there are no evidences of obstruction to urinary flow still have attacks. 
This is true of large stones in the kidney pelvis where there is no hydroneph- 
rosis. It is another confirmation of the frequently observed attacks of renal 
colic due to some other cause than obstructed urinary outflow. During a severe 
attack of renal colic, in addition to the pain, there are often vomiting and nau- 
sea, and frequently some irritability of the bladder. Where infection is present 
the urine which has been purulent may clear up and marked fever develop. An 
interesting and common occurrence is abdominal distention, with severe pains 
in the abdomen and failure of gas or any material to pass by the bowel, so that 
the whole picture strongly suggests intestinal obstruction. Not a few such cases 
have actually been operated upon for intestinal obstruction. Israel has drawn 
especial attention to this clinical type. 

Walking or active exercise may bring on attacks of renal colic ; they may 
arise, however, without any such apparent mechanical cause. Wo have never 
observed a case of kidney colic on the opposite side* to that in which the stone 
was present, when that kidney was normal. One finds frequent reference to this 
transferred pain in the literature, but most of these reports probably rest on 
insufficient evidence; for example, it would be quite possible for a large stone 
to be present in one kidney and give no symptoms, and for a small ureteral 
stone to be occasioning attacks of colic on the opposite side. We have had one 
case of obstructed ureter on the one side with severe colic, while on the other 
a large stone was present in the pelvis of the kidney. This patient was watched 
through the attack. The X-ray showed the stone on the one side, and an 
apparently clear kidney on the other. Immediately after the attack the stone 
was removed from the kidney by pyelotomy. This patient was well for several 
weeb, when another attack occurred, requiring opening and draining of the kid- 
ney which was the site of pain, and removal of the small stone from the ureter. 
Rxcd Pains. — ^Fixed pains, usually continuous, may be in the back, or in 
front over the crest of the ilium, or near ilcBurney's point, or its corresponding 
point on the left side. These pains vary greatly in severity, and are frequently 



no 



RENAL AND URETERAL STONES. 



attributed to lumbago, gallstones, chronic appendicitis, and almost every con- 
ceivable condition which may give rise to pains of such a character. In 32 per 
cent, of the cases in our series this was the type of pain. It is almost always 
made much worse by bodily movements ; in many instances it prevents active 
exercise or work. Occasionally the reverse of this deleterious influence of bodily 
motion and exercise has been met with, as in the case of Westerman (Dlsch. 
med. Wchnschr., 1904, xxx, 1475), where the patient was relieved of his pain 
when he began to walk. A number of our patients complained that the pain 
was increased by worry, mental fatigue, and anxiety; nevertheless, a few 
patients in whom psychasthenic treatment had been undertaken reported little 
or no relief from it. 

Hematuria. — In practically all cases blood can be found in the urine imme 
diately after an attack of colic In some cases it can be brought on by exer- 
cising and active movements. It is usually in small 
amounts ; occasionally large hemorrhages, simulating those 
due to renal tumors, have been met with. We have ob- 
ser\'ed no cases of this kind. In our cases 50 per cent, of 
the patients reported that they had, at one time or another, 
observed blood in the urine. In 30 per cent, of the caaes 
blood was discovered at the time of examination. A micro- 
scopical examination will sometimes show a few blood cells 
when there has never been enough bleeding to attract the 
patient's attention. 

Spontaneous Passage of Stones. — The spontaneous pas- 
sage of stones, especially of the uric acid variety, during 
or following an attack of colic is not uncommon. In tlie 
95 cases which form the clinical basis of this chapter the 
patients gave a history of having passed stones sponta- 
neously in 10 cases. Occasionally very large stones are 
Konigstein (Wien. klin. ^VchnJ<chr., 1904, xvii, 1128) tells 

Stones which have been 

As a symptom 

In one case 




Fig. 316. — Small 
Stone Measuring 
12 x 6 X 4 MM.; 
Passed Spontane- 
ously. Fig. 338 
shows scratch- 
marks made by it 
on wax-tipped 
catheter. Natural 
size. (Mrs. M. M. 
G., Gyn. No. 7405, 
Dec. 23, 1899.) 



passed in this way. 

of a patient who passed a stone as large as a hazel-nut. 

spontaneously passed are pictured in Figures 31G, 317, and 367. 

of stone kidney this passing of stones must not be underestimated. 

which came to our observation, a man of 50, there had been repeated attacks of 

renal colic and some blood in the urine. Excellent X-ray pictures showed no 

stone, the two kidneys on cystoscopic examination were found to be acting 

equally, ureteral catheters were passed without meeting any obstruction. The 

condition had been pn^st^nt for several months. While under observation the 

patient, during an attack, passed a small stone about half the size of a pea, and 



SYMPTOMS OF STONE IN THE KIDNEY. 



Ill 



since then has been relieved of all his symptoms. Occasionally large numbers 

of small stones are passed in this way over a period of years. ^ 

Vesical and XTrethral Symptoms. — In women one rarely observes the classical 

symptom so often described in men ; this consists, in its worst form, of a severe 

cutting pain, in its mildest of a tickling at the end of the urethra after voiding. 

This s^Tuptom is particularly characteristic of stones in the lower part of the 

ureter. It has long been known that vesical irritability, in some cases amount- 
ing to strangury, may occur with kidney and 

ureteral stones without there being any disease 

of the bladder itself. This symptom we have 

found as commonly in non-infected stone cases 

as in those associated with inflammation and 

infection. It is practically as common when 

the stone is in the kidney as when it is in the 

ureter. During the attacks of colic it may be 

quite severa We observed it in 40 per cent, of 

the ureteral cases, and in 37 per cent, of the 

kidney cases. In cases where no infection was 

present, 45 per cent, showed more or less ves- 
ical distress during the attacks, and sometimes 

during the intervals. In the infected cases the 

propf)rtion was somewhat less, about 38 per 

cent. In some cases, in place of irritation or 

strangury, there was simply pain in the blad- 
der. 

Gkutrointestinal Symptoms. — Meteorism, as 

already noted, is quite a common symptom 

during attacks of renal colic, and also attacks 

of nausea and vomiting. The large fixed 

stones cause indigestion. In six cases rather 

marked and persistent indigestion was 

Calculous Anuria. — Probably the most alarming symptom which occurs in 
tssociation with the stone kidney is a complete suppression of urine. In the 
majority of cases of renal colic there is a diminution in the amount of urine. 
Of all the causes of sudden anuria stone is by far the commonest There has 
arisen much discussion as to the causes of a complete anuria due to stone. F. 
Legueu {Ann. d. mal. d. org, genito-urin., 1895, xiii, 865), who reviewed this 
subject very completely, positively denies that the condition is anything but a 
mechanical obstruction, and asserts that both ureters must be obstructed, or 




Fig. 317. — Long Calculus Passed 
Spontaneously. Stone sup- 
posed to have been ureteral in 
origin, but probably originating 
in a bifid pelvis. (R. L. Pa3me.) 

relieved by the operation. 



I 

1 



112 RENAL AND URETERAL STONES. 

that one ureter is obstructed and the kidney a functionless organ on the other 
side. Israel, on the contrary, has advanced very convincing evidence of the 
view that sudden blockage of the ureter on one side can lead to a complete 
anuria of reflex origin in both kidneys. In his original series of 78 cases Israel 
met with this complication 5 times. Of these 5 cases, the ureter of one kidn^ 
was plugged with a stone in 2, the other kidney being completely out of func- 
tion from previous disease. In 2 cases one ureter was plugged and the other 
kidney had ceased secreting, owing to reflex influence upon it. In one case the 
data were insufficient to show the exact condition of the two kidneys. Four 
out of the 5 cases at the time of operation were uremic. One of the cases 
which was successfully operated on was in coma at the time of the opera- 
tion. In 4 of the 5 cases observed, there was definite disease of both kid- 
neys, and in the fifth sufficient evidence was not obtained to determine whether 
there was disease of both sides. Evidence for reflex anuria is afforded in 

2 cases by the fact that, after removal of the stone that obstructed the 
ureter, cystoscopic examination showed a return of flow from the other side 
at once. Israel goes further, however, and shows that reflex anuria may occur, 
not only from stone, but from obstruction of one ureter from any cause. Dr. 
Arthur Goetzl experimented on 3 dogs, and was able to produce a complete 
stoppage of secretion from both kidneys for a period of 65 minutes in one 
of the animals by stopping the secretion from one kidney through connect- 
ing its ureter with a manometer and bringing a pressure of 24 mm. of Hg. 
In the other two animals he succeeded in getting a marked diminution in tlie 
amount of urine secreted, but not a complete anuria, Eovsing has reported 

3 cases in which he left clamps upon the pedicle of the kidney which he afte^ 
wards removed. Complete anuria existed in each case until the clamps were 
removed, a period of 2 to 3 days. F. S. Watson {Am. J. UroL, 1910, vi, 18) 
refers to 3 cases ; Albarran, to one, in which one ureter was plugged and thfc- 
opposite kidney was opened, when secretion began both from the nephrotomy" 
wound and through the ureter. This case is also referred to by Israel, as well ai^ 
an exactly similar case of Ransohoff, of Cincinnati, and finally a case of Dr^ 
Hugh Cabot, of Boston. In our series anuria at time of operation was observwM^ 
in only one ease, Mrs. S. M. M., age 01, Nov. 8, 1905. In this patient the lef^ 
kidney, as shown by autopsy, was completely destroyed and its ureter closed --. 
while the right kidney was pyonephrotic and the outflow of urine completelj^ 
obstructed by a stone. A nephrotomy was done on the right side and a lar^ik= 
amount of pus evacuated ; the patient, however, survived the operation but 2—^ 
hours. A second case, in which there was complete anuria, was ^Irs. E. M. M — 
age 52. The patient had a left-sided nephrotomy and removal of stone in 169*^" 



SYMPTOMS OF STONE IN THE KIDNEY. 113 

In 1905 a large pus kidney on the left side was opened and drained and stones 
removed. At this time all kidney tissues seemed to be destroyed. One year 
later, the patient was suddenly seized with pain in the right side and had cal- 
culous anuria. Nephrotomy was done on a right hydronephrotic kidney caused 
by obstruction in the ureter. The patient survived this operation about 9 
months, dying in 1907. In addition to these 2 cases, 2 others gave histories of 
complete anuria for periods of 24 hours. The first was Mrs. J. B. S., Decem- 
ber 8, 1903, age 42. This patient was shown by X-ray to have several large 
stones in the right kidney. The left kidney showed no stones. Cystoscopic ex- 
amination showed both kidneys secreting normal urine. The function of the 
right kidney, as shown by urea, was about 3 times that of the left in a period of 
10 minutes. No other functional tests were made. This patient gave a history 
of violent attacks of pain in the right side associated with anurias lasting for 
24 hours. The right kidney was explored and 3 stones removed by neph- 
rotomy from its pelvis. The patient made a prompt recovery from this operation 
and has since then had no attacks of colic and no anuria. The second patient, 
A. A. L., July 3, 1900, age 2G, had a left-sidod infected stone kidney. Six 
days before coming to the clinic she had a severe attack of pain in the left 
kidney associated with chills and fever and complete anuria. X-ray showed 
the trouble limited to the left kidney. Separate catheterization of the ureters 
was not carried out. Patient made a prompt recovery from a left-sided neph- 
rotomy, and left the hospital well at the end of 3 weeks. Subsequent history 
is not obtainable, as patient has been lost sight of. In each of these cases we 
have what is apparently a true reflex anuria. 

A complete anuria, lasting for over 24 hours, was observed in one other 
patient at the Cambridge Hospital, Cambridge, Md. The patient, Mr. B. C, 
age 50, was desperately ill at the time of operation. He had been a heavy 
drinker and had come into the hospital under the care of Dr. Brice Golds- 
borough for delirium tremens. While in the hospital, resting in bed, he was 
suddenly seized with violent attacks of colic in the right side, associated with 
passage of large blood clots through the bladder, and complete anuria. The 
right kidney was found greatly enlarged and tender. A diagnosis of stone kid- 
ney was made. At operation a large tumor of the kidney was found, evidently 
malignant. The pelvis was choked with blood clots. The condition of the 
patient precluded removal of the kidney, so that the operator contented himself 
with opening the pelvis, which was greatly distended, washing out the clots and 
packing it. There was no secretion from this kidney, but the other one 
promptly began to secrete normal urine. The patient improved greatly for a 
few days, and it was hoped that his condition would allow an attempt at re- 



114 RENAL AND URETERAL STONES. 

moval. He died, however, suddenly, from a profuse hemorrhage at the end of a 
week. This case is apparently one of true reflex anuria. 

There is no case in the literature where, at autopsy, a stone has been found 
plugging one ureter while the kidney on the other side was healthy, and yet the 
patient during life has had a complete anuria and died in uremia. This fact 
alone would afford absolute evidence of reflex anuria and of death from such a 
condition. Kiimmell (Ztschr. /. Urol.^ 1908, ii, 329) has observed complete 
anuria six times in fourteen cases of double kidney stone. He says that he has 
never observed anuria except when both kidneys were thoroughly diseased. 



DIAGNOSIS. 

Previous to our modern methods, the diagnosis of stone in the kidney was a 
most difficult undertaking, as in a large measure it depended on the symptoms 
and the examination of the urine. As is already evident, symptoms closely 
similar to those of stone are furnished by a number of conditions in the kidney 
of an entirely different nature. It was only possible, therefore, to make a 
probable diagnosis in all cases except those in which stones could be felt in the 
lower end of the ureter, or, very occasionally, by palpation, in the kidney itself. 
The problem which confronts the diagnostician of to-day is to determine, in a 
suspected case, whether the symptoms are due to the kidney, and, after decid- 
ing that point, to determine if the disease is stone in the kidney or the ureter, or 
some other trouble. In the next place it is necessary to locate the position of 
the stone or stones in the kidney and ureter. Finally, it must be determined 
whether, and to what extent, the function of the kidney has been interfered 
with. It is essential to determine all of these factors not only about the 
suspected kidney, but also about its fellow. The diagnosis must rest, there- 
fore, on: 

A general examination of the patient, temperature, pulse, blood pressure, 
etc. 

Examination of urine. 

Palpation of the urinary tract, especially of the terminal portion of the 
ureters. 

Ureteral catheterization, and estimation of the functional activity, and th^ 
morbid condition of the urine of each kidney separately. 

Use of the wax-tip catheters to secure scratch marks. 

X-ray pictures. 

Oeneral Examination of the Patient. — It is through the general examinatioi 



DIAGNOSIS. U5 

of the patient that the physician determines what deleterious effects have heen 
produced on the general system and health. In the end stages of renal insuffi- 
ciency due to stone, one has the same symptoms which follow renal insufficiency 
from any other cause. There are, first, headaches, nausea, and vomiting, and, 
finally, coma ; a high blood pressure is very commonly present. Kiimmell draws 
attention to the lowering of the freezing point of the blood in cases of renal 
insufficiency due to stone. He considers that a freezing point of below 62° 
always indicates marked renal insufficiency. He points out that, in cases of 
calculous anuria, on the first day the freezing point of the blood may be normal 
but that within a day or two it rapidly falls. 

The general examination affords much information regarding sepsis. In the 
acute stages of pyonephrosis there is always fever, and this may be very high; 
sometimes the fever is continuous and at other times shows an intermittent 
septic character, the typical curve ascribed to pyemia. Elevation of bodily tem- 
perature frequently occurs after a mild pyelitis, as well as pyonephrosis. On 
the other hand, in the old cases it is not uncommon to find large amounts of 
sacculated pus with no elevation of temperature. This matter is fully discussed 
under Pyelitis and Pyonephrosis. 

In addition to the anemia found in many of the old cases one finds here 

the changes in the white blood cells described under Pyonephrosis and Pyelitis. 

In a general way the increase in the leukocytes and in the relative increase of 

the polymorphonuclear forms runs parallel to the temperature, that is, in cases 

of pyonephrosis. Occasionally, however, with a normal temperature, there may 

be an absolute count of from 12 to 18 thousand and the polymorphonuclear 

leukocytes show a relative proportion as high as 80 per cent. On the other 

\iai\d, where we have merely an inflammation of the mucous membrane of the 

pelvis the temperature may rise to 10»*3° or 104° and still no changes in the 

blood be observable. The nature of the infecting organism apparently has no 

influence in determining this matter, although pure tuberculous infection, even 

in the presence of large amounts of pus, does not show an increase in the 

polvraorphonuclear leukocytes of the blood. 

Examination of the Urine. — A careful study of the urine can afford useful 
infonnation in diagnosing stone in the kidney, and frequently it is of greatest 
importance in drawing the observer's attention to the condition and pointing 
out the necessity of a complete urological examination. 

One occasionally finds gravel or small stonesin the urine of 
patients suffering with stone kidney, and, as already pointed out under Symp- 
toms, this occurrence is not uncommon. 

The presence of blood is a frequent and valuable sign. Immediately 



116 RENAL AND URETERAL STONES. 

after an attack of renal colic, blood cells are almost always present in the urine. 
Often in the intervals between attacks blood cells are present, and occasionally 
a hemorrhage of moderate degree may occur without pain and be due to stone. 
In general the blood which enters the urine from stone in the kidney is in small 
amounts, often determinable solely by microscopic examination. At the time 
of observation 30 per cent, of our patients showed blood in the urine on micro- 
scopical examination. We have not observed a case of severe hemorrhage 
due to stone in the kidney, although a number of such cases are on record. It 
is evident that if the kidney which contains stones, and in which the attack of 
colic occurs, is entirely shut off from the bladder the urine will be perfectly 
clear, even during and after an attack of colic. Whenever blood is present one 
is likely to find albumin by the ordinary clinical tests. Occasionally, albu- 
min may be present in excess of the blood. The presence of such albumin and 
a history suggestive of stone is further confirmation of a probable diagnosis. 
The disease in which microscopic blood is most commonly found in the urine 
is Bright's disease. Attacks of colic, however, are not common in it, and the 
diagnosis is suggested by the abundance of casts. On the other hand, we have 
found casts quite as frequently in the urine of our stone cases as in those of 
essential hematuria and nephralgia, and they are also as common as in the 
tumor cases. Many cases of stone in the kidney during the quiescent period 
show no abnormal elements whatever in the urine. In those cases where, in 
addition to stones, infection is present in the kidney, pus and bacteria 
are constant accompaniments, provided the urine from the infected side gains 
entrance to the bladder. In certain cases of double kidney and of focal abscess 
in the kidney, a stone kidney which is infected may show no pus or bacteria. 
The amount of pus may vary from a few cells to great quantities. 

The proportion of infection in some instances is quite high. In our series, 
out of 99 cases, 73 had been infected. Though the commonest infecting organ- 
ism is the colon bacillus, we have observed the various forms of pyogenic cocci, 
the bacillus proteus, the bacillus pyocyaneus, the bacillus typhosus, and, in five 
cases, the tubercle bacillus. 

Palpation. — Palpation in some cases gives conclusive evidence of stone in 
the kidney and in the ureter. Much more frequently the demonstration of 
increased size in the organ j)al])ated and of tendern(»ss merely indicates the 
site of the trouble without definitely showing its nature. During an attack of 
renal colic the renal region is nearly always very tender. This tenderness may 
extend over the entire side and, in many cases, over the entire abdomen. There 
is frequently marked muscle spasm of the aflFected side. In the intervals be- 
tween attacks, and in those cases where there are no attacks, there may be ten- 



DIAGNOSIS. 



U7 



I 



demess over the kidney, or at some p(>iiit in the ureter when the stone is nre- 
teml. As noted imJer Patliulogy a large proportion of stone kidneys are en- 
larged ones, but exceptions to this rule may ho found in the earlier stages and, 
occasionally, in the later, where the kidney ha^ been entirely destroyed by 
•trophy. It has been the good fortune of some observers to palpate stones in 
the kidney during life. This is only possible when the patient is very thin, 
when the kidney is low and the stones very large. We have succeeded in doing 
ill is in 2 rases during the {>ast year. Tn 9S cases, where careful nates were 
.abtained, the kidney was palpable 40 times, and not palpable 52. Many of the 
in whieh the kidney was palpable were large pyonephroses. On the other 
and, when the kidney is high— this is especially true in the male — it may not 
palpable even when greatly enlarged. Percussion in such a ease frequently 
l8ho\%*B a nuirked increase in dulluess in the back on the affected side. It is 
pecially interesting to note that we have been able to i>alpate the kidney in 
than half the cases, when we remember that the nonnat kidney can be pal- 
te<l in women in fully 50 per cent, of the eases. It would seem, therefore, 
at at times the adhesions about the kidney, due to the irritation of stone in 
t, actually make it more difficult to palpate than when it is normal. While, 
erefore, palpation of the kidney gives ns but moflerale information, palpation 
f the ureter, more particularly of the vesical end of the ureter, is most inipor- 
ant, particularly in women. Stones can often be found by vaginal examina- 
OD, The procedure is ilhistrated in Figure 318. We have made a diagnosis 
of stone in the ureter in this way in 8 cases out of a total of 20 with ureteral 
tone. One can readily palpate the ureter through the vaginal wall up to the 
vel of the junction of eer\^ix and corpus uteri; the stone in such a case can 
he pnsfised against the pelvic wall and felt as a hnrd body. Pressure ou the 
»iie often causes pain in such cases, and frequently irritates the bladder and 
xcites a desire to urinate. Not infrequently a stone can be felt at one examina- 
tion and not at the next, owing to its having slipped up in the ureter. When 
the fttone is higher up in the ureter it can sometimes, es|>ecially on the left side, 
be felt by rectal examination. 
^1 Considerable information is obtained by using one hand in abdominal pal- 
^■[^S^^iiy ^^ addition to the palpating hand below. In the male, rectal examina- 
^^Kib is the only form of palpation that oue can use. 

Catheterization of the ITreters.^By oathrterization of the ureters one can 

equently positively demonstrate the presence of stone as well as its location, 

;d likewise determine the functional activity of one or both sides, besides 

rtaining, in cases of infectiou, wdiether one or both kidneys are involved. 

Sometimes the examiner is fortunate enough to diagnose stone in the ureter 




118 



EENAL AND URETERAL STONES. 



by a simple cy^toscopic oxamiiiation. This is true in fhose c^scs where a 
Btone 16 present in the lower ureter and projects thro^igh the orifice into the 
l»la<l(Ier. Snch an observation was made by Dr. Hugh Young (Fig. 3U>) And 
likewise by Dr. H, L. NcwlaTul (Fig. 320). We have observed a similar con- 
dition in one of our patients, Mrs, I^. IL, Xo. 91 (i. TTiHtory of attacks of nnin 



Pig. 3 is. — Palpation of llRETBaAt Stone thkch^oh the Rectum, It is possible tc 
reach a higher |K>itit in the ureter through the rectum than through the vagina* Tb^ 
procedure is therefore one of considerable value, especially when the stone is on iba^ 
left side. 

in right kidney over period of ten years. Stone in kidney removed by nepl 
rotomy. Stone in ureter, which showed on eystoseopic examination, remove^fj 
intravesically. In another ease^ Mrs* R. A., ngv 45, April 17, 1902, the stoa. 
did not show in the bladder, but the calculi in the lower part of the nret^ 
caused a prolapse of the ureteral wall, making a little hard collienlus in tfc^ 
bladder. The ealeuli and the operative procedure employed for their remo\r 
are well shown in Figures 371^ 372, and 373* 




120 



RENAL AND URETERAL STONES. 



to the passage of the catheter on the affected side. The catheter is sometimes 
caught in a stricture and firmly heki If catheters are introduced into both 
ureters at the same tiiue, and the one goes all the way to the kidney, while the 
other goc?8 only to the ohstruotion, one gc^ts a graphic illustration of how much 
farther one enters than the other by drawing them out simultaneously. As the 
two kidneys are usually equidistant from the bhidder, it is possible to tell how 
far the ureteral stone lies from the kidney. It is also easy to show by actual 
measurement how far it lies from the ureteral orifice (Fig. 321), When the 

stone is in the kidney the catheter 
gives no direct evidence as to its 
presence unless the shellac is 
scratched off or, as has happened 
in a few cases, a piece of stone is 
caught in the eye of the catheter 
and removed. It is of interest to 
note here that the developraent of 
the wax-tipped method of deter- 
mining stone originated in an ex- 
perience of one of us (H. A. 
Kelly) in the case of Mrs. R. B, 
W,, August IS, 1895, The ap- 
p<*arance of the catheter and tlic 
stone that scratched it are t?hown 
(Fig. 322)* In this case the in- 
troduction of a catheter, in addi- 
tion to allowing the escape of a 
small quantity of purulent urine, 
also on withdrawal showed tlio catheter scratched and a small particle of stono 
in its eye. Within the next year .serafeh-inarks were definitely obtained in the 
wax coating which we had then begun to ejuploy. In passing, it is of interest 
to note that in two subse^iuent cases, stones, or rather fragments of stones» were 
found in the eyes of catheters which had been passed into the ureters. One of 
these was in the case of Mrs- L. L., Fehniary 23, 11)07. The patient had a 
large calculus in the pelvis of the right kidney, which was removed subsequently 
by nephrotomy. Another case was that of Mrs, P, H,, March, 1900, where a 
small fragment was brought down by the catheter. Occasionally one obtain8| 
grating sensation on striking the stones with the catheter. 

It must be borne in mind that several conditions may cause the obstruction 
of the catheter in the ureter, and the meeting of such an obstruction by no 



Fig. 320.— Prolapse of Vksic al Lni* vb Luktee 
INTO Bladder, Due to Stone, (From H. L. 
Newland, March 19, 1900,) 




DIAGNOSIS. 



^rtf"^** ****'*t*f S0 i 






>4. 



50-(a*b) 



m 
*^: 



Fio. 321. — Determination of the Distance of an Obstruction in the Ureter from 

I THE Bl.\dder. Let X represent this distamie, and 50 cm. the length of the catheter. 
By deducting the length of the sijeculuni, plus the length of the catheter oot^ide of 
the speculimi, from 50 cm. we have the valiio x, or the distanee from the vesical orifice 
of the ureter to the obstruction, which^ io this case, is a stone in the ureter. 
meatis positively indicates stone. This is the ease in ureteral strictures due to 
previous ureteritis, tuberculosis of the ureter, etc. Indeed, in some of the old 
tuberculous strictures one may actually obtain a gouging of the wax-tip. It 
is well, too, to recall that kinks and folds in a ureter which is normal may lead 
to obetructioD^ This is by no means an xineommon occurrence. In most cases, 



\q. 322* — Gouged Renal Catheter Holding in Its Eye a Small Fragment of Stonb. 
a ohovra catheter and stone, actual »he; b, gouged tip of catheter, 9 timcij magni- 
fied; c, fragment of stone, showing plainly the wliitLsh surface of the fracture, IS timea 
ma^ifiefJ* These specimens are of great interest in that they led to the conception 
mxkd development of the wax-tip^d methotl. The gouges shown are in the shellac 
covering of the catheter. The patient was referretl to me by N. S. Davis and was 
mibaequently operated ujx)n bv the late F. Henrotin, confimiing the diagnosis. (Mrs. 
E- B. W., San. No. 126, Sept. 25, 1894.) 





Pig. 323. — Bilateil^l Stopte Kidney; Large CnR.\L Stone Filling Pelvis and Cauci 
OF Right Kidney. Tlic left is a doiil:*U* kidney with two ureters, the upper pelvis au 
caliees were filli'il with a stone and t^niall frapiients of ealeuH were present in the urete 
The lower pelvis tmd ureter were elear. Tlie X-ray showed a stone shadow in the ritf 
kidney l)Ut none in left, beeause the plate was placed too low. Note upper liniit i 
skiagraph indieatwl by the rectangle, Furthennore, the cathet<?r which entered tl 
left ureteral orifice passed into the lower pelvis of this kidney and clear urine wafld 
tainetl; if it had been introduced only a few cm. from the vesical orifice, poa woui 
then hiive been found and sudpicioa arouBed. (Case of H. H. Young, 1901./ 





ifAL Catheter ENTEUiNij Pelvis of Kidney asb Rtriking a Large 
iXCHiu> Stonj:. a wax-tipped cutheter under such cotiditions will show gouge,*?. 



pitklog^cal. are present on either side. In addition to the chemii^al and bac- 
tmolo^eal methods, and mieroseopieal examinations, ordinarilj in use, the 
Tftlitive function of the two kidneys can be stndied. In the ehapter dealing 
with the Functional Methods of Determining the Activity of the Kidney the 
details of tiese proc^ednrea are deserihedj and it suffices to note here that every 



124 



RENAL AND URETERAL STONES. 



degree of change, from no interference with the function to complete destruc- 
tion of the kidney, may be observed. 

The functional tests alone can give no positive evidence of either the pres- 




FiG. 325. — Wax-tipped Catheter Scratched on Both Sides. (See Fig. 370.) Calculous 
pyonephrosis, left, hydronephrosis and hydroureter of right kidney, the latter due to 
a small stone in the ureter just above the crossing of uterine artery. The patient had 
recurring attacks of colic in both kidneys at irregular intervals of one month to two 
years, over a period of eleven years. Both kidneys active; the left showing colon baciUi 
and pus in urine. Both sides furnished scratch-marks on the wax-tipped catheters. 
Death about 5 months later from intestinal obstruction. (Mrs. E. J., Gyn. No. 7762, 
age 32; May 23, 1900.) 

ence or absence of stones. What they show is the functional activity of the 
kidney. They may suggest that stone is present by some change in function in 
conjunction with the history and findings, and they do afford data which will 
guide the operator as to the b<»st and safest operation. 

Another point which the renal catheter makes it possible to ascertain, 



DIAGNOSIS. 



125 



through injection of the pelvis with sterile salt solution, is whether or no there 
18 a dilated pelvis; in other words, whether thrre is a hydronephrosis. In our 
series, where this measure was accurately carried outj this point was determined 






m^ 



Fia. 326, — WkKLSQ Tip op" Renal Catheter. The tip of the catheter is dipped in 
melted wax wliich hardens on expos^ure t> air. The proper extent of waxing the tip 
» shown in the catheters to the right. In certain cases it is of advantage to place 

I strips of wax along the catheter^ as shown, or to wax the euttre catheter. 

before operation in 20 cai^es. The knowleds^e of sneh a condition is often of 
ralne in interpreting markedly dishx-atevl shadows^ in X*ray pictures. It is 
alio very helpful to eoufimi the loeatioii of shadows in the X-ray pictures by 
injections of coUargol or silver iodid. In stone cases, as in all other kidney 




126 



RENAL ANB URETERAL STONES. 



conditioDSj the qiiestion of determiuiug whether the kidneys are the cause of 
the trouble frequently arises, and there is nothing which affords such direet 
eviJence as the pain produced by injecting kidneys. In a 
large number of our eases this procedure was carried out, and 
it has always given positive evidence that the kidney is the 
organ involved. The technique and description of this pro- 
cedure is given in Chapters X and XVL 

In connection with the ureteral work certain anomaltet 
of the kidneys should be kept in mind, especially that of 
double pcdvis and bifurcated ureter. We met with such a 
case recently, where there were stones in the lower pelvis on 
both sides. On the right side, in addition, there was pyo- 
nephrosis of the lower pelvis. The X-ray showed stones in 
both kidneys and, remarkably low down, 
Tbi' bladder urine contained an abundance 
of pus cells. On catbeterizing the ureters 
the urine from both sides was clear and 
contained no pus on microscopical exam- 
ination, Tbe bladder itself looked per- 
fectly normal. This patient was Mrs, J, 
P., February 18, 1910. Without the thor- 
ough examination of the bladder in such a 
ease a diagnosis of vesical pus would have 
been made, A similar case has been ob- 
served and reported by Dr, Hugh Voung. 
Tbe conditions in his case are well shown 
in Figure 323. It should also be lK>me in 
mind that occasionally the foci of infection, located perhaps 
in a single calyx, become closed off and leave clear urine for 
a time. 

The Use of the Wax-tipped Catheter to Secure Scratch 
Harks. — Before the introduction of the X-ray, which it pre- 
ceded by several years, this was the solitary method for posi- 
tively diagnosing stones in the ureter and the kidney. The 
methtxl was first report4-d by IL A, Kelly (Medical News, 
18J)5, Ixvii, 59*1). Since its introduction it has become one 
of the most successful methods employed in his clinic, and has, on several 
oceasions, afforded evidence of stone when all other methods, including the 
X-ray, have failed to show the condition. The wax-tipping of the catheter does 



Fig. 327. — Wax- 
TIPPED Cath- 
eter. Actual 
size. Note long 
eye. In waxing^ 
care must be 
taken not to ob- 
struct this. 



Fio. 328. — Fl*t 
Facet on Wax- 
tipped Cath- 
etek, Due to 
Rubbing Side 
of Speculum. 
Note difference 
in appearance 
between 
scratches and 
l^uged due to 
striking against 
a stoQc. 




not interfere with its uso for ilie other examinations, and it is a regular routine 
to use a catheter so waxed iu each new catheterization. The actual method by 
which the scratches are produced is shown in a schematic way in Figures 324 
and S25. 

The wax mixture is composed of dental wax and olive oil mixed together 
md melted in the prnportions of two parts wax and one part oil. The proper- 




\fm> 329.— Method of Ex.\mining Wax-tipped Catheteb. Figtjre to the right shows 
Q0ttiod of examining wax-ti{>iM>d cathetf>r with nmgoif\nng-gliiss aft*?r it^ removal 
Itom kidney. Figure to llie left shows the appearance of wax after scraping against 
A stone in the pelvis of the kidney. 

iiou of wax mar l^e increased in very hot weather. This mixture is poured 

uh m open bottle holdin«]j an ounce, or into an ordinary test-tnlhe, where it 

aickly solidifies. The waxine; of the catheter is carried out by first meltine: 

' w»x in the h^ittle and then dippinir the pnint of the catheter into it, takin*r 

are not to occlude its eye* The wax shoidd he distributed in an even, smooth 

at» such as shown in Fii^iires 326 and 327. It harden^? on the catheter imme- 

liit^k, Snch a coatinc: readily seratehes when it ^strikes n stone. Before 

E«nich a catheter it should always be exnrnined to see that the wax is evenly 

riWted It is an easy proeedtire, with the open-air eystoseope and the 

[^ficntin the knee-breast posture, to introduce such a catheter into the ureter. 




128 



RENAL AND URETERAL STONES. 



This must be done with care to avoid touching the side of the spectilunt. Strik- 
ing the speculum makes a flat, smooth facet, which cannot be mistaken for tho 

gouge of the ciilcMihis (Fig. 328), 

After introducHig tho catheter into the ureter it is stripped off the stjlet 



Flo. 330. 



Fio. 331. 



Fta. 333. 



Fio. 333, 



Fto. 33i- 



Fiti. .335. 



Fio. 330, — Gouges on Wax-tipped Catheter from Impact against a Ueeteral Stoxi 

(Mrs. H.) 

Fig. 33 L--W ax-tipped Catheter Deeply Gouged by Impact against Stone in Right 
Kidney. A skiagraph was consjidered imp^issible on account of wry thick, fat. abdominil 
wall The s}Tiiptoma were frequent attacks of colic in the right side. The wax-tippal 
diagaosiB was not confirmed bv operation, as the patient refused to have aaythiQg 
done. (Mrs. D. W, Gyn. No.^995L Oct. 6, 1902.) 

Fig. 332.— Gouged Wax-tipped Catheter. Stones in both kidneys. The scratch-maHci 
in this case were caused by a stone in the pcl%4s of the left kidney. (Mias F. 8, GyiL 
No. 8458. June 14, ll>02.) 

FiQ. 333.— <j0Uged Wax-tipped Catheter Making Positive Diagnosis Where X-hat 
Pictures Had Failed to Show^ Stone. The sjTnptoms were repeated attacks of colk 
in the left kidney, over a period of four years. Mild colon bacillus infection of tl>e 
pc»lvis of the left kidfiey; hy drone pKrosia of 60 c. c. Functional activity of two sici« 
equal. Seven stones were found in the pelvis at operation. (Mrs. J. A. S., GyiL No. 
11104, March 16, 1904.) 

Fig. 334.— Deeply Scratched Wax-tie'ped Catheter, Due to Impact against a Sresi 
in Left Ureter. This .stone was subsequently passed spontancouslv. (Mrs. S. W. 
GjTi. No. 11220, March 1, 1904.) 

Fig, 335. — Gouged Wax-tipped Catheter, from Impact against Stoke in Pelvis Qt 
Right Kidney. Single large wtooe in pelvis of right kidney occasioning symptoiDS for 
two years, comphcatcd by mild proteus infection. Treatment, nephroUthotoiXQr* 
Prompt recovcr>^. (Mrs. J. B. R., San. No. 878, Jan, 30, 1900.) 



DlilGNOSIS. 



129 



nd pushed iBward until it reaches an oLstruetion which maj be the pelvis of 
lie kidney. Here it is our custom to move it gently to and fro two or three 
imes. The catheter is left in plaeo while the various teats are heing made. 
rhen these are finished we have the patient rise up on her knees with the body 
erticaly and pull the catheter downward. This is done in order to niako any 
tone drop to the ureteral orifice of the pelvis of the kidney and come in contact 



f^gflieterl 



Gouged Wax-coated Catheter and the Stonk wnn h C'ai .sed Gouges. The 
' to the left is the same as tliat to the right; in the one, the tip is shown and in 
the other a part of tbe catheter 24 cm. from tip. The larger picture of the stone is magui- 
fifai to the same degree as the catheter; the smaller picture shows the stone three- 
qmrtcre natural size. The stone in this case was embeilded in the wall of the vesical 
md of the ureter. The sjinptoitis were severe attacks of renal colic extentling over 
fcrtir montlifl. The pain was referred to the kidney. The stone was removed by extra- 
peritoneal abdominal incision. (Miss L McB., Nov. 25, 11)05.) 

the catheter as it is withdrawal. The paticiit can then resnine the knee- 

posture and the catheter in steadily drawn nntward. The vulva is held 

; 90 as to avoid contact with the catheter. The withdrawal catheter is then 

to a bright light and examined with a lens which magnifies from 3 to 5 

imeter?. The scratch-marks, when jiresent, are then rea<lily observed (Fig. 

They vary greatly in appearance and in general situation. Various 

of scratching are shown in Figures 330-34 L It is possible to deter- 




130 



RENAL AND URETERAL STONES. 



mine tbe position of the stone in the urc^ttT in tho^e cases where the catheter 
passes the stone by waxing the oiilheter in little strips from its point down- 
ward, or, as Dr. John A. Sampson suggests, by coating the entire catheter. In 



Pio. 337. 



FiQ, 388. 



Fio. 330. 



Pio. Wk 



Fio. 337.— Gouged Wax-tipped Catheters. Not** different appearance of gouges due 
to impact iijj;riins1 sain*- stoue l>y two catheters, intrcKiured on scpkarate occfLsionft. Dum- 
tion of illni'^s, 18 mouths. Severe at taeks of pain in right .side; colon bacillus? infection 
of right kidney; cystitiH. Ri|3;|it nephri4ilhotomy. Prompt, permanent relief. (Mrs, 
L. L., San. No. 1275, Dec. 5, PJOL) 

Fio, 338.— Deeply Gouged Wax-tipped Catheter, from Impact against Stones in 
Pelvis of Kidney as Well as in Ureter. Both kidneys were secrellnic appruxinmteJy 
equally, and normally, in spite of a luoderate hydronephrosis of the left kidney. Ne- 
phrotomy and remo\'al of one lar^e atone from the pelvis of the kidney. Sul>^(iuent U> 
ofwTation, the Hmall calculus slinwn in Fig. 316 was pas**ed ispontaneou.«l3\ This patient 
has renmmed well. (Mn^. M. M. G., G>^l No. 7455, Dec. 23, 1890.) 

Fig. 339.— Gouged Ureteral Catheters Obtained from Catheterizing the Two 
Kidneys. In this case both pelves contained stonejs, the left kidney was entirely fiuio 
tionlcss, the right kidney infected with streptococcus. Stones in right kidney removed 
by nephrotomy. Death three weeks later from uremia. (Miss A. C. T., Gyn. No, 
7648, March 17, l9tK).) 

Fio. 340. — Gouges in Wax-tipped Catheter Due to Stone in Right Uret£B, (Mib, 
R. D., U. P. I., Apr., 1902. From W, W. Russell.) 




DIAGNOSIS. 



131 



It 




such a case a ureteral stoue will scratch from tlie tip all the way down to the 
point on the catheter which ia in contact with the stone, when the tip is in con- 
tact with the ]K*lvis of the kidney. The point of the catheter which is in the 
M'sical orifice of the ureter can likewise l>e nnirked, 

This wax-tip catheter method has proved nf aid in some cases of retro^ade 
catheterization from the pelvis of the kidney after nephrotomy. Such a case 
was observed through the courtesy of I>r, Wm, Ilulstcd, Ortoher 2n, 1000. The 
patient, a very stout wouian, had a urinary calcuhLs, and Dr. liulsted did a 
nephrotomy on the left kidney. A wax-lipjied catheter was passed into the 
nrcter through the pelvis of t\iv kidncv down tnward the bhid* 
der; upcui its withdrawal the catheter showed definite 
seratcb-marks (Fig. 342), and vaj2:inal examination deninii' 
stmted H stone in the vesical end of the left ureter. At Dr. 
Ilali^tod's rei]uest a loni!:itudinal incisiun was made through 
lO vapiHU the ureter open<Mh and the calculus removed 
Fig, 34,1). 

Wi* have never employed the wax-tip method with tlie 
^ Tt wouhl 1h* ipdte possilde to use it with an open-air 
pe in the kneedireast posture or with the cystogeope of 
^iiys or any lonfi tulje. Dr. W. A. Avers (Am, J. Surff., 
xxii, 3nO ) describes the teebiii<pie for the use of this 
with hift cystoscope and records its successful use in 
where all other methods, including the X-ray, had 
ilc<i 
The value of the method is p^eat. Tt gives positive evidence, it is easy of 
application^ requires no expensive apparatus, nor consumption of time, and 
can easily l)e carried out at the same time as the other examination by the 
llf«teral catheter. It sometimes gives positive results when the X-ray fails. It 
times happens that a stone may be present in a poc»ket in the ureter, so that 
■theter passes it without contact. More often there is an obstruction btdow 
Btoite which prevents the catheter reaching it. There are many cases in 
h the stone is so situated in the parenchyma of the kiiiuey or in one of its 
lee^ that it is not reached. Occasionally even a stone in the pelvis may escape 
ratcbing. Out of 51 cases we have accurate notes, of which the wax-tip was 
itirdy scratched in 41. In 10 cases there was no scratching. Of these 10 
I, 4 were ureteral stones in which the catheters could not be pushed as higli 
fttone on account of stri<*ture or fobl in the ureter below it. In one case, 
flln!iidv referred to, where the st^imes were of the fibrinous type, they were too 
mft. In three there was a large pyonephrosis, and in only two, a free stone in 




Fig. 341.— Ar^ 

TEARANCE OF 
C A I. C U L U S 

wm ru Caused 
Scratch-marks 
Shown in Fio. 
340. ?i natural 
si2e« 




132 



RENAL AND URETERAL STONES. 



Hio pelvis of moderate size. In two cases scratch-marks were obtained by Uie 
catlietcr coming in contact with old strictures in the ureter having calcium salts 
deposited in the stricture. 

Tlie X-ray, — The ujse of the X-ray is indis- 
penaablc and affords the most valuable infarmation 
as regards the presence^ size, and location of stoncx, 
and no case should be considered satisfactorily in- 
vestigated until coniplett? X-ray pictures arc oIk 
tained of both kidneys and ureters. It should be 
borne in mind, however, that tlie technique of the 
skiagrapher must be uf the best» that poor X-ray 
plates may be worse than none, and that the inte^ 
pretation demands experience and judgment. The 
technique for taking atone pictures, as well as the 
method of interpretation, is fully gone into in 
Chapter XII. 

The progress of atones which are being passed 
in the ureter has bc*cn brilliimtiy studied by Leon- 
ard, and here, tim, the use of the X-ray is almost 
indispensable. The general tendency of X-ray 
specialists is to consider that, if the picture iB 
properly taken, every stone will be demonstrated 
on the plate. The experience of various operators 
does not entirely confirm this, but there is no ques- 
tion that a good X-ray picture will show mo«t 
stones, J. F. Smith (Ann, Surg., 1004, xridx, 
748) reports 27 cases %vhich were examined by the 
X-ray. In each case in which stones were found 
on the plate their presence was confirmed by opera- 
tion. In 13 cases no stones were shown on the 
plate and none were found at operation; in one 
case the picture was doubtful. Kiiramcll states 
that X-ray plates have practically always given conclusive information in his 
cases. In 1>1, whore stones were present, the X-ray pictures showed tbe exact 
location and the numlxT of stones; in an equal number of cases, where th« 
X-ray was negative, the operation showed that there were no stones. Excellent 
examples of X*ray plates shouting stone are presented in Figures 344 and 345, 
Fur full details showing I«i(?ation and appearance of stones see Chapter XII. 
Hugo Neuhauser (Folia Urologicaj 1909, iv, 361) has contributed a most 



FiQ. 342.— GouoKD Tips of 
Waxed Catheters, Duk 
TO Stone in Vesical End 
OF Right Uheter. The 
catiicter to the luft was ob- 
tained before oijcratioo h^ 
cuilieieriiiation of the arc- 
ter tfirough the 1» ladder. 
That to the right was done 
at the time of operation by 
retrograde catheterization 
from the pelvis of the kid- 
ney dowTiward, after open- 
ing the renal pelvis. The 
itone was removed through 
a small vaginal ineision, 
(Mrs. M. H, II., J. H. H., 
(Jyn. No. 32300, Oct. 26, 
19O0.) 




DIAGNOSIS, 



]dS 



rinteresting report on 245 cases fram James IsraePs clinic. After praising the 
X-ray as an indispensable method of diagnosis, he states that it may fail to show 
sUmeB, in both fat and thin people, and also when the stone is either a phos- 
^ate or a urata This faihire of the excellent X-ray plates to show stone has 
met with a number of times. Ho reports in detail three cases where the 
X-ray failed and yet the operation showed stone. In addition to these failurea 
Hto show stones when present, the author shows the skiagraphs of several cases 
^■where shadows were apparent, bnt proved to be due to 
Buther diseases of the kidney* This type of false evi- 
dence obtainecl by the method is well known, and can 
u^aially he interpreted. He reports 2 cases, however, in 

» which the kidney was found perfectly normal at opera- 
tion, though the X-ray had shovra definite stones. 
Our own experience inclines us to agree with the 
findings from the clinic of Israel. During the last year 
we had one case of stone in the ureter almost as large as 
the end of an adult thumb; the stone wae phosphatic 
and situated at the level of the sacroiliac ynni on the 
^left side. This case was Mrs. J. IT. R., dune 8, 11)10. 
BA splen<lid X-ray plate showing the detail of the hones 
and the psoas muscle was obtained, and yet no shadow 
was cast by the stone. 

In another case, ilr. A* P., age 40, the patient had 
never had any pain in the kidneys, bnt had marked 
Hv^ical distress, and a continuous pjiiria due to the 
^cokm bacillus. The cystoscopie examination showed a 
fairly normal bladder. Urine was obtaiiie^d from each 
kidney separately, and the two kidneys were found to 
be acting equally. The urine from both showetl pus, 
red blood cells, colon bacilli, and casts. The total out- 
put of indigo-cannin in 2 hours amounted to only 3 per 
cent The blo^>d pressure was 150. The Xray picture 
aeemed to show a small stone in the right kidney and a 

larg^ one filling the pelvis on the left side. At operation a stone was found on 
the Tight side, hut there was none on the left side; both kitlneys were small, and 
showed marked signs of chronic interstitial nephritis. The fat around both 
kiduevg, particularly the left, was very fibrous and densely adherent to the 
pelvM. There was no pyonephrosis, 

i» another case, Miss F. S., October, 1903, the X-ray seemed to show stone 



Fig. 34:1'-The Ure- 
teral Stone tsuich 
Scratched Cathe- 
ters Shown in Pre- 
ceding Figure. The 
smaller figure 
above shows the cal- 
cuhus natural size, the 
lower one^ five times 
magnified* The flat- 
tened siirfaee shown 
hi center of figure is 
the result of a frac- 
ture and indicates 
that this stone is a 
piece broken ofif from 
another. 





Fig* 344. — Sh*U)owgraph of Right Kidney, Showing a Largk Stone, This patieotl 
had only gastric aytnptoms, (Taken Jan. 22, 1912.) 



of the kidney to contain 7 stones. The wax tip in this case was positive, bit 
tho X-ray pi a to showed nothincr. 

In another case, Mrs, J* O. M., Fehniary H, 190€, there was a history c 
attacks of pain in the left kidney and pus in the urine. Separate catheterizatia 



136 



RENAL AND UEETEKAL STONES. 



The ureter wag considerably thiekeiied above the stoue. This patient made an 
uninterriipted eonvalescenee, and has been quite well sinec the operation. 

In still anothpr ease^ Mrs. E. G. W., January 12, 1903, the X-ray showed 
no stono in the left kidney. The patient had Wen having repeated attacks in 
the left back for a year and a half. The left kidney was found to lie* secreting 
actively^ but the urine showed pus and colon bacilli. The same condition was 
found on the right side. There had never been any pain in the right kidney. 
The wax tip was positive on the left side, negative on the right. The X-ray 
showed no stone on the left side, althongh at operation a large stone was 
removed from the pelvis, w^hieh ako contained pns. On the right side the 
X-ray suggested a stone. No operation was done on the right side; patient 
returned to the hospital later, October, 190S, when the X-ray showed 2 stones 
in the ki<lney, one the size of a pigeon's egg, one smaller. At operation 
several small stones were found in this kidney. 

In ,^*0 cases where the X-ray hiis shown stone, they have been found at 
operation. In quite as many cases, where operation was done for other reasons, 
and where stone was not present at operation, the X*ray plate had shown before- 
hand that they were not present. All of this goes to show that, while the X-ray 
affords the most valuable of all methods of diagnusing stone, it is not to be 
entirely relied on ; in some cases, it fails to show stones which are present, while 
in others, it seems to show stones which are not present. No examination, 
however, of a kidney is complete withont this aid, and it often affords positive 
evidence of the presence of stone when no other method does so* 

The foregoing remarks were based npon our views and experiencea np to 
within the last year, Imt with the development of fhf^ art of skiagraphy there 
has resulted such improvement that, provided a perfect plate showing the out- 
Une of the kidney is obtained, it seems likely that all stones will \)e shown. 
This matter is fully treated in Chapter XII. 

Treatment of a calculus in the urinary tract is either expectant or surgical. 



EXPECTANT TREATMENT. 

Expectant treatment is justified when the patient 
is not suffering much and the stone present is a small 
one, wbicli may be expected to escape spontaneously, 

A foreign IkhIv (stone), lodged at any point on flic nrinary tract, is always 
a source of danger, a swnrd of Damix-les hanging over the head. A stone may 
grow in size, cause infections and hemorrhages and, in the upper urinary tract, 
prove an obstruction to the outflow of nrine (anuria ). In this way it is liable 




DIAGNOSIS. 137 

to become a source of destructive changes in one or both organs whose integrity 
is of vital importance to the economy. 

Most calculous patients suffer from more or less discomfort or sharp attacks 
of pain, which are peculiarly wearing, and sooner or later impair the health. 
It is also not without significance that tuberculosis and carcinoma are found 
associated with calculi. For these reasons every case demands serious con- 
sideration. 

Various hygienic, dietetic, and medicinal measures have been advocated to 
prevent the formation of stones in the urinary tract. Most of these procedures 
have been directed against the accumulation of uric acid in the urine. The 
meats are reduced to a minimum. Tea, coffee, and chocolate are con- 
traindicated. Alcohol is forbidden. The patient is advised to lead an active 
Jife. 

Among the dnigs advised are bicarbonate of soda, gr. 15, three times a day, 
iirotropin, gr. 10 to 20, three times a day, and piperazin, gr. 10, three times 
a day. 

The use of diuretics and the drinking of large quantities of water are uni- 
versally urged. 

While not attempting to deny the value of such measures, we must confess 
to having had but little encouragement from their use, and we believe it is 
very questionable whether stone formation can be controlled by following them. 
All ureteral calculi by no means demand surgical treatment. C. L. Leonard, 
^ith perhaps the largest experience in this country in the X-ray detection* 
of calculi, believes that in about 50 per cent, of tlie cases of urinary lithiasis 
presenting marked symptoms the natural forces are capable of expelling the 
calculus (/. Am. Med. Assoc, 1909, Ivii, 289). Leonard points out the fact 
that the apparent increasing frequency of ureteral calculi is in reality due to 
their readier detection by the X-ray, which furnishes an accurate method 
of diagnosis and at the same time affords a rational basis of differentiation 
between cases demanding immediate operation and those in which an expectant 
conservatism under strict supervision may reasonably be expected to result in 
the passage of the calculus by the natural channels. The calculi which may 
be left to nature, intelligently supervised, are those of small size — ^not much 
larger than the lumen of the ureter — which the successive attacks of pain are 
evidently forcing to a lower level ; in other words, in which a sufficient vis a 
iergo is developed to drive the calculus on and out. Occasionally very large 
stones are passed. Such a one is shown in Figure 317. The supervision which 
renders this method of treatment safe must also observe by cystoscopic examina- 
tion that there is no persistent anuria due to a blockade of the ureter, no 



138 RENAL AND URETERAL STONES. 

marked fever, and, most important of all, no acute infection of the urinary 
tract. 

While waiting for the calculus to pass, the pain may be relieved and tlie 
spasm relaxed by morphia with atropin, keeping the patient in bed, giving 
enemas of water as hot as can be borne, and making local applications of hot 
water poultices, at the same time giving urotropin, say 5 gr. every 2 hours, 
after or during the attack. By drinking an abundance of water, preferably 
carbonated water, and using buttermilk as a diet, the increased urinary secre- 
tion serves to promote the progress of the calculus toward delivery. Al- 
though this treatment applies to most small ureteral calculi, it must at the same 
time be remembered that even tiny calculi may be lodged persistently at any 
point in the ureter. We have had to dig a calculus out of the ureter at its renal 
end, and in another case tear a little spiculate calculus not more than 5 or G 
mm. in diameter out of the vesical end of the ureter. 

Sometimes a patient who has passed one small stone will, at irregular inter- 
vals, be taken with attacks of pain, passing stones, as a rule, similar in size 
and character. In all these cases the association of a competent urologist with 
the X-ray expert is earnestly advised. 

INDICATIONS FOR OPERATIVE TREATMENT. 

If the patient is compelled to lead an active life, and attacks of pain are 
brought on by exercise, or if there is blood or pus in the urine, or if the stone 
is a large one in any part of the urinary tract, it should be removed surgically 
at the earliest convenient opj)ortunity. The general rule may be safely laid 
down, always operate for fixed stones and for stones 
which cannot reasonably be expected to pas^ down and 
escape per vias natural es. Another valuable rule is always to 
operate when infection is present. 

Stones may be found lodged in any one or in several of five cardinal posi- 
tions in the urinary tract : in the renal calices, in the renal pelvis, in the ureter, 
in the bladder, or in the urethra, each position demanding special separate con- 
sideration. 

OPERATION FOR STONE IN THE KIDNEY. 

The surgeon proceeds to operate w^ith all the data before him gained by the 
urinary analysis, showing the presence or absence of pus and blood, the scratch 
marks from ureteral catheterization, and the X-ray finding. It is best to have 
an X-ray plate or print in the operating room for consultation. Sometimes 



TREATMENT. 139 

there is a bunch of stones in the pelvis and adjacent parts of the kidney near 
its lower pole, and a single isolated stone in the upper part of the kidney. Un- 
less the X-ray plate is carefully consulted the upper stone is apt to escape the 
surgeon. 

It is of the utmost importance to know whether there are stones on the 
other side. If a stone on one side, where the disease is bilateral, causes a stop- 
page in the escape of urine or pus, that side ought to be relieved first ; if one 
gide is quiescent and the other is badly infected we would advise operating on 
the worst side first. It will be proper to relieve both kidneys or both ureters of 
their burden when neither operation is very aggressive. 

The incision to expose a stone kidney is best made posteriorly in an oblique 
direction from the angle between the quadratus lumborum and the last rib (the 
superior lumbar triangle) downward and outward about four inches in length 
(Figs. 173, 174, 175, 176). The latissimus dorsi muscle is exposed under 
the skin and lifted up or divided, so as to expose the superior lumbar triangle, 
which is opened by thrusting in a pointed forceps. The retroperitoneal fat 
pops out of the little opening made, and this is enlarged with a blunt instru- 
ment; then the finger is inserted and the opening pulled widely apart without 
using any cutting instruments. The kidney can be best exposed in this way 
when it is not much above the normal size. If the kidney is a large one, more 
room is needed than can be gained by blunt force; the incision can then be 
enlarged in a direction downward and outward, first parting the fibers of the 
external oblique muscle in its course, and then dividing the fibers of the inter- 
nal oblique and the transversalis (Figs. 183-187). The incision can thus 
be readily made twice the size of the first opening. If the kidney is not en- 
larged, the fatty capsule is readily opened by thrusting the finger through the 
fat in a direction backward toward the vertebral column (Fig. 178), when 
the finger enters and readily hooks up the posterior plane of Kiister's capsule, 
within which lies the kidney, enveloped in the perirenal fat. As soon as this is 
widely opened the hand is introduced and the kidney palpated. Often the hard 
stone is felt at once in the pelvis of the kidney. 

Pyclotomy, — Whenever it can be done with safety, the stone in the pelvis of 
the kidney ought to be removed through the pelvis (pyelotomy) and not 
through the kidney tissue. A pyelotomy under favorable conditions is a simple, 
aaf e operation involving no hemorrhage, not even one drop, and absolutely free 
from any mutilation, while every transrenal operation is more or less muti- 
lating, and even in skillful hands sometimes associated with great hemorrhage. 
There is always, too, the risk, following the renal operation, of hemorrhages 
iDto the pelvis of the kidney and down into the bladder. All these dangers are 



140 



RENAL AKD URETERAL STONES. 



avoided by pyelotomy^ which is, therefore, the operation of election when condi- 
tions favor it. 

A pyelotomy should be done when the kidney is movable and can be brought 
down within easy reodi, and wlien its pelvis is easily accessible. Pyelotomy is 
contraindicated when the kidney is more or less fixed by inflammatory tissue 
and, above all, when its pelvis is so encased in hardened fat that it can not be 



Ro.346» — Lahge Stone in Left KmNEY Successfully Removed by Pyelotomy, In 
addition to this large stone in tlie p^^lvis of the left kidney, there were stones 
and pvonephrosb of the right kidney, (Mr. E. J., Cb. II. and I., Sept., 1909. 
Age 36.) 

distinetly reeop^iized and differentiated from the adjacent structures. Under 
such cireiiriistaiieea to attempt a pyelotomy is to risk tearing the rigid peh'is 
to pieces and leaviuf^ a permanent fi^tida behind. A pyelotomy is not to be done 
in a pelvis concenk-d within the kidney substance; it is als^o Wtter not to do 
it when there are multiple hrauehed calculi. Infected cases ought to be opened 
and drained through the dorsum of the kidney. 

If the kidney is mnvaljle^ after a little effort, hy freeing it with the fingers 
at its upper pole, grasping ihe perirenal fat with successive pairs of forceps, 
so as to pull upon it sinuiltaneonsly with four or five pairs, it can often be 
slipped out of the incision onto tire surface without any trouble. The stone is 
then carefully located by palpation; the pelvis of the kidney is next exposed 
by removing some of the loose fat covering it, and the calculus is made to 




TREATMENT* 



141 



[appear at the roost convenient point This, is usnally in the lower angle of the 

'pelvis on a line with or k^luw the insertion of the ureter, where a small or 

moderately sized stone can be forced np under the protecting shelf of renal 

^ tissue bordering the hiluni. 



'^V 



I v* ' 



aUuti 



J 



mciftian *rt uTtter far 



Urtter»l lUsue 

Flo* S47. — ^Hydromephhotic Right Kidkit Due to OasTRUcrnoN or the Upper Ureteb 
Br Stop^es. In sketch a, the api^earance of patieot before operation is shown, with 
the location of the swelUng due to a big hydronephrosis* In b, is shown exposure and 
incision of renal peK4s and apjwarance of the upper part of the ureter, where ita con- 
tour is altered by calculi in itn lumen. In c, is shown removal of adherent stones from 
ureter through a longitudinal incision directly over them. Duration of symptoms, 
Desisting of intennittcnt tumor^ pain in side and headache, 8 yeans, Syiniitonis in 
form of attacks lasting a few days and reappearing every two or three months. Urine 
Darmal^ both microscopically and chemically. Most of renal function carried on by 
opposite kidney. The operation shown resulted in jxirmancnt relief. (Miss M. L. K,, 
Gyn* No. 6598; age 37, Dec. U, 1898.) 

With the kidney drawn down and out, the vessels angle upward for the moat 
part and leave the pelvis bare of vessels, exposing a wide area convenient for 
extraction of the stone. 



143 



RENAL AND URETERAL STONES. 



Sometimes tLe renal pcOvis is the reverse of the usual type, lying in fwmt 
of and not heliiiid the kidney (see Chapter XIV). In thisi, too, the deep natdi 
at the lower angle of tiie pelvis, which mark^ the limits of the zones of arterii) 
distribution, is in front* Tn siieh va^es k is easior and safer to op<»u the fielrii 
in front. Very hirge stones can he removed through a pyelutomy incision when 
the pelvis is extrarenal (Fig* 346). With a hydronephrosis it can he quite 



UAmm f^, 






^4:* I 



^.1 



in 

Fig. 348. — ^PTrEi>oTo\ry for Stone in the Pelvis op Kidney. Not^ how the 

broQBtlit info view by prcssure from the finger. Note aUo the position, length and di* 
rection of incision* Be rarefiil not to rub away, injure or displace the ovcrlyijjg 
perii>elvic fascia which is iiiviiluable in closing the wound. 

simply managed, as shown in Figure 347. Pyclotomy is impossible iritk 
stones in the ealices, as well sho\\Ti in Figtire 212. 

The ]>elvis may be incised in a dire<'tion extending from the renal margin 
toward the ureter, if the exfjosure is a good one, making the opening just large 
enough to remove the stone by its smallest diameter with a seoop or delicite 
fenestrated stone forceps without tearing the tissues of the pelvis. 

If the fat sticks to the pelvis ami there is langer of tearing it, or if there 
is danger of cutting a vessel which lies hiiblen in the hard fat, we have founA. 
it a good plan to push the calculus forward from behind so as to make it proflkr 




TREATMENT, 



143 



inent (Fig* 348 )y and then to take a siimll, pointed pair of nrfery forceps and 
push it through the tissue onto the stone, opening the pelvis in this* vvmv. Then 

|#eparating the hlude.s carefully atnl watcliiiig to sc*e that the opening sjvrcinU 
slowly in one direction, instead of making an irregular rent, we enlarge it until 
the stone slips out ur can hv withdrawn. When the pelvis is ofjened in this way, 
slowly and with t-are, tbercvis no risk of rnptnring a large vessel* Examine the 
^tone at once for broken branches or facets showing the presence of other stones 



10. 349. — SuroaiNO op Pv^lotivmy Imclsios Akikr Removal of Stone, This should 
bt' done, when [>os8ibk% in two layers, as sliown; the first layer is ttie i)elvis proper and 
the sec<aid the tough, strong hl>rous coat overl\ing the pelvis, the so-<'allc<l renal 
fa^ia. The suture material should be fine catgut. If one of these sutures has to be 
omilU^d I would rather letive tnit the first mm passed directly through the tissues of 
th** pelvis anrl n^ly on the fascial suture. 



ill the caliees. 1Vm> much eni|diasis cannot be put on this exam inaf ion, without 

rhieh stones are sure to be left behind. A reconstruction of a large frajj- 

lied stone is shown in Fi^re o54. Fnipuentation almost invariahly 

ird with the large coral stones. By notine: the position of the stone in the 

bIto one can then tell wdiere to look fur any fragments or fingerdike stones 

Sp in a calyx. 

After taking out the stone the little finger or a uterine sonnd may he inserted 
and the whole ikpIvIs and the calices jialpated. 

If a perfectly satisfactory X-ray picliire has l>een made, locating a single 
tloii€ in the pelvis, one may then avoid the nncertainty and sometimes injnri- 
OQt effort of exploruig the renal ealices through the opening, 

Tlie incision is then sewed np with fine cbromicized or cnmol catgnt, in 




144 



RENAL AND URETERAL STONES. 



figure-of-eiglit or mattress sutures, cafrhing the filirons tissues enveloping the 
pelvis carefully, without appearing on the nuieous surfat^e ( W. J. Mayo, H- A. 
Kelly), III this way the incisioii h smigly chispil with fmoi 3 to G sutures 
(Fig, 340). A short dean cut may lie safely left to nature to close: iiideeJ 



n7ft).( 



Fio. 350, — Stones Filling the Lower Calyx of Kidney. Note the dilated pelvis 
and calico.'i dyo t<i stricturinR of ureteral |>t4\nc junction. Tliis was not due to 
kink or twist of ilie ureter, hut more likoly to an inflammatory com I it ion induced 
by the passage of stones. The |>elvia of the kidney is thiekenetl and tl»e paren* 
chvina greatly altered^ indicating serious past trouble* (J. H. IL, Autopsy No. 
3295.) 

not a drop of urine may escape after the operation even when the wound is 
left without any attempt at elosure liy suture. 

The kidney in then returned to the ahdomen and the wound rlosed, a small 
gauze drain, wrapped in proteetive, heing inserted, leading haek to the position 
of the kidney. 




DUGNOSIS. 



145 



Hcphrolithotomy.— Where the stuiies extend out into the calicesj branching 
in various directions, or where there is much surrounding inllauiniatory trouble, 
fixing the pelvi:^ of the kidney, or where there is a marked infectioOj nephro- 



' ealnilt 



r,-^ 



ilf (Micvft 



« latfwar ptiln 



M»t| miidU ttlcgljlt 



^ 



>^ 






fl% 



l/^' - . 



^^^:- 



Aptj «f calf > 
pointkfig Met .! 



% 



35 1.— Removal op Laroe Corai. Stonb from Henal Pelvis and Calices through 

riCPHRO^itjMY Incision. Sucli a stone is praclieally never removed in one piet-c. The 

itral piece, nearly always broken away from upper piece, may be removed first. 

rUe lower pole may be broken, or if very hard, removed with middle portion. Such 

r>n«^s are often quite adherent to iho walls of the jH*lvis and mu.st be freetl by gentle 

Jlinj< assoeiated with rotary movements. The stones in the fwlar ralieei^ htq removed 

ahuwn in upper diagram. Such a stone should always be reconstructed, aa shown 

I llic right-hand figure, in order to demonstrate that the entire stone has been re- 

Thc fenestrated forceps shown are moat eerviccable. 



TitliotomVy or the removal of the stones from the calices and pelvis through the 
domtm of the kidney, is the most satisfactory operation. Stones such as those 
fihowii in Figures 303, 304, 323, 350 and 350 can only be removed by a wide 
nephrotomy incision. If it is possible to free the kidney carefully on all sides 



14i 



RENAL AND URETERAL STONES. 



and to slip it out of tlio mcision onto the surface of the bndy, 
this is the simplest and most satisfactory way of handling it 
As a rule, however^ the kidney 



IS so fixed by the surrounding 
perinephral iulhinniiation that 
the stones must he removed in 
sliii or not at all. Tn this case, 
after making an incision suffi- 
ciently long to expose the kid- 
ney perfectly, the nearest stone 
in the cortex is located by pal- 
pation, or by gently using a 
s-traight needle. The opening 
down onto the stone or stones 
is made directly inward, par 
allel to the long axis of ihe 
kidney, by means of a blunts 
flat needle armed with a single 
silver wire, accordhig to the 
method devised by M. Broedel 
and worked out experimen- 
tally by E. K. Cullen and U. 
F. bocrgc I Figures 218, 211), 
220, and 221). By the use of 
the blunt, curved needle and 
the silver wire the kidiiey can 
be separated into its two vascular leaflets from 
cortex to pelvis without any noticeable hemor- 
rhage and without any injury to any important 
vessels necessarily resulting in an infarct and 
the destruction of the zone of renal tissue sup- 
plied by the injured vessel, A No. 3 silver 
wire is usedj being introduced through the sub- 
stance of the kidney deep dowm toward the 
trunks of the vessels. The ciipsule of the kid- 
ney is caught at the points where the wire 
emerges. The kidney itself is supported by a 
firm counter-traction as the wire is brought 
slowly to the surface with a see-saw movement 



Fig, 352 -Deep- 
ly HCRATCHED 

Wax • TIPPED 
Catheter, 
From impact 
agaifist stones 
in pelvis of kid- 
ney. (Mrs, M, 
H,, Gyn. No. 
8639, April, 
1001.) See four 
succeeding fig- 
ures. 



I. 



Imt rmrt 



(%/« 



I. 



rmle i» 

Arhff 

Fig. 353.— Length and Posmow or 
Nephrotomy Incision in Case 
Illvstrated in Three 8l cceed- 
ING Figures. Lower fijBfure shows 
transverse set t ion of kidney. Note 
position of incision in non-vaacu- 
lar plane. Note thinning of par- 
ench>Tna, which renders inciaiop 
ea,sy and comparatively bio 
Note likewise how in such 
fragments of stones in remote 
pockets may be overlooked. (Mrs, 
M. tL) 



mcisioD 
loodl^H 
± ac9H 




TREATMENT. 



If7 



/* 



^ 



>^'5t 



like that used in manipulating a wire saw. When tha needle enoounters on© 
of tlie renal vessels in the eourae of its intrtKliietion the resistaiice ia recognized 
ftt once and, n|K>n moving the needle slightly 
to one side i>r the ntherj the vessel is avoided 
and »o escapes Injury. 

After opening the kidney, which sliould be 
delivereii into the abdominal incision, the as- 
sistant graaps the pedicle, or it is compressed 
by packing gauze down against it, and then the 
B stone ia removed by a conveniently shaped for- 
Hec^ps, OS shown in Figure 351. 
^L A complete record, showing the wax-tip 
^^Nlttieter scratched, the incision to expose the 
stone, the fragmented stone, and the appear- 
ance of the kid- 
ney removed one 
year later, owing 
to persisttait in* 
feet ion, is shown 
in Figures 352, 
353, 354, 355, 
and 350. The 
case well illus- 
trates the diffi- 
culty frequently enconnten'4 in alleviating in- 
fected kichieys. When most of the parenchyma is 
destroyed it is far better to do a nephrectomy. In 
this case we hoi>ed f<»r healing, as the secreting 
part of kidney was well ]>reservod. 

After a stone filling a ealyx has been removed 

it is* as a rule, possible to fei-l the pelvis of the 

Fio. »o5.— Kidney Removed kidney and other calices to dcttennino whether 

One Year After Nephrot- others are present or not. Where there are large 

OMY, FOR 8TOXE. Notc scar }j^j^,i,.|,i,i,, nj^sses it is well to continue the splitr 

TiiC mime case as illuatrated . r i i i /» .i i - j j 

in the tlirce preceding and *»"1^ ^''**"^ *^"^ ''^^^^'' F*'** *'^ *"*" kidnev upward, 

till! foUowing * draining. % opening the pelvis widely, so that the whole can 

natural siie. (Mrs. M. H.) j^^ taken out as far as possible in one mass. An 

r^pfjxing made in this way ought to follow Broeflel's lines (see Chapter XVI), 

sWiuh avoid the veasels* In Figures 357, 358, and 35D are shown the entire 




Fig. 3.^. — Fragments of Stones 

liKMUVEn JN THK (*ASE 8nOWN 
IN FliErEDlNG Two FiGUREfl. 

The lint's iiKlieate probable re- 
eonstmction of stones. % nat- 
ural size. (Mrs. M. H.) 



148 



RENAL ANI> URETERAL STONES, 



reeanl of a singular and interesting ease: 1st, the scratched wax tip; 2nd, 
the incision into kidney; 3rd, the stones. When the lower pole of the kidney 
has been emptied of its stones one can sometimes carry the finger intx) the pelvis 





-.^ 


MHHIK 


Hi « 




J^^^^^^H 


1 «94^«.V 

J 


3F^' ' '^ '^ 


-' rftl^S!^^^^^^ 


fjp 




i " :. 










"^wP 


1 







Fig. 356, — Kidnky Shown in PRErEDiNG Fk,' « id Open. Dilated pelvis and cal- 
icesi after a year of uri()f«.stnictc'*i drainage; thinning of cortex, abscess, small aalcuU 
and scarrmg. Symptonii^, n^pcated attacks of C4*lie lasting several hours and nv 
curririg from four to six times a year. Duration of symptoms, fiftee^i years. PaUi 
and frequency of voiding. Stone rlcmonstratcrl by wax-tipix^d catheter and by X*ray. 
Urinary iufection and pns, opj>osite kidney nornial. N«'phrotomy, rcraova! of st-oncai 
April, HKH; continued puin and pyuria led to nephrect^uny March, 1902, followed by 
a promj>t and pernianeui cure, {Mrs. M. H., tlyn. No.s. 8039 and 9M2. Apr,, 1901, 
March, 11)02.) 

and up into (he iip[M*r pole and dislinprni^h a separate set of stones there. Using 
the fincrer as a guide in this way thr* nprralnr tlii-n makes a separate incision 
into \\w uj>per pole, in no way connected willi the lower incision, and removes 
the stones idnivp as well. After such an operation deliberate st(*ps shouhl bo 
taken to make a carefnl search, using the finger or a cnrv^d metallic sound to 
enter each calyx and discover whether any stones have l>een left behitid. The 
use of a strong stream of saline solution or warm bf>rie aeid is s^imetinies of 
value in removing the dt'bris of thf> stones. 

When the kidney is distended witli ^fuh or is hydronephrotic from the stone 




TREATMENT. 



140 




ID the pelvis bl4K.*kin^f tlie nictt^nd oriliee, ii is oasy to open 
the fltiettiatini?^ thiiirH'd-out corlrx, and rjirry tlie fingor at 
ouce into tlie jn^lvis, then, nt« the fluid nislieg rmt, catcli and 
deliver tb* »tone. 

If a 8iii<i:ie atone is precisely located by the X-ray, cither 
ill the upper or lower pole of the kidney or in its median 
Eone, it can sometimes he sneaked out tlirnnirh the doi-siim of 
tho kidney by the simplest operation possible. For example, 
if the stone is in the lower pole, tliis is exposed and tilted up, 
and tlie precise location of the stone is determined by using 

a fine needle fixfd in a eurk* 
The eapsnle proper is then in- 
cised and a sharp instrument, 
such as a pair of tine scissors, is 
pushed in, nnfil it touches the 
stone, which is supported by the 
fingers grasping the kidney. The 
wound is then enlarged a little 
by opening the scissors, a small 
stone forceps is introduced, and 
the stone is extracted. One fine 
suture will, as a rule, close the 
incision. In like manner the 
nppt^r pole can be tilted oxw mul 
operated upon, 

C 1 o s n r e of t h e W o u n d. 
When there is no hemorrhage, 
the wound is lx*st olosc»d by using 
a straight needle and suturing 
the capsule with a continuous 
suture passing to and fro until the wound ia com- 
pletely closed. Fine silk or cuniol-fonnalin catgut 
may be used for this. If marked heui(»rrhage is 
nntrd at any point on the cut surface it is best to 
control this while the vessel can be isolated^ by 
drawing it out with a pointed artery forceps and 
Where the bleeding can not Ik* controlled in this way 
it eim be controlled by taking a htng needle with a blunt point, transfixing the 
Iddofiry from side to side, and then bringing the suture back a^in so as to 



Fio. 358.— Nephrotomy in- 
a&iuN IN THE Non-vas- 
cular Plane Used in the 
Cask Hhown in Prkced- 
INQ AND Following Fiti- 
UREs. The dotU'd line 
shows ypwanl extcui^iou 
of this inci^on. (Mrs. 
C.J.) 

Ug«titig with fine cat^it. 



Fig. 357.— Wax- 
tipped Cath- 
eter, Showing 

CiOCGES FROM 

Large Stone in 
Pelvis of Left 
Kidney* The 
rathcte* from 
rig lit kidney 
also scratched. 
See succeeding 
figure, (Mrs, C» 
J., Ci.m No, 
12880, April 30, 
UK)6.) 




150 



KENAL AND UKKTEKAL STONES, 



embrace the blending area (Figs. 225 and :22(V). When the sutiiro ia tieA Uic 
bleeding h stopped effeetnally. Tlir funrtion of this portion of the kidm^v in 
necessarily suspended until this suture is absorbed. In piissing tlie needJo one 



O 






Pus 



5ac 



-:«>■' 



Fio. 350,— Large Coral Stone in Rioht Ktdney, Filling Pelvis and Caucks* l^ 

reRuliir stoiu's iii pelvis of left kidney and fiilalatioii of lower calices into a pun cell, 
with partial dei>tructioii of that part of kidney. Repeated attaokB of r(*nal coUc In 
both kidneys, and spi^ntaneoiis jiaasages of fm^ienis of stones. Both kidneys infedfri 
with colon biifilhis. Both X-rity and wax-tip diagnosis of stone jDositive, Bikteril 
iieijhrotomy, rcunoval of ^tonca. Patient continue^! to live without colic, hut with |jff- 
aistent infection on both aides. (Mrs. C. L, Gyn. No, 12880, age 30; April 2S, \m) 

must avoid the vascular zones of the kidney evidenced by the white lines be- 
tween the lobules. 

It is extremely necessary to seen re eoin|»lete hoino^ta.si^, as serere liemor^ 
rha^ can, and uften (h>es occur. Even when the hemorrhage is not dangrrou^^ 
so far as rxsaiigiiiiuilinn h eoneerned, it nuiy Ira J to plugging of ihe ureter wit\j 
elotjJi, sneli ha thost' shown in Figure 3(10. 

In infected eases a mnshrooin catheter should Vm inserted into the kidne 
and badly infected kidneys are best left open without suture, 





.—Cash of .- m.,,,^. ,:. i,.u*\h:\' and Ureter, Bilateral Rexal Tuberculosis 
TrBERCLTLOSis OF THE BLADDER. A nephrotomy and partial nt^phrectomy waa 
ftpted on the left kidney. Marked post-operative hemorrhaAe uccurred with the 
ige of the clots shown on the right, making casts of the ureter. Note number and 
ibution of srtones. Patient recovered from thi*^ operation, but died from uremia 
brch 3, 1900. (Miss M, W., operated on at the Ch. H. and Inf., Oct. 13, 1905.) 

151 




152 



RENAL AND URETERAL STONES. 



Sinn a 



Hephrectomy. — If the examinations previous to the operation have made it 
clear that the opposite kidney is sound tiiicl doing oil the work of excretion, 
wliilt' \]w 'liFcH'tiMl t^ide is liiidly iiifet-ted, f^eeri^tiii^ Hi tie *>r no nrea (Fig, .*Jril, 
also Figs. .*501 and W2), showing that the stone kidney has Ikjcu converted into 
a pus kidney, then a iiei>Iireetoniy is the best course. In this ease the kidney is 
carefnlly freed on all sides, special pains hcing taken on rhe right side not hp 
injure an adherent duodenum or colon. As a ndi% it will be necessary to 

diminish the size of the kid- 
ney before attempting ta 
bring it out of the incision. 
It is impossible to avoid iu- 
feetiiig tlic wound, and with 
gcKjd drainagi^ there need be 
no ill n^siilt from doing this. 
We Willi Id, therefore, reeom- 
uivnd tjoldly opening the 
dorsinn of the kidney, 
eiitptying it of its pus, 
breaking up all hx!nli, and 
removing the stones as far 
as they can he conveniently 
^Ureter reached. Tho collapsed kid- 

ney is then further freed 
from its attaehmcnta, par* 
Fig. 3(iI.-S.mivEi.r.., K.i,nev Sr«BorNr>ED bv Fat ^j^.^i^^Iv „r,n,nd the- hilura, 

WUMH ON PaH'ATION MMI'LATKD A NoHMAU KiD- * * 

NEV. The ureter is blocked by a f^niall stone. A the ureter is exjMJSed and 
sinus ran froiii an old riejjljrotoniy inrisioii, down ligated, iind its lower end 
to the pi^lvis of the kidney. (Miss M, D., Dec. 16, .t^Hlized with carbolic acid 

and dropped. Then drawling 
the kidney downiward, if it will come readily^ so as to bring all vesscds within 
reach at the same time, the iR'diele is tied idf step by step with strong catgut 
by means of an aneurysm needle. Honielimes one can remove the kidney best 
by proceeding in the opposite directi(»n, from the upiier p<dc dowrjward step 
by step, tying one vessel at a time, lying and cutting until the last is severed, 
when the organ is lifted out (Figs. 203, 204, 205, and 20(>). 

Sometimes it is easier to altaek the vessels in a direction from below up- 
ward, takiiig them one liy one, passing the ligature with an aneurysm or other 
blunt needle. It is our practice to overlap these ligatnres as they are passed in 
order to make the assurance against hemorrhage doubly certain. If the veseela 



TREATMENT. 153 

incline to pull away as the hilum is severed, creating a risk of hemorrhage 
from a rupture of the last strands in the hilum, it will be a wise plan to clamp 
the remaining vessels at a point well away from the hilum and then to tie them 
in a leisurely manner. 

Nephrolithotomy Followed by Nephrectomy (Intracapsular Enucleation). 
—If the opposite kidney is affected, or if the surgeon is doubtful whether or not 
the affected kidney ought to be saved, or if the patient is in bad shape, the 
first step may be that of doing a nephrotomy to relieve urgent symptoms, to 
remove the stones, and to give free drainage to the pus. Sometimes a kidney 
treated in this way will rejuvenate and do good work. Often, however, the 
result will be a disappointment. The patient will suffer from a semi-purulent 
fistula in the side, necessitating the constant wearing of gauze pads, and the 
operator will regret his attempted conservatism. Not infrequently the patient 
is so desperately ill at the first operation that it is impossible to do anything 
more than the briefest operation, which is to open and drain the kidney. Under 
these circumstances a nephrectomy following nephrotomy gives complete relief. 
These nephrectomies are, for the most part, dreaded by our surgeons. This is 
because of the dangerous effort commonly made to shell the inflamed kidney 
with its adherent capsule and perirenal fat out of the often densely adherent 
surrounding tissues. While such an operation can, as a rule, be brought to a 
successful conclusion, the risks are great. There is danger of opening the 
peritoneum, of opening the duodenum, and of rupturing the renal vessels. The 
ideal operation in such a case is an intracapsular nephrectomy. This is done 
in the following manner : The fistula is taken as a guide and a grooved director 
inserted well into the kidney. The old incision is then opened up in its length 
and down in its depth into the kidney substance, or better still the fistulous 
tract and much of the scar tissue is excised. The opening of the kidney is then 
made large enough to introduce one or two fingers, which are carried well up into 
the abscess cavity within the kidney itself; the fingers are then hooked and 
forced through the kidney substance in the direction of the capsule, rupturing 
the cortex. The capsule is so dense that the fingers will not penetrate it. A 
plane of cleavage having thus been established between the softer renal cortex 
and the dense capsule, the fingers are slipped around on all sides above and 
below, shelling the kidney out of its capsule, in the course of two or three min- 
utes, and leaving it attached only at its base by its vessels. The operator now 
proceeds with greater care and caution, freeing the kidney tissue proper until 
it is only held by the few vessels which enter its hilum. As he pulls the base 
of the kidney toward himself the vessels are, to some extent, skeletonized, and 
can be seen and tied off one by one, or grasped with a strong clamp, while the 



154 



RENAL AND URETERAL STONES. 



kidney substance is cut away, after which the exposed vessels are readily tie^ 
and the clamps removed. In this way a dangerous operation is converted into 
one which is pc^rfectly safe. This procedure is illustrated in Figures 293, 294, 
295 and 296. 

A liberal loose drain is inserted intc* the cavity of the thickened capsul 
propria and the outside o{}eniug left large enough to drain freely and rapidlj 




V 



OPERATION FOR URETERAL STONE, 

Stone in the Upper Ureter,^ — A stone is apt to lodge in the upper ureter, just 
helow the pelvis of the kidney. It is readily felt in this position after an 

incision ia made to expose the kid- 
ney in the niiinner described. In- 

deed* on palpation through tVie 

woi»id» it is oftc^n not possible to 

say wh€*thcr the stone is in the 

nretcr or the lower part of the 

renal pelvis. The extenial wound 

should he large enough to afford 

free access to tlic ureter. This is 

carefully bared by pushing the 

peritoneum and fat away from its 

anterior surface, but taking euro 

not to detach it entirely from its 

hc(!. In incising the ureter it is 

important not to dissect off or re- 
move the delicate but strong fas- 

einl envelope, as this can be user! 

to the utmost advantage in closing 

up the wound. The strong invest* 

ing sheet affords a firm hold to the 

thread, and is of it^self sulhcient to 

hind the e<lges of the ureters close- 
ly together during the process of 

he^iling. Th(* hard area which 

marks the stone is freed from the 

surrounding fat, the ureter being 
exposed, when an ineision is made over the IfAver pole of 
the stone, usually jriot aiore than one or one and a half 



Fig. 362.— Extraction 
OF Stone in the 
Ureter by Means of 
Stone Forcej'b, In- 
troduced THROUGH 
Incision in Manner 
Shown. This method 
can be used when the 
low pusitiun of the 
stone makc« direct 
incision onto it diffi- 
cult. Alligator for- 
ceps can \jo uHcfl for a 
long reach from pel- 
vic brim to floor or 
even anterior pelvis. 



Fig. 363.— Diagram 
OF THE Right Kii>- 
ney and I'reter; 
Stone jn Ureter 
AT Pelvic Brim; 
IseisioN Made to 
Jit: MOVE Stone. 
Symptoms, repjeat- 
ed at tuck 8 of pain, 
begitming in riglit 
lota and radiating 
to bhiddcr; dura- 
tion five years. At- 
taeks originally 
short and coming 
infrequently have 
steadily increajsed 
in severity and re- 
cur every few 




TREATMENT. 



155 



itimeters in length in the long axis of the nrotcr, caro being taken to avoid 

Dteral vessels. The stone thns exposed is grasped with snitahle gtone forcx^ps 

and withdrawn (Fig. 3(52). The linear wound in the ureter is then closed 

vrith tine silk sntnres and a delicate, curved French needle with a split eye. It is 

besit to slip in a little cigarette drain (>f gmiZQ. surrounded by protective near 

the 9^at of the wound. This can be removed after three or four days if there 

Uno leakage. The incision is closed down to the drain, layer by layer. In one 
I of our cases we found a curious little stone Ix^nt on itself in the form of the 

letter 1% pinching tightly a part of the ureteru! tissue in the angle, a<^ that the 

Mone was not free in the ureter, but, as it were, grown to it. It required some 
I litlle inilling to deliver the rough stone from its bed. 
Stoie m Ureter near Felyic Brim. 

--When the stone is lodge<l near the 

briro of the pelvis, somewhere about the 

middle portion of the ureter, the incision 

should l>e ma<le either about the posi* 

rion of ilcBumey's point on the right or 

left side, or, preferably, we think, in the 

semilunar line (Fig. 3G3). In a tliin pa- 

tirnt a small incision, about six centi- 

meters long, may suffice; in others it 

shontd Ik? made eight or ten cent i meters 

in len^^h. The incision is carried down 

t0 the peritonenm, which is then carefnlly 

lifted up and pushed over toward the 
iian line. The intestines can be ft*It 
flometimes seen through tlie perito- 
Jnetm, When the iliac vessels are reached 

the operator knows that the ureter is close 
\ by. As he continues to lift the perito- 
nenm the ureter is lifted up with it, re- 
I Milling attached to the peritoneum rather 
jtliDto the posterior abdominal wall like 
rtbe vessels. If the stone has been pre- 

Tiouflly located a little careful palpation 
soon reveal it^ position. The ureter 
then bared below, over, and above the 
rtone for a little distance. It is sometimes a good plan to pass sutures before- 

od from side to side, and then, pnlling the sntnres apart, make a longitudinal 




Fn;. 36 L— Extra-peritoneal Expo- 
sire OF Portion of Ureter Con- 
taining Stone, Shown in Last 
Figure. Note convenient incision 
of ureter between two guy sutures. 
Take great care to presence the peri- 
ureteral fibrous investinj^ tissue 
whidi surrountls it like a loose strong 
web and if uninjured except by in- 
cision is most valuable asset in the 
closure. This is not shown here. 



15G 



RENAL AND UHETEHAL STONES, 



Fig. 365. — Incision and Removal of Stone Het.ow 'raE 
8THiLTuriE. Tlie iirUml pnjcetlun^ farrifd ciut in the 
COHQ of tlip stonr pii'tured. Wlicii tfit- stone can l>o 
clearly rt'CoiijiuztHl liy tom*h, then l!ie snuillet^t jxiKsiblt; 
incision should be made, direetly tiouii onto i1*i lower 
pole, A etrictnre st> sluirply definetl may aluo be di- 
latwl bluntly. Remenilier that after tvlosiiiK the 
ureter with a direct suture, tlie overlying fascia must 
then be ai>proxiniated. 



incision for t-he removal of 
ilie stone (Fig. a 64), Wo 
prefer ourselves*, howevi*r, 
to grasp the stone in such 
a way as to close the ure- 
ter ahovo and below It, 
ujid then to incise it over 
whichever |io!e is moat 
convenient and squeeze it 
gently out of the ureter, 
di^ivtTing it by ita small 
diameter. As soon as the 
stone is removed, fine silk 
sutures are passed, enga*^- 
ing the walls of th«* un'tcr 
with its surrounding Ji- 



■J 



bruns investment, without 
appearing on its nnicnns surface (Fig. H<J.'»). It d«*es not iiuttter much just 
what form of suture is used, provided llic sides uro brought together with 
accuracy. Wo prefer in 
all these cases a figure of 
eight. The w u u n d is 
elo8ed completely with the 
exception of a cigarette 
drain, which is carried 
down to the ureter. 

Stone at the Pelvic 
Floor, ^ — Wlien the stone is 
th;wn on the floor of the 
pelvis, or kxlgi'd in the 
last five or six centimeters 
of the ureter, the upern- 
tion may l>e either easy or 
dithenlt. Knowing the 
location of the stone th<* 
operator makes his inci- 
sion over the scuiihrnar 
line, as was jtist d(»scrilKHl, a little lower dovni over the side of the brim of the 
tielvis. The peritoneum is iben separated in its depth, exposing first the iliac 



Fio, 366. — Calculus is Lower Ureter, Causing 

HYj>r{ovHETEH. The Ktone in this case was grmlually 
milked up from nc^ar tbe bladder to the pelvic brim, 
where incision was niarle iuto the m*^\vr and the stone 
r<*nioved. (From li. Young, Ch. H. and Inf., Oct. 6, 
1901.) 




TREATMENT. 157 

vessels and then the pelvic walls, until the internal iliac vessels and the ureter 
cliufring to the peritoneum are exposed. If the ureter is manifestly dilated, 
owing to the obstruction of the stone, it is often possible to enlarge the skin 
incision in an upward direction until the ureter is exposed nearer the pelvic 
brim, where it is closer to the surface, and where it is conveniently reachorl. 
Then lifting it up carefully, so as not to bruise it or its vessels, a longitudinal 
incision is made into its lumen, when a pair of forceps carried down the ureter 
grasps the stone and draws it up and out. This is the simplest way to remove 
a stone low down on the pelvic floor. The ureteral incision is then closed, and 
the abdominal wound is closed, leaving a little drain in situ. The next simplest 
plan for removal of such a stone is this: After exposing the ureter the 
operator continues to make a blunt dissection with his fingers, freeing the 
anterior portion of the ureter and pushing into the fat until he feels the 
stone in the ureter. The dissection is then continued until the area around 
the stone is liberated, and until the ureter is also set free in front of the stone, 
care being taken not to detach it, however, from its lateral attachments to the* 
peritoneum or the bladder. After a considerable portion of the ureter has 
been set free in this way it is gently caught between the thumb and the fore- 
linger below the stone, and an effort is made to push the stone up the ureter. 
If the ureter has been dilated and the stone is free and not too large, it is 
often possible to work the stone upward to a point at or near the pelvic brim, 
where it can l>c removed with ease. This was accomplished 
bv Dr. Young in the case pictured in Figure 366. This is 
the plan known by Israel's name. We found it possible to 
do this, and in one case where a spiculate stone was lodged 
in the left ureter in a man, in a position very difficult of 
access on account of the depth of the pelvis and the amount ^^^' 367.--Ure- 
of fat present, we were able to work the stone about five or ^us Lodged in 
six centimeters backward from the position where it had Vesical End of 
lodged, and there to incise the ureter and remove it. The Ureter. The 
operation was awkward because the wound was deep and the ^j^^ -y^^ ^^ 
stone was still on the pelvic floor. It was, however, much passed sponta- 
easier than the almost impossible operation of removing neously and 
it in situ. We closed this wound by sutures engaging . ^ . , 

only the ureteral fascia, which is more marked on the size. 
floor of the pelvis; fine silk sutures were used, and the 
patient recovered without the slightest leakage of urine at any time. 
Stone in the Vesical Portion of the Ureter. — When the stone is lodged in 
the anterior or vesical end of the ureter, and on account of its size or attach- 





Fig. 3(>8.— Combined Aijdominal and Vaginal Incisions to Rkmove Stone Shown in Fig. 
367, The abdoniitml incision rnablod the ofXTator to grasp llir stone in thr ureter and puaii 
it against the vaginal wali, through which it Wius removed by incision through lx>th va^^tt- 
al and ureteral walls, as shown hi picture. This was a large stone jcmbedded in adhc 

In a WYmiai) tlie ureter passes tlirousrh a little ehaniiol under the uterine art 
and veins at the base of the liruad ligament, lateral to the cervix* The fia 
eaii be worked through this channel without injury to the ureter^ and with t! 



TREATMENT. 



159 



ger booked up, the uterine vessel$^ nre brnn^ht within reach and control If 

diiiihlo ligutnre is now passnl tliron^h this opening on the fingi^r inid tied 

both sides, und the vessels nvv divi*led h'- 

the ligatures, the hroad ligament por- 

m of the ureter h rendily exposed (Fig. 

IImVK Following tlie ureter tints plainly sei*n 

and Iriicin^ it ilnwnw;U'd, its anterinr prjrtinn 

can be expis-ecl, a stone located, tlie nret^T in- 

cImh], and the stone removed. An aasistant, 

putting his fin^^r in the viiirina and pnshinii 

[apward, can wimetimcs nuiteriidly assi;*! in 
t»rlij^ing this portion of the nreter within easy 
reaeb« In one of onr patients, wlir^n' we had 
ifx'nred the most distinct scrnteli niarks, \%\' 
fiminl fi KtHf, sharp, gpicidate stone fixed 
^^. firndy into the wall of the 

nreter mu\ enihedded in it 
fFi^^ *^n7), just a short dis- 
tance from the vesical end 
of the nreter. We cnuld not 
feel it or find it throtiirh the 
vagina, as it was so small 
We incised the nreter^ re- 
moved flic si line and chiscd 
the wonnd, when the patient 

recovered, tlimijih not withont leakage and a stormy eon- 
vak'seencp. In one case, where there was a large stone em- 
bedded in a mass of adhesions hack of the nterine vessels 
(Fig. 32.'), we npriH'd the ahdonien, l<icati'd the stcme, and 
pnshed it in the dircefion nf the vaginal vanlt, not displacing 
it in the nreter, but displacing the nreter with the stone until 
the stone was made aeeessihle, when we incised the vaginal 
vanlt and incised the nreter extraperitoneally over the lower 
pole t*f the stone, which we renifned without injnnng the 
{xTitonennv (Fig. SfiS). The actual appeanmee of this stone 
and of scratch marks made hy it are shown in Fignres 309 
and 3Tt>, This patient recovered fnnn the operation and 
vptilhumc, bnt later snfFered from intestinal ohstniction. owing to adhesions 
about tlie original site of the stone at the pelvic floor, and died. When the stone 



Flo. 369, — Stones Removed from 
UiiETER IN Case Shown is 
PaErEDiNO Figure, Also Fio. 
'i25- The iij>pcaran€c is thai of 
a pare oxalate stone. The sharp 
knife edges are well ralciikt*Ml 
to ahrade the mucosa; where the 
attrition is greatest they are 
worn rmiiKled (Mrs. E. J., 
Gyij. No. 7702, Apr, 28, 1910,) 



no. 370,— 
GotiJKD Wax- 
TtPPED CaTH- 

ETEE Die to 
PASSAGE Over 

&!OKE IN HlGBT 
rRKTBR. (Mrs, 

E.i.,GjTi. No. 
mi Apr. 28, 
1910,) 



160 



RENAL AND ITRETERAL STONES. 



pim l>p fclf thrnimli lln^ vaiiiiia nn ineision can he miitle tliroiii^li the anterior 
lateral vaginal wall, rxposing the ureter. Then, enttinij in the len^itutlinal axis 
of the ureter over the end of tin* stone, it is reatlily pnlleJ our and the ineigion 

rloHod with tine silk sntnres, leaviiiir 
tilt* vaginal wound to rlose with 
draina(j;p* One must be careful in 
theso eases that tlu^ stone docs not 
slip np and away in the midst of the 
operation. In sneh an event it wuuld 
he In^ter to make the siipcTior in- 
cnsion and draw tlie stone rnit of tlie 
nrrtrr near the prdvie hrim. 

Transvesical Removal of Ureteral 
Stones* — Wlien the intone is ludt^ed in 
rhe Vi'j^ieal end of the ureter it can 
be reniovi^d in one of several wiiv-s. 
This condition is shown in Fignre 
*H*K The easi(»i^t cases are those iii 
which a st^n** is seen pngccting frtmi 
the ureteral orifice- 

dislodging a Stone 

Wedged in Treteral Ori- 
fice, — Here it is safe to grasp the 

T. ^-- „ t^ <^iwl uf the 5 tone with a pair of alii 

riii. 371. — Transvesical Removal op ^ 

Stoves from Vesical End of TRETEn, ^"ii^"^ forceps throngli an open cysto 

TunorcjH Veskovaginai- IseisroN. At.- scojx*, to extract it from the nretrr, 

tarks of luiiii iiUhe rr^nori of riKht kH^ and to remove it at once from the 
at irrej^inar intervals lor 3 H veurs. CvsttH ti- i i • r ^ 

soupio «^xllnlilUitio^ showed a hig swclliUK ^^''b'- ^^ ^^^'X ^»*^ P^'"*^ of the stone 

in the l)ladder at the site of the right ure- ia seen and the rest will not follnw 



tcral orifice. Oj>eration through cysto- 
srope, though Homethncvs suitable, was not 
adapt t:d to this cu-so. A rionnal-sized and 
[leifeetly rionnal urrtr-ral orifiee was ulti- 
nuiti'ly found after removal of stones. 
(Mrs.H, A., age 45, Son. No, 1366, May 
14, I'Mli.) 



readily, the orifice may be dilated 
with Si [)air of alligator forceps bo a; 
to facilitate the cieli very. I3ransford 
J.ewis (Acre Yotk Med, J,, VMS, 
xevi, 1002) rep<irts several snccess- 
ful (*ases and describes the very in- 
genions instninients he employs with his eystoseopc. 

Dilating the Ureter with Tl n ii g i e s. — Where the stoue is 
Mt iH'hind thr ureteral orific»% if it is nt*t Um large or ton firmly fixed, one can 
sometimes sneccvd in dilatinij the oritii*e of the ureter with catheters or 



TBKATMENT. 



161 



Bsively larger in size nutil one is ititrndiiped as large as 5 or 
Imra. in diameter. After thus dilating the orifice a little oil may be injected 
I to lubricate the passage and facilitate the escape of the stone. One of ns 
(Kelly) did this successfully in the case of Airs. IL, in Jauiniry, 11»00, She 
had been snflFering from repeated attacks of colic in the left kidney extending 
I down the ureter to its vesical orilice when' the paiti was centered. The left 
ureter at it« vesical end was 
exquisitely tender, and one 
^^)llltl feel a distinct firm 
enlargtinent half way be- 
tween the internal ureteral 
orifice and the cervix ntcri. 
The tireter and the sur- 
rrmnding parts were first 
ctx^ainlxed by injiK-ting a 
one jtcr cent, sol nt ion of 
coe«in through the vaginal 
into the tissues adja- 
to the ureter* Then, 
with the patient in the knee- 
bftast posture, and by the 
J of a No. 10 open speon- 
to, \he deeply reddened, 
everted left ureteral mucosa 
immd in marked con- 
to the healthy right 
orifice A waX'tipped cathe* 
tor was introduced a short 
diituDce and showed scratch marks, proving the presence of a stone- After 
ctnying the catheter fnrther np the nreter, K* e. c. of pent-up urine escaped, 
showing a low grade of hydronephrosis. The impact of the cuthoter also broke 
off 8 little piece of stone 1 mm. in diameter; this was examined chemically by 
I)r, Louis Ilamburger, of Raltimure, ami shown to be niadr* of uric acid. A 
lawteral dilator was then pnghcd thri>nglj flic strictured v(*sical nreternl orifice 
until it was stretched to a lumen ^ mm. in diiUHi4er. Nineteen honrs after 
this an oblong stone, 10 mm* in length and 3 mm. in diameter, escaped, with 
the immediate relief of all the sNTiiptoms, 

Transvesical Opening of the TTreter. — Where a mass of 
ureteral stones or a large calculus is lodged well back of the vesical orifice and 



Fig. 372. — View of BLAonER and I'tkhis in the 
Knee-chest Postuke, Sfiowing Opening in Tri- 
ooNUM AS PicTt"RED IN La8T Figure. Note tlirec- 
tion of ureters as ihey eon\orgr toward tlie trij^o- 
niim. The calculi fiilod tiie lower end of the right 
urHer as shown in figure. (Mrs. R. A., San. No. 
1366.) 



162 



RENAL AND URETERAL STONES. 



i 



9 '^01 



McfyJ^'oi. 



r/*« 






yet near enough to the bliuUIrr to priHluco it bulging on the vesical inueosa, ii 
it is not easily accessible through the antero-lateral vaginal wall, one can 
at the cnleuli hy pnttiug the patient iii the knee-breast posture, thus h?ttiug air 
into the vaginuj introducing a eatlieter into the bladder and distending it with 
air (Fig. 371)- 

The posterior vaginal wall h then lifted up bv a 
broad Sims' sjK'culuni and retracted at ihe same time 
80 as to give the operator a perfeet view an<l easy access 
to the anterior vaginal wall* The cutting part of this 
operation may he done by the injeetiou of cocain into 
the vaginal septum, obliterating all sensation, If» 
however, the patient is nervous it will be better to u^ 
general anesthesia. Then the vaginal wall is opened 
by thrusting a narrow-bhided scalpel, preferably one 
set onto the handle, at an angle of 45 degrees, through 
the vosieo-vagiual septum in the median line about! 
half-way between the internal urethral oritiee and the 
cervix. As I lie knife penetrates the septum into the 
air-distended blmlder it sometimes givers a sound sim- 
ilar to that of a sharp instrument being thrust through 
the parehnu'nt of a drum licnd. The wo\md is then 
enlarged in an antero-jwsterior direction until the 
i>pening is big enough to introduce the index finger. 
On introducing tliis finger, the exact location of the 
jiromiuence niiide by the calculus is determined near 
the poisition of the urethral ru'itiee. The tiuger deter- 
mines also to whiit extent the incision may be safely 
nuide. There is, as a rule, no Ideeding, as the vesaela^^d 
are emptied of their blood by their position, Any^^ 
blood that escapes, runs down into the vertex of tho 
air-distended bladder and so does not inconvenience 
the operator. With a narrow spatula the side of the 
opening is retracted until tlie hnrd, bulging prominence is exposed to view 
(Fig. 372). This procedure was carried out in the case illustrated in 
Figures 371, 372, and 373. Incision is then made under the end of the 
stone nearest to the ureteral oritiee and the stone extracted, A careful search ^h 
must then be made for other stones, and it will be an easy matter at the same^H 
time to carry a wax-tipped bougie up into the kidney to see if there are any 
atones there. When the stone is lodged close to the nreteral orifioe, it may be 



3ton«.t, 



i 

Fig. 373.— Stones Re- 
MOVED AT Opera- 
tion AND Passed 
Subsequent to Op- 
eration, IN Case 
Illustrated »y Two 
Preceding Figures. 
The stones, as shown ^ 
are li natural size. 
(Mrs, R. A., Sao No, 

i3de.) 



M 




SUMMARY. 163 

a good plan to introduce a grooved director and to cut through the orifice up to 
the stone. Where the stone is extracted by cutting directly through the vesical 
mucosa we think the best plan is to allow the opening to remain as the future 
ureteral orifice. Often there will be no bleeding and the wound in the bladder 
may be left to take care of itself. If there is any hemorrhage at all it may be 
easily stopped by fine catgut sutures passed over the vesical and ureteral tissues 
at the bleeding points. The incision ought to be made far back into the bladder 
in order to avoid opening the loose cellular tissue and to escape infection. After 
the operation the bladder should be wiped out through the capacious opening 
in the vesicovaginal septum and the opening into the vagina closed by fine in- 
terrupted silkworm gut sutures placed a little less than 1 cm. apart, embracing 
all the tissues except the vesical mucosa. A mushroom catheter is then inserted 
through the urethra, and the bladder drained for six or seven days, being 
washed out every day with a warm boric solution through the catheter. In the 
male this operation should be done by a suprapubic route. If there is no cys- 
titis, the bladder may be closed snugly at once, and the skin wound closed down 
to a small protective drain. Figure 373 shows the stones removed from the 
right ureter by this method, April 29, 1902, and on four different dates the 
remaining stones shown in the upper part of the figure escaped, showing the 
importance of leaving open the ureterovesical woimd. The patient recovered 
and has since remained well. 

AFTER-TREATMENT. 

The after-treatment of patients who have had one of the various operations 
described for stone in the kidney or ureter, does not differ materially from that 
employed in other operations, particularly kidney operations, and has already 
been described in the preceding chapters. 

It is a good plan always to give abundant water and urotropin. The chief 
complications are hemorrhage after nephrotomy, which may require immediate 
secondary removal of the kidney, suppression of urine, and uremia. One of 
the commonest complications in the uremic cases is post-operative insanity, a 
condition which is very alarming and frequently fatal. We recently observed 
snch a case. 

SUMMARY. 

Onr information as to the frequency of occurrence and the morbidity of 
stones in the kidney is manifestly insufficient. Under the more frequent em- 
ployment of the exact radiographic method of diagnosis the disease is known 



J 



164 RENAL AND URETERAL STONES. 

to be very much commoner than was formerly supposed. What percentage 
of the population, however, is affected by these stones is not known. It is 
well known that patients may go for years without great discomfort. The 
outlook is much better for patients where only one kidney is affected, and 
for those where the complication of infection has not supervened. It is cer- 
tain that the mortality is very high in cases of bilateral stone with bilateral 
infection. 

The occurrence of anuria is one of the absolute indications for immediate 
operation, and the cases operated upon early have a much better outlook than 
those postponed. The operation in such cases should be nephrotomy invariably. 
A comparison of the results of operation in antiseptic cases and those with 
sepsis justifies the conclusion that every stohe which will not readily pass de- 
mands operation. Compare, for example, the personal experience of Kafin and 
Arcclin ("Calculs du reins ct de I'urctere," Paris, 1911), who in 19 ascjptic 
cases had one death from operation, while in 29 septic cases there were 5 deaths. 
Interestingly enough, all of these deaths were from nephrectomies. There are 
no satisfactory statistics at hand to show the relative danger of nephrotomy and 
nephrectomy. In large pyonephroses in cases with bilateral involvement 
nephrotomy is the only operation allowable. 

With multii)le abscess of the kidney, the other organ being perfectly normal, 
nephrectomy is perhaps safer and better. 

The investigations of Sondille ("These de Paris," 1907) have apparently 
shown, by functional studies of the opposite kidney, that it is usually more or 
less affected in stone cases, and this perhaps accounts for the frequency of 
anuria following oi)erative interference. We have never lost a patient operated 
on for unilateral non-septic stone in the kidney in 27 cases; on the other hand, 
our death-rate in septic cases has been 11 cases out of 69 operated upon. One 
was in a solitary kidney; 6 were in bilateral kidney infection, and 4 in uni- 
lateral infection with an apparently normal kidney on the other side. 

Legueu ("Traite chirurgical d'urologie," 1910) notes in 420 non-septic 
cases colleetod from the lit(?rature a death rate of a little more than 9 per cent. 
This high rate is doubtless due to the fact that many of the deaths occurred 
where both kidneys were involved. In 473 infected cases there was a death 
rate of 23 per cent. 

In non-infected cases there is very little difference in the death rates between 
pyelotomy and nephrotomy, although the convalescence is much easier after 
the first operation. In septic cases pyelotomy should never be done. 




CHAPTER XXL 
BLADDER AND URETHRAL STONES. 

BLADDER STONES. 

Obj^ervations and good descriptions of stones in the iiriinry bladder are 
f,rtiijd in ihv earliest medical lilerfituro. The suririral removal (if stoiirs froiii 
t!ie bladder by perineal seetion, from its introdneliun by Frere Jarqiies in th*^ 
MiJille Ages, remained the greatest surgical opera- 
tion widely praetieed np t*) the modern anesthetie, 
antiseptic period. Many t^iirgrons still li%^ing recall 
tlm period's birtlu The treatment of vesical calculi 
bjiij l>euefitcd less by modern diagnostic methods 
than tliat of renal and ureteral atones, nevertheless 
it has been enonnonsly developed. 

(tocurrence. — While vesical jstnne is met with at 
every period of life, and in bath sexes, it is com- 
moQt*t iu old men and in yonng eliildreii. It is, 
intimb a rather rare afTi'ction in women, being 
usually met wnth a>lely in divertieuhite Madders or 
incflst*s with large cystoceles and incomplete empty- 
iupof the urine at each voiding. Allliuiigh wt see 
wmparatively few c^hildren, we have liad njore cases 
in lililr girls than in adnlts. The inmmnity of 
en is explained by the short, large-cnlibcred 
^jithras which allow any stone that cojnes down a 
Uff'U'r to pass to the ontside with ease, and by the 
rirityof residual urines. Tlic great-er frecpiency in 
diiMn'Q can be appreciated by the statenient of 

May qnoti'd by Leguen ('^Traito chirurgical 

furologi^" 1910, 750), who found in a review of 

IfiU §tone cases that 1,150 w^re in infants. 

Stnn«*8may originate in the bladder, or start in the kidney and migrute do\ni- 

hfii inTitinuing to grow by accretion in the bladder. Many o^ the nratic, uric 

105 




Fig. 374,— Piece of Rubbeb 
Dropped through Su- 
prapubic Opemng into 
Blawjkb and Remain- 
ing Thkhk Three 
Wkkks., Ndtt' the pxten- 
s?ive iiieriiblatioR farmed 
ill so short a tiiiic. 



HLAUDKR AND URETHRAL STONES. 



acidy and oxalic stones, or stones with these salts as nuclei, are of kidney 
origin, while the true bladder stone, usually dependent on obstruction and 
alkaline ^iriiie, is Hktdy to be eomi:M.>8ed of phosphates or aiiiinoniura urate. 
Stoneiv of considerable size are almot?t invariably of very mixed constitution- 
Etiology* — The causes of 8tone formation, as mentioned in the last chapter, 



Fia, 375.— HAiapm Calculus. The stones are itiostly phosplmtie. The hairpin had» 
aa usual, t>eeii Introdueed tluough the urethra, tillhoueh moi^t of these piitierit^ pretend 
to be greatly mystified tn^er ttie discovery of lhe«e evidences of previous misdeeds and 
evil habits, (F. R, Eecles, Liindoij, Ontario.) 

are not altogether clear; tnit obstruetioii to the outflow nf urine, as in enlarged 
jirostate aflfecting the diseases or injuries of the spinal conl ; bladder infection. 
and the presence of any foreign substance are the favoring conditions in the 
bladder, A foreii:!! bo)ly in tlie bhidder means inevitably stone fonuation in a 
very short time. This is illustrated in Figure *i74. In the female, foreign 
bodies are sometimes introduced by mistake into the bladder and the hairpin 
eeems a favorite instrument (Figs. 375 and 370). The patient is usually at- 




BLADDER STONES. 



167 



tewptJng to prodiK^e alKirlioii, S<»iiR'tiiUfs it is a rubber catheter, as siiowu in 
Fiffiire ;i77, A curious ftjriiuitiou about a suture which had awkwardly penc- 
tnitivl the bladdor in a titcrinc suspension is shown in Figure 1578. We liave 
found a ^eat variety of foreign bodies in the bladder^ but nothing stranger 
({inn an onion stalk, at least six inches knig, which a man of sixty had intro- 
jtjred through his urethra for causes best known to himself. 

Size, Shape and Number- — Stones varying in size, from a small pea to im- 
ggieOB^ structures weiuliing hundreds of grams, are met with* It is remarkable 



FlO» 376.— Hairpin Calculus. lotrudueed in the Uisual manner j7?j cxtcrno^ and not, as 
often pretended, by the mouth, (Specimen from E. V. Everitt.) 



W fn^e from s^^mptoms a man ran be with an immense calculus filling the 
hUdder. The shajK? is almost as varialdr as the size; oeeasinnally perfect jack- 
*lone» are met with. Most of the large stones are ovoid and occasionally an 
Hlmogt perfe<^t sphere is found af operation. The concentric lamination and 
djBtinct nuclens so frequently fonnti in large stones are illustrated by the speci- 
meti Bhowii in Figure 379. 

An interesting group of faceted stones is shown in Figure 380. The ap- 
pearinc© of one of these almost identical concretions in cross-section la repre- 



168 



BLADDER AND I RETHRAT. STONES. 



sented in Figure 381. Most frequently but one small stone is present, but oeca- 
sioually hiimlreJs are foiiiul. 

Site of StOBe. — Exduiliug those calculi fixed hi the urethra and thos^c found 
in narrow-necked diverticula, stones of the lower urinary tract arc charac- 
terized by their exceeding mobility. With each change of posture the stone 
moves to seek the most dependent portion of the bladder. The posit iuUy espe- 
cially during examiiiationj may be greatly modified by the musenlar contrac- 
tions of the bladder w^all, which form veritable shelves and pockets. Forming 
a distinct group by reason of the diHieulties they offer in both diagnosis and 
treafinenK are fho fixed stones which occur in diverticula of the bladder. These 

separate cavities, which may be either eon- 
genital or acquired, are favorite sites for 
stone; the condition is more fully treated 
in Chapter XXXL These diverticula, 
when hirgt^-uunithed, alluw the ]>assiige of 
the stone from the main cavity of the blatb 
der to the rec€^ss and then back again. 
When tlie neck is narrow, ns shown in Fig- 
ure *4S2, the calculus is fixed and frequently 
Ijccomes tightly adherent to the walls of the 
cavity. 

Changes in the Bladder Bae to Stones. 
— A stuiie may remain l«»ng in the bhid- 
der, and, except for an occasional trau- 
matism li/ading to temporary bloeding. 

Frequently 



Fm. 377. — Incrustation about Rud- 
BKR Tube. The {>atit*nt had at- 
tempted to induce abortion, but 
liiid miHtiiken the urethra for the c-uise no change w^hatevcr. 



neck of tfic womb uiiil slippt'd I lie 
tul>e into the f)huhhr; It was re- 
moved in the sixth month ui preg- 
nancy through the nrttlira, through 
Kellv's open-vur cvslo-secipc. (G. 
L. Hunucr, Nov. 17, 1902.) 



there is merely a mild congestion. | 
^\^len, as is almost invariably the casc^H 



sonner or later, infectiou and inHartuna- 
tir»n set in, all tlie changes characteristic 
of chronic cystitis develop* Ulceration is 
eonmiHU. 
Symptoms.— Pmludjly all vesical calculi at the initial stage of their devel- 
opment are sympt^aiiless; Sfiuie renuiin su fnr years. It is most astonishing 
that a history of only a few months of discomfort is obtained with many im- 
mense stone cnses. Sometimes, however, nu attack of renal colic is almost 
immediately follnwe<l by frci]nency of micturition and dirticulty in voiiling. 
The classical sMuptoiris are: frecpiency of urination and pain on voiding* 
mtide much worse by exercise or by jolting, as in an automobile or on horse- 




BLADDER STONES. 



im 



I bade; liematiiria, fresh and prineipally tf^rmiiial ; and a sudden interniption 

^0i the stream during the act of voiding. This hiat svTuptoni is coiumtm in 

fCBUiles; rare in adult males; in iufauts it l<'nds to nnetnrnal ennresis and 

•cusionally to true iucontinc^nce. Male biihicB with this affectiuu are often 

'seen pulling at their prc|juccs. 



a 



"^ ^ 






i<<^' 



I*. * 



^9h 



rCalcuU 



h^wt: 



FIC3.JI78. — Vesical Calcitlub. Dup to incrustation on a nW ligature which by mistake 
li^ been passed throuj^h the hladtier wall in an oiieration for suajjension of the uterus. 
(Mrs, H., Apr. 5, 1001, J. H. H.) 



When infection occnrs the RVinptom-coniplcx nj^nnlly hernmes thot of a vc^rv 
vere cysfitis, namely, frequency of urination and pain on %Tiiding, great 
traininj^, and blood and pus in the urine. 

Sift^osis, — The oldest, and often the mofit safisfaetory, method is the em- 
fplojment of a metallic sound or Bcarcher. For this examination about 200 c-c. 
of Bait solution, plain %vatrT, or, hetter still, ^/^ per cent, carbnlic acid solution 
sMJ be introduced into the bladder, and then the instrnment used in a sys- 
tPMtic method always seeking wn'th its Ix^ak to make a dependent post of the 
bWder airainst which fhe stone w^ill strike, giving the characteristic metallic 
dick. Stones in diverticula or under folds, or in very irritable bladders, which 



170 



BLADDER AND l^RETHRAL STONES. 



J 



are constantly contracting, escape detection Ly tbis method even in the most 

skilled hands. 

Ill tile female large stones can easily be detected 
by the biiiuiinuil alHloniinal vaginal examination of 
the empty viscus. A large Ixnigie coated with wax, 
if introduced, will show gonges from contact with 
tile Btoue, 

The cystoscope should always be used, as it gives 
information as to the size, number, and shape of 
stones !iot otherwise obtainable. It often shows the 
inontli uf a divertieuliini with thf^ end of a stone pro- 
jecting from it* It is advantageous in searching for 
a diverticulum to distend the bladder to the utter- 
most. When an open-air cystoseupe is emplo^^ed it 
is often posHihle to introdnce a small metallic searcher 
into llic neck of the diverticuhim and so obtain the 
click, 

Tlie X-ray sometimes affords positive results 
where all other methods have failed* Tbis 
the ease in a recent patient, where tln^ stone 
found in a divertienlinn (Fig. 383). For the 

best results in X-ray work the patient should be put on liquids for a day or 

two, the hirweis ihoroughly cleaned, and both hiadder and rectnm distended 

with air. 



Fia. 379.— Section of a 
La HOE SroNK Removed 

FROM THI-: BLAT>f>i:R OF AN 

Eight -YKAR- OLD Cmu 
Note diiTemitre of color 
and appearance at the 
center of the stone and 
bet ween the central 
lamella? from the {XMipli- 
eral ones. (Froni F. R. 
Eccles of I^ndoti, Ont.) 




OPERAXrONS FOR VESICAL CALCULUS. 

A vesical ealenlns can he removed tbrongh the nrethra, either by cniBbii 
it with a pair of fureeps intrudiieed tbrongh the nrethra and drawing it ont 
the bladder tbrongh the natural ehannels, or by ernshing the stone with a suit- 
able instrnment until the fra^ients are so small that they are readily washed 
out through the pc^rineum (in the male), or the vagina (in the female), or above 
tlic symphysis pnbis. Small ealrnli, the size of a pea, which have pBi?sed down 
the nreter, are commonly ^liscbarged spontaneonHly after they enter the bladder. 
A c^lcnhiSj which is not over \^U cm. in diameter, of whatever length it may be, 
can be cangbt by forceps and gradually withdrawn thnjngh the nrethra, A 
good way to do this is to place the patient in the knee-breast posture and to 
inspect the caleuhis thnmgh the open cystoscope (Figs. 384 and 385). One 
can see in this way just where it lies in the vertex of the bladder and pour a 





I 



little sweet oil in to hiliricate the parts rlnring the extraelioii. 
Next, the measureoient of tlie diametrT and Ipii^Ii of the 
cjileuhis 18 easily made hy takiu^ the vnt\ of tlie cystoscopy 
whose diemeter is known, as a imit of nioiisurement. If the 
calcnltis is 12 mm. in diameter, it is well to dilate the urethra 
with Hegar dilators np to this? extent; then, withdrawing the 
speciilumt a stone foreeps is introduced and directed to that 
pirt of the bladder in which the stone was seen to lie. On 
opening and p*aspiiig with the forceps, thp stone is canght, 
brought up to the urethra, and gradually extracted. If the 
stone IS graspe<J tw near the middle, it can be dropped and 
caught again. The forceps holding the stone makes a wedge 
which opens up the urethra, w^hile the blades of the forceps 
grasping the stone protect it from injury. A long foreign 
body, the only kind which nature permits to be introduced 




FiG,381.— Trana- 

VERSE Section 
OF One of the 
Pyramidal 
Stones Shown 
IN Last Figure, 
Note stratified 
structure, char- 
act erisfic of all 
stones^ showing 
that the atones ^ 
when small, were 
irregular in 



shape. 




172 



BLADDER AND I'RETIIKAL STONES. 



into the bladder, can bo caught by one end through the specuhim with a suitable 
instrument; and as the speciihim is withdra^vn, the instrument is drawn out 
and the foreiiiii bodv with it. In tins way a hairpin can be caught by its blunt 
end with a simple hook, drawn up iuto the luuieri of the Bpeenhim aud with- 
drawn through the urethra aiuiultanefjusly with the speculum. In like manner 
a piece of the catheter can Ik? graspt^d with an alligator forceps and withdrawn 




Speculum view ^omng 
opening iftta diveHicu^m 





1 .f 



e 



Fia. 3H2. — Removal of Ston£ from Diverticulum in Bladder through Open-aie 

CvsToscoFE. The upper two figure-s show the front and side views of the condition. 
The dotted lines in the k^ft upjMT figure iiiditnilo the incisions for widening the orifice 
of the diverticulum. In the left lower figure the (iiverticulum is laid wide open and 
the ijtonc exposed. In the lower figure to the right, the removal of the stone througli 
an open-air cystoacope ia illustrated. (Mrs. J., t>an., March 3, 1909,) 



through the speculum or with it A calculus or a stitch in the bladder wall 
can be caught with the alligator forceps and withdrawn, and, if neeeasarv, a 
knife or a pair of alliuutor scissors introduced to cut its loop and free it tirsf- 
We did not encounter the slightest ditfieulty in removing the long pieces uf 
glass catheter shown in Figure 38*1. By means of the open-air cystoscope it iB 
poesiblts to remove a stonti from a diverticulum, as shown in Figure 382. 




174 



BLADDER AND URETHRAL STONES, 



the simpler and safer one of crushing and washing out the stone at one Bitting; 

while, as a surgical proeedure, it has h:J8t none of its historic dignity, it by no 
means approaelies in di^ciilty the numerous ahdoininal and brain operations 
whic*h are eoiisfautly nndirrtakcu. 

Lithotripsy is the operation of enishing a stone witli an instrument 
(Fig, 387) called a iithotrite, a stout instruinrut with a i-urvcJ iM'ak, which 



^1 



f 



^^ 



Fig. 384.^ — Demonstration of Small Stone in liLADUfc-H THaoutiH OpEN-Am Cysto- 
scopE. The istone ia brought clos^e to speeulam by jiushiag up the auterior wall of 
bladder^ lifting up calculus as on a shelf. (Mrs, S., Feb. 18, UIOL) 



is introduced into the hhidder and. with V^niug's instrument (Fig, t389), the 
stone is seen as it is grasped Iw^tween the crushing blailes. The blades are closed 
auil the stone broken iuti» tw<» or several pieces* The blnchler is then washed 
out and, the snuill pieces of stone being removed, a stone cnisher is again intro- 
dueed aiul the hirgcr pieces of stone are caught anil crushed as long as tliey can 
be distinctly seen in tlie mediunu A lithotripsy done in this way is an operation 
a!x)ut lOD years old, and, in skillful hands, is exceedingly successful. It is par- 
ticularly a(Ui]>ted for phosphatic chIcuH, and those which easily break up into 
small fragments. 

Litholapaxy. — In 187(> Bigelow introduced litholapaxy by an instru- 



BLADDER STONES. 



175 



Fig. 385, — Open-air Speculum 
View of Stont: Shown in 
Last Figure, 



calculi (Fig, 387), and then, bj means of a 
UrgG, open, evacuating catheter with a pump attached, to irrigate the bladder 
HkXhi siirk out the debris of the intone, the oporationti of enishiug and washing out 
being continued until the entire 8loiie was removed at oue sitting (Fig. 388). 

It is outside our purpfme to ^o into a di*- 

scription of the meehunisni of the asjpirator, 

wliich can be found in varions instrument 

catiilogs. The operator ought to familiarize 

lilmsclf with the use of the catheter iind the 

fcivacaator by washing sand or small pi^bbles out 

■of a bottle filled with water into the rcceptaele, 

■ After testing and understanding the apjiaratus 

in iliis way it is not a difficult mntter to apply 

it 1o the male bladder. All lithotriptic and 

litholapaxic operations ought to bo conducted with the utmost regard to asepsia. 
Tho various metal instnnuents which come in contact with the body can be ster- 
ili«Kl by boiling or with formalin. If the patient has severe cystitis, it is of 
irrenl adrantage to ket^p him in bed for some days before the operation, and to 
wa.'^li the bladder out repeatedly with boric acid, or, better still, formalin solu- 
tion. If he is extremely sensitive, it may be necessary to give a general anes- 
thetic, but, as a rule, a local one, such as a 2 per cent sohition of eueain, is snfR- 
deDt to diminish the sensibility of the urethra and the bladder. Cocain is dan* 
[gieroas and should not Ix* used. 

Before attempting to grasp the stone, the bladder should be distended %vith 
[IMto 120 c, c, of fluid. This obviates the risk of pinching the bladder walla 

as the male and 
female parts of 
the instrument 
are brought to- 
gether. It is 
well to keep ac- 
count of t h c 
duration of the 
opc^rations as 
well as to know 




I ftti, 386.— Cf LASS Catheter Splintered in Bladder During Labor. 
The five small pieces shown below were removed ten days after 
^e accident through a No. 10 Kelly speculum. 




the a\iml>er of times the operator finds it necessary to open the beak of the 
in?troinent and to bring its parts together again to erush the stone to effect it^ 
complete removal. The skilled operator will markedly reduce the time and the 
number of the separations. By this means large calculi can be removed with- 




176 



BLADDER AND ITRETDRAL STONES. 



out any injury to the patient in from a quarter of an hour to an hour, or more, 
Nitze has succeeded in removing a calculus '^as large as an apple." 

While an Aniericiinj iSiii^elow, hmught this nprTatioH to tlie front, it has heen 
comparatively neglected in this connrry until qwtv recently. It has heeu used 
for years by English surgeons in India, particularly Freyer and Keegan, the 
latter of whnni rep.»rti^ H>,073 cases. Although Nitze, Casper, Walker, and 

others have devised combined cystoscope and 
litliotrite instruments^ the credit for devisirg an 
iipplianee of this character, which gives all the 
crushing power and evacuation ease of the 
Bigt^low instrunic^utj with the enormous ad van- 



3ic 



:^ 



Fig. 387.— Bigelow's Lithotbite, 1, Hw handle of 
Bigelow*s litluitrit^ o]>en and closed. Not-e the 
rou(^li serrations which oft^^'n tilistrr the hands. 
2, The jaws of Bigt'low's litliotrite open and 
closed. Note ttie shallow female blade and the 
self-cleaning notches in the male blade. 

tage of doing the operalion under vision, is due to that ingenioiis surgeon, Hugh 
IT, Young. Hia instrument is shown in Figures 389 and 3i>0, and would 9i*em 
to mark a new era in this work. 

After the operation is over the cystoscope is introduee<l and the bladder 
carefully examined to see that there arc no fragments left behind. The intro- 
duction of the cystoscope has given the final element of certainty to this delicat*:* 
and conservative operation. As a final step, a 1 to 500 solution of nitrate of 
silver is injected, retained a little while, and then discharge*^] and rephiced by a 
boric acid aobition. The pafif^nt shonhl begin talking urotropin, in SO-gr. doses 
four times a day, before* the operntion, and continue for several days after. 



BLADDER STONES. 



177 



Lithotripsy and litholapaxy carmnt he prartic*c(i when there is a high grade 
of stricture of the urethra, when tlie prostate is very large, or wlieu there 
is an extreme catarrhal condition of the bhidder, rendering it intolerant 
<»f distention. It is only applicable to those cases in which the stone 
lies free in the bladder, and cannot be employed in cases of stone in 
diverticula. 

Perineal Section for Stone.— The radical section ftf tlic jK^rincnnu the clas- 
sical operation for vesical calcnlns, di^uovcrcd by Frcrc .]tU'i|iic8, nsed by Kau 



■a 



tMANN 



^cl 



Fig. 3S8. — ^Bigelow's Evacuating Apparatcs. 



of Holland, introduced into Englaiid by Chesehleu, and almost exclusively 
practiced by our own immediate predecessors, has largely -been given up. When 
I»erineal section is nsed, a median section is preferred on account of the 
liability of the lateral incision to injure the ejacuhitory duct. The median 
]iicii»ion is made by putting the patient in the lithotomy posture. The assistant 
fljen holds the sound, with a deep groove on its convex side, introduced into tlio 
bladder, the scrotum is drawn up out of the w^ay, and the surgeon divides the 
skin and the tissues immediately below it horizontally across the raphe for 
about 5 cm. The bulbus is exposed and the fibers uniting the sphincter ani 
muscles with the bnlbo-caveruous muscks are divided. A groove in the catheter 
is then felt iM'hind the bulb and markod with the nail of the left thinub» while 



the point of the knife ia introduced into the groove and pushed forward into 




178 



BLADDER AND URETHRAL STONES. 



or through the prostatic parts, according to tho size of the stone. The stone 
is then grasped by a stone forceps and withdrawn. Nitze, whose description 



h 





Fig. 389. — Young's Combined Lithotrite Evacuator and Cystoscope. L Evacuator at- 
tached to lithotrite. The stop-cock, B, can be opened and closed while the evacuator 
is attached. 2. Ixjng straight cystoscope insertetl tlirough lithotrite for examination of 
bladder. Beak of hthotrite closed, held against the anterior wall while the search is 
made for calcuh vnih the cystoscope. 3. Blades separated, cystoscope looking out be- 
tween the blades as when about to pick up a fragment. 

we follow, quotes Volkmanu as declaring that iincxpoctedly large stones can be 
removed by dilatation and without incision of the prostatic portions, he himself 
having succeeded in extracting a stone 3.5 by 2.9 cm. in this way without any 



*»! . ^^ com- 

; 'fe tie wound ij 

hlMr in cases of 
^"^ Prosfafp 
?'«n'is. which TO. 

^'■"".r other Condi- 
H„-^T"*' Opera. 

r ♦"^te'ifc.veni.j,- 
'«^ n.-ehofapaxv) 
•'''''^t method of 
"^»';«? a .tone is 

2"""' «nd th,-s ;, 

Ikmghh, thou 
7^'"? 't and fta,,90 

11 "r '^- 

^In open 
*^P« '■« '-nfro- 
**^''"'^ tie stone 



BLADDER .STONES. 



li 



y 





0- ■590.— jP^f ^ S 



180 



BLADDER AND URETHRAL STONES. 



CrOn be seen Ijing in the vertex of the bhiddcr. By means of the cystoscope the 
bladder is filled with air. The posterior wall of the vagina ia then lifted and 
n^traeted by means of a Sims' speculum, exposing tlie anterior vaginal wall 
(Fig. 301). The position of the iutenial orifice of the urethra in its anterior 

wall is then carefully noted. This can 



be marked by introducing a mushroom 
catheter into the bladder and pulling it 
in It until the bulbona end joggles at tlie 
int carnal orifice. A knife is then thrust 
into tlie vesical vaginal septum in the 
middle lino and, with scis^sors or a 
knife, the opening is enlarged fore an<l 
aft. Then, a stone forceps is taken in 
the hand, introduced and opened, after 
which the intone is grasped and extracted 
throngli the cut at the base of the blad- 
der and the vagina (Fig, 3S)2), As a 
rule, it ia well to close the wound np at 
once. Moderate and even rather severe 
catarrhal conditions of the bladder get 
^ ' well very rapidly when the distressing 

W irritating cause is removed under irri- 

m gation through the urethra. If the 

pf - C4itarrh is of unusual severity, however, 

the wound may be left partly open for 
drainage. The cystitis must then be 
treated during the convalescence. The 
w^oiind may be closed with interrupted 
fine silk worm -gilt sutures embracing all 
the layers except the vesical mucosa. A 
mushroom catheter may be inserted into 
the bladder through the urethra for 
drainage and fur dnily irrigation, until, 
in about a week's time, it is safe to leave it out and let the patient urinate 
spontaneously. 

Suprapubic Section or Sectio Alta. — When the stone cannot be crushed ; when 
it is very large; when it is concealetl by a diverticulum; when the prostate is 
large, hut doc*s not iii^ed removal at tlie same time; and for boys under fourteen 
years of age the suprapubic route offers a moat satisfactory method of approach- 



FiG.391,— Vesico-vagikal iKrisioN for 
Removal of Stones in Bladder and 
L^WER Ureter. The incision is me- 
dian and extends from the cervix almost 
to the internal urethral uritice. Tlic 
patient is in the knetvhrcast {losturc 
and air is let into the Ijladder mlh a 
catheter. The knife is then pinniped 
thrrHi^h the thin septum between blad- 
der atiil vat^na. 



BLADDER STONES. 



181 



ng and extracting a calciihis. While a gcnc^ral anesthetic is preferable, if the 
tienl's condition forbiils it, thigs operation can l>e readily done under a local 
lesthesia with eucain or novocain. After the bladder is thoroughly washed 
mi ft catheter is introduced through the urethra and a thin riil)l>er tube or 
uarrow gauze bandage tied around the penis. A transverse incision alKnit 10 
cm long is made above the symphysis across the rectus niusele into the fatty 
tissues above and behind the symphysis. After dividing the overlying deep 
fascia the rectus muscles 



/ V- 



I 



can readily be retracted 
without cutting them. As a 
rule, an assistant, by pull 
inij strongly with a retrac- 
|gr just above the syinphy- 
will hold the muscles 
Biifficicutly apart to give a 
gatisfaetory exposure of tlie 
retroperitoneal space in 
which the bladder lies* 
After separating the luus- 
cles, most of the section 
should be done with the 
fingers or blunt instru- 
ments, to avoid opening the 
peritoneum. Should the 
periloneum be cut by acci- 
dent it must be closed at 
(rtice with suture. The eel- 
hilar tissue in which the 
bladder lies having been 
riiaed, a Davidson's bulb 
ayringe is attached to the catheter and air pumped into the bladder until it rises 
mk view in the wound, looking like a large t}^g. Be careful not to create an 
(*xtreuie dilatation in old patients, aa tho l)lndder has been known to rupture. 
Wlien the bladder rises like a balloon into the upper part of the field of opera- 
tion» it is well to catch and fix it by a fine blaek siik thread passed well through 
itacoatfion either side, or above and below, which serves to hold it up and steady 
itdurinfj the subsequent manipulations. The operator should note with care the 
point of reflexion of the peritoneum, which may be pushed back for several cen- 
timetcr^ if necessary. Ho should avoid as far aa possible any wide detacliment 



Fig. 392. — Removal of Stonti; from Bu%di>er through 
A Vbsico-vaginal Incision. Tlie patient is here 
represented as lying on her side^ but the operation 
is best done in a frank kuce-chcst posture. 



k 



182 



BLADDER AND URETHRAL STONES. 



of tho Lhultler from its tmvelopiug: tibrons tisanes. The air-distended bladder 
cau bo so easily isolated by a little rapiil» l)lmit di45seetion with tho tiugera that it 
is sometimea a temptation to free it iu this way. If the steno is not excessively 
large the inclsian through the bhidder walls is best made from side to side 
between the threads. As soon as the nincosa is opened the air escapes and the 
bladder tends to collapse, bnt the opening is held well np by the threads intro* 
dueed for this purpose. The paticmt should now be elevated in the Trendeleu- 
bnrg position, which frees the blafldcr from pressure of the viscera above, 
allowing a better expansion and exposnre. A retractor is now intnxlueed into 
the bladder^ mid nothing is better at this juncture than the narrow blade of a 
Sims' speculum. Any fluid in the base of tlie l>ladder is removed by suction or 
by stuffiiig it loosely with gauze. It is wtII during these and subsequent manipti- 
lations to protect the edges of the incision and the surrounding parts with gauze, 
ao as not to infect the wound. The wound is then enliirged with scissors or a 
knife until it is big enough to permit the extraction of the istone. The various 
steps of this t>perative procedure are shown in Figures 5t»8-ti02, If there 
is much catarrh in the bladder one may follow Nitze's sxiggcstioua and add a 
boutouniere operation, draining the bladder with a good-sized rubber catheter 
thrtmgh the peritoneum. Nitze, after the fashion of a retrograde catheteriza- 
tion^ introduces a long, slender forceps ihruu^h the internal urethral oritiee^ 
antl, pushing its puiut down against the pcriueunij between the anus and the 
bulbus, cuts down on (be point of the forceps, thrusts it through the perineum, 
and grasps a Nelaton catheter JCo. 33, drawing it into the bladder. In this 
way the wound is drained while the suprajudjic incision is healed. 

Closure of thk Supkaim uie Incision into the Bladder, — The supra- 
pubic o|K'ning into the bladder ought not to be completely closed when the infec- 
tion is so severe us to make the attempted closure hopidess. The wound in the 
bladder may be closed with either silk or catgut. Fine silk makes a good 
closure when there is no infection. It may be used as a continuous suture 
from end to end, juissing thrnugh all the tissues except the nuicosa, and but- 
tressing the nniscnhiris and t!ie edges of tlie incision against each otlter. After 
placing the first layer of suturing, the second layer of catgut shoidd be inserted 
ab<:>vo the first, this time grasping only the muscular outer coat of the blad- 
der from end to end, great care being taken to overlap tlie ends of the incision 
where a leak is most likely to occur. The third most important suture is the 
one uniting the perivtsical fascia. Often it is well to rely on this alone. If 
catgut is used throughout, it mtist be prepared with cumol and formalin or 
weak chromic acid* so as to prevent its too speedy aasorption and The break- 
down of the wound. The effect of the suturing of the bladder should be to 



^ 




URETHRAL STONES. 183 

unite the margins of the incision and the vesical walls for about 5 mm. to either 
side of the incision in such a way as to invert a ridge in the direction of the 
bladder. 

After closing the vesical wound in this way, with every possible precaution 
to prevent contamination of the wounded tissues outside of the bladder by 
infected urine, the operator proceeds to close the rectus fascia and finally 
the abdominal incision by interrupted silkworm-gut sutures, passed figure-of- 
eight fashion from the skin through the fascia and back through the skin 
on the opposite side. Under these circumstances the lower angle of the wound 
should be left open and a little rubber tube, not more than 1 cm. in diameter, be 
insert<>d, wrapped up in iodoform gauze and protective. This may be left in 
place from three to five days, until it is evident that there is no infection and 
that the wound is not going to break down. When there is a bad infection the 
vesical wound will, as a rule, break down, and, for this reason, it is better to 
anticipate this accident and leave a small opening in the bladder. A mushroom 
catheter is inserted into the bladder through the opening, filling the orifice so 
completely that all the urine escapes through the catheter and is conducted 
into a receptacle at the side of the bed, discharging under carbolic acid and 
water. If the surrounding tissues have been soiled an additional drain must 
be placed adjacent to the catheter so as to provide for any infection in Retzius' 
space. With the suprapubic drain, and with a perineal drain or with a catheter 
inserted into the urethra, the bladder can be kept empty and irrigated freely. 
When the catarrhal process is cured it will often be necessary to free 
the bladder from its skin attachment, so as to get rid of the diverticulum at 
its top, which may lodge an infection and become the cause of repeated abscess 
formations. 

URETHRAL STONES. 

A stone is rarely found lodged in the urethra in a woman on account of 
the shortness and the greater laxity of the canal, as long since noted by Celsus. 
The female urethra only presents one ])oint of marked obstruction, namely, the 
external orifice. Stoeckel counts 19 cases in the literature, mostly in women 
over 10 years of age. Quonu and Pasteau (Ann. d. vial, d, org. genito-urin., 
1^9f), xiv, 280) have carefully reviewed the literature of the subject and issued 
an elaborate paper dealing more particularly with the suburethral calculi foimd 
in pockets adjacent to the urethra. 
Finsterer {Dtsche. Ztschr. f. Chir., 1906, Ixxxi, 140) has studied urethral 

calculi in both sexes, including many in children, with numerous valuable 

references to the literature (Fig. 393). 



184 



BLADDER AND URETHRAL STONES. 




Jfjbsoti (Antcr, Jour, Med. Sc,, ISMJ^^ cxxiii, IH) reports two cases of im^ 
pacttMl t'iik'iili in bovs three and three and one-half years of age. The gtono In 
both cases was removed by nrothrotoniy, posterior to the scrotum. The firgt 
cliild had nrinary exIravasatioOj due to rnpliire of tlie urethra, and died with 
rash and higli fever, while flie second reeovered, 

T. Holmes, iu his **Snrgieal Treatment of Disease in Infancy and Child 
hood," 1868, gays that when gnmnioned to a case of retention in a child we ' 
may almost always assimie that it i^ dne to an impacted ealcnln^* in ihe nrethra. ' 

The stones arc eitlier intra -nrethral, that 
is, lying in the canal of the urethra; or sub- 
urethral, that is, lying in a diverticiilura un- 
derneath tlie urethra bnt c<jimeeted with it. 
This latter form is also called diverticular oi- 
urethrocele calculns. 

Again, some large st<»ues lie partly in th^ 
urethra and partly in the hhidder. and arta, 
vcaico-nrcthraL Usually there is but one 
stone, but sometimes there are several. In a 
iliverticulum they may exhibit numeron.^ 
facets, with a nice mutual adjustmenl bv 
their Hat surfaces^ while tlie entire conglom- 

Fio. 393. - Pipe-shaped Akticu- ^^'*^«n«n forms a well-defined ovoid body fill- 
L.\TED Calculi Lying in a Ure- ing the sac (Fig, ;i93), 
THiuL Diverticulum and Ex- ^ The orii^in of the stone is usually fmm 

TENDING INTO THE I RETH1L\. (J. . ., r Vi i i i i x. * f 

FlmteTCT, DUch, Ztschr, /. Chir., ^'^^ ^^^^ <^^ ^^"^ bladder. It may escape from 
190<5, Ixxxi, 149.) a ureter and then pass through the blaJiliT 

and lodge in the urethra, as in llalban's cjn" 
{Cenimlht /. (Jynak., 1903, xxvii, 374), where an elderly patient had a urate 
^tone, the size of a bc*an, extracted from the urethra, an immediate cystoscopir 
exaujinati(»n showing a inarked laceration of the right ureteral orifice, throu|i^li 
which the 8tonc liad clearly passed. These calcnli are appropriately cullrjl 
wandering stones. 

Again, tlie stone may have formed alx)nt the nucleus of a rough fragment 
which had escai>ed fmni the bladder and lodged in the urethral folds. ArounJ 
this central point the phor^[>hates and carln^nateB accumulate until the origiail 
fragment liecomes a mass of considerable size. Again, a stone may form 
around a foreign body introduced into the urethra, notably a neetlle or a hai^ 
pin, or, as in the case of a man reported, around a stalk of grass, A slouc 



m 



URETHRAL STONES. 185 

iginating in the urethra is autochthonous, as contrasted with the wandering 
ones. 

Calculi found eccentric to the urethra and in a diverticulum, may either 
le formed there primarily, or the calculus, first formed in the urethra, may 
10 displace the inferior urethral wall as to create a diverticulum for its lodg- 
ment, when communication with the urethra is a large one and more of the 
nature of a sacculation. 

Halban reports (Centralbl. f. Gyndh., 1900, xxiv, 659) a woman, 79 years 
of age, who had had a utero-vaginal prolapse for 25 years, and for six years 
suffered from either retention of the urine or incontinence. The urethra was 
choked with five stones, varying in size from a pea to a hazel-nut. After re- 
moving these with a forceps, the bladder itself was found full of stones, con- 
eretions of uric acid with phosphatic coating. 

Clinical History. — If the tumor has lodged in the urethra, after escaping 
from the bladder, the symptoms may be urgent on account of the sudden ob- 
Btruction to the passage of the urine ; this is oftener observed in the male sex. 
The patient is seized with distressing sensations of bearing down and straining 
which may become acute and result in an abscess or even extravasation of urine 
in a male. On the other hand, if the calculus is small and forms in a diverticu- 
lom, the first sensations are apt to be a local discomfort, a sense of heat, diffi- 
culty in walking, and difficulty in urination, especially if a cystitis supervenes. 
There may be a sensation of a foreign body in the parts and decided pain. 
Direct pressure of any kind aggravates the distress. A large calculus may even 
perforate the urethro-vaginal septum and escape by way of the vagina. A stone 
in a diverticulum does not interfere with the outflow of the urine. Chrobak 
had a case of a young woman who suffered from dysmenorrhea until he re- 
moved a small diverticular calculus. 

INagnosis. — This is readily made when inquiry discloses discomforts con- 
nected with the bladder and pus is found in the urine, while a local examina- 
tion reveals a hard, tender spot in the urethra or a hard tumor like a 
nrethrocele projecting from the lower anterior vaginal wall. Several calculi 
in a pocket give a sense of crepitation. On conducting a metal sound into the 
nrethra it hits against an obstruction, or, if appropriately curved, it enters the 
pocket where the stone is lodged. A catheter coated at its tip with wax will 
rereal gouges and scratches. One must not confuse the suburethral prom- 
inence with a tumor of the soft tissues. 

Gellhom (Ztsch. f. Geburts. u. Oyniih., 1908, Ixii, 147) has published a 
aae of a vaginal cyst of the anterior wall immediately behind the urethral 
lominence, which, on removal, was found to contain a soft phosphatic stone. 



186 BLADDER AND URETHRAL STONES. 

He conjectured that it originated in a unique way from a urethral diverticu- 
lum, which had become closed. An X-ray plate, so exposed as to avoid the 
shadow of the symphysis, ought to show the stone with an opaque catheter 
alongside of it, as well as the presence of any other stones in the bladder, or 
in the ureters, or in the kidneys, which should always be included in the exam- 
ination. 

Treatment. — A stone can be removed in one of two ways: either by the 
external urethral orifice or by a vaginal incision. In one case a soft cathetor 
introduced into the bladder for irrigation was so firmly wedged in by a urethral 
calculus that it could not be withdrawn, so it became necessary to extract it 
transvesically through a suprapubic opening. If the stone is a small one, or 
if it can be crushed easily as it lies in the urethra, it is well to take it out by 
the external urethral orifice, which can be dilated, after incising the outer 
orifice up to 14 mm. in diameter or even more, without injury. 

When the stone, or stones, rest in a diverticulum, the proper plan is always 
to remove them by cutting into the diverticulum, ending by resecting the 
sac, taking particular pains to extirpate its entire mucous lining, and cutting 
out a wedge of the vaginal tissues so as to form a urethra of the proper size. 
The resected area is then closed with two tiers of catgut sutures, the external 
portion being splinted with a few of fine silkworm-gut. 

A vesico-urethral calculus of large size, particularly one forming about a 
foreign body (hairpin), should, as a rule, be extracted suprapubically. If the 
woman has borne children, a large stone can be more conveniently removed 
through the base of tlie bladder, after which the bladder should be drained, if 
there is much cystitis. 



CHAPTER XXII. 

SYPHILIS, ECHINOCOCCUS, ACTINOMYCOSIS, AND OTHER PARASITIC 
DISEASES OF THE URINARY ORGANS. 

SYPHILIS. 

Syphilis plays a comparatively unimportant role in the surgical diseases 
of the kidney, ureter, and bladder. The best known and most frequent lesion 
is chancre ofthe urethra. It is not our place to consider its treat- 
ment, which is fully discussed in many text-books on venereal diseases. It is 
a hard, indurated nodule. The spirochete can be demonstrated. It should be 
thoroughly cauterized and general syphilitic treatment instituted. 

Syphilis at any stage may lead to nephritis. Occasionally in the acute 
gtageof the secondary period an acute nephritis develops; some of these "kid- 
neys" pass over into chronic parenchymatous nephritis. I. Neumann (Noth- 
nagel's "Specielle Pathologic und Therapie," 1899, xxiii, 684) states that 
albuminuria is a common symptom in every stage of syphilis. That parenchy- 
matous, chronic interstitial, and gummatous nephritis may occur singly or in 
any combination is well known. Amyloid disease is also gommon in tertiary 
syphilis. Foumier, quoted by Legueu ("Traite chirurgical d'urologie," 1910, 
690) observed syphilitic nephritis in only 9 out of 3,429 cases of nephritis. 
The first observer to note the association between syphilis and nephritis was 
Kayer. 

Gumma t a of the kidney do not appear to be so very rare ; 
there are a number of specimens in the pathological museum at the Johns Hop- 
kins Hospital. Spiess (Inaugural Dissertation, Berlin, 1877) found this lesion 
seven times in two hundred and twenty autopsies performed on syphilitic sub- 
jects. In nearly all observed cases only one kidney is involved. Usually the 
gnmmata are multiple, and rarely lead to the formation of large tumors. None 
of the eases obtained from the pathological records at the Johns Hopkins Hos- 
pital gave any distinctive symptoms during life. James Israel (Dtsch. med. 
Wchnschr., 1892, xviii, 5) has reported two cases of gumma of the kidney. 
[n the first, a woman of 23, a tumor in the right kidney region developed, 
ssociated with attacks of colicky pain, frequent micturition, and fever. 

187 



188 SYPHILIS, ECHINOCOCCUS AND OTHER PARASITIC DISEASES. 

There was a definite history of syphilis and pronounced signs of the disease 
elsewhere. The urine was clear, except for a few pus cells, and contained 
albumin. The second case occurred in a man of 39, who gave a histoiy 
of disturbances of micturition and showed a tumor in the side; his urine 
contained pus and albumin. In both instances Israel removed the kidner 
ai^d substantiated his clinical diagnosis by microscopic examination. No cys- 
toscopic or collateral data are given. Both patients recovered promptly. 

Syphilis of the ureter is the greatest of rarities. Proksh (Archiv /. 
Dermat. u. Syph., 1899, xlviii, 221) has collected all the cases reported in the 
literature up to his time. 

Syphilitic lesions in the bladder were but little known until quite re- 
cently. The widespread employment of cystoscopic methods is showing many 
more cases than were formerly known. Hurry Fenwick reports a case of 
condylomata observed in an autopsy upon a young man of 23 years, who 
was killed by accident, and at the time was suffering with syphilitic lesions. 
G. MacGowan (/. Cutan. and Genito-Urin. Dis., 1901, xix, 326) reports the 
cystoscopic observation of several ulcers behind the right ureteral orifice, due 
to gummata, 

Margulies {Ann. d. mal. d. org. genito-urin., 1902, xx, 385) reports tkiee 
cases. In the first there were polypi ; in the second, ulceration ; and in the 
third, cystitis. All were observed carefully and all yielded to ordinary anti- 
syphilitic treatment. 

While keeping in mind the possibility of syphilis it is well to recognize its 
rarity in connection with urological diagnosis. Practically all cases observed 
have shown marked evidence of syphilis elsewhere. The Wassermann reaction 
should afford a great help in the diagnosis of obscure oases. Even in the pre*- 
ence of general syphilis, caution should be observed in pronouncing it as the 
cause of an observed bladder or kidney lesion. All other conditions with which 
it can be confused must be excluded. 

It is probably rarely ever necessary to follow Israel's plan of removing the 
gimimatous kidney, although his results were most gratifying. The treatment 
should be that accorded to syphilis elsewhere in the body. A complicating sec- 
ondary infection would demand surgical interference. 



ECHINOCOCCUS DISEASE. 

The embryo of the Taenia echinococcus, a common intestinal parasite oi 
dogs, develoj)8 in the human body and causes the formation of cysts, which varj 



ECHINOCOCCUS DISEASE. 189 

in size from small growths, the size of a marble, to very large tumors. These 
cysts are occasionally met with in the kidney and in the tissues surrounding 
the urinary bladder. The avenue of infection is the gastro-intestinal tract and 
then the blood-stream. The eggs of the parasite are swallowed in food and 
begin to develop in the stomach and upper intestine. The new-formed embryos 
first break into the portal circulation and pass to the liver. In order to reach 
the kidney they have to pass through the riglit heart, the blood vessels of the 
lungs, the left heart, the aorta, and the renal arteries. The disease is rare in 
the kidneys, as would be expected, when the mode of infection is considered, and 
yet the kidney would seem to be a fertile groimd for the parasites to develop in, 
IS the proportion of cysts here is almost as great as in the lung, and at least 
one-tenth as frequent as in the liver. The cysts in the perivesical tissues seem 
to be sometimes infected, 112 times in 2,474 cases. Cranwell and Herrer 
Vegas (Bevista, de la 8oc. med. argentina, 1904, xii, 215) found 3G instances 
in 1,696 cases. 

ECHINOCOCCUS DISEASE OF THE KIDNEYS. 

According to some statistics women are more subject to kidney lesions in 
the echinococcus disease than men. Garre and Legueu express this view ; on 
the other hand, in some statistics, male subjects predominate. 

The two kidneys are rarely affected at the same time. The relationship be- 
tween right-sided and left-sided cases shows no essential difference in numbers. 
The common age of occurrence is between 20 and 50 years of age. No 
ige, however, is immune. Nicolich (Ann. d. mal. d. org. genito-urin., 1908, 
xxvi, 1773) records the condition in an infant three months old. 

Pathological Anatomy. — The typical location of the cyst in its early stage is 
in the cortex of the kidney. It may start in any part of the kidney and, very 
larely, in the perirenal fat. During its development the cyst shows a marked 
tendency to push through the medulla, down to the pelvis of the kidney, into 
which it may rupture. Not infrequently the development is at one pole or the 
other, the opposite pole in such a case presenting a normal appearance. As the 
cyst develops it presses the kidney tissue together and causes atrophic changes, 
and, in very large cysts, the kidney parenchyma may be spread out over the 
wall almost as in hydronephrosis. 

In its early development the wall of the cyst is thin and translucent ; as it 
pows the wall becomes thick and fibrous, and, in many instances, impregnated 
with calcareous deposits. There is no sharp line of demarcation between the 
kidney parenchjnna and the cyst wall, which renders an enucleation impossible. 
The cyst may be solitary, but is frequently multiple. Cysts have been observed 



100 SYPHHJS, ECHTNOCOCCUS AND OTHER PARASITIC DISEASES. 



in solitary kidneys a number of times. Kidneys, the seat of hydatid cysts, may 
show other pathologic conditions^ such as stone, hydronephrosis, or, as observed 
by T^giicu in one instance^ tulxrcnlosis. In the conrse of their development 
these growths show a marked tendency to perforntc into contiguous organs, 
though rarely into the peritoneum. The common jioint of rupture is into the 
pelvis of the kidney; some authors ida(*e the fretpieney of this eomplieattou as 
high as 75 per cent. Nicaise (*'These de Paris/' IDOii ) found it 1*^ times in 
357 cases, a percentage of 37.5. Occasionally the rupture is intu the stouiaeh or 



Fig. 394.— Sediment fkom Echinococcus Cyst. Above and to tlic It^ft are two degen- 
erated scolices (x about 00) ; to the right is the head of a scolcx (x 400) ; Wlow are hook- 
leta of various ^apes and a small mass of cholesterin crystals (x 400), (After Emerson.) 

intestiues^ sometimes into the pleural cavity. Sometimes an entire cyst is 
disehargeil thn^tigh the ureter into the bladder and sprnifaneous healing occurs. 

Symptoms.— As a rule the cysts develop very slowly over a period of years. 
Frequently the appearance of a tumor in the side is the first symptom. In some 
patients there is dull pain in the hiin. Very large cysts may cause a variety of 
symptoms due to pressure ou surrounding organs. Rupture into the perito- 
neum may cause sudden deatL Rupture into the intestine is followed by pyone- 
[dirosis with all its manifestations. When rupture occurs into the renal pelvis, 
there follows, as a rule, yqtj severe renal colic, and the passage of blood, pieces 
of cyst membrane, and parasites in the urine. The duration of such attacks 
varies from a few hours to days. The interval between them varies from 
short periods of a few days to years. Death rarely occurs from such a rupture, 
and immediate infection is the exception. Wherever infet*tion <x'curs the picture 
becomes that of pyonephrosis* 

Diagnosis.^ — ^This is rarely made before the presence of a tumor or rupture 



I 
I 



I 



occurretU 1 ht* discovery of tbe booklets shown 
in FipTre 394 thirinc: a urine exaniination ia patbogfiiomoiiic of the disease. 
The size of the oysts varies from a pea to a iinin's head, Tii a few iiistaiiees a 
skiagraph has >4]kjwii the preBenee of a tumor before it wa.s tlistiTietlj palpahle. 
When the wall of the cvst is ealei fieri it ia easy to imderstaud how the X-ray 
produces a gootJ shadow. During the period when the conteuts of the cyst are 
discharging in the urine a diagnrwis is n^adily made hy finding parts of the cyst 
wall and the typiral ho<ikIets of flie parasites. Manasse, who eystosooped a 
patient during the discharge nf the cyst, thrnngh the ureter, actually observed 
the passage of the material down from the kidney. Before rupture the diagm.isis 
is made by careful palpation and cyatoseopie studies, eomhined with examina- 
tion of the blood. By means of ureteral catheterization and tlie functional tests, 
the confusion between these cysts and those of the ovary, liver, and spleen, 
should be avoided. By pelvic measurements hydronephrosis also can usually 
be excluded. Tbe various simple cysts of tbu kidney, polycystic kidney, and 
the neoplasmata of the kidney offer greater ditfieulty. Occasionally it is pos- 
j^ible to detect the often described fremitus of these cysta, TLey are rarely 
fluctuant. In many cases of hy<latid disease the blood shows a marked eosin- 
ophil ia, which has been known to reach as high as 50 per cent of all the white 
blood cells. To this useful bloud analysis has been added the reaction of 
complement fixation descril»e<l by Lanbry and Parvu (llutl, soc. med. iL hop, 
de Par., 1008, i^s,, xxvi, 211-226; SOl-OOO), This would seem to be a great 
step in the diagnosis. 

Provosts* — This is all but impossible in the individual case. Cysts occa- 
sionally remain small for years ami occasion no syniptonrs; at other times 
they develop rapidly and lead to uitist f^crious coniplications. The prognosis is 
bad where both kidneys are involved and in those cases where there is but a 
single kidney. 

Treatment.— The treatment is operative in every case, preferably as soon as 
the con<lition is diagnosed, Tbe cbaracter of tbe operation shmdd depend on 
careful preliminary studies of the function of the involved kidney and upon tlie 
findings at operation, 

AJVTien the kidney is well preserved, and the cyst extrarenal or attached to it 
by a small pedicle, the cyst should be removed and the kidney left intact. This 
favorable condition is but seldom encountered. 

When the cyst is located at one j>o]e an*l the other pole is normal, the kidney 
may be resected, provided tbere has been no rupture. This can only occur 
with cysts of moderate size. It has been successfully carried out a number 
of timca. 




192 SYPHILIS, ECHINOCOCCUS AND OTHER PARASITIC DISEASES. 

Where but little parenchyma is left, or where resection is impossible, and 
often where infection is present, nephrectomy is the operation of choice. 
It should be undertaken, however, only in tumors of moderate size, which can 
be removed by the extraperitoneal route. This has actually been carried out in 
a number of cases. Nicaise noted that in 22 transperitoneal nephroctomipg 
there were 7 deaths due to the operation, and in 12 lumbar nephrectomies, 
one death. Before nephrectomy, just as in all other kidney diseases, the ope^ 
ator must be sure that the opposite kidney is capable of carrying on the function 
of both. 

Incision and drainage, the oldest of operations, is quite simple 
and leads to good results in most cases. Its disadvantage is that it takes 
from four months to a year for the fistula to heal. Urinary fistula following this 
jirocedure is very rare. Great care must be exercised in preventing implanta- 
tions of the disease in the incision. This can be avoided in two ways: first, 
by a two-stage operation, the cyst being exposed and its wall sutured to the 
skin, while, at a second sitting, the wall is incised with a Paquelin cauterv, 
the contents evacuated and the cavity filled with iodoform gauze ; second, bj 
injecting a sterilizing solution of some kind into the cyst after its exposure. 
Richlorid of mercury, 1 to 1,000, or, better still, formalin, 1 to 100, may 
be used. After injection the operator waits a few minutes and then opens the 
cyst with the precautions already noted. If the cyst wall is not too rigid, it is 
a great advantage, after sterilizing with formalin, to remove the interior of the 
cyst, to sew the walls together with catgut sutures, and close the incision with 
a drain down to the walls. When successful, this mode of treatment reduces the 
time of healing to a few weeks in place of months. 

HYDATID DISEASE OF THE BLADDER. 

This is secondary to hydatid of the peritoneum. The cysts may rupture into 
the bladder and cause marked vesical irritation. Tumors in this locality are 
really pelvic cysts and must be distinguished from cystic tumors of the pelvic 
organs. The diagnosis can occasionally be made by consideration of the points 
already given in diagnosing hydatid of the kidney. The treatment is by peri- 
toneal incision and drainage. 

BILHARZIOSIS. 

This is a parasitic infection of the urinary organs by a trematode worTa^, 
first described by Bilharz (Ztschr. /. Wiss, Zoulogie, Leipzig, 1852, iv, 72-7G) 



BILHARZIOSIS. 



193 



The parasite has U'un called tlie Schistosoma h c m a t o li i ii m, or 
D I s t o m a h c m a 1 b i 11 m. The habitat of tbis worm is the veins sur- 
fc)nnding the bladder^ urethra, and lower l>owel. The lesions in the iiriiuiry 
nr^jaiis are due to the presence of the eggs of the parasites (Fig, 31)5), The 

FiUer and uretbi*a are the prineipal foci of the disease. The ureter is more 
ely involved, and the kidney but seldom, 
MchIc of Infection. — Human beings develop this disease through the drink- 
tu^^ uf water containing the parasite or its eggs. This 
m be considered the first stage, one which manifests 
if by no symptoms. In the second stage young para- 
iIps pass through the intestinal wall and gain access to 
portal vein system. In the portal vein one rarely 
ids fully developed worms, and the symptoms are not 
racteristic. The third step is the passage of the 
parasites into the veins about the bladder and the 
urethra and ureters. This occurs through the auasto- 
ptiees between the hemorrhoidal veins and the veins 
larrounding the urinary organs. On reaching these 




ttrer veins the parasite attains its adult form (Fig. Fig. :iU5.— CnAitACTEEis- 

mh and the female begins laying eggs, whic^ tIL^bIL'II.r^^^^^ 

je present in the mucous membrane of the bladder, atobia. 

irethra, and ureters. The muscular coats of the blad- 

cr are frc?e from eggs, but they are present in the perivesical tissues, 

le eggs break through into the bladder and are discharged with the 

nine. 

Occurrence, — The disease occurs principally in Africa and notably in Egypt 

[aiilj^ky, quoted by Legiieu {/'Traite ehirnrgicai d*nrologie,'' Paris, 1910), 

ilHjiid the eggs in the urine of 97 out of 124 children in one of the schools in 

Cairo. The infection comes from drinking contaminated water. It is 

mnch commoner among the lower classes than the upper, and in the 

I'liited States is an exceedingly rare affection, T\, O'Xeil (Boston Med, Surg, 

[, 1904, di, 453) states that only six cases had been recorded up to his 

be. 

Description of the Parasite, — Contrary to most trematodes the males and 
IcmiiWs are quite diflFerent in appearance; the adult male worm is from 12 to 
14mm. long, and has two openings on its ventral surface; the anterior one is 
free, the pf^sterior holds the worm on to its attaelnnent. There is a groove along 
tlKt ventral surface of the male worm inti* which the fenude enters. The female 
is a JoDg, thin worm, 20 mm. long, and has a distinct uterus^ filled with eggs 




194 SYPHILIS, ECHIN0C0CCU8 AKB OTHKR PARASITIC DISEASES. 



(Fig, 390). The eggs of the parasite are large, mtsasuring .10 by .6 nun., aii<I 
often contain a ciliated embryo. The shell of the egg is quite transparent, 
8taint?d with hematoxylin, the living eggs are bhie, the dead ones violet In 
the veins of tlip hlailder this is the form of parasite observed* In tlie pOTt«I 
vein the male ib about 3 mm, long, and the female, mm. ; these are younc 

parasites and the sexnal character has not 
developed. These eggs and parasites may 
exist for years, and many of them undergo 
calcification, 

Fathobg:ical Anatomy,— The reader h 
partieiiliiriy referred to the excellent paper of 
Goehcl iCrNfralbK /, d Krankh, d, Ifam.-u, 
8ejr,-0rg,, 100(5, x\ni, 504-615), and that of 
Li^tiille {BulL ei mem, de ta Sac. anaL^ 
lt)Ol), Ixxxiv, 24ft-273), 

The lesions in the bladder at the earliest 
stage are little patches of hyperemia, A little 
later these become yellowish-gray, and ai^ 
slightly raised, Microscofiie examination of 
such a patch shows the epithelium thickened 
and often spreading downward into the sub- 
mucous tissue* Between the epithelial celk 
free eggs are rarely seen, but little cy^ts, 
large enough to be seen by the naked eye and 
fillet! with leiitoc\i;e8, are often visible. The 
deeper layers of the bladder are congested 
and edematous. In a later stage patches o€ 
ulceration and granulation occur with great 
thickening of the bladder. This is the Htag«? 
shown in Figure 31)7, a specimen kindly sent 
us by Dr. Juridini, of Cairo, The number of 
eggs, which stands out beautifully in micro' 
senpic section, varies greatly. 

In advanced cases the bladder is greti 
ly thickened and covered with ulcers and 
polypoid excrescences ; not infrequently fistula? occur through the abdom- 
inal walla. The picture may be greatly altered by the presence of second- 
ary infection, usually due to tlie erdon bacillus, Goelfel has pointed out that 
not only do stones form in a great many cases^ but that malignant tumorsj 



Fig. 390, — Schistosoma Hemato- 
B I u M . Adult worm, (From 
Bratm.) 



.A 



BILHAHZIG8I8, ^^V^p 195 

>th cancerous and sarcomatous, likewise develop in some of the advanced 



The lesions in the 
arcthra, frequently in- 

^volvmg ha entire lengthy 
en r respond to those in the 

. bhi<lder« Strietures and 
fistulie are very eoinmon. 
Involvement of the 
ureter at its lower end is 
c^^nimon; at its upper 
part rare. The kidnry is 

IpracticHlly never affected, 
altlicMi^h p/i^gs of t h e 
parasitt*s have bet^u found 
in it in certain rare in- 
stiinces. Tlu> Ipsious in 
the ureter enrrfsprjud to 
those in the bladder. 

llydronepiirosis oc- 
curs in some cases of the 
disease from oooluHioii of 

[the ureteral Innien. 

Symptoms.— The dis- 
ease is extremely sIcjw iti 
its development, nsnally 
extending over a ptTiod 
of years. The severer 



Fig. 397,— Pohtion of Bladder Viewed from Interior 
Showing Lesions Due to Bilharzia Heautubia. 
The papillary cxcrcsceticcs are shown actual size and 
represent the changes in the blatlder nmcosa iluc to 
tlie ova of th(* parai^itea which are found everjTV'liere in 
till' walls yf tliL^ Ijladtler. Note the small cyst at right 
upper margin of specimen. (From Dr. Juridim, Cairo, 
Eg>'pt.) 



ciimpHcations do not oc- 
cur in most of the cases. Complete healing is rare, for, even after the death of 
the parasites, the presence of the egg may give troiihle for years. In the early 
Ijtages the cardinal symptom is lipmatnria, which occurs at irregular intervals. 
The Dg^ may he discharo;ed in urine in which there is no blood. There may be 
marked irritation of the biailder, even Ijcfore secondary hucterial infection 
occurs* The commonest cause of 9ei*t>ndarv infection is instrumentation. In 
the later stages, w^hen the bhiilder is no lonj^er able to contract, the suffering 
may be intense, particularly where thern are constitutional effects due to com- 
plicating infection. In non-suppurative cases the blood shows a secondary 
anemia and eosinophilia. There are few constitutional s^Tuptoms and no fever. 




196 SYPHILIS, ECHINOCOCCUS AND OTHER PARASITIC DISEASES. 

Diagnosis. — This trouble should be kept constantly in mind in localities 
where the disease occurs, and in every case of hematuria in patients who have 
lived in such localities. Proof that the disease is present depends on finding 
the typical eggs of the parasite in the urine (Fig. 395). 

Treatment. — No treatment has proved curative. Infection may be guarded 
against and, to some extent, controlled by the usual internal medicaments and 
local treatments employed in cystitis. Operative treatment is confined to those 
cases in which there is a retention of the urine, which requires suprapubic, 
perineal, or vaginal drainage of the bladder. 



ACTINOMYCOSIS. 

Etiology. — It has been stated that the organism Actinomyces bovis 
is occasionally found growing in different kinds of grain, and that these 
grains, eaten in the raw state, are the exciting cause of the disease. This view 
is not in accord with the biologic characters of true Actinomyces bovis, 
as first accurately described by Wright {J, Med, Research, 1905, xiii, 387), 
and the chief argument against it is the fact that pure cultures of the organism 
are anaerobic. Xevertheless, the disease is especially prevalent in agricultural 
districts. 

Actinomycosis can be communicated from animals to man, and from man to 
other human beings by direct contact under favoring conditions. Diseased 
gums, borilering on carious teeth, frequently give a point of entrance to 
the germ. When once the disease has become established in the system it 
spreads by continuity and by metastasis. In 032 cases in which the primary 
focus was given, Euhriih {Ann. Surg,, 1800, xxx, 431) found that the head 
and neck wore affected 350 times, or 55 per cent. ; the digestive tract 133 
times, or 10 per cent ; the pulmonary tissue 02 times, or 14 per cent. ; the skir*. 
IG times, or 2 jier cent. ; and there were 33 doubtful cases, or 5 per cent* 

Pathology. — The chief characteristic of the suppurative process caused bjr 
this germ is the presence of characteristic granules which are composed of aggre- 
gates of the branching filamentous microorganisms. The granule, which igt 
one to two mm. in diameter, is usually of a sulphur-yellow color, but it may te 
grayish or even greenish. Seen under the microscope the granule is made up^ 
of numerous club-shaped bodies which are disi)osed radially, whence the name-' 
"ray-fungus." Actinomycosis must be clearly distinguished, according iczM 
Wright, from streptothrix, cladothrix, and oospora. Wright has shown tha "^ 
the only name tenable for this latter group is "Nocardia." 



ACTINOMYCOSIS. 197 

When the fungi enter a tissue they begin to grow in the characteristic radial 
way. Around the organism inflammatory reaction takes place, with the forma- 
tion of granulation tissue arranged in circular zones. Calcification may occur, 
and the process thus come to an end ; but it is far commoner for it to go on, 
and, after a time, the granulation tissue undergoes necrosis. Pus is then 
formed and a small abscess results. The destructive process caused by the dis- 
ease is often very extensive. It has been known to start in the jaw, extend 
along the neck, gain a foothold in the lungs, travel through them, attack the 
diaphragm and invade the organs below. Coexistent pathogenic bacteria un- 
doubtedly play an important part in causing rapid extension of the disease. 
Although spreading by a process of gradual encroachment is more common, 
yet in many instances the disease is carried by metastasis. Both the blood-ves- 
sels and the lymphatics may assist in carrying the germs, but especially the 
blood-vessels. 

It is doubtful if the kidney is ever the organ first attacked, and the disease 
probably always reaches that organ either by metastasis or by continuity. In 
the reports of 128 autopsies, collected from various sources by Garceau ("Tu- 
mors of the Kidney," 1909), in which actinomycosis of some organ was noted, 
metastatic actinomycosis of the kidney was found in 11 instances, or 8.6 
per cent.; in 11 other cases the kidney was affected by continuity; in 2 
cases there was doubtful primary actinomycosis; and in one there was ac- 
tinomycosis of the ureter. Besides these autopsy cases, there were 2 instances 
of actinomycosis of the kidney, apparently primary, with nephrectomy and 
recovery. One is given by Israel ("Chirurgische Klinik der Nierenkrank- 
heiten," Berlin, 1901, 270) as occurring in a male, aged 33; the other is from 
Kunith (Dtsch. Ztschr. f. Chir., 1908, xcii, 181), in a boy, aged 5. In both 
the authors admitted carious teeth, and they were unwilling to state positively 
that there were no previous foci in other parts of the body which had healed. 
Stanton had a case {Am, Med., 190G, xi, No. 2, 401) in a male, aged 53, where 
the kidney lesion was the only one apparent, but he found at the autopsy a small 
scar-like area in the colon with peritoneal adhesions around it, and thought that 
this was the primary focus, as no others were found in the body at autopsy. 

The changes in the kidney in the early stages of the disease are those of 
miliary formation where the colonies are beginning to grow. The cortex is 
usually first attacked. These snuill areas are usually pale yellow in color and 
their edges have the appearance of i)alisad(^ike rows of clubbed bodies. As 
the colony grows it excites inflammation with round-cell infiltration; softening 
results, and, if there are colonies in the vicinity, coalescence occurs; finally, 
an abscess is formed, floating about in the pus of which are the loosened col- 



Fio. 398. — Actinomycosis of the Kidney. In the drawing to the left note the-foei I 
cortex and medulla, more numerous in latter. Each focus shows one or sevnml njf 1 
The largest focus shows central breaking down. Note also tissue reaction anNmd 
The tubules in the cortex arc choked and have practically disappeared, while fhs | 
eruli are dilated. The capsule is thickened. The small square in the fini fijp 
shown 80 times magnified in the second picture above to the right, where the i 
matory infiltration and tubular degeneration are more clearly brought out. Tlie 1 
die picture below shows a ray fungus 500 times magnified, with inflamnuitoty < 
about it, consisting of polymorphonuclear leukocytes and small round ceUs, The Vnnt 
picture to the right, also 500 times magnified, demonstrates the atrophy and obfitah 
tion of the tubules of the medulla and tha great increase in inter-tubular intentilU 
fibrous tissue. The small squares in the upper figure to the right indicate the i 
shown enlarged below. (MacD. From Bender Laboratory, Albany, N. Y.) 



198 



200 SYPHILIS, ECHINOCOCCUS AND OTHER PARASITIC DISEASES. 

onies, which form the characteristic yellow granules. The tendency is not 
toward the formation of one abscess of large size, but rather toward the forma- 
tion of many small abscesses. The kidney changes around the abscess cavi- 
ties are in the nature of granulation tissue, with a tendency to proliferation; 
hyalin degeneration is seen in places, and there are also atrophy and cicatricial 
formation (Fig. 398). The result is a tissue of considerable density. If the 
pelvis of the kidney is reached by the gradual progressive softening of the ab- 
scesses, the pus finds an outlet and is discharged with the urine. When the 
disease attacks the kidney by continuity, adhesions are formed between the 
affected organ and the kidney, and the usual changes in the kidney result. Of 
the secondary degenerations which may attack the kidney, amyloid is the most 
common. 

Symptoms. — A patient affected with actinomycosis of the kidney, this being 
the seat of the sole or at any rate the principal lesion, suffers from the symptoms 
characteristic of a suppurative nephritis. If the symptoms are severe, and 
there is general systemic disturbance, we may suspect secondary infection with 
another germ, severe pyelonephritis, with general septicemia, resulting. In 
Israel's case the patient, an army officer, had a sudden attack of hematuria after 
exposure to cold ; with this there was a dull, heavy pain in the kidney region. 
After several weeks of intermittent bleeding there remained sensitiveness under 
the ribs, which was worse on exertion. Pyuria soon appeared, and the patient 
began to lose health. This condition lasted a year, and then there was a recur- 
rence of symptoms, with fever and chills and pain in the abdomen. After three 
years of suffering a number of small lumps appeared in the lumbar region at 
the site of a previous nephrotomy wound, and when these were incised, pus was 
discharged; in this pus the characteristic granules were discovered, and on 
examination of the urine similar granules were found in the sediment. The 
patient was cured by nephrectomy. 

The clinical appearance of an actinomycosis infection closely resembles that 
of tuberculosis in that there may be high afternoon temperatures, followed the 
next morning by an afebrile condition. When secondary infection is not pres- 
ent this temperature is accompanied by a leukopenia. 

In cases in which there is general systemic infection the patient suffers 
from fever, chills, great prostration, sweating, and, toward the end, delirium, 
with drowsiness and other symptoms of severe pyelonej)hritis. When the disease 
is secondary to actinomycosis in other parts of the l>ody the kidney symptoms 
are generally overshadowed by those of the ])rimary affection and, in most cases, 
the lesion is apparent only at autopsy. 

Diagnosis. — Most reliance may be placed upon the urinary findings. The 



CHYLURIA. 201 

discovery of the microorganism in the urine is conclusive evidence of the dis- 
ease in some part of the urinary tract. Involvements of the kidney may be sus- 
pected if there is pain under the ribs, but even if this is present, one must 
bear in mind the possibility of the disease affecting other organs in the vicinity. 
Treatment. — If the kidney is the only organ involved, a nephrectomy will 
effect a cure; but if other organs are affected, especially internal organs, the 
chances of cure are very slight indeed. Duvau (^These de Lyon," 1902, 100), 
in a list of 255 cases of actinomycosis affecting the various parts of the body, 
estimates the mortality in the thoracic form at 85 per cent, and in the abdominal 
form at G5 per cent. In these serious cases, with secondary involvement, pallia- 
tion is all that can be accomplished. The administration of iodid of potassium 
was at one time thought to do good, but experience has shown that it is not 
very valuable; arsenic may be used in conjunction with it. The iodid should 
be given in large doses, as much as six grams daily if the patient will stand it. 



CHYLURIA. 

The name chyluria applies to a symptom, namely, the presence of chyle in 
the urine. It is a condition of rare occurrence in temperate climates, but is very 
common in tropical and subtropical regions. It is due, for the most part, to 
the i)arasite Filaria sanguinis hominis, although found occasionally 
independent of this disease. 

The Filaria is a parasite discovered in 1863 by Demarquay, and thoroughly 
studied by Manson. The adult worm, which measures about 38 mm., lives in 
the thoracic duct and lymph passages of the human being. The embryos, which 
are al)out .2 mm. long, appear in the circulating blood during the attacks of chy- 
luria. They are taken up from human beings by mosquitoes and after passing 
through one cycle of their existence in the alimentary tract of the mosquito, 
they rei*nter the human being by the intestines. 

The disease is endemic in Brazil, Egypt, India, and Japan. 

The presence of the chyle in the urine is generally preceded by certain pro^ 
dromal symptoms. It may come on as the result of exposure to the cold. Often 
there is pain in the kidneys, which radiates to the testicles, and there is generally 
nausea and vomiting. Usually the urine is a little red at first, and then becomes 
the color of chyle. The presence of chyle may be noted at night in some cases, in 
others, only in the day. The general health may Ik? good for quite a while. If 
the urine passes into a glass, it separates into three layers, a creamy upper layer, 
a lower layer of little clots, and a middle layer looking like milk. This clotting 



202 SYPHILIS, ECHINOCOCCUS AND OTHER PARASITIC DISEASES. 

sometimes occurs in the bladder itself. The embryos of the parasites are often 
found in the urine. The chyle results from a dilatation of all the lymph vessels, 
due to plugging of them by the parasite. 

Diagnosis. — The diagnosis is made by examination of the urine. The pari- 
sites may be found in the blood, and there is also a marked eosinophilia. The 
prognosis becomes grave only when the amount of lymph lost is very great. 

Treatment. — During the attack the patient ought to be in a bed with his 
foot elevated. Methylene blue was formerly employed. Atoxyl has given 
occasional improvement. Recently encouraging reports have been made from 
the salvarsan treatment. Manson advises light diet and mild purging. 



1 



CHAITEK XXIII. 
P1:T3L1T1S. 



PYELITIS m GENERAL. 

Pjelitis, strictly considered, is an luflammatinTi of the mucous membrane of 
the pelvis and calices of the kidney, in contradistinction to pyelonephritis, 
which means an infection of borh the pelvis ami the parenchyma of the kid- 
M^y^ and is frequently associated with ureteritis, as well as with cystitis. This 
trict pathological definidon has no real clinical value. Whether such a local- 
izer! condition ever occurs is doubtful. The use of the word dates from the time 
of Kayer, and has so grown into the 1 if era lure in a purely clinical significance 
that in describing the milder and non-surgical forms of pyelonephritis it seems 
best to employ the usual term. Strictly speaking, all infections of the kidney, 
from the simplest to the gravest, represent different stages of the same condi- 
tion and should be treated under one heading. 

Portak of Entry* — ^Pyelitis, with the exception of the cases due to chemical 
irritants, which are not considered here, is always due to bacteria. In most 
cases these reach the kidney through the blood stream. As already pointed out 
in Chapter VIII, in order to produce inflaniniation there must be some added 
source of lowered resistance in the kidney. Bacteria can pass through the kid- 
ney out of the blood into the urine in great numbers and for a long time 
without exciting inflammation, Infeclion of the kidney by means of the lym- 
phatics is possible bnt extremely rare. Infection by ascension up the ureter 
is also possible but exceptional, occurring only in cases presenting marked 
changes in the vesical orifices of the ureters due to prolonged cystitis. Such 
ctLse& do occur in the ordinary infections and particularly in tuberculous infec- 
tions* In a perfectly normal bladder there is no reflux of urine from the blad- 
der to the kidney, w^hich has been ascribed to the oblique direction of the 
ureter in the bladder wall, bnt is not entirely due to this, as it is quite possible 
to show that there is no reflux when the ureter is implanted by operation directly 
into the bladder. 

Etiologry* — In Chapter VIII is given in detail the bacterial fauna of the 

ads 



204 PYELITIS. 

urinary tract. In chronic cases the colon bacillus is usually found in pure cul- 
ture, while in acute ones the staphylococcus, the streptococcus, and the protens 
bacillus are more frequent. The infection is usually single, but may be multi- 
ple, from the etiological standpoint. Many of the streptococcus and typhoid 
bacillus infections finally yield to the colon bacillus. Among unusual organisms 
are the gonococcus, the pneumococcus, and the bacillus of grippe. One of the 
earliest cases of gonococcus infection was described by one of us (Kelly, "Opera- 
tive Gynecology," 1894, i, 524). Since this early case a number of others 
have been reported, and cases have been described by a number of fo^ 
eign authors (Tedenat, Ann, d, mal. d, org, genito-urin,, 1907, xxv, 1215). 
One of the last, reported by an American, is that of Dr. Louis C. Lehr (Trans, 
Amer. Urolog. Asso., 1912, vi, 236). 

Among contributory causes to bacterial inflammation in the kidney are 
stone, hydronephrosis, pressure on the ureter from without, retention of urine 
in the bladder, general infection, local infection in other parts of the body, 
cystitis, etc. 

Pathology. — The pathology of pyelitis is most beautifully shown in the atlas 
of Rayer, now more than 70 years old. As might be expected, the location and 
intensity of the lesions vary greatly. It has been customary to describe that 
form in which the lesion is mainly in the kidney as a descending infection, and 
that with marked pelvic and ureteral involvement as ascending. Such a descrip- 
tion, while still allowable, should not be taken as evidence of the portal of ent^ 
of infection, this being almost invariably, as already said, the blood. 

If the flow of urine from the kidney into the bladder has been interfered 
with on one side, as in the case of the pregnant uterus, or on both sides, as b 
prostatic hypertrophy, the result is to render the involved kidneys peculiarly 
liable to infection. This occurs through the blood. If such a case comes to 
autopsy one finds a fairly normal looking kidney, but marked disease of the 
pelvis and ureter. Clinical studies demonstrate beautifully, however, that such 
kidneys are far from normal: in many cases the secretory power is reduced 
almost to nil. Where a kidney has yielded to a violent infection without 
any retention weakening being superadded, the picture may be quite different 
Here, in the acute stages, the kidney is large, and abscesses may be present in 
the cortex ; in the chronic stages patches of inflammatory tissue represent these 
abscesses. The capsule is thickened and the whole kidney may be shrimkcn 
up, yet, with these marked changes in the kidney parenchyma, the ureter and 
the pelvis may appear practically normal. The cases, however, are not divided 
into two such clcar-cnt groups. Few, indeed, are typical, for every stage of 
transition between the two exists. 



PYELITIS IN GENERAL. 205 

Symptoms. — In a disease with such variety of location and marked variation 
in intensity, there is also a great variation of symptoms. These may be general, 
due to the a])sorption of toxins, or failure to eliminate waste products; or they 
may be localized in the kidney ; or, finally, they may be confined to manifesta- 
tions of disturbance in the function of the bladder. Uremic manifestations are 
common enough with cases of bilateral pyelitis, and are typically presented in 
old prostatic suif erers. In such patients there is loss of appetite ; thirst ; loss of 
weight and strength ; nausea ; mental torpidity in the early stages, and, in the 
later ones, death from coma, often with typical uremic convulsion. In simple 
pyelitis this condition is rarely seen, even in very old and advanced cases. Tem- 
perature is always present in the acute cases, and may or may not be present 
in the chronic ones. No type of fever is characteristic of pyelitis, for there 
may be continuous elevation of temperature in some ; remittent temperature in 
others; and typically intermittent temperature in still other cases. The degree 
of temperature does not depend on the severity of the case, and is not propor- 
tional to the pus and infecting organisms found in the urine. We recall one 
patient who, following labor some six months before, began having intermittent 
attacks of chill followed by fever reaching 104°. This condition greatly dis- 
tressed the physician, who had acted as accoucheur, and was attributed by him 
to some obscure i>elvic infection, but it proved to be an infection of the left kid- 
ney of such a mild character that only scant pus and colon bacilli were present. 
At first it was difficult to believe the kidney condition anything but secondary 
to some other focus in the body. Nevertheless, on hexamethylenamin and water 
this patient cleared up at once and permanently, leaving little doubt of the 
diagnosis. 

The fevers which occur in little children are discussed in a separate section. 
Fully as interesting as these fevers are the apyretic cases where the urine is 
loaded with pus and organisms and the general condition goes uninfluenced for 
months and even years. 

As a rule, pain or other symptoms referable to the kidney are rarely found. 
Now and then, however, the patient will complain of dragging pains and, occa- 
fflonally, of a distinct renal colic 

The development of bladder symptoms is the rule, and, in many cases the 
cystitis so dominates the field that it is the only thing complained of. Some 
authors have laid particular emphasis upon the frequency of micturition at 
night, insisting that simple bladder inflammation without involvement of the 
kidney will show much less frequency at night than during the day. It is our 
Impression that all cases of genuine pyelitis are associated with frequency of 
roiding, whether there is or is not definite involvement of the bladder. This 



206 



PYELITIS. 



frequent emptying of the bladder is, in fiurl, due to its irritability^ and in part 
to the fact that most eases of pyelitis of the chronic variety are associated with 
large quantities of urine. 

Diag'nosifl.^-The diagnosis of pyelitis resta on a careful examination of the 
xirioe, and, finally, on examination of the urological tract by catheterization of 
the ureters and soparafo studies of ibe kidneys, as deyerih-d in Chapter IX. 

In aeiite pyelitis the urine contains a surplus of albumin, some red blood 
cells, pus cells, anrl the l>acteria which are causing the inflammation. In the 
chronic stages red blood cells may be absent. It is, however, a matter of con- 
siderable interest for the clinician to know that a pynria of kidney origin is 
alninst always, if not invariably, associated v;ith a considerable amount of serum 
albumin. On the oilier hiind, many pyurias are of vesical origin and show no 
serum albumin. There are exceptions liotb ways. In addition to obtaining ihe 
eatheterized urine, it is always an advantage to test the total renal function. 
As a rule, the kidneys are not enlarged and are not tender on palpation. In 
chronic cases the vesical ends of the ureter are very likely to be thickened, jnst 
IIS they are in tuberculosis of the kidney, and pressure ni>on the ureter, by 
vaginal examination in the female or by rectal examination in the male, is 
almost invariably followed by pain and an intense desire to empty the bladder. 
These two symptoms, in combination with the cord4ike feel of the ureter, are 
very charaeteristic. 

The cystoBcopic picture may disclose almost any degree of cystitis or, as is 
often the case, lesions in the bhxdder around the uretx^ral orifice of the aflfected 
side. Here one may see a reddened, ponting orifice, or a retracted golf-hole 
opening. If the pynria is intense turbid urine can he seen on one side and 
clear on the other, and, if indigo-carmin is used, the differences may be most 
marked. The function of the kidney and the urine content and character 
are determined by catheterization of the ureter as described elsewhere in this 
book, llany C4ises of chronic pyelitis are associated with strictures of the 
nreter^ and such demand special consideration and treatment. The diagnosis 
of stricture of the ureter is given in (Uiapter XXX. Here, we repeat briefly 
that every obstruction of the ureter **met in introducing a catheter" most 
not be regarde<i as a stricture, but must be thoroughly examined by functional 
test, by X-ray collargol injection, and by various catheters. 

In addition to the urinary analysis a careful general examination should 
always be made. Jfany cases of |iyelitis may be but secondary to 
other foci of infection* This is particularly true of the gonococcns cases. In 
the female one should always note the condition of the cervix and particularly 
of the Fallopian tubes. Many conditions of abscess in the body are associated 




PYELITIS IN GENERAL. 207 

^th pus and organisms in the urine, which readily heal when the primary 
cause is removed. 

It is important to recognize that, while some pyelitides associated with 
fever are characterized by an increase in the absolute number of white blood 
cells and a relative increase of the polymorphonuclear leukocytes, with a de- 
crease in the eosinophiles in the blood count, there are many exceptions. Many 
patients presenting high fever, with few or no local symptoms, except the 
pyuria, will show a perfectly normal blood count. We have seen this in a case 
of left-sided pyelitis in pregnancy, with the temperature 104°, and intense pain 
in the affected organ. When there are no local symptoms, such cases are fre- 
quently confused with malaria, tuberculosis, or typhoid fever, depending on 
the type of the pyrexia. 

Pn^osifl. — The prognosis of pyelitis depends on its extent and its stage. 
Acute cases usually heal rapidly under appropriate treatment. On the other 
hand, long-continued infections are most difficult and often impossible to clear 

Treatment. — In acute cases, rest in bed, abundant water, and urinary anti- 
septics, particularly the formalin liberators, are most important In chronic 
ciises, the same treatment, with the addition of lavage of the kidney through an 
ureteral catheter, vaccine therapy, nephrotomy, and drainage, with the removal 
of any cause for the condition, such as stone, hydronephrosis, stricture of the 
ureter, external pressure on the ureter, etc. 

As already stated under Diagnosis, it is most important to be sure in a 
ease of pyelitis that there is no primary focus of infection elsewhere in the 
body and no local conditions of the kidney rendering it vulnerable to bacterial 
attack. In every case, therefore, such conditions must be looked for and re- 
moved as a part of the treatment of the pyelitis itself. 
We have found abundant water drinking of great value in all cases. 
I Urinaby Antiseptics. — Of the various urinary antiseptics, none compare 
i with those which liberate formalin. The type of this group of drugs is hex- 
amethylenamin, introduced many years ago into medicine by Nicolaier. It 
has come into very general use. One of us (Burnam) reported at the meeting 
of the American Urological Association (1912, vi, 286) a series of studies 
with it We believe that in many cases there is no liberation of formalin in 
the urine after taking urotropin by mouth. A simple test for it is the addition 
of from one to three drops of .5 per cent, aqueous solution of phenolhydrogen- 
iydro-chlorid and the same amount of a 5 per cent, aqueous solution of sodium 
nitro-prussid, with an excess of the saturated solution of sodium hydroxid. 
The presence of formalin is indicated, when abundant, by a deep blue; when 



Fio. 399.--S1MULTANEOU8 Lavage of Pelves op Both KroNEYS. The renal catheters, 
marked by in-pointing arrows, must be introduced all the way up into the pelves and 
should be of such small size that a free reflux is possible around them into the bladder. 
An ordinary glass catheter, marked by the outgoing arrow, allows the irrigation fluid 
to escape from bladder. The funnels holding the irrigation fluid should be of ample 
ose and held at the desired elevation (a little distance above the level of the body) by 
a nurse, or by some convenient apparatus. 



208 



210 



PYELITIS. 



very dilute by a green color. This color is transient. The freeing of formalin 
from urotropin is invariable in very acid urines. It occurs at the level of the 
kidney. It may occur in a urine which reacts alkaline to litmiia and phenol- 
phthalein. It is often absent in alkaline and moderately acid urine* The 
liberation can be increased by increasing the dose of urotropin. The ordi- 
nary dose of 5 gr. three times a day can be increased to 20 or 30 gr. three 
times a day. The liberation is also increased, as we have found in recent 
experiments, by giving acid sodium phosphate in combination with the uro- 
tropin. Casper and Citron {Zisch, f, Urol,, 1911, v, 241) describe marke*l 
liberation of formalin from 7V^ gr. doses of myrmalid, which is a combina- 
tion of hexamethylenamin and sodium acetate. We are confident that the 
good effects of all formalin combinations are due to tho liberation of free 
formalin, and that a very good estimate can be put on the ilrug by the test 
de8cribc<l. 

We have recently been employing a 1 per cent alcoholic solution of phloro- 
glucin as a te.st for formalin. It is very delicate, showing formaldehyd in dilu- 
tions as great as one to one million at body temperature. The test ia carried 
out by adding one or two drops to the suspected rtiiid and then making it very 
alkaline with a saturated aqueous solution of sodium hydroxid. The presence 
of formaldehyd is evidenced by the gradual development of a pink color. The 
color of the urine markedly interferes with this color, so that in testing it is 
always necessary to dilute. For quantitative work it is of value to dilute down 
to the end point of the reaction. 

Lavage of the Kidney. — If, after a thorough treatment of this kind there 
is no clearing up of the condition, the next step is to use lavage of the kidney. 
This metho<l, well illostrated in Fig^ire 300, has been used for many years since 
its description by one of us (Kelly) in the treatment of pyelitis. It yields 
very splendid results in many cases, and has been favorably reported upon by 
almost every urologist in the world. It is important to select a suitable medium 
for irrigating after catheterixing the ureter, and silver nitrate, in strength up 
to 1 per cent., has been much used, often yielding excellent results. It has, 
however, the disadvantage of being precipitated in the urine, so that it is 
never quite certain what quantity is active. All of the organic silver salts are 
of value; bichlorid of mercury solution, 1 to 10,000, can be used, and we 
have had some excellent results with solutions of formalin, bc^nning with 1 to 
3,000 and working down to 1 to 1,000, The toleration for formalin varies 
very greatly. 

Autogenous Vaccines, — Persc^nal experience with autogenous vaccines has 
not been very encouraging, and we have not succeeded in curing any of the 



PYELITIS IN GENERAL. 211 

chronic cases which have resisted other forms of treatment by their use. The 
technique of both small and large dosage was used. 

^iichsLelia {Folia Serologtca,ldll fViiyJlit 1) reports favorable results, also 
Bremerman (J. Amer. Med. Assoc, 1911, Ivi, 1843). In the Zeitschrift f. 
Croloffie, Beiheft, 1912, are given experiences of Reiter, Rovsing, and others, 
of a most favorable character. H. H. Cabot {Medical Record, New York, 
1910, Ixxviii, 600) found distinct improvement of the symptoms, but no influ- 
ence on the bacteriuria, while J. T. Geraghty {Medical Record, New York, 
1910, Ixxviii, 600) reported no improvement in 14 cases. 

We have seen no ill results from the treatment and, therefore, in spite of 
our own failures, do not feel justified in saying that the method is without 
value. 

Surgical Procedure. — Surgical procedure is invariably necessary when 
there is some anatomical condition rendering the affected kidney or kidneys 
liable to infection. The pressure of a uterine fibroid upon the ureter which 
contains infection is an indication to remove the fibroid. Infection with stone 
kidney has already been dealt with. Stricture of the ureter will indefinitely 
postpone the healing of a kidney infection and demand treatment. In many 
cases the ureters must be cut across and implanted into the bladder to secure 
the drainage necessary for healing the kidney. A full account of this is given 
nnder Strictures of the Ureter, Chapter XXIX. 

We have not been particularly favorably impressed with nephrotomy for 

chronic pyelitis. In a number of cases where it was done, relief only resulted 

while the incision was open ; in no case have we seen a cure, and there is the 

jiossibility that a procedure of this kind is destructive to the already weakened 

kidney parenchyma. Therefore, let it be resorted to only in those cases which 

give a great deal of trouble and have resisted every other form of treatment. 

Xephrectomy is rarely, though occasionally, indicated in cases where a pyelitis 

on one side remains as the heritage of a previous pyelonephritis by which the 

kidney's function is greatly impaired. In such cases a kidney which no 

longer acts for the body becomes a source of infection and constant irritation 

of the bladder. Cases of chronic cystitis duo to such kidneys only yield when 

freed from their damaging influence. 

Pyelitis in children and in pregnant women presents so many unique feat- 
ures as to demand separate consideration. 



212 PYELITIS. 



PYELITIS IN CHILDREN. 

Occurrence. — These cases are seldom seen, even by those who deal most ex- 
tensively with kidney infections. Escherich and Holt in the same year (1894) 
reported cases for the first time, pointing out the existence of the disease, \yhile 
to Finkelstein is due the credit of epiphasizing the frequency of the troubla In 
recent years a large literature has grown up on the subject. Among the contri- 
butors in this country have been I. A. Abt {J. Am. M. Assoc, 1907, xlix, 1072 ) 
and Edgar B. Friedenwald (Arch. Pediat., 1910, xxvii, 801). The disease may 
occur almost from the first day of life. In Friedenwald's 80 cases one child 
was only 11 days old, and his oldest case was 22 months. It is not only common, 
in infants, however; it is also frequent in childhood. Many of the early ol>- 
Hervers noted the condition only in females. Groppert (Berl, Min. Wchnschr,, 
1909, xlvi, 639) found 89 per cent, in females, but Friedenwald in his seri&a 
observed that 27% per cent, were males, showing both sexes to be frequently^ 
affected. 

Etiology. — The disease is most frequently a complication of some infectio:^^ 
elsewhere or some severe nutritional disturbance. The colon bacillus is th^ 
organism commonly found, though other pyogenic organisms occur occasionally*. 
Dr. George Waugh, of the Great Ormond Street Hospital, London, cottzi.- 
municated personally that he had observed persistent bacteriuria in chil- 
dren which would not yield to the ordinary treatment or, if it did, recurrcxi 
shortly afterward, but was permanently relieved by removal of the appen.- 
dix. This would seem strong evidence that many of the cases have thei "■: 
origin in conditions of the intestine which permit the absorption oi 
bacteria. 

There seems but little question that most of the infections in childhood, 2l s 
in older periods, are through the blood. Just why females are more ofte:^^^ 
affected would not seem to be explained by a short urethra and ascending infect— 
tion, although many of the cases do show the combination of cystitis and pye — 
litis. Even in early childhood a condition of stone or hydronephrosis may b^3 
the determining cause of infection. There are no available data to indicat«C3 
that one kidney is usually infected. It is quite probable that these infectioas 
are frequently unilateral. Dr. William M. Jeffreys {Quart. J. Med., Londoci., 
1910-11, iv, 267) found that in 30 cases 15 were unilateral and 12 of the 1 5 
were right-sided. 

Symptoms. — The condition may be either chronic or acute, while the symp- 
tom-complex varies immensely. In the acute case the onset may be very sud- 



PYELITIS OF PREGNANCY AND THE PUERPERIUM. 215 

deiL The child becomes restless, pale, feverish, and rapidly loses weight and 
^ttren^th. The tomperatiiro chart shows great variation, presenting almost 
every type of fever. Some cases are very mild, presenting no constitutional 
symptoms but merely frequency of micturition with paim On the other hand, 
there are the cases whieh are quickly fatal, with high temjx^mture and much 
general prostration. Some are greatly prolonged and most obstinate in their 
resistance to all treatment 

Biagnosis.— Diagnosis rests on a carefitl history and a thorough urinary 
examination* The presence of pns and bacteria in the urine is almost invari- 
able, sometimes accompanied by marked albuminuria and casts. Wherever, 
as in a hospital, the X-ray h cnnvenient, pictures of the kidneys and bladder 
should be taken. In older children, where the condition is chronic^ and ordi- 
nary treatment fails to relieve, there should always be a comprehensive uxo- 
logieal examination. 

Treatment. — If the condition is due to stone, or infected hydronephrosis, 
treatment is indicated exactly as in the adult; such patients respond readily 
to appropriate surgical procedure. In view of the importance of intestinal 
origin great care should be taken to do away with all stasis and inflammation 
of the bowel, while, in obstinately recurring cashes, attention should be given 
to the findings of Dr. Waugh. 

Local treatment of the bladder is not valuable, but, on the other hand, 
urotropin and its allied eompounds are. Urotropin can safely he given in 1 gr. 
doses several times a day; its increase Ijcing guided by testing carefully for the 
liberation of formaldchyd in the urine. 



PYELITIS OF PREGNANCY AND THE PTORPERIUM. 

Pyelitis is a very frequent accompaniment of pregnancy and the puerperal 
period. The diagnostic errors to whieh it has k'd have been numerous, and, 
until quite recently, its importance has not been fully and generally appre* 
ciated in this country. Reblaub (Congrcs fratig, de chirurg,^ Proe, verb,, 
Paris, vi, 6!)21 opened up this question by describing quite accurately several 
cases. A iiuml»er of other French writers followed him. One of the most 
complete reviews is that by Opitz (Zfsehr, f, Oeburtsh. u. Qyn., 1905, Iv, 209). 
Among French contributors sliould be espceially mentioned Legueu, Cathala, and 
Bar; among German, Barth (Dlsch, Zischr. /, Chir,, 190(5, Ixxxv, 57) and 
ilirabeau (Arch. f. Gijn,, lfH>7, Ixxxii, 485). At the meeting of the American 
Medical Association (1912), a valuable contribution was made to this subject 




214 



PYELITIS, 



by Dr, Edward P. Darig, of Philadelpbia (/, Amer. Med. Assoc. ^ 1912, lix^^ 
859), 

A pre-existing pyelitis or pyelonephritis is raade much worse by a preg 
nancy. Such cases, however, should be clinicaliy separated from those which 
arise during the pregnancy and because of it. 

Etiology;— The colon bacillus is usually the infecting organism and gener- 
ally in pure culture. There are, however, cases on record where other pus- 
forming organisms are present, either alone or in association with the colon 
bacillua. The condition may develop at any perirnl of pregnancy or after 
labor, in the puerperium. It is usually a unilateral infection and principally 
found on the right pide. Bilat-eral infections, however, are common enough, 
and we have seen several limited to the left kidney. Many theories have been 
advanced to explain the freqiK^ncv on the right side, such as pressure of the 
pregnant uterus on the ureter, pressure of the head of the child, congestion and 
swelling of the mucous membrane of the Iihnlder eloping of the ureteral orifice. ^J 
Is seems quite likely that it is a mechanical hindrance to the flow of the urine^^^ 
on the right side, plus an unusual absorption of colon bacilli from the bowel, 
which leads to this infection, 

Symptoms*^ — Here, as might be exiiocted, the clinical picture varies im- 
mensely With the extent and severity of the infection. Some cases present 
no symptoms, the condition being revealed by urinalysis. In others there 
is only marked general dii^turbanee, as shown by elevatiou of temperature and 
loss of appetite, with eonset|nent uutritionai disturbance. The type of the 
fever is most variable. It may Ik? a typical typhoid cun^e running at an even 
high level, or it may be, and frequently is, markedly remittent, associated 
with chill and sweat. When the condition occurs after labor, it is invariably 
thought to be a puerperal infection. In quite a numter of cases there is 
marked pain in the kidney region, and this may be intense, as we have ob- 
served in a number of cases. Frequent voiding, with pain, is common, but 
not often distressing Its existence is more often brought out by careful 
history-taking than by voluntary statement by the patient. 

Biagnosis* — ^The diagnosis rests on a careful urological examination in 
every suBpectcnl case* With fever alone, it is necessary to exclude tul^ercnlosis 
and typhoid fever, but when pain is present also, appendicitis and inflamma- 
tion of the gall bladder may be suspected. In the puerperal period the condi- 
tion must be carefully distinguished from ordinary puerperal fever. We have 
frequently relieved an anxious doctor, seen in consultation, by the almost 
magic effect of giving hexamethylenamim 

Sippel (CenlralbL f. Oyn,^ 1905, xxix, 1121) describes a perirenal abscess 



PYELITIS OF PREGNANCY AND THE PUERPERIUM. 215 

following a pyelonephritis of pregnancy. After delivery, most of the acute 
symptoms general, as well as local, disappear. Some cases heal without treat- 
ment, but, if not properly treated, many pass into a chronic condition; some 
spontaneously abort. 

Treatment. — Pyelitis in association with pregnancy should be regarded as 
a serious complication and receive prompt, energetic, and complete treatment. 
Begulation of the bowels and abundant water consumption are always indi- 
cated. Hexamethylenamin is well borne and should be given in full doses. 
If the condition persists, and especially if pregnancy is advanced to a period 
where a viable child is possible, great amelioration and sometimes relief of 
the condition may be reached by catheterization of the ureter and irrigation of 
the kidney pelvis. In the early months of pregnancy such cases as resist these 
measures should be promptly treated by bringing on a miscarriage. The per- 
sistence of a kidney infection for months nearly always means irreparable 
damage to the affected organ if nothing worse. In the later months the pro- 
cedure to follow is that of nephrotomy, which has been especially advocated 
by Barth (loc. cit.) and by Dr. Edward P. Davis (loc. cit.), both authors 
reporting a number of favorable cases. Sometimes the fistula closes before 
delivery, in other cases it persists until the child is bom and then closes. 
There is no tendency to interruption of the pregnancy; most of the constitu- 
tional symptoms disappear, and the kidneys, when cleared of infection, are not 
impaired. In determining upon this operation, let there be careful consider- 
ation not only of the obstetrical but also of the urological features. In these 
later cases interruption of pregnancy is a serious procedure and more difficult 
and dangerous than nephrotomy. 

As shown by a number of cases — for example, report of Cova (Annali di 
ostet. e ginec, 1903, xxv, 692) and the discussion of Dr. E. P. Davis' paper 
(J. Am. Med. Assoc, 1912, lix, 859) — it is possible to do a nephrectomy with- 
out interrupting the pregnancy or killing the patient. A nephrectomy, how- 
ever, is an extreme measure and probably never necessary. 



CHAPTEE XXIV. 

PYELONEPHRITIS, PYONEPHROSIS, MULTIPLE ABSCESSES AND INFECTED 
INFARCTS OF KIDNEY, PERIRENAL INFLAMMATIONS. 

Pyelonephritis is a tenn applied to inflammatory processes in the 
kidney parenchyma. It is usually associated with pyelitis. Multiple ab- 
scesses and infected infarcts are really an early stage of pyelone- 
phritis, constituting conditions in which, in certain of the acute stages, the symp- 
toms may be so distinct as to require separate classification. Pyonephrosis 
is a term applied to those cases in which there is an accumulation of pus in the 
kidney pelvis or parenchynna. Perirenal inflammation is a tenn ap- 
plied to inflammatory processes in the fatty capsule of the kidneys and in the 
retroperitoneal fat. It may or may not be associated with involvement of the 
kidney itself. It may lead to the formation of immense abscesses. The direc- 
tion which these may take in the fascial planes is well shown in Figures 40 
and 41. 

INFLAMMATION OF THE KIDNEY PELVIS OR PARENCHYMA 

ETIOLOGY. 

It is quite impossible to draw hard and sharp lines between the various 
conditions of the kidney due to infection. Very many acute pyelitis cases are 
probably also pyelonephritic The same factors which occur in pyelitis are of 
importance in the causation of those more serious conditions. Pyonephrosis is 
always associated with some obstruction to the outflow of urine, as pointed out 
under Pyelitis. The obstruction may be in the lower urinary tract, or in the 
ureter, and is often at the ureteral pelvic junction. Pyonephrosis mav 
develop from a pyelonephritis or a pyelitis in a kidney previously healthy. 
Such a condition is usually, and properly, termed a primary pyonephrosis; it 
may develop in a hydronephrotic kidney where the pelvis has already been 
dilated but infection has not taken place. 

Experience has led more and more to the belief that most of the kidney and 

216 



ETIOLOGY. 



217 



ureteral iufectioDs are blcHMl infections, Caiintloss oxpcrlments on aninials 
have showii that it is very easy to produce kiduey iafections by injecting pus- 
forming organisms iuto the blood, aiid that the probability of infection is 
reatly increased by any influence tending to lower the vitality of the kidney. 
This has been shown experimentally by obstructing the ureter in animals, and 
i» shown clinically in countless cases where ureteral obstruction has followed 
some pathological process within its own wall or is caused by pressure from 
contiguous tissues. 

It has been contended that movable kidney favors the infection. We have 
not been iM?r9onaIly impressed with it as an etiological factor. On the other 
hand, in 99 cases of stone in the kidney, infection was foimd in no less than 
72. In 70 cases of kidney tnU'rculosis, there w^as an associated colon bacillus 
infection 12 times. Animal experimentation likewise* as a rule, speaks against 
the ascending infection. This is more clearly shown in the case of the tubercle 
bacillus than any other organism, as clearly demonstrated by Durand-Fardel, 
rSaunigartcTi, and Walker. Its occurrence after cystitis does not in itself pre- 
clude the infection coming from the blood. 

All the oi^anisms which cause pyelitis may lead to the severer lesions. 
Definite kidney abscesses due to the gonwroccns have been reported by Tedenat 
(Ann, de maL d, org, geniio-urin,, 1S)07, xxv, 1215) and Le Fur { Assoc, franq. 
d, urah, 1904, Sess. viii, Proc. verb., 753), Dr. William Kixon, recently 
of the Johns Hopkins Hospital, has communicated personally two cases and 
ndlected a numl>er of definite cases fn»m the literature. The typhoid bacillus 
15 undoubtedly a more benign organism than most of the others. In some 
cases the colon bacillus has a tendency to create mild disturbances but in others 
very marked ones. On the other hand, quite mild conditions may ho associated 
with staphylococcus and streptococcus infections. No sharp lines, we believe, 
can be drawn l>etween these r^rganisms as regards either the gravity of prog^ 
nosis or the indications for treatment. 



PATHOLOGICAL ANATOMY. 

A description of the lesions which can occur is a difficult matter, because 
there are variations all the way from congestion of the kidney, with a few 
small abscesses, to complete destruction and enormous distention in some of 
the pyonephrotic cases. It has beeorae the custom to descrilie a pyelonephritis 
aa of descending or blood origin or of ureteral or ascending origin. This 
classification was formerly used in reference to tuberculous kidneys, which we 



i0W know are all Idood infections. 





218 



INFLAMMATION OP KIDKEY PELVIS OR PARENCI 



la acute sej>tic nephritis the kidney h increased in volume, shows 
tion, and often presents upon its surface areas of hemorrhage or litUe ab- 
scesses. This is well shown in Figure 400, On section these areas are tmni 
extending down to the medulla, often, as in the case noted, in the form o( 



f 



^ 



Fig. 400. — Multiple Infected Infarcts of Kidney, Tlie left-liaml drawing shows th 
characteristic grouped nodular whitish areas, oft^n surrounded with a deeply iDjectd 
zone. The section on the right sliows ho^' these zones extend wedge-like into the de«per 
parts, each also surrounded with an inflanmiatory area. (H, G,, Ch, H^ and Inf., Jail 
6, 1910.) 

infarcts, llieroscopic examination may show the vessels of the glnmeniH 
packed with organism^^. In a little later sta^e^ in place of the hemorrhagic. 
zones, there appear definite abscesses. There may be no lesions whatever of 
the pclvis» though generally there h dis^tinct pyelitis. In the so-ealled asceod* 
ing fomi the lesions of the kidney may be simply those of sclerosis or there 
may be abscesses, situated principally in the medulla and spreading ont toward 



SYMPTOMS. 219 

the cortex. The ureter and pelvis always show marked inflammatory changes. 
In both forms there is fibrous inflammatory reaction about the kidney in its 
fatty capsule, and sometimes purulent inflammatory reaction. 

As already stated, pyonephrosis is an inflammatory condition of the kid- 
ney in which there is a distention of its pelvis with pus. In the pyonephroses 
wiiich develop from pyelonephritis it is often difficult to determine just what 
abould be called the initial condition, though certainly any pelvis which holds 
Ofer SO e. e. should be so classified. In cases of infected hydronephrosis the 
imount of pus and the distention of the pelvis may be enormous, often amount- 
I ing to two or three liters. The form of distention varies with the amount of 
hbdiiey deetnicticm and the amount of distention of the pelvis. Where the 
^Jesiou is principally limited to the latter, extensive sclerosis in the kidney 
Iparenchjniiij usually more marked than in hydronephrosis, is often found. In 
eases of double ureter there may be a pyelonephrosis or pyonephritis of only 
half the kidney* In one of our cases, Mrs. P., there was a pyonephrosis of the 
few0r poles of bjfli kidneys associated with calculi. 

The meter, in many cases, presents great thickening with inflammatory 
leactkni about it This is always true in those cases associated with obstruc- 
tioui in iti etnmey and is especially to be noted in the case of stone. 

SYMPTOMS. 

Tnb0 symptoms of a disease presenting so many pathological conditions and 
dependent <m bo many primary causes arc necessarily varied. In acute 
pjelonepkritis there may at the beginning be nothing but high fever 
and Bigna of a severe intoxication. The degree of the fever and the intoxica- 
tion, however, show great variation. Every stage from that of a mild acute 
pyelitis symptom-group up to that of sudden and violent septicemia and uremia 
may be seen. G. E. Brewer (Surg., Oyn,, and Obst., 1906, ii, 485) has called 
attention to a severe type, accompanied by high fever, going to 104° and over, 
rapid pulse, reaching 130, marked signs of intoxication, usually tenderness 
over the kidney affected, and generally slight traces of blood, pus, and albumin 
in the urine. This condition is associated with multiple septic infarcts of the 
kidney, such as are shown in Figure 400. Brewer, contrary to most observers, 
regards this condition as unilateral. He has observed prompt recovery from 
one-sided nephrectomy in a number of cases. Sometimes there is severe pain 
in the side affected, usually in the form of colic. 

The characteristic symptoms of pyonephrosis are pus in the urine, 
pain in the side, tumor in the side, and fever. The pus may be present in 



220 INFLAMMATION OF KIDNEY PELVIS OR PARENCHYMA. 

large amounts. If the ureter of the side affected hecomes closed during a 
period when all the other symptoms are most pronounced, the urine may be 
clear. This condition is known as intermittent pyuria. Pain may be entirely 
absent. It is often present only during acute exacerbations of the condition. 
Tumor is always present when a pyonephrosis reaches large size. It is remark- 
able, however, especially in deep-chested men, how difficult it may be to diag- 
nose increased size, even with large accumulation. Fever is a very variable 
symptom and, with an opened and old pyonephrosis, may be absent for montk 
During exacerbations it may become very high and be associated with marked 
septic manifestations of an acute pyelonephritis. 

The fever is usually of the septic type, going up in the afternoon and 
falling to normal in the morning. There are frequent chills and sweats. Witb 
many cases of pyonephrosis the worst subjective symptoms are those associated 
with the bladder, the constant downpour of pus leading to severe and intract- 
able cystitis. 

It is remarkable how the general health of these i)atients, in some cases, is 
unimpaired for years. Most of the old cases are colon bacillus infections, and 
this may account for the condition. Patients may have large pyonephrotic 
kidneys and show no fever, nor disturbance of general health under long peri- 
ods of observation, even when there are frequent exacerbations. On the other 
hand, many patients fail rapidly in health and soon present evidence of 
metastasis in other parts of the body. Rheumatisms are common, while 
definite joint infectious often occur. 

DIAGNOSIS. 

Pyelonephritis. — The diagnosis of acute septic pyelonephritis is often very 
difficult. This is especially true in the cases associated with septicemia due 
to severe infections elsewhere. There may be no renal or vesical symptoms 
and the urine may be normal. The appearance of small amounts of blood, pus, 
and casts in the urine is suggestive, and this is especially true if there is anv 
tenderness in either kidney. The urine is usually scanty. If the disease is 
markedly double-sided there are almost sure to be uremic developments. AVith 
a known infection in some other part of the body, the sudden onset of pro- 
nounced sjTnptoms of sepsis should be very suggestive. Some of the most 
violent cases come on suddenly, without any warning and without any demon- 
strable trouble elsewhere in the body. This was the case in the patient, H. G., 
C. II. and r., a^re 14, shown in Fi^ire 400. The infecting organism was a 
streptococcus, and the fever suggested typhoid. The blood examination in these 



DIAGNOSIS. 221 

cases invariably shows a high leukocytosis, from twenty to thirty thousand, and 
the polymorphonuclear cells may reach 90 per cent., or higher. The employ- 
ment of indigo-carmin or phenolsulphonephthalein might assist in such a case, 
and certainly, if applicable, a catheterization of the ureters and separation of 
the urines from the two sides would aid in diagnosis, though usually the 
patients are so ill that such procedures have not been carried out. In the 
more chronic cases, when once the abscesses have opened into the pelvis, 
and especially when cystitis has developed, the diagnosis becomes compara- 
tively simple, catheterization of the ureters readily showing the true con- 
dition. 

Pyonephrosis. — The diagnosis of pyonephrosis is made on the clinical symp- 
toms, but, above all, by careful urological examination and catheterization of 
the ureters. Often the diagnosis is made by the cystoscopic examination alone, 
when the pus is seen coming down one ureter. This is particularly striking 
where chromocystoscopic methods are employed. A closed pyonephrosis is 
readily determined by this procedure. 

By a cystoscopic examination the condition of the bladder is determined. 
The separate catheterization of the ureters and collection of the urine will 
yield the following facts: First, whether one or both kidneys are involved in 
the inflammatory process (frequently a pyonephrosis is seen on one side and 
a pyelitis on the other) ; second, the character of the organism, which is ascer- 
tained by cultural and staining methods. It is always of the highest im- 
portance to exclude tuberculosis, which must be thought of in every case. 
Third, the actual secretory power of the two kidneys, determined by functional 
test methods. It should be constantly borne in mind that the function of a 
pyonephrotic kidney may greatly improve under proper treatment. It is not 
wise to draw absolute conclusions from such a test even when carried out for 
hours. It can show that the healthy, or relatively healthy, kidney is capable 
of carrying on the entire function, but it can not give positive evidence 
as to the possibilities of the diseased kidney. This is well shown in the case of 
Mrs. A., in which there was a pyonephrosis of colon origin, due to an impacted 
ureteral stone. In this case we foimd a dilated ureter, the dilatation extending 
to the pelvic brim, where the stone was caught in a close stricture. The kidney 
had been catheterized, and the catheter left in for seven hours continuously. 
A nephrectomy was carried out on account of the condition of the ureter. 
On macroscopic and microscopic examination there appeared to be a great 
deal of normal, functioning parenchyma in this kidney. The functional 
tests also show that it is not the amount of pus nor the distention of the 
pelvis which always determines the amount of kidney destruction. One 



222 INFLAMMATION OF KIDNEY PELVIS OR PARENCHYMA. 

occasionally meets large pyonephroses doing good work. The actual capacity 
of the pyonephrosis can in some cases be measured by injecting the distended 
kidney and measuring the amount injected and the amount recovered, as shown 
in Chapters IX and XVII. It is always well in these cases to be sure that 
the catheter is actually in the pelvis. We had the unpleasant experience in 
one case of distending -the kidney and then not succeeding in getting a back- 
flow, due to valve-like closure at the ureteral pelvic junction, and it is con- 
ceivable that this might lead to very disagreeable symptoms. The ureteral 
catheter, if waxed, will often show the presence of stones in the ureter or 
pelvis. 

An unusual complication, met with by Dr. Hugh Young, is illustrated in 
Figure 323, and recently we had a like experience in the case of Mrs. P. This 
patient presented a mass in the right side. The urine from the bladder 
contained pus and cdon bacilli. Cystoscopic examination showed a normal 
bladder. Both ureters were catheterized and normal urine obtained from 
each side. The patient had given a history of pain in both kidneys extending 
over a period of several years, and was brought into the hospital for an acute 
appendicitis. X-ray pictures and skiagraphs showed large stone? in both kid- 
neys. Operation demonstrated the presence of an acutely inflamed appendix, 
which was removed ; it also showed stones and pyonephrosis in the lower half 
of double kidneys present on both sides. The lower pelves were opened, the 
pus emptied, the stones removed, and the patient recovered. The right kidney 
was done at the same sitting as the appendix, the left kidney three weeb 
later. In this case there were only two ureteral orifices in the bladder, and 
the pus could have been obtained from both kidneys if the catheters had been 
introduced only a few cm. u]) the ureter. The presence of the two ureters and 
the double pelvis would doubtless have shown in a collargol injection, carried 
out in the way described by Voelcker and Lichtenberg. We have had an 
identical* experience in the case of bilateral tuberculosis of the kidney. The 
bladder urine contained pus, but the bladder was not inflamed, and the urine 
from the kidneys was normal. 

X-ray pictures are, of course, essential in all cases of kidney infection, and 
should include both kidneys and both ureters. It is not uncommon, where 
the main sjTnptoms are those of pyonephrosis, to find a stone in the other 
kidney. 

As already noted, even large pyonephroses may not be palpable on bimanual 
examination. Careful percussion of the back and marking out of the areas of 
dulness of the two sides are of great value in some cases and show clearly the 
enlarged kidney on the side of the pyonephrosis. 



TREATMENT. 223 

TREATMENT. 

In considering the treatment of the graver infected processes of the kidneys 
nany factors must be borne in mind. Such questions as : is the infection one- 
lided or bilateral, is the total renal capacity sufficient, is the diseased side still 
aipable of function, is the disease primarily or essentially renal, must be an- 
iwered. The treatment of acute pyelonephritis is essentially a different subject 
from that of the treatment of old pyelonephritis and pyonephrosis, so that 
hese questions are best taken separately. 

Acnte Pyelonephritis. — In acute pyelonephritis of the milder types the symp- 
toms and the treatment, so far as medical measures are concerned, cor- 
respond to those of pyelitis. In every case, if there is a primary focus of infec- 
tion elsewhere in the body, this must be located and treated. If there is any 
)bstruction of the lower urinary tract, this must be removed. Even when 
[here is no obstruction, the use of the retention catheter is of great advantage. 
It can be introduced and left in for days. The patient should always be put 
to bed, kept on a milk or a very light diet, given large amounts of water, and* 
urotropin or helmitol in doses up to 100 gr. a day for the adult, and about 8 gr. 
for infants. In those cases which tend to drag on, an autogenous vaccine should 
be made and employed. It is of advantage in some cases to supplement the 
Heater taken by mouth by salt infusions. 

The surgical treatment of acute pyelonephritis has, up to the pres- 
?nt time, been very limited. It should be restricted to the severest types of 
infection. Surgeons have been deterred from operative procedures in these 
'ases by the conviction that the disease is bilateral. K. G. Lennander 
(yordiskt. Med, Arkiv., 1901, xxxiv, 1) reported several cases in which he 
?eeured recoveries by opening the kidney, removing abscess foci, resecting badly 
iliseased portions, and draining the kidney. Schede, quoted by Kiimmell and 
Graff ("Handbuch der Praktischen Chirurgie," Bergmann u. Bruns, 3rd ed., 
1907, iv, 212), has twice successfully resected the kidney without doing a 
nephrotomy. Wilms (Munschen. med. Wchnschr., 1902, xlix, 476) has like- 
wise reported successful cases and advises that the method be limited to one- 
sided cases. G. E. Brewer (N. Y. Med. J., 1906, Ixxxiv, 361) divides the 
cases into three types: severe with high temperature and marked toxemia, 
requiring nephrectomy; mild, in which the initial temperature may be high 
but begins to fall within 48 hours, and in which the treatment is decapsulation 
of the kidney and opening of any small abscesses on its surface ; mild cases 
which can be treated medicinally. Five eases of the severe type in which he 
did a nephrotomy all died. Eight cases of the severe type, where one-sided 



224 INFLAMMATION OF KIDNEY PELVIS ON PARENCHYMA 

nephrectomy was carried out, all recovered. Decapsulation and drainage in 
6 patients of the milder type resulted in recovery. Several of Brewer's cases 
are most interesting and instructive. In one case a patient had been present- 
ing symptoms for 11 days before coming to his attention. This patient died, 
the only operation performed having been an exploratory incision down the 
kidney. Autopsy revealed multiple septic infarcts of the right kidney and no 
sign of infection elsewhere in the body. The clinical course of several of his 
successful nephrectomies indicated that the disease was one-sided. Brewer is 
especially urgent that in severe cases the sooner the operation is done the better 
the result. Autopsy reports on these cases have almost invariably shown the 
disease to be bilateral. In several cases which have come under our observa- 
tion, where the symptoms have been most fulminant and death resulted in a 
few days, this has been the condition. 

It is of interest that most of these cases of Brewer presented no apparent 
primary focus outside the kidney. This was the case with one of our patients, 
H. G., age 13, Jan. 5, 1910. The patient, a young girl, without any apparent 
cause, began running a high and continuous fever. The temperature ran from 
1021/2° to 104V<>°. Her physician. Dr. Louis Hamman, first suspected 
typhoid, but the blood showed a leukocytosis of over 20,000, and the urine a 
few pus and a few red blood cells. There were no other symptoms except an 
appearance of intoxication and slight tenderness over the right kidney. Per- 
cussion of the back indicated enlargement of this kidney. The operation was 
done at 6.30 P. M. A lumbar incision was made down to the right kidney, 
which was found adherent to its fatty capsule. It was about twice the normal 
size, showed definite and multiple hemorrhagic areas, and nephrotomy dis- 
closed the fact that these were present throughout the kidney in the form of 
infarcts. The condition seemed so serious that nephrectomy was carried out. 
The infecting organism in this case was a pure streptococcus. The kidney, as 
it appeared after removal, is shown in Figure 400. The temperature by mid- 
night had fallen to normal and the pulse to 88. The temperature continued 
to fall, and the patient markedly improved. The temperature in the after- 
noon, however, would go to 99 V^^ or 100°, and on the 18th day after opera- 
tion it suddenly shot to 104° and the pulse to 130. The patient looked ill 
and was very toxic. For three days the temperature ran from 104° to 105°. 
The first day of its elevation was marked by a reduction in the urine out- 
put to 800 c. c On the next day it rose to 2,000 c. c. Five days after the onset 
it dropped down, but the patient continued to have some fever until the 26th 
day after operation. She was discharged on the 37th day after operation 
with still a little pus in the urine but otherwise well; 50 days after the 



TREATMENT. 225 

operation the urine was entirely normal, and the patient has been well for 

more than a year. We have quoted this case in detail because it illustrates the 

fact that, even with severe symptoms, in involvement of the solitary kidney 

improvement can follow medical measures. In this case a milk diet, infusions, 

large amounts of water by mouth, and 10 gr. of urotropin every 4 hours were 

given. In view of this recovery we were impressed with the fact that the 

patient might have recovered without the nephrectomy. Dr. Brewer's fatal 

cstse, in which death occurred from the involvement of a single kidney, the 

other being healthy, showed the other side of the question. His results from 

nephrotomy stand in contrast to those of Lennander and Wilms. This may 

have depended in part upon double-sided involvement in his cases. 

In several cases where we have done a preliminary nephrotomy, a nephrec- 
tomy has subsequently been necessary. An excellent result was obtained in 
another case of multiple abscesses of the kidney by nephrectomy. The patient, 
]Irs. S. F., May 16, 1907, had had symptoms and signs of cystitis for a year. 
On March 13 a vesicovaginal fistula was made. This was allowed to drain and 
the patient was perfectly well until April 14:th, when she suddenly began to 
run a temperature of 101° to 103°, and suffered severely with pains in the 
rigrbt kidney region. On April 17 a few pus cells and the colon bacillus were 
obtained from the right kidney. Her condition grew worse and on the 19th, 
in addition to severe pain, a mass was felt in the right side. The right kidney 
was catheterized and abundance of perfectly clear urine obtained. Unfor- 
tunately no estimation of the function in comparison with the other kidney 
was made. The diagnosis of perirenal abscess led to exploratory incision 
in the back. No perirenal abscess was present, but the kidney was en- 
larged, presented many pin-point abscesses on its surface, and on section was 
foimd riddled with abscesses. A nephrectomy was carried out, the temperature 
dropped to normal, and the patient made an uninterrupted recovery. This case 
again emphasizes the fact that the ordinary urinary findings may be very mis- 
leading as to the condition of the kidney. 

From the above considerations it is evident that the question of the treat- 
ment of the severer cases of this group is a very difficult one. Prompt, efficient 
medical measures, as indicated here and under Pyelitis, must be carried out. 
The diagnosis should always be fortified by separate catheterization of the 
ureters and the employment of the functional tests. Recourse to operation must 
depend on the surgeon's judgment and, when possible, nephrectomy should be 
avoided. This subject deserves more study and careful recording o*f cases. Dr. 
Brewer is apparently the only surgeon who has carried out many nephrectomies 
for this condition. 



226 



INFLAM^IATION OF KIDKEY PELVIS OR PARENCnYMA, 



Chrome Pyelonephritis* — In chronic pyelonephritis the conditions are praisfl 
ticallj similar to those in chronic pyelitis. At the very beginning of the con- 
sideration of the treatment it is essential to determine whether the condition is 
unilateral or bilateral and, if luiilateral, what is the relative functional capacity 
of the other kidney. The medicinal measures outlined for chronic pyelitis 
should be carried out, if tiie kidney presents aiifficient functional capacity to 
justify it, and also if the patient is in good general health and not siifTering 
from the condition. If the disease is one-sided and the patient sniFering from 
it, either in general health, in an intractable cystitis, or in rheumatic manifes- 
tationSy the treatmc^nt should be nephrectomy* Many otherwise incurable 
cystitis cases are thus promptly relieved and the integrity of the healthy kid- 
ney secured. 

In one patient, operated on more than a year ago, at the Cambri(Jge Hos- 
pital, Maryland, great relief from chronic rheumatism followed the removal of 
an old colon bacillus infected left kidney, wiiich still showed considerable func- 
tional capacity. The right kidney in this case was healtliy. The mere presence 
of pus, however, from a kidney is not in itself an indication for operation. It 
should be borne in mind that a chronic pyelonephritis may persist for years 
with practically no local or general disturbances. 

Fyonephrosis.^While chronic pyelonephritis, provided the ureteral drainage 
is free, is a disease on the border line between medicine and surgery, pyoneph- 
rosis is pretiminently a surgical condition. Little can be ho]K?d for by ordinary 
medicinal treatment. Altlmugh rarely curative, marked bpiiefit and, under cer- 
tain conditions, great prolongation of life may follow judicious treatment 
through a renal catheter. Operative procedures can he divideil into two groups 
from the standpnint of their aims : e on s e r v a t i ve, which attempt to cure tho 
disease and preserve the kidney; radical, which cure the disease by removing 
the affected organ. 

Various considerations arc influential in defermiuing whether to attempt to 
save the kidney* First, the cfjndition of the opposite kidney is a matter of 
prime importance. If it is healthy, the diseased kidney can be safely removed. 
Next in importance is the condition of the diseased kidney. An early, acute 
pyonephrosis may be associated %vith very little kidney destruction, and, conse- 
quently, with little imi>airment of its function. Where the function is 
entirely or almost destroyed the operation of choice is nephrectomy. Un- 
der certain conditions it may be imi>ossibIe to undertuke so radical a pro- 
cedure. This is tlie case w^ith patients extremely ill, and with very large 
pyonephroses, when a preliminary drainage of the kidney may be followed by 
a secondary nephrectomy. With both kidneys involved and both secreting, a 




TREATMENT. 



227 



aephrcctomy should never be done. Often tlie most difficult cases to decide 
mrc|rar«I to this jwint are those in which one kifhiej is healthy and the other 
fitiiJ capable of good function. Conservative measures always mean longer 



'VlWiKbl «*#Bi'U 



I 



Fio. 401. — Pyonephhotomy. First Step in Exposure antj Evacuation of Pur Kidney. 
Note posture of patient on bag, thp length and position of th<* iririsiun and the aspirator, 
which hold^ 500 c. c. Tlie sinalk^r drawing above ijhows the relation of the pus to the 
kidney and the relation of the kitlney to the surrounding structures. Note the small 
stone pluggiog the opening of the ureter int43 the pelvis which ia the cause of the pyo- 

^Deph^)ftis, After emptjing the pus, a wide oldening in made into the collapsed kidney. 
ness, less likelihood of absolute cure, and not infrequently must be followed by 
nephrectomy. 

Conskrvative Treat MKXT.—Tlie most conservative treatment of pyoueph- 

roffis 18 evacuation of the pus thron^h a renal catheter and irrigation of the 

plvis. If the disease is unilateral and recent this treatment may greatly 

aeliorate, or even cTire the condition, and it is thus possible, occasionally, to 

eatly prolong the life of a j>atient with a single pyonephrotic kidney. Often, 

0, a single emptying and washing out raay relieve the symptoms for months. 




INFLAMMATION OF KIDNEY PELVIS OR PARENCHYMA- 

Not every case of pyonephrosis can be emptied by a catheter, tbough it ia 
always worth trying, even in cases where it is detennine<l iihimately to o|>erat^ 
because the patient's general condition may be in»proved and the field renAwwa 
more sterile. I 

The conservative operation has a twofold aim; first, relief of the obetju 






-lllf 



V 



n^nhK, 



I «^(n^9t#l;y I 






Fio. 402.--PYoyEPiTROToafY. Secont> Step m E>rucLEATioy of a Large Pyosrsi 

Kidney. The pus having been evaluated, the finger intrmluced into the pus ca v^//I 
readily pushes through the friable kidney substance, but is c becked on reaching t}^^ 
strong, thickened fibrou.s capsule. The finger then sweeps between the capsule nini 
parenchyma, a^ indicated by arrows, until the kidney is entirely free witliin its capsuib 
do^vn to the tiilum, and is peclci^j out, much like an orange detached from its skia, doinj 
to the pole at its stem. The detachment is usually more easily carried out in this way 
than by Ijeginning the separation at the point of original puncture for aspiration. Thia 
intracapsular enucleation obviates a difficult dissection of the kidney outside it^ capgde, 
which often detaclies it at great risk from an adljerent bowel, besides saving much 
time, and n/tiiimizing the dangers of infection following the complete nephrectomy. 
Calculi, when present, should be delivered at this step of the operation. 

tion which is causing retention; and, second, cure of the infection. In cases 
of mild infcH;tion of hydronepbrotic sacs it is cx'casionally possible to do one of 
the plastic operations described in Chapter XVIL It is nsnally wise as a pre- 
liminary procedure to do a nephrotomVj and attempt a cure of the infectian. 
Occasionally it is of advantage to combine a nephrotomy and plastic operatioo. 



TREATMENT, 



229 



! the obfltniction is duo to stone iii the ureter, this can l>e reraoved. Here, 
toOf if there is a large pjouephroais, it is always best to do a nephrotomy. In 
cases where there is stricture of the lower end of the ureter an extra vesical 
i/uplnntation of the ureter may \>v eiirried out, nn nperation we have successfully 
j^erformed in several cases. The procedure is shown in Figures 443 and 444. 






eapfthit* adKcrcrrf 



T 



m 



.^X- 



ilyaftMU 



*IG. 403.^PTONEPHROTosrr. Thikd Step in lNTR.4CAP8m-AE ENtTCLiL\TioN. The kid- 
ney, liberaletl on all sides diiwii to its vasrolar pci!iclc, is grasped by strong forrpps, 
AS shown, close Uy the kidney in order to secure as long a stunip as i)ossible for ligation. 
The clamp should be smooth-edged^ it should give an even pressure, and it must not shp. 



The chief consen^ative operation is nephrutuniy. This is usually a simple 
operation, which means little shock to the patient and no interference with the 
kidney function. As a rnle, a lumbar incision is the best. In very large pyo- 
nephroses this nuiy be lateral, or even ventral, and still be extraperitoneal, 
^The operation should always lie carried on outside the peritoneum. After ex- 
sing the kidney, as shown in Figure 401, it is of advantage to draw off the 



230 



INFLAmfATIOK OF KIDNEY PELVIS OR PARENCHYMA. 



pus in a large syringe. Tliia prevents extensive soiling of the field of op^ntioo. 
A drainage tiil>e is inserted into the kidney through an opt^ning made by pliiog. 
ing a blunt clamp into it. The oj^eniiig i>f a large pyonej^hrosis is praclicaHv 
always bloodless, and no attempt should be made to determine the line of va©- 
cnlar cleavage as in an ordinary nephrotomy. When the kidney is not greatly 



TViriUnecl rcrubl capftutt 



^^7/^:^ 



^^J.i^^^'^S^ 



■ , I 



Fig. 404.— PYONEPHROToaiT* Foitrth Step in Intracapsular Envci^eation* The ki/* 
ney is removini witli a« mucli of the thickened cap4*ulo as can safely t>e resected. By 
means of an aneurysm or round needle threaded with stout catgut, the vessels are h^M 
Mow the forceps, which m then removed. The cavity is packed with iodoform game 
drains, and brought out through the lumbar incision, which is closed down to a small 
opening at the lower end. 



distended and ciin ]ye readily reached, the landmarks should be sought after 
and the opening made in a vascular zone. If there is an obstruction of tW 
ureter and the kidney is still capable of secreting, this operation is invariably 
followed by a permanent fiatnla in the side. Albarran first emphasis^ed ik 
fact that many of these fistulie would close if a ureteral catheter was intriMluctsi 
at the time of operation and permanently kept in place. In many cases the 
nephrotomy, relieving the pressure and clearing up the inflammation, tUo 
serves to do away wath the obstruction, Kiister, in 100 nephrotomies, note^l 27 
cnres. In some eases where the kidney is completely destroyed and fimctioa- 
lesa there follows prompt healing withont fistula or sinus. On the other hand, 
in certain cases where the pyonephrosis is combined with abscesses in the oor- 



ETIOLOGY. 



2^ 



ieXj the symptoms may not be greatly relieved. It is often necessary in cases 
of multiple i>ockets to open several times. It eertaiiily would be of advantage 
in many cases of pyonephrosis to do an early nephrotomy in the hope of saving 
the kidney. This is an especially important procedure when tlie patient has 
but one kidncv- 

Radical Tukatmknt* — The radical treatment consists in removal of the 
diseased kidney. The indicationa for this operation have already been out- 
lined. According to Kiister, quoted by Wagner (**Ilandbiich der Urologie," 
Frisch u. Zuckerkandl, ii, p. 190), in 143 patients treated by lumbar 
nephrectomy there wa-s a di'atb rate of 16.7 i)er cent., and in 7 potienfs treated 
by transperironejd ni/jthrectomy, a death rate of 57.14 per cent. In 100 
nephrotoniit's llitn'e whs a deiitli rale of 17 per cent. Tliese tiijiires mean very 
little. To begin with, iiephrutomy in iisually t-arried out in des|)erate eases, 
and where the disease is fretiueiitly bilateral. In unilateral pyonephrosis the 
death rate of nephrotomy should be almost iu>thing, and certainly the death 

iTate from nephrectoiny is very small* 

The operation of ehoiee in most cases is the intereapsular method, which 

Jean be carried out almost as quickly and safely as nephrotomy. This method 
is shown in Figures 402, 403, and 404. Intracapsular nephrectomy can 
be carried nut perfectly safely after a primary nephrotomy. This method of 
primary nephrotomy and secondary ne]>hrectomy, when necessary, is gaining 
ground every day, and is the ojieration of choice. 

PERIRENAL INFLAMMATIONS. 



ETIOLOGY. 

Perirenal inflammations may follow inflammatory processes of the kidney, 
or develop primarily in the perirenal tissue, or have their origin in the inflflm- 
latory processes from some other organ. The arrangement of the perirenal 
'and pararenal fats (Figs. 40 and 41) indicates how abscesses may spread 
from very distant sources. Ileinrich Stromberg (Folia IJrologiea, Leipzig, 
1910, iv, 533) has gone into this question from the historical as well as the 
experimental standpoint with great care. lie notes that the classical mono- 
graph of Gerota only deals with the question of the fascia immediately around 
the kidney. Limited space does not permit of a thorough review of this work, 
but the reader can grasp the possibilities of the extensions which can take place 
by carefully studying Fipire 31). It is not an uncommon finding to see a peri- 
renal abscess originating from the apjjendix. Almost every surgeon has noted 



232 PERIRENAL INFLAMMATIONS. 

such. Kiister, in 230 cases of perirenal abscess^ has noted that 3 had their 
origin in the appendix. Cases on record have originated in abscesses of 
the liver and the gall passages, also in perforating ulcers of the intestines 
stomach, and pancreas. Tuberculous abscesses from the ribs and vertebra 
are not uncommon. Occasionally, an empyema breaks through the dia- 
phragm and leads to a perirenal inflanunation. By far the commonest 
source, however, is the kidney itself. R. Guiteras (iV. Y. Med. J,, 1906, 
Ixxxiii, 169-178) furnishes some statistics in regard to the source of peri- 
renal inflammations. 

The primary perirenal abscesses develop as the result of trauma and infec- 
tion of a hematoma. In some cases the suppuration does not develop until long 
after the trauma. Abscesses are not uncommon in the course of various infeo- 
tious diseases, notably typhoid, scarlet fever, and smallpox. Many cases ariae 
from puerperal infections. W. Albrecht (Beitr. z. klin. Chir., 1906, 1, 147) 
has furnished an interesting contribution, showing that perirenal abscesses may 
develop from purulent infections of the lower urinary tract. The involvement 
is not from the kidney, but by metastasis tlirough the blood. 

According to Kiister, the common age of occurrence is middle life, males 
are more commonly affected than females, the right kidney region oftener than 
the left. His study is to be found in the report of Woshimasu (Inaug. Diss., 
Greifswald, 1905). That cases do occur in children, however, is sho\Mi bv 
Townsend's report (J. A7n. Med. Ass., 1904, xliii, 1626) and in that of 
G. R Curran {Saint Paul Med. J., 1905, vii, 645). 

PATHOLOGICAL ANATOMY. 

Since the original descriptions of Rayer it has been customary to describe 
perirenal inflammations as sclerotic, fibrosclerotic, and suppurative. The latter 
particularly concern us in this connection. It has been pointed out in the chap- 
ters on stone kidney, tuberculosis of the kidney, and pyonephrosis how com- 
mon it is with such conditions to have the i)erirenal fat disappear as such and 
become transformed into a dense fibrous tissue, adherent to all the surrounding 
organs. Often this tissue takes on a hyalin, almost cartilaginous appearance. 
With this type of perirenal inflammation intracapsular nephrectomy must be 
carried out. 

Often in old stone or tuberculous kidneys the kidney itself is largely re- 
placed by a fatty fibrous tissue which may preserve fairly well the original 
kidney outline. Cases are on record where operators have examined both kid- 
neys through an abdominal incision and found one enlarged and seemingly 



SYMPTOMS. 233 

iiaeased, while the other appeared normal. On the basis of this palpation they 
have removed the enlarged kidney, only to find it an organ which had under- 
gone compensatory hypertrophy, while the supposedly healthy kidney was a 
functionless body of fat. This condition is shown in Figure 314. 

In perirenal abscesses the abscess cavity is usually unilocular; yet occa- 
rionally there are many pockets. The common location in reference to the 
kidney is behind it, so that the organ constitutes the anterior face of the abscess. 
Such an abscess is likely to point either in the superior lumbar triangle or in 
Petit's triangla Occasionally the abscess is in front of the kidney. Such a 
ease is reported by H. Mallins (Lancet, 1901, ii, 913), where the abscess rup- 
tured into the peritoneal cavity. Much more frequently these abscesses rupture 
into the intestines. As shown in Figure 39, abscesses which develop below 
the kidney easily descend into the iliac fossa or the ischiorectal fossa, and may 
point in Scarpa's triangle, underneath Poupart's ligament. It is not an un- 
common occurrence for an abscess to develop upward, become a sub-diaphrag- 
matic abscess and break into the pleural cavity. It is fortunate that most of 
them are behind the kidney, for this location tends to the least number of 
complications and is most readily accessible to treatment. 

SYMPTOMS. 

The symptoms of perirenal abscess vary greatly in their onset and course; 
usually they are very insidious and at first present but few symptoms; occa- 
sionally, however, the onset is sudden, with marked pain and tenderness in 
the side, high fever, signs of general infection, etc. In acute cases infection 
at its outset manifests itself, as a rule, by high continuous fever. In the more 
chronic cases the fever may be remittent, and is often intermittent, the rise 
being in the afternoon. In very chronic cases large abscesses are occasionally 
found in which there is no elevation of temperature whatever. 

The pain is also a variable factor. It may be severe and paroxysmal, radi- 
ating from the loin across the body down the leg, or even occasionally up toward 
the shoulder. Often the pain is simply of a dull, aching character, and in some 
cases, of the chronic variety, it is practically absent. 

In early acute stages there may be no enlargement in the side, but sooner 
or later tumefaction is pretty sure to set in. In a thin subject swelling is 
usually readily detected by inspection and palpation. In stout people, with 
thick abdominal walls, it is sometimes quite difiicult to determine. As a rule, 
no definite outline is determinable on palpation, there being only a general 
sense of resistance. Careful percussion of the suspected side and comparison 



234 



PERIRENAL INFLAMMATIONS* 



with the opposite side is a valuable procedure. The areas of dullness in caees 
of perirenal abscess, especially those located on the posterior surface of the kid- 
ney, are greatly increased. Occasionally there may be reddening and swelling 
of the skin. In the acute conditions there is always a marked leukocytosis and 
a relative increase in the polymorphonuclear neutropbylic elements. As a result 
of the intoxicalions and the fever there are often marked secondary anemias. 
Frequently there is great disturbance of the gastro-intestinal system* Unless 
ihere is renal trouble accompanying the perirenal abscess^ the urine may be 
perfectly normal and there may be no symptoms pointing to the urinary 
organs. 

DIAGNOSIS. 

In the very early stages, when there may be no symptoms except fever and 
evidence of infection, the diagnosis is most tliffictdt. In such cases the entire 
body has to be gone over, and it is rare indc<?d that tlie focus of the trouble is 
located. When pain is present a valuable pointer is obtained. In eases where 
pain is present with very little fever, the differentiation from neuralgia, lum- 
bago, and spinal nerve lesion may be quite ditScult, In every case the kidney 
should bo catheterized and its urine carefully studied chemically and micro- 
scopieally; a comparative estimate of its functional activity and that of the 
other side should also be made. As already pointed out, it is not uncommon in 
pyelunephritla, when the infection does not conimnnicate with ibe pelvis of 
the kidney, to tinj urine which contains no pa tlm It Sirica 1 elements. In such 
a case it would he of great value to know the functional value of the kidney 
in comparison with its fellow. If the two kidneys are found functioning 
equally, it is improbable that the *]isea?^e is associatet] with let^ious of the 
kidney. On the other band, a marke<l ditTercnce pnirits strongly to associated 
renal trouble. The presence of fever and the absence of leukocytosis with 
other symptoms of perirenal abscess point to a tulx^rculous infect ioFi. The 
actual giving of tuk^rculin by the opbtlialmic method in such cases further 
fortifies diagnosis. 

PROGNOSIS. 

If promptly submitted to treatment the prognosis is usually very good. It 
depends, of course, on the complications and the patient's condition. Wlien 
not properly treated, some of the acute cases may result in rapid death from 
severe sc-pticemia, hut this is exceptional. In most acute cases a large ab- 
scess will form within two weeks, and is likely to point and often to rupture 



in one of the directions pointed out In some cases the development may be 




TREATMENT. 235 

very slow and extend over many weeks or even months. Spontaneous cures 
occur with great frequency when the abscess ruptures in Petit's or Scarpa's 
triangle. Eupture into the intestines and pelvis of the kidney is much less 
favorable. Eupture into the pleural cavity through the diaphragm is usually 
fatal, but a certain number of cases are on record which have spontaneously 
healed. Rupture into the peritoneal cavity usually means death. 

TREATMENT. 

The treatment for perirenal abscess is surgical. It should be opened and 
drained as soon as diagnosed. The proper incision is in the lumbar region, 
through the superior lumbar triangle, as shown in Figure 173. When the 
ahecesses are very large, or situated at the lower pole of the kidney, the incision 
may be lower and more anterior, as shown in Figure 183. The treatment of 
the kidney will depend on what the preliminary examinations have shown as 
to its condition. If it is functionless, it is often wise to do an intracapsular 
nephrectomy at the same time as the drainage of the perirenal abscess. Let it 
be remembered in every case of perirenal abscess that the condition in fully 
one-half of the cases is secondary to disease in other organs, and it is of the 
highest importance to bear in mind the treatment of the primary condition. If 
the organ primarily affected is the kidney, the rules in regard to treating it 
are those laid down in connection with the various diseases of this organ. 



CHAPTEK XXV. 

NEW GROWTHS OF THE KIDNEY, URETER, PERIRENAL TISSUES, AND AD- 

RENAL GLANDS. 

TUMORS OF THE KIDNEY AND URETER. 

The knowledge that the kidney is the site of malignant growths dates back 
to the very beginning of medicine. There is a vast literature bearing on 
the subject, although it is only within comparatively recent times that it 
has begun to be comprehensively studied. Among the contributions of great 
value should be mentioned the studies of Albarran, Israel, the Mayos, Garceau, 
and the works emanating from the associates of these men. 

These tumors are rare. According to Kiister's general statistics onlj 23 
cases were observed in a series of 30,000 patients. Many busy general surgeons 
may go for an entire year or more without seeing a single case. Up to July, 
1912, there had been but 83 in the Mayo Clinic at Rochester, Minn. (W. F. 
Braasch, J. Am. Med. Ass., 1913, Ix, 274). Garceau ("Tumors of the Kid- 
ney," 1909) found only 90 cases in 3,592 autopsies performed at the Massa- 
chusetts General Hospital and Boston City Hospital. 

These growths can be classified as benign and malignant, and subdivided 
as growths of the renal parenchyma and of the pelvis. The benign growths of 
the renal parenchjTiia are adenoma, angioma, lipoma, and fibroma; and of the 
renal pelvis, lipoma and papilloma. The malignant growths of the parenchyma 
are carcinoma, sarcoma, adenoma, and hypernephroma; those of the pelvis, 
papilloma, epithelioma, sarcoma, and carcinoma. In addition to these primary 
tumors, with which we will deal here alone, there are many secondary growths 
due to metastasis or extension from other organs. 

BENIGN TUMORS OF THE RENAL PARENCHYMA. 

These growths are rare and surgically unimportant. They are usually dis- 
covered accidentally at autopsy. The li pom at a are almost invariably very 

236 



MALIGNANT TUMORS OF RENAL PARENCHYMA. 237 

gjoall, although Kelynack ("Eenal Growths," London, 1898, 64) mentions one 
gj-cwth of this type which attained the size of a child's head. 

Angiomata, invariably small, are mostly situated immediately below 
/1j,« kidney capsule. Fibromata occasionally attain large size, as in the 
*»se reported by R Bruntzel (Berl. hliru Wchnschr., 1882, xix, 745). The 
l;^X^OT in this case weighed 20 pounds and occasioned severe hematuria. The 
^^lUnors when small practically never give symptoms; when large, they give 
-pressure symptoms and occasionally the other manifestations characteristic of 
-renal growths. The treatment, when they are recognized, is surgical, as it is 

oTily by operation that they can be distinguished from the much commoner 

malignant growths. 

BENIGN TUMORS OF THE RENAL PELVIS. 

These growths are extremely rare, with the exception of the papil- 
lomata, which will be described in detail under Malignant Tumors of the 
Bladder, because they, show all the peculiarities of similar growths in the 
bladder, especially those connected with the rapid transformation of parts of 
the growth into malignancy.. Small mesodermal tumors, particularly angio- 
mata, are not uncommon. A. Croisier {Congres frangais de chirurgie, Paris, 
1907, xz, 1009) reports finding a lipoma in a woman of 33. It was -of 
moderate size and removed by operation. Unless they grow to large size or 
cause hematuria, these growths usually entirely escape observation in life. 
When they present these symptoms, or any others characteristic of renal 
tumor, the indication is prompt and radical operation. The chances of any 
tumor of the kidney being benign are too small to warrant considering a 
postponement of operation. 

MALIGNANT TUMORS OF THE RENAL PARENCHYMA. 

It is extremely difficult to go through the immense literature which has 
been written about malignant tumors of the kidney and to gather a clear con- 
ception of the clinical findings and course of the different pathologic types 
of growth now known to us. The hypernephromata and the embryonic tumors 
are the best known, as they are the most frequent. In addition to these car- 
cinomata and sarcomata are definitely recognized, subdivided into round-celled, 
spindle-celled, fibre- and lipo-sarcoma. There is also a semi-malignant type of 
adeno-carcinoma, which has been given the name of malignant adenoma. We 
do not propose to do more here than briefly outline the generally accepted facts 
as to the occurrence, structure, and course of these growths, and to give in more 
detail the same criteria for hypernephroma and embryonic tumors. 



23S NEW GKOWTHS OF KIDNEY, ITBETER, AND ADRENAL GLANDS, 



OecErrence. — In adult life the hypernephroniata are by far the most fi 
quent tumors of the kidneys ; in ehildhood the embryonjata. Some idi 
as to the actual freqiiencj eao be obtiiiTied by reading the reix»rt of Louis 
Wilaon {Aftn, Surg,, 1LH3, Ivii, 534)^ who fannd that in 92 tuDvors studial 
St. Mary's Hospital, Roehester, Minn,^ 71 were hypernephromata, or, as ^jJ 
prefers to call them, mesothelioma ta; 3 embryomata, 1 Wolffian tumor^ 7 s^fJ 
comata, 1 adenoma, 1 fibroma, 3 papillomata of renal pelvis, 4 carcinnmata of 
renal pelvis, 1 sqn anion s-eelled epithelioma* In a ^oup of 120 cases of mn, 
lignant tumor, seeured in the clinic of Jaraea Israel, Arthur Block {FoUq 
Uroloffica, 1909, iv, IGl) repctrts that 86 were hypeniephromata, 6 sarconiata, 

6 papillomata of th« 
kidney pelris, 4 car 
cinomata, 5 embryo- 
mata, 6 papillary 
cysts, and 1 teratinna. 
Edgar Garceau ('*Tu- 
mora of the Kidney,'^ 
1909), in 90 &j)cti- 
mena secured from the 
Massachusetts Gencn] 
and Bciatim City Urn- 
pitals, makes the fol- 
lowing clasaificiition: 
beni gn h\T)ernep|jronii 
of tlie adrenal gland, 
Ij malignant liyjicr 
nephroma of the ad- 
renal gland, 3; peri- 
renal ^arciima, 1; pap- 
illoma of the renal 
pelvis, 1 ; hyperne- 
phroma of the renal 
pflrench\Tna, 45; car- ! 
cinoma of the renal 
parench\Tna, 3 ; papil-J 
lary cyst-adenoma ci4 
the renal parenchyma, 15 ; sarcoma of the renal parenchyma, 2; libroma, 
14; lipoma, snuill, »5. 

Malignant disease of the kidney is found especially in the extremes 



Fig. 405. — Carcinoma or the Km net. Primary carcinoma 
of the kidney in which both cortex and medulla are shown. 
Patulous ducts are seen optming at the papilla. The car- 
cinoma tends to spread in the lx>uridary zone between the 
medulla and tht? I'ortex. The small sf|uare is shown magni- 
fied in the next figure. (Path. Lab., Boston City Hosp., 
No. Bo. 590L) 




MiVLIGNANT TUMORS OF RENAL PARENCHYMA. 



239 



life, in childhood, and after forty years of age. Excluding eases in cbildren, 
and the oldest of whom was 6 years old, iu 30 eases taken from our own and the 
surgical records at the Johns Hopkins Ilr^pital, only one patient was imder 
40 years of age. Tliis Wii8 a young man of ll>, who died without operation 
from a very uuiHgnant hypernephroma. 

Renal Carcinoma, — Tlio firsr aulhur whu definitely demonstrated a cancer de- 
veloping from the adult renal epithelium was Wa Meyer (Areh, /♦ paih, Awd. 
u. Phj/s,, Virchnw, 1S07, xli, 4t>ii), The grt^ss appearance is not cluiracterlstic. 
Starling in the parenchyma, the disease rapidly advances toward Intth the cap- 
siile and the pelvis. It is disseminated by the lymphatics and blood vessels, 
just as in hyperue|)hroma; thrombi may extend through the vena renalis into 
the vena cava. The growth rarely attains large size, as met^istasis is early. 
Strikingly characteristic iu the microscopic structure is the arrangement of 
the cells in masses without th^tiuite form. Occasionally^ the cells are found 
arranged in columns and cords, suggesting the tubular arrangement of tlie 
normal kidney. Sometimes au alveolar type of arrangement is seen, giving 
rise to the so-called alveolar carcinoma. The individual cells often sh^^w irreg- 
Lular karyokinesiSj but are not particularly cancer-like. The diagnosis on the 
ralide rests mure uikui the general arrangenjent than upon the structure of the 
individual cell. The gross appearance of a tumor of this class is W(»ll shown 
in Figure 405. The microscopic appearances, with various degrees of magni- 
fication, are given in the diagram in Figures 406 and 407. The symptoms 
aiKl treatnn*nt of this type of malignant growth are so similar to those of 
frarcoma, hypernephroma, and enibryonia, ihut we shall treat them all under 
<.rie head, whieh follows shortly. 

Ecnal Sarcoma.— Sarcoma of (he kidney is more common than carcinonia; 
it rarely attains gi-eat size, it is not infrequently bilateral, and usually begins 
in the capsule^ but sometimes deep in .the parenchyma. It may be either the 
round-celled or spindle-celled type ; occasionally the cells are stretched out 
into distinct tilx^rs, niaking the so-(*alled fibrosarcoma. The tumors aro usually 
soft and, on section, ju^esent a gray, uneven appearance. The general micro- 
scHipii' a ]i pea ranees of the tumor are well shown in Figure 408. 

Adenoma of the Kidney, — Adenoma, as already stated, may be either benign 
or malignant. The benign form, which is the conim^mer, is usually very 
small, and gives no symptoms whatsoever. It is especially common in chronic 
interstitial neivbritie kidneys and usually occurs after forty years of life. It 
may Ijc single or multiple, it varies in sixe from a pea to a small orange, and ia 
usually attached to the capsule. On section, it is soft, frequently showing 
oi9 of hemorrhage, and is usually a grayish-red color. It may be solid or 




Fig. 406. — Carcinoma op the Kidney. The central picture shows that part of the tumor 
indicated by the square in the last figure, magnified 100 times. The cancer cells are 
packed together in a solid nodule, without any tendency to alveolar arrangement. 
Around the nodule is some round-cell infiltration, lieyond it are a number of irell 
preserved glomenili and tubules; and some isolated cancer foci, shown in the Bznafl 
squares magnifiod alwve. Noto the details of the enlarged cancer cells. In the middle 
dra>\ing there is a mitosis of a cancer cell in a capillary. The two figures below give 
an idea of the cellular arrangement of the typical cancer arcafl. 



210 



Fig. 407. — Carcinoma of the Kidney. The figure above shows a section inc 

and medulla 8 times magnified. There are many separate foci ai varying riae ia Hm 
cortex and the medulla. The cortical cancer areas have a tendency to ooeur in 8RNp 
of glomeruli, the intervening tubular structures Ukewise being involved. Tliis type cf 
distribution differs from that shown in Fig. 406; there the cancer spreadB out like A«nt^ 
while here it seems to jump from point to point, with subsequent fiuloin of flmall ini 
into nodules of larger size. This corresponds to the advance of cancer in : 
organs. The square shown in the upper picture is 80 times magnified in the ^ 
below and to the left. The part of this section included in the rectangular strip m ^ 
tured 300 times magnified to the right, showing the extremely irregular and irildi 
ance of the individual cancer cells. 



242 



Fig. 40S. — Sarcoma of Kidxey. Tn upper fipnire to tho loft is shown the i^rnneral uranRP- 
mont of tho rolls as to (listribiition of tumor. Tho nodulos show central nocrosifl. The 
cort<*x is thinnod, but ftiirly normal. Ono of tho capsular veins above under the capsule, 
sho\\Ti in tho small square, contains a motasta.«?is. The arrow points to a drawing of 
tho same 240 times ma?;nifie(l. Tlie lower picture shows the square indicated in fcnr 
magnification SO times magnified. Xoto Ik^Iow and to tho left the closely packed sar- 
coma colls, and to the rij^ht an<l above tho compressed and inflamed parenchyma irith 
flattened glomonili. Between these two is a zone sho\\in«? marked round-cell infiltn- 
tion. Tlio square in \]\o midst of tho sarcoma tissue, as indicated by arrow, is riuNm 
above, mapniifiod 240 times. TIk* character of tho individual cells is shown in the mig- 
nification 000 times. Note tho irrejcularity in shape of the cells and nuclei, as well as 
in size and staininf];; ono coll shows nonnal mitotic division. (Patholopcal Labotatoiy, 
Boston City Hosp., No. So. 6250.) 



244 










x6oa 



^xJ8 



IB 




I 



245 





Fig. 4U0* — Tubular .Adenoma of the Kidney. The upper picture to the left shaws this 
specimen 8 times magnified. The adenoma occurs io iiodulea separated by deiiM* bands 
of fibrous tissue. The small area shown in the squan* is 80 t*me-s magnifiiHl Ixlow. 
The tubules are irregular in size and have iirj definite arrangement excerpt a ptTsu^trni 
inclination to form end ampulla', like the horns of a ram (a), which is found in the jjer- 
iphery of eml)ryonic kidneys, (Fig. 78.) Some of the tubules are found in the roo- 
nective tissue septa. The small figure to the righf above shows the square indicated 
on the picture below, magnified 240 times. Note that the tubules rorrespond closely 
in structure to the normal collecting tubules. (Path. Lab., Mass. Gen* Hosp., No. 1093,} 





Fig. 410. — Papillary Cvst-adenoma op the Kidney, Figure to the left and above shows 
a section of tumor 8 times magnified. It is made up of a framework of connective 
tiflsue, the main septa are rather thick, the ijeeondary septa more delicate, and the ter- 
tiarj- quite fine. This connective tissue is lined by epitheUal cells w!ut^:h show many 
finger-like projeetioni^ into the cyst-like spaces, Tlie structure of this growth closely 
resembles the well-known papillar>^ cyst-adoiioma of the ovary. The fluid filling all 
of these spaces still persists? in the alveolus below to the left. The square appe^irs in 
the lower figure SO times magnified. The finger-like projection encased in the httle 
frame to the right is shown above, 240 times magnified. Note the delicacy of the fibrous 
eenter, the formed blood vessels, and the epithelial cells covering the papillar>^ .structure* 
There is no definite arrangement in layers of the epithelJal cells, although there U a 
tendency to be multiple, (Path. Lab,, Mass. Gen. llosp., No. 1521.) 

247 




24S NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

cystic. Tlicre are three distinct types: (1 ) the tubular type* where the cell* 
are arranged in tubules; (2) the alveolar tyix-; and {Z) the papillary type It 
is especially this papillary' tumor tluit is inclined to develop into large cystic 
growths. The mieroscopic appearanees of llic simple glan<l tyi>e of adenottu 
are shown iu Figure 409, while the papillary cy^t-adenoma is shu\ru in Figait 
410. ~ 

Before taking up hypernephroma it seems well to state that, with the exc<?p. 
tion of the adenomata, the other mali^iaut tumors of the kidney present th? 



!• nwf proj •dine -^ 



Fig. 41 L — HyFER^TEPmiOMA, Tlic tumor is split longitudinally. Note the small qn 
of kidfit?y tisb'UL' k^ft at the lower poIt% and the rupture of the tumor into the i^ 
the [lapilla^, as well as the tendency to form cystfi. (3^ natural size.) (From H. il 
Young, Jau, 25, 1901.) 



game symptoms as hypernephromata, but uaually run a much shorter coarse, 
Especially malignant are the carcinunuita and tin* round-ctdled sarcomata, Gvn 
eral eaobcxia may be the first symptom. Tumor is not so important as iti 
hypernephroma. Hematuria is common. AccortHng to Garceau, the avenip- 
duration of the diseaise, after the onset of symptoms, is only a few niontba; 




r 

H thi» was true in six of his patients. The diagnosis rests on a thorough urolop- 
H cal and general examination. The data obtained by these examinations, in- 



MALIONANT TT MORS OF RENAL PARENCHMrfA. 



249 




Fig. 412.— Hyperxepfiroma. The tumor mass affecting the right kidney was reraovhe 
through a wide T iricii^ion (Fig. 189). The (^onvulescencc was tinintermpted and let 
patient was Uving 3 years hi^T. Above and to the right about one-half of the intaed 
kidney is seen; in the renal pelvic there are two stones. From the lower calyx 3 tongues 
of tumor tissue closely packed togetlier project into the pelvis, each representing the 
outflow of the tumor from diseased papilla? of the lower calicea. The entire lower half 
of the kidney b replaetxi by the new growth, which m still confined within the true capsule 
of the kidney. In the principal tumor nia^s-s there are three distinct sones, an outer 
dark hemorrhagic^ a middle pale necrotic, and an inner cystic. AH parts of the growth 
present a honeycomlxKl appearance. A nodule of new-growing tumor is shown which 
is advancing down the pyramid and will ultimately break into the calyx and then grow 
out into the pelvis, A plug of tumor is seen in the renal vein (b), (Mrs. M. G„ age 52, 
July 6, 11K>7.) 



250 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

eluding tlio valiiabk' pyelographic pictures, do not differ essriitially from those 
found with hyperuephroraa. It is impossible in au adult, before operation and 



^1 






1g, 413,— Hypernephroma. Enormous? right hypcnipphroma, servinj^ to demonstrate the 
great dirti€ul1ips wliieh may be oiirouiitcTi'd in a radical upLTatiDri. Tht* upjjer part of 
the kidney wna fairly noniia! and the adrenal glands were pt^rfeetly nomial There 
was a small metastasis in the left kidney. The cecum and the ascending eobii were 
intimtitely attaehed to the growth. The transverse cokm was cbsttnided and tortuous, 
the duodejiuio wjis pushed downward and forward, and there were metastaiics into 
the iliac mesenicTy. The genital organs were uninvolved, cxee]>t some anastomoses 
betweini the vessek of the mes4:>salpiux and the tumor. The ureter was not involvcKl. 
The renal vein way free, but the ovarian vein hiid been invatteti iiiiii filleri by the tu- 
mor, which extentied to the vena cAva. (See folloi^ing figure.) There were metas- 
tases to the pleura and inguinal glands, (Mrs. D,, J. H, H.^ June 7, 1901. Autopsy.) 

before patboloj^^ic examination, to distinpnnsh the different types of malignant 
tuuior. In general, lar^e tumors speak for bypertiephroma, as does also bone 
metastasis. The age of the patient is practically of no value. The prognosid 



E=il 



MALIGNANT TUMORS OF RENAL PARENCHYMA. 



251 



ifter operation has not hoen sufficiently founileJ on careful observations to 
jnalify a definite conclusion, though in general it may be stated that few of 
these patients survive more than a year after an operation, and many of them 
^ die within a few months. 



^:^r%a 






f^>-^^-- 



\ 



^a. 414. — CoKONAL Section through Tumor Shown in Last FiGtmE. The honey- 
combed structure is charact-eristic of hyi>pniephroma. In the fonnatbu of the tumor 
both poles have been spiared and nearly all of the luedulia. The growth, in place of 
extending into the pelvis and the renal veins, has broken through the capsule and ex- 
tended peripherally. The normal adrenal gland is separated from the kidney by a layer 
of fat. V* natural size. 



Hypernephroma, — The name hypernephroma we owe to Grawitz {Arch* f. 
foih. Anai. u, Pbys,, Virehow, 1883, xeiii, 3U) and to O. Lubarsch {Ibid,, 
1894, exxxv, 195). Until the time of Grawitz's Jeseription, the tumors, on 
accotint of their yello^v appearance, had been described as liporaata. The con- 
chision of Grawitz was that these (^owtbs developed from small pieces of 
aberrant adrenal gland. Many pathologistst have ilenied this origin^ and the 
eridence to-day is perhaps less conclusive than ever before* The smaller 



252 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLiVNDS, 

growths suggest in their appearance the cortex of the adrenal gland, and are 
mostly benign* The larger growths, which in places look exactly like the small 
ones, resemble much more the sarcomata and careinoniata. The smaller tnmors 
occur moat frequently in t!i6 upper pole of the kidney, but may occupy any 
part of iU They are rarely larger than a walnutj and are usually close to the 

Kidney flAtt0Ti«d[ oat ovtr tumor 



wrvij 



FiQ. 415»— Mesial View op Hypernephroma of Rioht Kidp^y. The kidney here 
cncapgyktes tl e tumor on all sides and the tumor is still conhtied to the retml cavities. 
The patient sirvdved and was well ten years later, l^ natural size. (Mrs. K, M,, age 
61, July 13, 1100.) 



kidney capsule, haviujor a defiuitt? rapsule of their own. In many ciisea they 
are distiitetly degenerating, .showing hemorrhages and liyalin areas. The 
general color is sulfdiur yelhnv. The mieroscopie appearances of the small 
growth strongly suggest that of the normal adrena! gland, and indee<l, occur- 
ring in the adrenal gland, fhey would be spoken of an Bimple hyperplasias. 
There is a net-work of caj>illnries, and on tliese en]iilhirio.s are set the typical 
large, clear eellsj which are polyg<»nal in outline, and c«mtain a rather small 



rf^ 




MALIGNANT TUMORS OF RENAL PARENCHYMA. 



253 



nucleus, lecitliin and glycogen. The larger turaors, which are usually malig- 
naut, are, nevertheless, very distinctly incapsulated. Some of these reach 
enormous size. They frequoiitly spring from the lower pule of the kidney 
and show^ a remarkahle tendency to extend into the calices and pelves as well as 
the veins, (See Figtircs 411-410.) Ko one site is characteristic. Metastasis 
is by the blood current, as a rule. Almost every part of the body can be 
infected, and it is extraordinary how remarkably the metastasis mimics the 



O ^ ^^ 



^^:, 



\ 



Pig. 416.^Tranbverse Section of Tumor Shown in Last Figcrb, Tlie kidney has 
been bisected by the growth so that it is practically separated into two kidneys. 



parent tumor in histologic structure. An excellent illustration of the extent 
of metastasis is shown in Figure 417. It is only very occasianally that the 
regional lymph glands are involved. 

While the sniallor tumors in histologic structure closely follow the adrenal 
type, it is remarkable what variations occur in the large growths; the polygonal 
cells are larger, and are often arranged in alveoli ; abscesses and inflammatory 
pots are common. The microscopic appearances of the growth are well shown 
in Figure 418. Figures 419, 420, and 421 are sections from the same ttimor, 
and serve well to illustrate the multiplicity of the pictures and to explain the 
frequent classificatinn by the French authors of these growths as epithelioniata 
with large, clear cells. The tendency to classify them in this way is due to 




MALIGNANT GROWTHS OF RENAL PELVIS AND URETER. 255 

the influence of Albarran and Imbcrt. It is also this type of tumor that has 
teen so frequently called "perithelioma." Note the close association of the 
tumor cells with the blood-vessel walls. 

Grawitz proffered the following reasons for believing that these growths 
hereof adrenal origin: first, their position underneath the capsule; second, 
the type of cells so similar to adrenal cells; third, the characteristic fatty 
infiltration of the cells, which is never found in the kidney epithelium; fourth, 
the presence of a limited capsule ; fifth, the arrangement of the cells in rela- 
tion to the stroma, so like that of the adrenal cortex. Louis B. Wilson (Ann. 
Surg., 1913, Ivii, 522) entirely throws aside the conclusions of Grawitz and 
accepts those of O. Stoerk (Beiir. z. Anai. u. z. allg. Path., 1908, xliii, 393). 
Wilson, however, differs a little from Stoerk in that he considers that the 
tumors start from little islands of nephrogenic tissue which have never been 
connected with the pelvis of the kidney, while Stoerk holds that they develop 
/rem regenerating convoluting tubules. The arguments used against Grawitz 
are: that the tumors do not contain fat; that they are occasionally present 
in the lower pole of the kidney, where there are never adrenal rests ; that they 
are never in the kidney capsule, where these rests invariably are found ; and 
that they almost invariably contain tubules — a structure never found in the 
adrenal. 

We have no personal observations upon which to base judgment as to the 
relative truth of these two theories. Many authors hold that these growths 
are of coimective tissue origin and some that they are due to a metaplasia of 
the renal epithelium. They are distinguished from other tumors by their slow 
growth, large size, and relative benignity. 

MALIGNANT GROWTHS OF THE RENAL PELVIS AND URETER. 

As already stated, these growths are the papillomata, the papillary epitheli- 
oma ta, the epitheliomata and the sarcomata. 

Papilloma and Papillary Epithelioma. — Albarran and Imbert ("Les tumeurs 
da rein," Paris, 1903, 450) found in a series of 54 cases of primary tumor 
of the renal pelvis and ureter that 22 were papillomata. They usually arise 
in the pelvis of the kidney, but occur also in the pelvis of the ureter. They 
are frequently unilateral but sometimes bilateral. Hurry Fenwick ("Ureteric 
Meatoscopy in Obscure Diseases of the Kidney," 1903, 84) reports recurrence 
in the ureter one year after removal by nephrectomy from the pelvis of the 
fa'dney. In Wilson's paper (loc. ciL) it is stated that there were three papil- 
tomata of the renal pelvis out of a total of 92 tumors. In Bloch's 126 cases 



Fig. 418. — Variation's ix Structure of Different Parts of Tumob Shown in Figuu 
412. The various iiiagnifications and areas from which pictures arc taken are indicated 
by rectangular figures and arrows. The 80 times magnification shows the regular 
alveolar arrangement and the large clear cells. In the 240 times magnifications, at 
the top of the picture, the open structure of the new growth is shown to the right, and 
the more compact structure of the older growth in the center; in this, the nuclei cl the 
cells show great variations in size, shaix;, and staining. In the drawing to the left at 
the top of the picture, the colls appear crowded together, as by pressure. This may 
be due to the influence of the surrounding blood. 



2:^) 



258 NEW GROWTHS OF KIDNEY, URETEK, AND ADRENAL GLANDS. 

6 were papilloraata of the pelvis. The growtli is usually multiple. It is soft 
and velvety and floats out when placed in water. On microscopic examination 
a small central blood vessel is made out, running up the center of each 



■7\ifn 









.'■ ■ ? '" 



;•«?•< 



itjV 






^m 



Fio. 419. — Section througr Edge of Tumor Shown in Figure 41 L To the left is shown 
a portion of the fibrous capsule of the kidtiey. To the riglit the tumor. Note the alve- 
olar structure^ ttie largo clear eelb, the tendency to hciiiorrluigc into the alveoli, aod the 
irreguhirity as to number of layers of cells lining alveoli. About 100 tunes magnified. 
(From J, L. Yatca.) 

prnjeetion and covered with the many layers of typical ptdvic epithelium 
(Fig» 422). The growths are identical in appranmee, lx*th maeroscopically 
and microscopically, with papilloma ta of the bladder. They show the 




Fig. 422. — Papilixjma op the Rexal Pelvis. The picture above on the left shows a k^ 
tion of the kidney from the capsule into the pelvis, which is the scat of papilloma, $ 
times magnified. The medulla contains a cyst-like ca\ity partially filled by a blood clot 
coiitainini; tumor cells. Tliis is shown 300 times magnified, following the arrow. The 
corU'x, containinK numy tubules filled with blood, is clearly shown in the upper figure 
to the right. Tlu; large drawing below shows the portion of the kidney pelvis indioitciL 
by the scjuare in the first figure, 80 times magnified. The finger-like projections, with 
a core of conn(^ctive tissue containing blood vessels, are covered by many-lajrered tnmsi- 
tional epithelium. Note further the sharp delineation between the epithelium and th<5 
connective tissue. One of these finger-like processes, indicated by a rectani^, is see-"^ 
magnified 300 times, jast above. There is a remarkable regularity in the shape of tb^ 
cells and the nuclei and an absence of irregular mitosis, the central blood vessel is thii»- 
walled. (Path. Lab., Boston City Hospital, No. 2754.) 



2G0 



262 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

same tendency to malignancy, not only by invading the deeper tissues, but bv 
metastasis. If this condition has developed we have the papillary epithelioma. 
In the deep parts the cells are grouped together, giving an alveolar aspect 
The renal parenchyma is almost invariably involved. 

Epithelioma. — ^An interesting growth is that first observed by Kundrat 
(Wien. klin. Wchnschr., 1891, iv, 949) and Eundle {Med. Week., 1895, 
iii, 555). These growths originate either in the pelvis of the kidney or in 
the ureter, and are made up of layers of flat epithelium which tend to infiltrate 
in nodules. The growth is something like that found in lip cancer. N. HallS 
(Ann. d. mat. d. org. genito-urin., 1896, xiv, 617) is of the opinion that these 
cancers take their origin from plaques of leukoplakia. Wilson (Joe. cit) 
found one of these cases in his series and attributes it to embryonic Wolffian 
remains. 

Sarcoma. — Sarcomata of the renal pelvis and ureter occur, but are of 
great rarity. They need no description here. 

EMBRYONIC TUMORS. 

The title "embryonic tumor" is most properly given to the interesting 
group of tumors known as neoplasmata, because they definitely develop from 
embryonic kidney structures. The name "nephroma embryqnale maligniun'' 
was given by Birch-IIirschfeld, who was the first to recognize the hiatogBDede 
origin of the growths. They had been previously classified as saroomtti, 
carcinomata, adencxjarcinomata, myosarcomata, etc. They are all chaneto- 
ized by the fact that they contain at least two and sometimes three or &Br 
tissue elements. 

Since F. V. Birch-IIirschfeld's original contribution (Beitr. %. pA 
Anat. u. z. Ally. Path., 1898, xxiv, 343), a number of interesting and Tilt' 
able papers have appeared. Especially valuable are the papers of Mn 
Trappe (Frankfurter Zeitschrift f. Path., 1907, i, 109) ; Heinrich KIm 
(Beitr. z. klin. Chir., 1911, Ixxiv, 9) ; Edward Garceau ("Tumors (rf tl» 
Kidney," 1909, 150) ; Watson and Cunningham ("Geni to-urinary Dit- 
eases," 1912, ii, 236); and Jenckel (Dtsch. Ztschr. f. Chir., 1901, h, 
500). 

These tumors, which represent the majority of the malignant growths in 
children, are rare in adults. Only two perfectly clear cases are on record in 
adults, those of Muus (Arch. f. path. Anat. u. Phys., Virchow, 1899, civ, 406) 
and Jenckel (loc, cit.). Tumors of this class have been found in new-born 
infants. Steffon ("Die nialipien Geschwiilste im Kindesalter," 1905) states 
that in 219 cases 1C8 occurred in the first five years of life. George Walker 



EMBRYONIC TUMOHS. 



203 



s 



FlO . 423. — h MB R \ < » M C I I M < J IL ^ ri" IW- 

ing the definite tubular bodies 
lying in the emliryfitiic i^arroma- 
tous connective tisHUe bast-s. (Max 
Trappe, Fnmkjurter Ztsch^f, Path., 
1907, i, 130.) 



(Ann, Surg., 18f>7, xxvi, 520) in 142 cases 

found 1 U» ill the first live years of life. He 

also notes that in 73 cases the left kidney 

alone was involved, in 58 the right kidney 

alone, and in 37 both kidneys. These em- 

bryonie tiimora of the kidney constitntc a 

large proportion of all malignant tumors of 

childhood. Ilirsehspning in 21) easet< of can- 
cer in children fnnnd the kidney involved 

15 times. These figures contrast with tho 

general cancer statiatics of W. K. Williams 

(BriL Med. /., 1800, ii, 1281 |, which state 

thaty in 8,*>71 cnses of nialigmint tiunorK in 

adnlts, only ,*i per cent, were in thf kidney. 

The characteristic pathologic condition is that the tumors are composed of 

several different kinds of tissue, and that they represent malignant changes in 

the entire tissues of the embryonic kidney, ilax Trappe (loc, ett.) was tho 

first to demonstrate this forcefully and clearly, and has brilliantly illustrated 

it as shown in the reproduction in Figures 
42-3, 424, 425, and 42(i. Note the resemblance 
ljetwt»on the normal embryonic kidney and the 
nnilignant tumor. With the exceptinn of these 
tumors the kidney tumors of childhood are 
mostly bcuign^ — fibronia or liponui, Franek 
(Beilr. z, kUn, Chir,, 1010, Ixvi, 11) reports 
a true hypernephroma in a child 8Vm years 
old, and notes that only three other cases are 
on record. The growths often attain innnense 
size, which esi>ecially impresses the observer 
when the small body of tlie child is compared 
with the growth. They are very irregular in 
shape, mottled in color, often extend into the 
veins like the bypernephromata, oftener still 
into the jKdvis of the ureter, are rarely encap- 
snlated, do not metastasize very rapidly. 
Walker found metastases 55 times in 142 
cases, the lungs and liver bcdng the orpms 

oflenest involved. On microscopic examination, gland strncture, smooth muscle 

fiber, embrj^onic connective tissue, and sometimes cartilage are found. A high- 




FiG. 424. — Emuhvunjc Tumok. 
Section from tumor shown in 
Fig. 423, composed more com- 
pletely of the tubulea. (Max 
Trappe, Frankfurter Ztsch, /. 
Path,, 1907, i, 130.) 




264 NEW GHOWTHS OF TvIDNEY, URETER, AND ADRENAL GLANDS, 



Fio. 425.— Ti'PiCAL Embryonic Kidney 
BETT^'EEN Third a.vd P'ourth Month, 
Note rcmarkaijle re.si:*nib lance to tumor 
shown in Figiin\s 42,5 and 424. (Max 
Trappe, FmiikfurUrZUcL f. Path,, 1907, 
i, 130,) 



power magnification is well i^howTi in Figure 427, taken fn>ni \\\ Gnihmann 
{An-K /, pnth. Anal. u. Phfisiol n. Min, Med., 189U, c^lv, plate 10). The 

iiiuself' liljera, closely reseniljling nor- 
mal muscle fibc^rs, He in a tinely filifil- 
lated tissiHi vvitli few nuclei, Gareeiiu 
(7or. cii.)y in 100 cases, found the stri- 
ated muscle 42 times and the gland 
structures 50 times. The glands are 
lined either by single laye^rs of high 
epithelium or by several layers, and 
often contain pear 1-1 ike Inidies, ^faiiy 
interesting speculations as to the histo 
genetic source of these tissues have 
been made, but no definite conclusions 
attained. The interested reader is re- 
ferred to the original literature. 

The most characteristic fact in re- 
gard to the symptoms is that tumor and 
emaciation are usually the only signs. 
Occasionally there is pain and very 
infrequently hematuria. The patients rarely come to operation except in a 
few of the large children's hospitals, snch as the Great Ormond Street Hos- 
pital in London. l)r, George Waiigh, of that institution, has a number of 
these patients every year. In the SO malignant tumoi^ reported by Wilson 
from the Mayo Clinic at Rochester, Jlinn., only three ]x:^long to this group, 
while Bloch, in 12G eases from Israel's 
clinic, found tive. The tumors ni^uat 
he differentiated from other abdominal 
tumors, which can be done along the 
lines laid down for distinguishing reual 
infections from other varieties. 

The treatment is exclusively surgi- 
cal, the earlier the hf^tter. Taken early 
many of thest* children might possibly 
he saved. The primary death rate is 
high, according to Albarran and Im- 
brrt, 20 por cent. Aciordinj; to Klose Fig 426.-Eni^boement of PREVioua 
, ' . , Section, Showing Cjlomeruli (Max 

there are only two or three eases m the Tnippc, FmnkfurUr Ztsch, /. Path., 

literature where the patient has lived 1907, i, 130.) 




Fig. 428.— FiBiKj-MYXoBARCOMA of Right Si^pra renal Gland. The kidney is 
but is ]3la.HttT€^(i down onto t\w thifk capsule of tht^ tumor and the uret^T is ft 
over the growth. The renal veiiLs are patuloys and free of growth. (Gyn 
J, H. H., reported by Dr, Otic* Hanisay, J. H. IL Bull, 1899. x, 20.) 

in a aeries of 8,378 nialigiiant tumors only one was found primarily ] 
in the supra rernil cbuids, 

N. Briiehanow (Ziftrlir, /. ThiUcmuk, 1809, xx, 38) bas rf*poi 
of 33 casef) from Chinri's Patbological Institute. 




ADRENAL TUMORS. 



267 



Occurrence.— The disease may occur at any age from childhood on. It is 
equally coniinon in both sexes. Kamsay observed it in 36 males and 26 
females. 



6V* /*»//#!. 



Via. 429. — Section of TuMtm axd (iRowTH Shown in Figuke 428. The kidney Is flat- 
tened out hut normal, except for slight hit+Tstitiul nephritis. The lj7ni>h glttiid above 
shows hj7>crplaaia but no tumor ceils- The eenter of tbe tumor is tilled with yel- 
lowish, gelatinous material, and a few* similar spaces are io the tliick walL Tbe inside 
lining of the cyst is almost structureless fibroUH lisHue; deeper in the wall we find ir- 
regular groups of cells varying from round to large cells wth several nuclei. In place^M^ 
there is detinite myxomatous degeneration. Tliere are no remains of adrenal tissue. 
The tumor had tR^en noted in the abdomen one year bi*fore operation, during which 
time it had increased rapidly in size but there were no metastases. The patient, 
operated upon in Jan., 1897, made an uneventful recovery. 



Classificaticn of Tumors.— These tumors may be classified as benign and 
malignant or as solid and cystic, Tbe gn^eatest confusion exists in tbe classifi- 
cation, as would be expected when one considers the rarity of the spt^cimeii. 

The benign tumors, with tbe exception of eyst«» are nsually small, 
rarely give symptoms, and are principally known from accitleiital findings iu 
autopsy examinations* Excellent accounts of these tuinors can be found in 




268 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS^ 

"Tumors of the Kidney," by Garceaii, 1909, 274-301, and in the papei — . 
Blackburn (Am. J. Med. Sci., 1906, n. s., cxxxii, 266) and Briiehanow ^» 
cit). Among the solid growths are lipoma, ganglio-fibroneuroma, nijr^ ' 
angioma, and benign hypernephroma. This latter has been describect l ' 
Virchow as a simple hyperplasia of the parenchyma. It often shows ^, * 
formation which, in some cases, may be quite a large accumulation. 

In addition to the cysts found in this so-called hypemei)hroma of fj,^ 
adrenal, there are also cysts due to echinococcus, and cysts of small size lined 
by glandular epithelium, and finally pseudo-cysts, which are simply accumula- 
tions of blood or senmi. 

In Figures 428 and 429 is pictured a very large cystic tumor of the ad- 
renal, which was removed along with the kidney. This was classified by I>t. 
Otto Ramsay (loc. cit.) as a cystic degeneration of a sarcoma. Careful stu<lj 
of his findings would seem to indicate that we were perhaps dealing with sorM^ie 
simpler form of adrenal cyst, a fact further supported by the patient remai :3i- 
ing perfectly well. Terrier and Lecene (Rev. de chir., 1906, xxxiv, 321), »^:ap 
to the time of their publication, could only find ten cases recorded in {'Most 
literature. 

MalignantTumor s. — While cases of malignant growths are on reco:^Krd 
under various names, such as carcinoma, sarcoma, malignant struma, mali ^- 
nant hypernephroma, and endothelioma of the adrenal, their classificaticzzan 
all together as malignant hypemephromata, which Garceau adopts, seems tfciae 
only feasible plan. 

Under various names the same type of tumor is always described. T^fee 
growths may be either single or multiple. Frequently both adrenals are l n- 
volved. Occasionally the growths develop into very large tumors. Metasta^=!sis 
is likely to occur through the blood-vessels — the lungs, liver, and bones boi^^mg 
predominantly affected. In little children metastasis to the bones of t^Hie 
cranium has been observed, so that at the Great Ormond Street Hospital in 
London such a growth on the skull is regarded as almost pathognomonic of 
primary adrenal tumor. The microscopic studies show groups of cells ^^nr- 
ranged in columns closc^ly resembling cells of the normal adrenal cortex. E!31p- 
tween groups of cells run thin-walled capillaries. The groups of cells sm^re 
further divided by fibrous tissue septa, running in from the capsule wh^cS 
usually surrounds the growth. This arrangement in the malignant tumor is 
closely simulated in the benign. Microscopically, the growths resemble tie 
so-called hypernephroniata of the kidney, but can readily be distinguished 
through the absence of the tubular arrangement found at one point or arother 
in the latter growths. 



ADREKAL TUmOHS. 



269 



I 



I 



Symptoms and Course. — Tho beBigii tumors praeticallj never ^ve rise to 
^mptouis, and, preHunialjlj after attaining their maximum size, which is 
rarely larger than a hazchmt, remain stationary for years. The malignant 
growths sometimes remain stationary for lung periods and, again, they develop 
and metastasize most rapidly. With the 
cystic tumors a palpiiblc mass in the side is 
occasionally observed. Garceau notes that 
the chief symptoms of malignant growths 
are loss of strength and weight, frequently 
aeconipanied by marked gastric and intes- 
tinal disturbances; tumor and pain may nl- 
timately develop, and occasionally the bronz- 
ing of the skin characteristic of Addistm's 
disease. Ramsay (loc, ciL) notxid this 
bronzing in three* out of his 37 cases. 

In addition to the symptoms mentioned, 
a remarkable fcttnre in fully one-half the 
cases recorded in children is a tendency to 
premature development. This not only af- 
fects the genital system and the hair, Init 
also the general muscular development. 
Linser {Betir, z. klin. <*liu\, tlH);j, xxxvii, 
282) suggests that this tendency to rapid 
growth 18 due to the fact that these tumors 
function as adrenal glands. This author 
reports a remarkable case of a boy five 
years and seven months old who, in aasot'ia- 
tion with a hypernephroma of the If^ft kid- 
ney, showed a general degree of Iwdily de- 
velopment equal to a child of at least 15 or 
16. The patient died from an operation 
undertaken for the removal of this tumor, 
and no cause for his premature develop- 
ment other than the adrenal tumor could be found in a careful autopsy inves- 
tigation (Fig. 430), 

Biagiiosis. — The diagnosis rests on the facts brought out in regjird to the 
s;^Tniitoms. In children pigmentation of the skin, or metastases to the bone;^ 
of the head, or premature development, all point to the disease, particularly if 
there is a tumor in the side, Tn the adult the same symptoms, plus a careful 




Fig. 430»— Remahkable Case of 
Giantism Associatkd with Ad- 
KEN'AL TuM<jR. From autopsy 
and clinical record in five-year 
old boy. (P. Liaser^ Heitr, », klttu 
C/aV., \<m, xxxvii, 282.) 





270 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

exclusion of renal tumor by functional test methods and skiagraphy, will 
point to the disease. Absolute diagnosis can never be made except bj 
operation. 

Treatment. — The treatment of a tumor of the adrenal, when diagnosis i^ 
made, is purely surgical. As yet, few such surgical operations have been 
carried out, as the disease is usually found to advance so rapidly that no 
statistics are available to prove the value of surgery. Practically al| 
the operative cases have died in a short time following operation. An 
exception is offered by the cystic growths to which Otto Kamsay's case 
belongs. 

Aa a preliminary to any operation, the relative functions of the two kidneys 
should be determined, and at operation the opposite adrenal should be pal- 
pated to determine, first, its existence, and second, the fact that it is not 
involved by the disease. 

PERIRENAL TTTMORS. 

The first comprehensive report on these growths is contained in the publica- 
tion of O. Mankiewicz (These de Paris, 1887). They are very rare, although 
Rambaud (These de Toulouse, 1904, 247) was able to collect 102 cases out 
of the literature. J. G. Adami (Montreal Med. J., 1896-97, xxv, 621) col- 
lected 41 cases of lipoma in the retroperitoneal tissues. The disease is slightly 
commoner in women than in men, and is rare in childhood. 

Classification. — It is convenient to classify these growths into the cystic and 
solid tumors. Practically all the cystic tumors are benign. The solid are 
both benign and malignant. The commonest cyst is a simple encaj)sulation of 
a perirenal hematoma. Some of the cysts are unilocular. Albarran (Bull el 
mem. Soc. de chir. de Par., 1903, n. s., xxix, 117) has rej)orted a polyocular 
cyst. A. Krogius (Nord, vied. Arhiv., 1904, iv, pt. i, 1-29) reports a case 
where a perirenal cyst communicated with the kidney pelvis, and collects 10 
other such instances from the literature. With the exception of the blood 
cysts and hydatid cysts it would seem that most of these growths developed 
from remains of the adrenal body. They are practically always unilateral, 
varying in size from little growths to immense collections holding hundreds of 
c. c. of fluid. The cyst wall is usually thin, made up of fibrous tissue, and 
frequently lined by a single layer of epithelium. The solid tumors are seldom 
found eoinposod of the single tissue. Ilartmann and Cuneo (**Travaux de 
clnrnrgie anatoni.-elinique/' Paris, 1904) note in 33 tumors that 6 were lipcv- 
mata, 4 fibro-lii)oinata, 9 fibro-myxo-lipomata, 2 fibromata, 3 fibro-myomata, 



PERIRENAL TUMORS. 



271 



5 fibrosarcomataj 2 angio-sareomata, and 2 mixed tumors. These mixed 
tumorSj probably of Wolffian duct origin, are similar to the embryomata found 
in the kidney. They occur generally in adults. Most of these turaora take 
their origin from the tisaues immediately around the kidney, and, with the 
t exception of the sarcomata, do not involve the organ. Some of them attain 
great size, weighing many pounds, 

Symptomi, — ^Exeeptiug the sarcomata, these growths are of slow develop- 
ment and occasion, for a long time, no general or local disturbance except the 
development of tumors. The sarcomata are usually very malignant, leading to 
general metastasis and death within the first year. The lipomata may have 
a cystic feeling equal to that of the true cyst^ Occasionally pain from prea- 
^ sure has been noted, and in a few cases varicocele. 

Diagpioiii* — As a rule, correct diagnosis is made only by exploratory in- 
cision. These tumors are nearly always mistaken for either ovarian or renal 
tumors. 

Prognosis. — The prognosis of these tumors, when of large size, is nearly 
always serious, even if they are benign. 

Treatmcnt^^^Tho treatment is exclusively surgical. In the case of cysts it 
18 comparatively simple. The approach should be througli the lumbar region. 
When the cyst is reached its contents should be evacuated and, when possible, 
the wall then stripped out In the simple cyst, evacuation and drainage will 
suffice, llalignant sarcoma is invariably inoperable. When possible, with the 
non-malignant tumors^ the kidney should be presented, ilicroscopic diag- 
nosis at the operating table is almost indispensable. According to Hartmann 
(he. cit,)f in many cast^^ it is necessary to remove the kidney with the tumor in 
order to be sure of glutting it all out. There is a marked tendency to recur- 
rence even wuth the benign growths. 



CYSTS OF THE KIDNEY, OTHER THAN POLYCYSTIC KIDNEY, 



Cysts of the kidney are rare^ with the exception of the tiny retention cysta 
found in so many cases of chronic interstitial nephritis, which have no surgical 
or clinical Importance. 

Excluding the echinococeua cyst, which has already been treated in Chap- 
ter XXII, the cysts may be divided into three classes: dermoids; retention 
cysts from obliteration of the main collecting tubule or tubules in a papilla of 
the kidney; and serous or sero-hemorrhagic cysts, 

Dermoid Cyiti, — Only three examples of dermoid cyst in the kidney are to 



272 NEW GROWTHS OF KIDNEY, ITRETER, AND ADRENAL GL.VND8. 

be found reported in the litertitiire. The first is referred to by Paget (**Lec- 
tures on Surgical Patliolo^y/' London, 1853, ii, 34). Ilaeckel (Berliner Win. 
Wchfh^chr., 11*02, xxxix, JKU) rei>orti^ the removal of a small typical dt^rmoid 
cyst from the right kidney of a woman, 58 years old, who recovered promptly 
from her operation. Dr. W. S, Goldsmith, of Atlanta (Surg., Gytu, and Ob$L, 
1009j viii, 400), removed a cyst measuring Ty^^^xS cm., ^\ong with thd 
right kidney, from a joimg man 20 years ohl The growth was in the upper 
pole of the kidney and had made it.-ielf manifest by pain and hematuria ovef 
a period of four years. Both this specimen and llaeckers consisted of typical 
dermoid tissuey hair, and snrfaee epithelium. 

EeteEtion Cysts.— Occasiunally marked cystic tranaformation in a kidii«j 
is enennnfered from obliteration of a papilla or of several papillae, Curtis 
and Carlier (Ann. cL niaL d, org. geniio-uriru, 1906, xxi, 1) report tbo develop^ 
nient of stieh a cyst from a ttibercnloui^ f)roce39 in the kidney. In the chapt 
on Tuberculosis and Stone we have already deserilKnl similar transformatio 
of parts of the kidney. Striking specimens are shown in Figures 285 
315. 

Serous or Sero-hemorrhagic Cysts.— Occitrrence. — These cysts arr* app 
cntly qiiile rare. *!. (iuirisbuiirg (*'C\*ntributio!i a Tetnde dea grand*) ky^teu 
rein/' Dissert., Paris, 1003) was able to find, up to the time of hia report, 
only 30 instances. We have bad two cases (Figs. 431 and 432). They are 
met with oftener in women than in men, and usually in patients over 30 ye«n 
of age. 

Etiology. — The cause of these tumors has not been gatigfactoriljr eluci- 
dated; some authors consifler them reteution cysts and others as belonging to 
the same gi^oup as polycystic kidneys. Neither explanation seems satisfac- 
tory. 

Pathologic Ai. Anatomy, — These tumors are almost iuTariably nni lateral 
They vary in size from a diameter of one or two cms. to immense structiircs 
filling the entire abdomen. They are mostly situated at one pole or the other. 
J. Simon (**Contribution a Tetude des grands kystcs eereux du reiu»" Dit- 
sertation, Paris, 190G) noted the location in 36 cases and foimd the lower fKile 
involved 18 times, the upper polo eight times, and other parts of the kidnej 
eight times. 

In many instances the cyst wall has been found quite clear and thin, and 
has coursing in it blotxl %x*s?els derived from the renal vessels. The cyst wall 
is made up of delicate fibrous tissue. Sometimes there is an incomplete lining 
of flattened, single, large, red, epithelial cells. Often the kidney parenchyina 
is but little altered. In some cases the wall of the cyst has beooine greatly 




Fia. 432.— Cyst op Kidney. Multilocwkr kidney cyst. The krge ca\ity has appwoitljr 
resulted from the breaking down and absorption of the walls of many small cyst«. Note 
the intact condition of the two poles, Thia cyst contained 1,000 c. c, of clear fluid. 
The patient reco%'ered promptly and a year later repjorted a normal pregnancy and labor. 
H natural size. (Mrs. L. K., age 34, Apr., 1902, Gyn. Service, J. H, H.) 



POLYCYSTIC KIDNEY. 



both of our patients, A few of the cases on record have l>cen associated with 
hematuria. Recamier (Ami. d, maL d, org, geniio-urin., 181*3» xi, 185) re- 
ports a case where there were severe attacks of pain in the kidney region. 
When the tumor reaches great size it may occasionally cause disagreeable pres- 
I sure symptoms. 

B Diagnosis, — In large tumors, tlie diaipiosia of o%'arian cyst is usually 
^■plAd^. The differentiation from hydronephrosis by ureteral catheterization 
^i»Bd X-ray nieth(.Hls is simple. As a rule^ the diagnosis is made only by ab- 
j dominal exploration, 

H Tkeatmknt.— The treatment is purely surgical. Where it ia possible to 
" do so, a conservative operation, removing the cvi^t and leaving the kidney, 
L should be carried out. This operation was first done and reported by Tuffier 
B{6az. hebd, de med, ei de chir,, Paris, 1897, n. b., ii, 1135). In advocating 
his operation Tuffier stated that the death rate from nephrectomy for this con- 
dition was 45 per cent. In many of the large kidneys, such as the two shown 
in Figure 429 and Figure 4.30, conservative surgery is almost impossible. 
Provided careful preliminary demtmstration is made that the other kidney 
has normal functioning power, npphrertojnv should be possible w^ithout great 
risk- Often the greatest dittienlty is in detaching the cyst from the peritoneum, 
just as in all other tumors of the kidney. For very large cysts the transperi- 
Btcmeal route is the best, while for small ones the lumbar route is better. Occa- 
sionally it ia of advantage to remove a part of the kidney with the cyst This 
might have been aceoniplisbed in the case illustrated in Figure 4**0. There is, 
however, considerable risk of renal fistula, and it is not always easy to exclude 
aome possible malignancy. 



F 



POLYCYSTIC KIDNEY. 



Although rare, this condition has long iK'en recognized. Rayer, in 1839, 
accurately described as well as pictured it in his atlas. 
B Occurrence,— The disease occurs principally at two periods of life, immedi- 
ately before or after birth, and after 40 years of age. 

Sieber (Disch. Zhrht\ f, Vhir., 190r>, Ixxix, 409) in a series of 173 cases 

Bfound 107 occurred between the ages of 40 and 60. In our own clinical merno- 

Branda we find 8 cases recorded, all between the ages of 42 and 57, all 

in women, and all bilateral. Between birth and 20 years old Sieber was able 

to find in the entire literature 32 cases. The disease is a little commoner in 

women than in men. Some influence has been ascribed to heredity. Osier 




276 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

observed cases in a mother and son ("Practice of Medicine," 1905, sixth 
edition, 716) ; Hohne (Dtsch. med. Wchnschr., 1896, xxii, 757) in 
a mother and daughter. The disease is rare, as shown by the fact that 
Garceau found but 10 cases in 2,429 autopsy records of the Boston City 
Hospital. 

Luzzato ("La, degenerazione cistica dei reni," Venezia, 1900) in 226 
cases found that 185 were bilateral. Sieber, in his report of 150 au- 
topsy records, found that 140 were bilateral. That the disease is nearly 
always bilateral is well illustrated by its almost invariable recurrence 
in the opposite kidney after nephrectomy, as shown in a case of Dr. 
Roswell Park ("The Principles and Practice of Modem Surgery," 1907, 
969). 

Pathology. — As a rule, while both kidneys are aflFected, they are not equally 
involved. A common condition is that shown in Figure 433. The cysts arc 
scattered throughout the entire kidney, particularly, however, in the cortex 
and in the two poles of the kidney. The pelvis is frequently markedly de- 
formed. In contradistinction, however, to the narrow necks of the calices 
noted in hypernephroma, they are wide and flattened out, a fact which haa 
been utilized by Dr. William F. Braasch (/. Am. Med. Ass., 1913, Ix, 274) 
in developing a diagnostic difference between the two types of growth through 
skiagraphic collargol pictures. It is not an uncommon occurrence to find stones 
in such a pelvis. 

The cysts vary in diameter from a millimeter to two or more centimeters. 
Their actual size and appearance are well shown in Figure 434. The large 
cysts are formed from the coalescence of smaller ones. The contents are most 
frequently a clear fluid, which may become darkened by hemorrhage. The clear 
fluid is quite watery, and usually contains traces of urea. The cyst wall is 
made up of a thin layer of fibrous tissue upon which is set a single layer of 
cubical epithelium. This epithelium is frequently thrown into folds and 
projections simulating papilloma. When these little inversions are present the 
cystic contents are particularly marked by the large number of cells, which 
are quite free. This proliferation of cells is an evidence of the activity 
of cell growth. The secretory part of the kidney lies between the cysts, 
and, although most frequently markedly changed by a process of parenchymal 
atrophy and overgrowth of fibrous tissue in every way identical with that of 
chronic interstitial nephritis, it is preserved to a remarkable extent^ which 
accounts for the ability of the orirans to functionate sufficiently to sustain life. 
The arnniiremeiit of kidney parenchyma in relation to the cyst wall is shown in 
Figure 435. 



POLYCYSTIC KIDNEY. 



277 



I 



VarioTis theories have been utlvaiietHl as to the cause of tlipse tumors. 
Some authors have attempted to separate the coiigeaital growths from those in 
the adult They are, haw- 



ever, apparently identical. 
The theory that they are 
true new growths, strongly 
6upp4>rted by C*. Nanwerck 
and K* Ihifschmid (Beiir, 
£. pa(h. AuaL u, z, aUg, 
Paih., Jena, 1893, xii, 19), 
has lost jErroimd, and is not 
generally held to-day. 
There is also very little to 
mipport the view originally 
advanced by Virchow that 
they arise from an intersti- 
tial inflammation of the 
papilla*, with a resulting 
occlusion of the tubnies. 

The generally accepti?d 
explanation of the develop- 
ment of these tumors is 
that offered by G. (\ HuIkt 
(^m. J. Anat,, 1904-5, iv, 
Supplement, 17), the es- 
sence of whieh is that in 
embryonic develoiiment a 
perfect union of the tii- 
bnles of the renal vesicles 
with the primary colleet- 

ing tubules has failed. Further evidence in favor 
kthe fact of the frequent m*eurrencc of cysts in the 
ling the cystic kidneys. Siebt^r {loc. ciL) noted this in IM) of his 212 
leases. 

IFoschowitz has also pointed out that in fetnses with double cystic kidneys 
there are frequently other congenital anomalies, such as supernumerary fin- 
gers, etc. It would seem that the condition is dependent on a congenital ten- 
dency to malformation and overgrowth of certain tissues not confined to any 
one part of the body, but leading to more serious consequences in the kidneys 



^*^ " ^'WM^»^- 



f 



Fm. 433. — Bii^TEtiAL Congenital Cystic KmriEYS in 
THK AniLT. (J. H. H., Autopay No. 1258, March 
2, 19U0.) 



of this view is 
liver accompany- 



278 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 



than elsewhe^^rc. The growth seems to be confined to the part of the rtoil 

tubule between tlie glomenihis and the collecting tubule. 

Symptoms and Course.— The evidence is that polycystic disease of the kid' 

ney is a progresgive mm- 
self-linn ting disease, lo 
the cong)enital casea, a 
remarkable iUnst ration of 
which 18 shown in Fij^ 
lire 43 6 y the progreaa ii 
rapid. Most of thm 
fetuses are lx>m deid, 
which is, in part, dtie to 
the gr^at iin pc*d iin<*nt 
which they occastoo t*> 
labor. Thorn* that mr 
vive birth almost iovari* 
ably die in a few days 
either of asphyxia or ta* 
a h i 1 i t y tti breathe^ or 
from uremia* 

The conrae in the 
a d u 1 1 IS variable^ In 
some cases it seeina quite 
rapid and in others veiy 
slow. We recently saw t 
patient, forty ^'cani of 
age, who had no symp- 
toms except tumor and 
practically no decrease in 
renal function^ as evi- 
denced by the phenol- 
sulphouephthaloin and 
i n d i ^t>ca nu i n t esta Thia 
slowness is wntneaaod in 
some of the cases of Sie* 
ber {Dtsch. Zhchr. f, 

Chir,, 1905, Ixxix, 4(59), who were over 80 years old. 

F. V. Milward (Birmhifjham M. Bev,^ 1904, Ivi, 476) divided the diseiae 

into three stages: first, progressive enlargement of the kidneys with no other 




Fig. 434.— Coronal Section of Right Kidney uf Case 
Shown in Figure 433. Tht^ kidney parenctuTna licji 
in all pnris of the kidney bt?tween tlie ryst cavities> 
particularly at the upper pole. */i natural size. 



POLYCYSTIC KIDNEY. 



270 



symptoms (from a few mem t lis to years) ; aocandj attacks of colic and pain 
of a drag^ng character in the kidueyg, with the usual sviiiptoms of renal insuf- 
ficiency, such as headache, dizziness, distiirhancen of vision, anorexia^ flatulence, 
diarrhea, and indeed all the svmploina of chronic interstitial nephritis; third, 
increase of ail renal insufficieiiey syraptoma up to uremic convulsions and 






Fio. 435. — Section of Porth>n of Large Polycystic Kidney. The arterial system la 
injected, showing that well-preservt*d glomeruli are present in i^cat numbers and in 
aU parts of the cortex, even in the thinnest jjepta^ which explains the fact that such 
cystic kidneys are capable of maintaining the renal function to a remarkable degree. 

coma. The complication of suppuration is marked by pain, fever^ and the 
typical alterations of sepsis on the blood. Many die of anuria. Luzzato {loc, 
rfV.) notes this fonn of exitus in 24 out of .'18 deaths* In this third stage 
there are the high blood pressure and left heart hypertrophy characteriRtie of 
interstitial nephritiB, and not a few of the sufferers die from apoplexy. In 
the early stages the urine may he practically norraah In the last stages there 
are invariably the marked polniria and low specific gravity met with in chronic 
interstitial nephritis. Patients with general symptoms of renal insufficiency 




Fio. 43^.— Bilateral Cystic Kidneys in Still-huk\ Baul. There were seven clipu 
on right hand, six on left, a brain cyst and spina bifida. Note the enormous dii^cDticill 
of the alidominal ravity due to the enlarKod kidneyH. The rij^ht kidney is moaoloeulsr, 
the left kidney multilocnlar. Tlie small drawinR almve shows the details of stnicturt 
of the left kidney. (From Dr. J. l\liitridge WiOiams, Jan. 26, 1899.) 

Diaifnosis. — When the disease is locat<^d much more on one side than the 
other, 90 thiit the tiniior is imilateral, there is the Beeessity of didtingiiisbing 
the growth from hydronephrosis and renal tnmor. Ilydronephrosis is readily 
excluded by a catheterization of the ureter If the sac is open, the large pclvifl 




POLYCYSTIC KIDNEY. 



be readily nieasiiret]. If the sac is closed, there is no secretion of the urine, 

which would not Im? the case with polycystic kidney. The pyelograph following 

eoUargol injection affords valuable distinguishing points kjtween neoplagm and 

^^ystic kidney. It cannot, bowcverj be Hcecfjted as final, and some cases can 

^■pnlj be properly dia«^ios<:*d by surgical expltiration down to the growth. On 

^■the left side it is sometimes difficult to separate this condition from a splenic 

^■lumor. We have observed one case of cyst in the tail of the pancreas that 

^rfrom its location closely simulated a growth in the left kidney. 

™ Treatment. — The treatment is lai*gely symptomatic. When general synip- 

toma have arisen, the regidation of the genc^ral habits of diet, exercise, water 

drinking^ and bowel evacuation should be carried out in such a way that as 

^little tax as possible is put upon the kidney* Albarran and Indxr-rt (**Les 

■tumeiirs du rein/' Paris, lt>0;3, 57G) report a list of 34 ncplirectomies with 

^■une primary deaths, one a few weeks after operation, four within a year, 

"Only two of the eases followed np survived i^vvvn years; a niunbt^r were lost 

^^jsight of. Nephrectomy should, under no circumstances, be carried out in cases 

Mof polycystic kidney. 

H Among the palliative procedtires which have been proposed are neph* 
"rotamy, decapsulation, and puncture of the cysts. This bitter method is by 
I far the simplest and Ix-st thing to do. There are, however, no very convincing 
Hreports of permanent relief from it. Probaldy there is a rapid recurrence of 
^nhe fluid. It should be remembered, too, in deciding ujxm such an operation, 
^thnt these patients take anesthetics very badly, as they frequently bring on 

Iaremia and death. 
Unless pieces of the tissue are passeil spontaneously or removed by the 
catheter, a differentiation of the tyi>e9 of renal tumor is not possible. The 

» general symptoms, therefore, can widl bo considired fogelber; the classical 
group consists of three: hematuria, tunmr in the side, and pain. It is the 
exception to meet with all three of these symptoms in the same case. Braasch 
(/. Am. Med. Ass., 1913, Ix, 274) notes that in only 32 of 83 cases were all 
three symptoms present. Hematuria was the initial s>*mptom in 104 of the 
12<) cases rei»orted by Blnch (he, rii.). Braasch observed it occurring in 64 
per cent, of his cases; it was a primary symptom in 26 per cent, of them, and 
the only symptom in 12 per cent. The hematuria is usually total and not 
icmiinal. It is likely to be iuterniittent. Often it is microscopic, but some- 
times it 13 very severe^ large easts of the pelvis and ureter being passed. 



GENERAL SYMPTOMS OF MALIGNANT TUMORS OF THE KIDNEY. 



NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

Tumor, which is the characteristic symptom in children, is much lesa fre- 
quently iiotpd ill the adult. Albarrau am] Inibert {loc. ciL) in 303 cases 
note that tumor was cnmplaiued of or made out by the examiniu^ physi- 
triau 295 times. In liloeh's cases only about 20 per cent, had noted tumor, 
but in 80 i>er cent, tumor was fouu*l on exi^uiinatinn. These findings almost 
exactly correspond to those of Braasch, where tumor was made out in 78 per 
cent, of the cases. In his tumor eases the gruwth was freely movable in only 
6 per cent. J and firmly fixed in 18 per cent, of the cases. 

Pain is very commom It may occur as a dull ache or as violent attacks of 
colic In Braasch's series it was observed in 83 per cent, of the casea, was 
a primary symptom in 32 per eent.y and a single symptom In 18 y^r cent. 

An interesting manifestatiun observed in the male and considered of great 
importance Is the development of varicocele. This symptom was given impor- 
tance years ago by Guyon, Various reasons for it have Ix^en advanced : first, 
direct pressure of the tumor on the spennatic vein; second, pressure of lymph 
glands on the vein; third, it has been suggested that it is due to a gen- 
eral dilating effect caused by absorption from the tiunor. It is, no doubt, 
often due to extension of the nmlignant j>roeess into the renal vein and 
vena cava, resulting in a passive hyperemia of the underlying regions of the 
lnjdy. 

Left alone, the disease progresses continuously and results in death. The 
variations between the different tyjx^s have already Ikk-u fvoiuted ouL Some 
of the bypernei>broma cases live for years* There is often marked cachexia 
early in the pure cancer casea. 

James Israel (f*nirlht /. Cbir,, lf)ll, xxxviii, 10), in 14(> malignant 
tumors of the kidney, has noted that in 8.2 per cent, of the cases there was 
fever. The fever was associated with the end stages of the disease and with 
cachexia. There was also an initial fever, whicli might K* tin* only s^-mptom, 
and in some of the eases a fever which came and went during tlie course of 
the disease. These fevers may be intermittent, remittent, or continuous. 

The differintial diagnosis is not always easy. The investigator usually 
has to work out the cause of pain, hematuria or tumor in the abdomen. The 
presence of varicocele should always suggest the importance of investigating 
for kidney tumor. Since the X-ray has given us positive help in differentiating 
atone kidneys, the presence of tumor, plus hematuria, almost invariably means 
neoplasm. When there is no tumor, but simply pain and hematiiriaj it is 
often necessary to separate the condition from essenJial hematuria. This diag- 
nosis is sometimes impossible to make. The persistence of hematuria, espe- 
cially when severe, is indication for operation. When tumor alone is present, 



^ 




Fio. 437. — View Obtainlo at Oi^kic^tion of Large HypERKEPKROitA. Shows the ex- 
tenmve inciBton necessary for exposure aod enucleation of tumor. Both the XII and XI 
ribs are divided, peraiittinK the liftini; up of the lowerniost part of the thorax hke throw- 
ing open a bam-iloor. (P'or details of incision see Figure 191.) The huge engorged 
veins are seen coiling over the surface of the tumor and running into the peritoneum, 
and all the neighboring viscera. Each of these capsular veins had to be doubly ligatedl 
and cut between, as hemorrhage on injury to any one of them may be enormous. The I 
retract^jr lying directly across the body pulls over the peritoneal sac and exposea thiod 
renal veins choked with tumor masaee. The tumor has the whitish, nodular character J 
characteristic of hypernephromata. Recovery after enucleation with recurrence lat«r, ' 
(Dr. M., San., Oct. 16, 1909,) 



284 NEW GROWTHS OF KIDNEY, URETER, AND ADRENAL GLANDS. 

and there is no secretion from the affected side on eathetorizing the ureter, it 
ia sometimes impossible to distinguish l)etwoen a closed pjonephrosis and a 
renal tumor. It is necessarj' to distingiiisli liet%veen tumors of the kidney and 
tomors of other organs, Miirked deiieiency in function of the kidney of the 
suspected side points to it8 being the site of the disease. If the function, how- 
ever, is found good, the contrary cannot be assumed, bticause in tumors of the 
renal pelvis, as well as hyiJemepbromataj there is frequently no impairment 
of the renal function. Braasch has greatly added to our differentiating power 
by the introduction of his ityelography method for renal tumors. He empha- 
eizes the following points (see Chapter on X-ray) ; first, retraction of one or 
more calices; second, partial obliteration of the pelvic lumen; third, irregu- 
larities of the pelvic cavity; fourth, retraction and dilatation of the upper 
ureter; fifth, abnoi-mal position of the renal pelvis. 



TREATMENT. 

Up to the present time neither a sjK'citic serum, drug, X-ray, or radium 
treatment hay lK?eii successful in \lih disease. The sole effectual treatment 
to-day is operation, and, in our opinion, nephrectomy. Accr^rding to Legiieu 
(*Traite chirurgical d'urologie," Paris, 1010, 827), partial iu>phrectomy has 
been done eight times. In doing nephrectomy, for nialigmuit disease of the 
kidney, it must bo borne in mind that the operation must be radical. The 
entire capsule and upper ureter must come out with the mass and uanally the 
adrenal gland. The widest kind of incision is necessary. These operations 
are fully describt^d in Chapter XIV. The simjjle lumbar route is applicable 
only to those cases in which the kidney is not too greatly enlarged and 
18 freely movable. The l>e8t plan is the para-peritoneal in front, although 
there is no objection to the transperitoneal route when it is found necessary. 
According to Bloch, no patient with a fixed tumor mass has ever remained 
well after operation, and Israel's results, when there is marked varicocele, have 
also been very bad. He, therefore, considers these two findings a contra- 
indication to operation. Very wide incisions are necessary in order to thor- 
oughly control hemorrhage. A good one is shown in Figure 437. The immense 
size of tumor removed through this incision is shown in Figure 438. In 
Figure 439 is illustrated a method of removing a plug of tumor tissue from the 
renal vein. 

Besults of Operative TreatmeJtt.^The permanent as well as immediate re- 
sults depend greatly on the types of tumor and the stage that they have attained. 





438. — ^LoNGiTUDiNAL SECTION OF TuMOR Bhown IN Last Fiourb. Not€ boney- 

oombed appearance. There is a plug of tiie tumor in the renal vein and a plug in the pel- 

I via hanging from an upi:>er papilla. A small amount of renal parenchyma is seen at the 

lower pole. The mjeroscopic sections show etsseutially the same atmcture m those 

pietured iti Figure 418. 



'286 NEW GROWTHS OF IvTDKET, UKETER, AND ADRENAL GLANDS. 

Katin (Amu d mal d, org, genUo-nrin,, 1911, xxix, 200B) reports his results 
an 20 nephrectomies; 7 died imniediatelj from operation, 5 within the 
next two years, and 10 remained well for longer than three years. Bloch in 
12G cases noted a primary death rate of 22.2 per cent. ; of these deaths 12 were 






M" " sip 



.^u\ 



Fy/l 



Fio. 439.^Metkoij of Removing Tumor Pluq from Renal Vein and Vena Cava, A 
circular incision is made around the renal vein, after having placed a purse-string suture 
proximal to it. The cava is compressed above and below the incision of the veins, 
taking care to include the oppoaite renal vein in the pre*jsurc» Tlie tumor and the 
plug are witlidrawn. If adherent, they are carefully lilierated and the purse-string 
drawn tight. A ligature may then be added. Such piug^ are not infrequently found 
in association with hyjiemephromata. 



from prolapse, nine from heart failure within eight days after the operation, 
seven from pneumonia, embed i, and intestinal paralysis. He was able to get 
carefnl records of the remaining eases in 91 instances. Of the patients who 
died with metastasis, it invariably showed within two and one-half years. 
After three years, 27.7 per cent, of the patients were still living, and at the end 
of five years, 25 per cent 



POLYCYSTIC KIDNEY. 287 

Braasch reports a primary death-rate of 11 per cent., and a five years' 
cure in 10 per cent, of the patients. 

The lesson from these statistics is that every suspected case should be 
investigated and treated as early as possible, and there can be no doubt that 
under this plan the number of patients permanently cured will increase in thG 
same proportion as observed in cancer in other parts of the body. 



CHAPTER XXVI. 
SURGICAL TREATMENT OF BRIGHT'S DISEASE. 

GENERAL CONSIDERATIONS. 

In its application to Bright's disease, surgery trenches upon a field pecu- 
liarly the property of internal medicine. Practitioners of medicine since 
Bichard Bright, who made known the disease which bears his name, have gone 
on treating patients suffering with nephritis without the remotest idea of an; 
assistance from surgery. The conception and practical application of surgical 
operation to the treatment of nephritis we owe to the late Gkorge M. Edebohls, 
who reported his first experience in the Medical NewSy 1899, Ixxiv, 481. 

Etiology. — True Bright's disease must be clearly distinguished from infec- 
tious nephritis or its complications. The term nephritis is misleading, becanae 
its proper meaning is definitely associated with the conception of inflammation, 
while Bright's disease is essentially a degenerative process of the cells making 
up the secreting parenchyma of the kidney. It does not fall within the range 
of our purpose in this chapter to consider the evidence upon which the theories 
as to the cause of Bright's disease are based. While it is clearly recognized 
that an acute poison, either a drug like carbolic acid or a toxin of some Imuj- 
terial invaders like that of scarlet fever, can bring about the acute degenera- 
tions of acute nephritis, and that this may continue and develop into chronic 
nephritis, it is not at all certain that all the nephritides are due to the irritation 
of injurious substances in the blood. Some of the chronic changes may well 
be due to lack of inherent vitality in the secretory cells or to improper circu- 
lation of the blood. It is this last idea that inspired Edebohls. No more can 
we consider the complicated pathological and clinical findings. The reader is 
referred to the many text-books on medicine for this information. Here we 
will but recall the elemental facts in regard to the condition. 

Pathology and S3rmptoms. — In acute nephritis, or, as it is better called, 
acute parenchymatous nephritis, the connective tissue framework of the kidney 
is unaffected, there is the well-known cloudy swelling of the tubules and glom- 
eruli. In some instances the change is mostly glomerular. In such cases the 

288 



HISTORY OF SURGICAL TREATMENT. 289 

ine is scanty, containing albumin, blood cells, and many casts; the chlorids 
) not well excreted and there is an accumulation of water in the tissues, 
own as edema, or in the body cavities as ascites. If the tubules are much in- 
ved there follow vomiting, headache, uremic convulsions, and in the extreme 
les convulsions and death. Geraghty and Eowntree have shown that phcnol- 
phonephthalein is well excreted so long as the tubules are intact, but in the 
reme cases, in the last stages, Scarcely at all. The fact to be remembered 
connection with acute nephritis is that in many cases it spontaneously and 
lidly recedes and leaves apparently normal organs. 

Chronic nephritis is divided into two groups, the parenchymatous and the 
3r8titial cases being clearly distinct, although the parenchymatous in its end 
568 may closely resemble the end stages of the interstitial variety. In the 
der parenchymatous cases there occur the edemas and dropsies and urine 
lings of the acute glomerular disease, and in the last stages, in addition to 
3e, uremia and coma. In the chronic interstitial type the glomeruli are 

little affected^ the disease consisting of atrophy of the tubules and over- 
wih of the intertubular connective tissue ; the urine is increased in amount, 
tains few casts, often no albimiin, and a dye, like phenolsulphonephthalein, 
)oorly excreted. The substances accumulating in the blood lead to arterio- 
^roeis, high blood pressure, hypertrophied heart In the end there is uremia 
I exitus. 

The gravity of chronic nephritis rests in the generally accepted belief that 
is steadily, although usually slowly, progressive, and that once set going it 
8 not hold up, and is not influenced, except symptomatically, by any known 
fttment. 

BISTORT OF SURGICAL TREATMENT. 

George M. Edebohls conceived the idea of improving or curing Bright's 
ease by decapsulation of the kidney and by the establishment of numer- 
j new depurating anastomotic vessels by way of the surface of the kid- 
r. Edebohls was led to the conclusion that such an artificial vascularization 
uld improve most and cure some cases of Bright's disease by noting the 
lunate effects in three out of five cases in which he had fixed the kidney 
:h a partial detachment of its capsule, in the presence of a unilateral chronic 
lal inflammation. His first case was that of a woman, twenty yfears old, 
irated upon January, 1898, suffering from mobility of both kidneys and an 
erstitial nephritis. Albumin and casts disappeared permanently from the 
ne one month after the operation, and a year later she was well. 



290 SURGICAL TREATMENT OF BRIGHT'S DISEASE. 

Edebohls next states (1901): "Encouraged by the permanent cures of 
chronic nephritis, I have during the recent years performed nephropexy by 
preference upon patients suffering from chronic Bright's disease. Of 191, 
therefore, upon whom nephropexy was performed, 16 suffered from a chronic 
inflammation of one or both kidneys." 

It is interesting to know that Edebohls' first idea was that the cure of 
Bright's disease in several of his cases was due to the correction of a displace- 
ment of the kidney ; it did not occur to him until later that the decapsulation 
was the efficient agent 

Dieulafoy enters a protest against designating as Bright's disease either 
those cases in which the sole symptom is albuminuria with casts in the urine, 
or those in which but one kidney is affected. If one of the kidneys re- 
mains free, the secretion of the urine is sufficiently assured to obviate the 
uremic sequelae, and the case cannot properly be labeled one of Bright's disease, 
but must simply be designated as a unilateral chronic nephritis. 

Edebohls considered that decapsulation was indicated in all varieties of 
chronic nephritis. His conclusion is expressed as follows: '^I am ready to 
operate upon any patient with chronic Bright's disease who has no incur- 
able complication, or one absolutely forbidding the use of an anesthetic, and 
whose probable expectation of life without operation is not less than a 
month." 

Keginald Harrison (Lancet, 1896, i, 18) arrived at a somewhat similar con- 
clusion by a totally different path. He operated upon three cases, in the first 
of which he cut down upon the kidney of a young man eighteen years of age, 
who had scarlatinal nephritis, expecting to find a suppurating kidney. Instead 
of this, he found a kidney distended with inflammatory products and closed the 
wound. There was a free discharge of blood and urine for several days, and the 
wound healed in the course of ten days. After this incision the excretion of 
urine became far more abundant and the albumin gradually and completely 
disappeared. 

He operated again, this time upon a man fifty years of age for a stone in the 
right kidney, associated with pain, hematuria, and albuminuria; he opened and 
explored the kidney but found no stone. There was a prolonged discharge of 
blood and urine, and following this operation the urine became normal. He 
operated, a third time, upon a woman, forty-four years old, with hematuria and 
occasional albuminuria, believing she had a calculus, and found a swollen, ten« 
left kidney. The patient made a complete recovery following a free drainage 
of the urine, with some blood. 

He argued that the cure wa§ effected by relieving the tension, the operation 



HISTORY OP SURGICAL TREATMENT. 



291 



in each case being a simple section of the capsule of the kidney without decap- 
sulation. 

Let us consider Edebohls' results: 

Edebohls' Results in Seventy-two Cases of Nephritis. 



Variety of 
nephntis 


Deaths 
occurring 
within two 

weeks of 


Ulterior 

deaths 

from 

chronic 

nephritis 


Ulterior 
deaths 
from 
other 
causes 


Unim- 
proved 


Improved 


Cured 


Result 


Total 


Chronic inter- 
stitial 

Right chronic 
interstitial and 
left chronic 
diffuse 

Chronic dif- 
fuse 


4 

2 

1 
7 


8 

4 

1 
13 


2 

1 

3 

3 
9 


1 

2 

3 


4 

1 

13 

2 

20 


10 

1 

3 

3 
17 


3 
3 


31 

4 
25 


Chronic paren-^ 
chymatous. . . 

Total 


12 
72 



In the seventeen cured cases, ten are labeled chronic interstitial, three 
chronic parenchymatous, three chronic diffuse, and one chronic interstitial on 
the left side — ^left chronic diffuse. 

The average time it took the urine to clear up was eight months; in one 
case, it was one month, in another two, and in yet another three. The remain- 
ing cases took varying periods up to twenty and thirty months. The average 
length of time since the seventeen operations was four years. 

This matter is one of such importance that in conclusion we summarize Ede- 
hohls' statements: Of sixteen sufferers from chronic nephritis who came to 
liim for operation, in whom death was immediately imminent by virtue 
of the disease, nine were saved by operation, while in seven the attempt to 
save life failed. Of twenty-two remote deaths none were due to operation. 
Thirteen of the twenty-two ultimately died of chronic nephritis, but of these 
only six received no appreciable benefit. The rest were more or less benefited, 
all experiencing decided improvement in general health and in the condition of 
the urine, while a majority of the twenty appeared to be on the high road to 
complete health, and were expected to figure among the cures in the next report. 

The best results are obtained in cases of edema associated with the passage 
of small amounts of urine. The chances of success lessen in the following 



292 SURGICAL TREATMENT OF BRIGHT'S DISEASE. 

order: edema alone^ edema with uremia and oliguria, edema combined with 
uremia, and finally uremia pure and simple. 

Patients with uremia, edema, and oliguria are more likely to be bene- 
fited than those with edema alone or those with edema and uremia. 

Pousson draws these important practical conclusions: When uremia is 
added to the other manifestations or acute crises of Bright's disease, the out- 
come is less likely to be successful. The expectation of a good result is still 
less when there is a diminution of the urinary secretion without edema. 

Of the seventeen cures of chronic Bright's disease obtained as results of 
the operation, the writer says: "They alone in themselves justify the work 
done, even if the others had experienced no benefit" 

James Tyson and C. H. Frazier report a remarkable case of a girl nine 
years old, who had had a scarlatinal nephritis four years previously. A year 
later she had an acute nephritis with albuminuria and general anasarca. After 
repeated relapses she came under the observation of Dr. Tyson, with general 
anasarca, ascites, albuminuria, and casts. The abdomen was enormously dis- 
tended and the face was so swollen that the eyes were almost closed. 

After considerable treatment she was operated upon by Dr. Frazier, who 
decapsulated the right kidney. 

For the first week after the operation the urine excreted, day by day, 
amounted (in ounces) to 211/2, 421/^, 721/0, 102, 63/60. In ten days the 
ascites and anasarca had entirely disappeared and the albumin had fallen from 
one-half to one-tenth the volume of the urine tested. 

Two months later the left kidney was decapsulated, and three weeks after 
this the patient was noted as free from dropsy. She continued in apparent 
good health for more than one year, when she died after exposure during t 
severe winter. 

INDICATIONS FOR OPERATION. 

The cases of acute nephritis following fevers, more especially the nephritis 
associated with scarlatina in children, occasionally call for operative inter- 
ference. In this group, while bacteria may be present, there is, as a rule, an 
absence of foci of suppuration in the kidneys. When pus is present, such 
cases are perhaps better classified as surgical kidneys, whose treatment has 
been described in Acute Miliary Abscesses of the Kidney. 

The removal of the capsule of the kidney is indicated in the extreme forms 
which have shown a high grade of albuminuria, often associated with rebellious 
anasarca passing over into the stage of anuria, and more especially, with asso- 



TECHNIQUE OF OPERATION. 293 

ciated uremic symptoms. Such cases should be treated by decapsulation, first 
of one kidney, later of the other. When the above signs are present, and there 
is any evidence of suppuration, then both decapsulation and nephrotomy, for 
the purpose of draining the pelvis of the kidney, should be done. 



PREPARATION FOR OPERATION. 

In chronic cases patients are prepared for the operation by rest in bed for 
a few days or a week to lessen the eliminative work of the kidneys and to 
improve the heart, as well as to permit a careful preliminary examination 
of the urine and of the general physical condition. Further, the question of 
food and drink is regulated. The operation done is a nephro-capsulectomy or 
capeulectomy. 

TECHNIQUE OF OPERATION. 

Nitrous oxid and oxygen are used by pressure as an anesthetic, and the 
patient is put face down on an Edcbohls cushion, this posture making both 
kidneys accessible. The usual incision is made from the last rib at the superior 
lumbar triangle down and out about three inches in length. 

The oblique muscles are drawn aside, exposing the retroperitoneal fat, 
Grerota's capsule lying imder the quadratus muscle is punctured, and the kidney 
exposed. The kidney is freed from its surrounding fat by a rapid, blunt dissec- 
tion with the gloved index finger, and, if possible, lifted out of the wound 
without bruising it. A delicate incision is carefully made along the dorsum 
from end to end, only cutting through the capsule. It is sometimes easier to 
make the incision on a grooved director carried along under the capsule. 

Each half of the capsule is gently stripped off the cortex and reflected back 
toward the hilum of the kidney "until the entire surface of the kidney lies raw 
and denuded before the operator" (Fig. 440). Care must be taken not to break 
or tear off bits of adherent inflated kidney substance with the capsule. Ede- 
bohls says: "I have found the smooth surface of the index finger of the rubber- 
gloved hand the best instrument for safely effecting the separation of the cap- 
sule proper from the kidney." The stripped-off capsule is then cut away en- 
tirely close to the hilum. When the kidney is high up, and only the lower 
pole can be reached, Edebohls has peeled off the entire capsule at a finger's 
length in the bottom of the wound and out of sight, and, when impossible to 
excise the capsule thus detached, has left it Drainage, except in rare cases. 




Fig, 440. — Decapsulation of the Kidney for Nefhhitis, The fatty capeule U dr&^ 

away from the kidney ex^wsinf? the true caj^HuIe^ through whith aii incision is made 
along the convex lx>rder of the kidney from {K>le to pule. The capsule is then stripped 
off with a dissector or the finger. Tliia method was originally introiluced by the late 
George H, Edcbohls. 

If there is much edema a pr^jtective drain should be inserted. Duration of 

the operation is from a half hour to OBe hour. The patient 33 kept in bed 
from two to three weeks. 



RESULTS OF OPERATION- 

The sequela* of the operation showed marked improvement in the cardio- 
vascular system^ which forma the surest indication of progress toward recovery. 



RESULTS OF OPERATION. 295 

Cases in which the heart is simply hypertrophied are safe, but if there is any 
decided dilatation or aortic regurgitation, the operation ought not to be done. 
Nine cases, in which there was an albuminuric retinitis, all died within a year 
of the operation. 

A. Pousson ("Chirurgie des Nephrites," Paris, 1909), who has written 
elaborately upon this subject, prefers nephrotomy with drainage, associated 
with antiseptic irrigations of the pelvis of the kidney, to decapsulation, and, 
further, does not claim to cure, but to ameliorate the disease, relegating the 
question of the curative surgical treatment to a consideration of Edebohls* 
claims and operation. 

Although nearly fifteen years have elapsed since Edebohls' publication and 
the treatment is but little practiced, a careful perusal of his clinical records is 
still inspiring. Careful studies, both by animal experiments and human au- 
topsy, have tended to show that there is no permanent betterment of the cir- 
culation. Undoubtedly the freeing of the capsule in the swollen kidneys of 
acute and chronic parenchymatous nephritis brings a temporary improvement 
and may tide the patient over a crisis. Our personal experience in three or 
four cases of chronic interstitial and chronic parenchymatous nephritis has not 
been such as to lead us to much hope in the method, although there has been 
no injurious effect In one case of chronic parenchymatous nephritis the com- 
parative functions of the two sides were carefully studied and then one kidney 
decapsulated. After the operation, by means of the functional tests, the two 
sides were studied for months and no improvement and no loss of function 
noted in the decapsulated kidney. 

The entire subject is really in need of most searching investigation, based 
on more cases in individual hands, where uniformity in investigation can be 
practiced. Even to-day but little can be promised* 



CHAPTER XXVIL 
TRAUMATIC INJURY OP THE KIDNEY AND URETER. 

INJURIES TO THE KIDNEY. 

Although the kidneys seem to be well protected by their anatomical position 
deep in the loin mider the thoracic arch, they are not infrequently injured by 
violence applied to the back or the abdominal walls in the form of a blow 
or crushing force, or by an extreme flexure of the body, or by severe mus- 
cular exertion alone. When both kidneys are injured other organs are usually 
seriously damaged at the same time. Out of 272 cases in Kiister's collectioa, 
142 occurred on the right, 118 on the left, and 12 on both sides. Injuries of 
the kidneys, without any solution in the continuity of the skin, are classified as 
subcutaneous, as well as those accompanied by an open wound due to a stab or a 
bullet 

Injury of the Kidney without an Opening in the Skin. — ^When the right kid- 
ney is injured there is often a fracture of the lower ribs and a coincident injury 
to the liver. Kiister has noted fractures 14 times in 278 cases. A horse- 
shoe kidney has also been ruptured by the kick of a horse (Henry Morris, 
"Surgical Diseases of the Kidney and Ureter," 1901, 162). There is no marked 
difference in the frequency of rupture between the right and the left kidney 
(Frank). 

Injuries may result in nothing more than a decapsulation with or without 
the kidney escaping from the rent. In other cases, due to the bending of the 
kidney across the last rib, the organ may be torn into an upper and lower half. 
Again, the fracture in the substance may be stellate, extending to both poles, 
or it may be so complete as to disorganize the kidney into a pulpy, jelly-like 
mass within its capsule. The pelvis of the kidney alone may be ruptured, or 
may be torn off from its ureter. In other instances the kidney has been severed 
from its vessels. Sometimes the overlying peritoneum is torn and the organ 
escapes into the abdominal cavity. 

O. Hildebrand {Beitr. z, klin. Chir., 1903, xxxvii, 782) reports 12 cases 
of rupture of the ureter, in two of which the renal pelvis was likewise torn. 

The sequelae of the ruptured kidney are : in the first place, acute symptoms 

296 



IN.nJHIES TO THE KIDNEY, 



I 



doe to liemorrhage ponring out behind the peritoneum, often forming a tumor 
of considerable size, the hemorrhage sometimes taking place within the peri- 
toneum; in the second plaee, su^jpirriition, or tlte furniation of a large abscess, 
Jue to the aceimiulation uf bl^jurl mixed with urine iu the loin, 

Posner (Centrlbl. f, inn, ^f€tL, 1906, xxvii, 307) distinguishes two late 
sequela; of trauma of the kidney, one due to bacterial invasion, the other to the 
development of Ih'ight's 
disease, whieli he con- 
siders frequent a n d 
likelj to give rise to a 
similar affection on the 
opposite side. 

Among the remoter 
sequeliD are hydrone- 
phrosis, pyonephrosis, 
jM^rinephric abscess, 
cyst fonnations of the 
kidney, impervious 
ureter, stone in the 
kidney, and aneurysm. 
In Korte's list a subse- 
quent movable kidney 
was noted, and in sev- 
eral crises a hard, in- 
duratt^d area persist- 
ed in the loin. 

Neumann describes 
a case of ureteritis and 
cysto-pyelitis following 
a trauma complicated 
by a secondary gonor- ^^^- 4^1- — Rupture of Aneurysm BETia^EEN Leaves of 
1 P r .. * TT 1 Renal Fatty Capsule. The vast lieniatoma surrounds 

the kidney, spreadin(^ up and down, and following the 
had another case in funnel-shaped ixjekot of the rcmd fascia. (J. H. H. 

which traumata had re- Autopsy No. 1G40, Dec. 11, 1900.) 

suited in the formation of hydronephroBis, whieli bec*ame seeondarily infected 
with gonorrhea. In one of his rases (CnfrlhJ. /. Chir,, VM(\, xxx, 2t)7), 6 years 
after injury, a nephrectomy showed a maliginuit papillary cystoma. 

Symptoms.— The cardinal symptoms of rupture of the kidney are; shock 
and collapse, hematuria, evidence of internal hemor- 




flife 



298 



TRAUMATIC INJURY OF THE KIDNEY AND ITHETEE, 



fhage, an iiiereaHing area of flulhiesa or tenderness, farmi- 
tion of ft tiiinur, often conaiderablt^ in size (Figs. 441 and 442)| ele?!* 
t i o n of t e m ]) e r a t n r e, peritoneal reaction, tympany, pain, 
nausea, simulating peritonitis, followed, it may be at a later date if 
absorption does not take place, by evidences of infection. 

Shock and collapse are often pre?*ent at inire in severe casea, or inij 

appear later witb the evideuers of iiiterioil bemurrba^a*. They are most marM 

in eunjiiuftioii with extenntvc asH^H-ialed injuries. If the lesion is a sliglit one 

the patient may go alRiiit bis busiius:^ for a tinit% sbrpwin^ no signs of illnei«, 

He m a t n r i a, one of the moat signiticant of all the signs of Iiijnry of the 

kidney, nearly al- 
ways appears with- 
in a few houfft, 
though t)ecasionaIly 
it may be delayed, * 
as in a caae of 
Korte's^ where it 
appeared on the 
sixth day. The 
bleeding may ap- 
pear intermittently. 
The amount is 
sometimes exces- 
sive, and the pa- 
tient appears to 



WteT^hrm 






EhloodcltftTn mesccoloini 



Fig. 442-— Ruptuked Anbfrysm, as in Last Figi he, in Trans- 
verse Section. The distributioD uf tbe blood rarrosj^tjnds to 
the dislribution of all fluitl accuniukition in tlie rt^nal fasma, 
such as a perirenal abscewi* or t^Toiis and blomh' eiTnsioos fol- pass large quanti* 
lowing injury. The aeeuniulation is in fnmi of tm\\ lR*lnnd the a: r ,,,,«(i KIim^I • 
kidney, pressing also into the liiluni and the sinua renalis. i . ' 

at other timea it is 

slight, and only discoverable liy the niicrnseope, aj> when it follows the trauma 
involved in palpation of a loovable kidney (Menge), After all evidences of 
hemorrhage have disappeared a .spectroscopic examination may still show 
hemoglobin in the urine, Folluwiiig hematuria, anuria has been observed lead- 
ing to an operation on account uf suspeeled rupture of the bladder. 

Temfwrary sui^jtension of the hemorrhage may be caused by the ureter he^ 
coming plugged by a blood clot, and when this is washed out, the hemorrhag^e 
begins again. It may also «top wb*'ii tin* vessels are tbrrunbosed, to reappear if 
the tlironduis liecomes dislodged. Maas observed hemorrhage in (J'* out of 71 
eases. Ilematnria is absent in extensive and complete rupture of the kid* 
ney, as well as in the opposite condition, where the rupture is merely confined to 




INJUKIKS TO THE KIDNEY. 



2t>9 



tie eftpBuIe or tlie cortex. It is also wanting when there is complete detach- 
ment of the kidney f rojn its ureter. Long after the blood disappears, the urine 
may show tbe presence of albumin and easts. 

Internal II e ni o r r h a g e. — One of the most serious and striking symp- 
toms connected with any cxtenir^ive injury of the kidney h the evidence of an 
inlerDal or retro- or iutra-peritoneal hemorrhage, n&ually associated with more 
or less shock and collapse. It is ijiiportant to distingiiish Ix^twcen simple shock 
and collapse, from which the patient tends to recover quickly under stimulation 
and BUstaining treatment, and the shock and collapse induced hy increasing 
licmorrhagc^ when death umy (x»cur as the surgeon is supinely looking gn. 

The evidences of such increased heinorrliage are growing pallofj rapidity of 
pulse with diminishing volume, and an accurMulatiun forming in the tlank. The 
area of dullness is not affected by the posture of the patient. Above all, the evi- 
dence of a progressive diminution in the hemoglobin is easily demonstrated 
hy any of the familiar instruments. 

Areas of Tenderness or Dnllness. — In the injured side these 
form one of the most striking symptoms of the renal injury, being present in 
all cases except where the shock is profound or where there are other grave or 
painful injuries for a time serving to obscure it. 

Formation of T u m o r. — A tumor of considerable size may be found 
in the loin, Korte in ^il) cases found a tumor in 4, each as large as a man's 
head. In one it was oblong, fol lowing the course of the ureter. The average 
lime for the disap]jearance of the tumor by abis^orfttion is 4 WT*eks. 

Elevation of Temperature. — Elevation of temperature, due to 
3tion of the effusion of blcwxl without infection, is one of the most charac* 
tic signs of convalescence, the temi»crature often rising as high as 102'^ F. 
This febrile elevation must be carefully distinguished from that due to an infec- 
tion. In the non-infective fever, the pulse remains slow and quiet, while the 
general apf)earance and the impression made by the condition of the patient are 
pood. Judging by experiences with extrauterine pregnanf^y, there will be a 
leukocytosis and high difFerential count, so that these important diagnostic aids 
tre of no service in distinguishing between the two conditions. 

Peritonitis. — In many cases of kidney injured by trauma, in a pro- 
nouncedly brief interval of time, often within a single day, a markedly dis- 
tended abdomen associated with muscular rigidity and vomiting give the eur- 
Ifeon grave fears of infection and peritonitis. These symptoms are confusing. 
In Korte's 30 cases peritonitis, however, was actually found only once. True 
^ritoneal cases are usually associated with serious injuries of the liver as well 
us the kidnev. 





300 



TRAUMATIC IKJURY OF THE KIDNEY AKD URETER. 



BiaiTi^osis. — The diagnosis of injuries of the kidney is not difficult as a nale, 
althouph if the patient is in profound collapse it may take a day or two to gn 
a very definite idea of the extent and character of the injuries. We have b 
these cases a condition of shock and the history of injury («XTasionally tiierc h 
no such history), and sometimes a contusion or ecchymo&is in the loin, blood in 
the urine, and a marked tenderness in the loin, with or without an area of dull* 
ness, increasing in size. Associated with these 13 a subsequent eleration of 
temperature. 

Let the patient^ when brought into a hospital, \w catheterized at onee ami 
the urine be examined. At a later date a cystoseopic examination may show 
at once which is the damaged side and the ureteral catheter may reveal the con- 
dition of the opposite side, a datum of importance in case of operative inter- 
ference. The blood should be examined for anemia^ the kidney region per- 
cussed for dullness and palpated for tenderness or tumon The tumor may 
grow while under rd>scrvation for several days. In s<nne eases there is much 
blood in the urine and a marked amouut of shuck with pronuunced peritonea! 
symptoms, conditions which may closely simulate rupture of the bladder. In 
one of Korte*s eases he secured bloodj' urine bv the catheter, but two hours later^ 
finding complete anuria, suspected rupture of the bladder and made a supra- 
pubic opening, which showed the bladder to be intact. In another instance, 
suspecting rupture of the bla<lder, on account of inteose pain to the left of the 
organ, an incision w^as made which also revcaJeJ an intact organ. We believe 
that for the future, with these cases before us, it w^ill Ik? well, having everything 
ready, to prot^eed to the operation, trying first the injecHon of a warm, mildly 
antiseptic fluid into the bladder^ running it in and out as in a vesical irrigation. 
If all the fluid is returned several times, suspicions of rupture may be dismissed* 
In event of an operation it is ahvays a matter of comfort to the ojierator when 
the condition of the opposite kidney can be determined cystoscopically, for he 
has then the assurance that he is not operating upon a solitary kidney and, 
possiblvj that the uninjured kidney is not diseased. 

Treatment. — ^The treatment of rupture of the kidney has entered upon a 
new phase with the recent and better methods of anesthesia — gas and oxygen, 
or gas aided by the addition of a little ether. Formerly, say twenty years ago, 
the important question w^as whether a patient with reduced vitality could well 
stand the added risk of further reduction due to chloroform or ether aneatliesia, 
and a more or less protractetl, difficult operation. These risks were so pro- 
nounced that the waitiug policy w^as, as a rule, adopted* except where the 
patient w^as evidently going from bad to worse. Ti>day an experienced swrgeon 
with a skilled anesthetist ought to be able to tide his patient along safeJjr^l 



INJURIES TO THE KIDNEY. 301 

through an operation without appreciably lowering the vitality. Where the 
special surgeon and the skilled anesthetist are not available, the wisest policy 
is to wait and watch the patient. For the comfort of those who feel it wiser to 
wait, we quote the statistics of Alfred Frank and Korte's Clinic : 

"In all our subcutaneous injuries of the kidneys, aside from those already 
infected and demanding operation for this reason, we had succeeded with a 
purely symptomatic treatment, that of resuscitatives in the beginning, with the 
strictest orders for rest in bed, using the icebag and morphia. When the hemor- 
rhage persists, ergotin, adrenalin, and gelatin injections have been of good 
service. Later, to promote absorption of the exudate, electric sweat baths were 
-used. The average treatment lasted four and one-half weeks, and not a single 
<!a8e was lost." (Archiv f. klin. Chir., 1907, Ixxxiii, 546.) 

Korte operated twice on account of suspected rupture of the bladder, which 
did not exist ; once for traumatic peritonitis where both liver and kidney were 
seriously injured, with death from collapse; once on account of a urinary 
phlegmon with death ; once on account of rupture of the pelvis of the kidney 
with calculus and urinary phlegmon following, where a nephrectomy was done, 
and the patient recovered. 

In other words, out of a series of 39 cases, 33, or 84.62 per cent., recovered, 
while 6, or 15.38 per cent., died. Expressed somewhat differently, out of 30 
isolated ruptures of the kidney Only one patient died. 

Expectant treatment is recommended as long as there is profound shock, and 
the character and extent of the injury are uncertain. To this end abso- 
lute quiet and rest are enjoined. The bladder should be emptied, the urine 
carefully examined, and if there is any severe local pain, an icebag should be 
applied and hypodermics of morphia should be given to diminish pain and 
seenre rest. With much bleeding and the bladder filling with clots, it may be 
necessary to wash it out, even using an evacuator or sometimes opening the 
bladder. If cystitis has developed in a later case, it is better to wash the 
bladder out frequently or to open it and let it drain. 

As the patient begins to react, and as long as there is manifest improvement, 
the waiting and watching policy must be continued, keeping an eye at once on 
the local symptoms in the side, on the urine for hematuria, and on the apparent 
general conditions. 

Should the patient show diminishing hemoglobin, it will be best to operate 

promptly upon the affected side, and if there is evident hemorrhage (as seen 

by the urine), with tension and the formation of a tumor and diminished 

hemoglobin, the side should be opened under gas, the blood clots cleared out, 

and the injury treated. A tumor may form in the side, but if the general con- 



I 



302 



TRAUMATIC INJURY OF THE KIDNEY AND URETER. 



dition of the patient remains good we think it better to continue the waiting 
plan. 

Let an operation \ye done as soon m there is elevation of temperature asso- 
ciated with qniekcning pulse and local tenderness — evidences of infection^ It 
is important not to mistake simple elevation of temperature, due to the absorp- 
tion of the bloodj for an infection. The advantages of operation are: 

1. It relieves nncertaintv as to the future course nf the ease, transforming 
the obscure into the obvious. 

2. The source of hemorrhage is discovered; the hemoirhage promptly 
controlled. 

3. The early operaticm insures apiinst hiter infeetiou. 

4. Such sequela* as nephritis^ hydronephritis, and aneurysm are prevented. 

5. The entire kidney, or a part, may be saved by an early conservative 
operation. 

6. Convalescence is greatly shortened, 

7. Mueh suffering may be prevented, as the patient Joes not then experi- 
ence the distress of clots plugging the ureter or filling the bladden 

The puri»ose of the operation is to ek^ar out the blood clots; explore the 
kidney and its immediate surroundings; discover the source of houHU'rbage 
with the character and extent of injury done to the organ ; then, if possible, to 
repair the damage, or remove the damaged kidney together with the aeeumu- 
lateJ masses of blood. At a later step the operation aims at clearing out all 
dead tissue and providing for abundant* free drainage and removal of infectioua'J 
material. It should be its aim also to discover and reme^ly as far as possible any 
eoniplicatiug injuries to the kidney pelvis* fracture of the ribs, injury to the 
liver and l>o\vel» and peritonitis. 

The patient is put under gas and oxygen anesthesia, a hypodermic of strych- 
nin is given, and, if the hemorrhage has been S€*vere, a salt solution infusion is 
used. If there is any peritoneal reaction or doubt as to the conditions of the 
abdominal organs, the incision sliould be made so as to admit of the opening of 
the abdominal cavity in its anterior part. If no injury to the peritoneum ia 
discovered this may lie closed at once. 

Where a mass of blood is found and cleared out, and there is no active 
hemorrhage, the wound should be packed and drained. By this means T. R, 
Neilaon {Am. J, MeiL Sri., 1898, n* s,, cxxxv, 54) had four cases with three 
recoveries. In two of these cases there were enormous tears of the kidney. 

J. G. Andrew {Lancet, Lon<L, 11)07, i, 21*1) had a case of traumatic rup- 
ture of the kidney, which he treated with the tampon and drain. On the occur- 
rence of a secondary hemorrhage the kidney could not be extirpated, for he had 




INJURIES TO THE URETER. 303 

determined by laparotomy that the other kidney was absent. If a rent in the 
feidney is found, it may be sutured in this way, uniting the fractured organ and 
promoting repair. If the kidney is too extensively torn to continue its function, 
oT if it is pulpified, it should be removed. Sometimes it will be possible to 
save a part, but if the ureter has been torn off, removal will be necessary in 
ixiost cases. 

Before removing one kidney the condition of the opposite organ should be 
ascertained. This can be done by injecting 10 c. c. of a 4 per cent, solution 
4y:i indigo-carmin into the muscles at the beginning of the operation. Then on 
^►:3posing the kidney the ureter can be shut o£[ for a few minutes while the secre- 
-tion is collecting from the opposite side from the bladder. 

In rare cases both kidneys may be injured, as in a case reported by A. L. 

^H'ranklin (Am. /. Surg., 1906, xvi, 1-8). A gi^l 16 years old was run over 

\yy a wagon ; intense pain, followed by vomiting and hemorrhage and a tumor 

ixppeared in the right side. As she was growing weaker an operation was done 

"X8 hours after the injury. The abdomen was opened, the left kidney found 

torn to pieces, and the right one also ruptured. The left kidney was removed 

in its entirety and three-fifths of the right one taken out. Six months later the 

patient sec^med well. 

A stab or a gun-shot wound of the kidney demands active treatment when 
the symptoms are sufficient to indicate that the weapon or missile has reached 
and penetrated the kidney substance; that is, when there is hematuria or an 
accumulation in the lumbar region, or the general condition of the patient indi- 
cates a concealed hemorrhage. 

In such cases expose and explore the kidney, together with the surrounding 
retroj)eritoneal space. A wound of the kidney structure itself may be treated 
by suturing its capsule or passing deep sutures through its structures, followed 
by a free drainage of the retroperitoneal space (A. B. Johnson, Ann. Surg., 
1907, xlv, 124). 

INJURIES TO THE URETER. 

The commonest trauma of the ureter is that produced, either intentionally 
or accidentally, during surgical operations, especially in operations for large 
tumors or malignant growths in the female pelvis. Such accidents are usually 
noted immediately, and can almost invariably be repaired. The general type 
(if such traumata and their repair are shown in Figures 443 and 444. 

The injury next in frequency is that associated with labor, which is usually 
accompanied by extensive injuries of the bladder. Such accidents may follow a 



Rt^:* 







i«&. 




INJURIES TO THE URETER. 



306 



to tlio ureter, Alniost every catlieterization of the ureter prcxhices a sligbt 
injury^ as shown liy the hlootl preHciit in the itrine. Oceasioimlly rough 
or ttuskillfiil handling of the catheter, and especially of a styletted inatru* 
uient, sueli as is employed in open-air cystoscopy, leads to a severe injury. 




( 



ic. 444.— Completed Uretero-vesical Anastomosis. After pulling the ureter down 
and diBplacmg the bladtlLT upward, the anastomosia was effected, after which the open- 
ing made in the vertex was closed. 



"We recently observed a case in which the operator had perforated the left 
ureter just as it left the true pcdvis, and injected a large amount of collargol 
sohition into the retroperitoneal ti^sHne. Such an injury may be very serious, 
and in this case led to death from sloughing and infection. 

A much rarer type of injury is tliat which results from external force 

Wthout any surface wound. C. Blauel {Beiir, z, klin, Chir., 1906, 1, 28) has 

carefully searched the entire literature and found but 13 cases. He poijits out 

Htbat the deep position of the organ, its strong structure, and its comparative 

■ freedom of movement, all gmird agaiimt injuries. In 5 of 32 cases the 

B injury was occasioned by a w*agon or a heavy weight passing over the abdomen; 

in only 2 cases by a violent traction on the bmly and resultant pull on the 

ttreter. In 3 of the 12 cases there wa« death from infection or shock. 

P. Wagner (Centrlhl f. d Iiranl\ ft Tlarn- il SexAhg.. IRIH^ vii, 1) has 
pointed out how often traumatic injury to the ureter results in hydronephrosis. 




306 TRAUMATIC INJURY OF THE KIDNEY AND URETER. 

In some of these injuries there has been reflex anuria. In the fresh injury the 
diagnosis is generally most difficult Usually there is no blood in the urine, as 
the side injured is cut off from the bladder. The appearance of a tumor imme- 
diately after the injury, especially when associated with anuria, is very sug- 
gestive. If the patient is not too much shocked, catheterization of the ureters 
and employment of the usual methods will help. Untreated, the death rate 
is very high. The proper course to pursue is immediate incision, with the possi- 
ble repair of the ureter. When this is impossible, and the patient's general 
condition good, nephrectomy is indicated. When the patient's condition is bad 
the ureter should be brought out on the skin and the nephrectomy left for a 
second operation. 

An occasional source of injury to the ureter is a penetrating bullet or stab 
wound. Morris ("Surgical Diseases of the Kidney and Ureter," 1901, ii, 332) 
reports 5 such cases from the literature. They are almost invariably asso- 
ciated with other injuries; the diagnosis rests on the escape of urine, and as 
the treatment will depend on the kind of injury to tlie ureter, as well as the 
associated injuries of other organs, it needs no special mention here. 



CHAPTER XXVIII. 
MALDEVELOPMENT OF THE KIDNEY AND URETER. 

The development of the kidney from a topographical standpoint is a com- 
plicated process, the various steps in the growth of the parenchyma going hand 
in hand with many changes in the relative position of the entire organ. It is, 
therefore, not surprising that we find a great number of deviations from the 
normal in this portion of the urinary tract. 

In the following description the classification of abnormalities as given by 
Kiister ("Die chirurgischen Krankheiten der Nieren," 1. Halfte, Dtsch. 
Chirurgie, 1896) will be followed and free reference is made to cases he has 
collected from the literature. 

When meeting with an anomaly it is often difficult to explain its cause, 
since the disturbing factors are frequently unknown to us; all we observe are 
the results. In many cases, however, the knowledge of embryology permits a 
fairly accurate surmise. 

The disturbance takes place either in a very early stage, in which case we 
would find the kidney insuflBciently developed and even in the embryonic posi- 
tion; or, in the later stages, when we see the organ fully developed but of 
peculiar form, or in peculiar rdationship to the neighboring structures and to 
the vascular centers especially. Eenal malformations seldom prevent normal 
fxiiiction, except when the minute structures are involved. Such malforma- 
tions may become the origin of tumors and as such endanger life. 

The forms of maldevelopment may be classified under three headings, viz. : 
Maldevelopment I. As to Number. 
II. As to Form. 
III. As to Position. 

MALDEVELOPMENT AS TO NUMBER. 

While complete absence of both kidneys, as observed in monstrosities 
( acephalus and amencephalus) and other forms incapable of life, does not, of 
ccurse, exist in the living, the absence of one kidney is by no means rare. 




Fig. 445, — Solitary Ectopic Kidn^ey and Pelvic Organs Been thhough a Median 
Abdominal Incision. Trendelenburg posture. Tliere was no vaginii an<l no uU'm; 
the uterine appendages were in the inguinal rings, while the kidney was a solitary* ftt«<J 
organ. (From Thus. S. Cullen, Ann. of Surg. Gyn. tfc Obst., 1910^ xi^ 74.) 

life. The anlage of one of the two kidneys then either fails to btid from tie 
Wolffian duct, which may itself be iTtsnffieiently developed, or the anlage paaeei 
ttrough the first stage, but becomes arrested and absorbed before it has com* 




MALDEVELOPMENT AS TO NUMBER. 



909 




leted its ascent The other kidney goes through the various stages of develop- 
ment and is then termed '^solitary kidney/* the "nn&ymmetric^l kidney" of 
Morris. 

This appearance may often he simulated by pathological conditions which 

(cause one kidney to degenerate and a]nio.st or entireiy disappear. 
About 10 per C5ent. of the cases of complete ahsence of one kidney in 
Kiiater's collection were found in newhorn habies. In them the condition ia 
usually associated with other anomalies, such as imperforate anus^ etc. 

If the kidney fails to appear on ono side there is, as luight be supposed, 
partial or complete absence of the corresponding ureter and also, quite fre- 
Lqueutly, uialfonnation or unilateral deficieury of the internal generative organs. 
Df these the conducting portions, vagina, uterus, and tulx^s in the female, and 
^ deferens and seminal vesicles in the male, are more often affected than the 
[glandular organs, ovaries, and testicles. Absence of the corresponding adrenal 
body is less frequent, 
^ L. Polack {These de Bordeaux, 190D, No. 64) has brought together from 
^Rthe litejature 264 case rejKirts and carefully analyzed them. In 153 cases both 
kidney and ureter were aWnt; of this group 89 were left-sided, 56 right- 
ttided, and 8 not stated. The kidney alone was completely ahsent 20 times. 
lln 41 cases there was assfwiatcfl nuilde%'clupmeiit of the sexual organs. Such a 
leondition is well shown in Figure 445* The associated adrenal was absent 25 
[times. A majority of the cases occur in males, W. F* Braasch {AmL Surg., 
[19l!2, Ivi, 720) reports, out of M anomalies, absence of the kidney 6 times. 
We have personally met with this anomaly in 3 cases. In one there 
tuberculosis of the kidney, in aiioth(*r stone and hydronephrosis, and in a 
iBird stone and tuberculosis. All were suspected by examimition failing to 
jfihow the ureter on one side, and all proved by cutting down ou Iwitb the kidneys 
[at operation. In case 1, nothing beyond exploration was carried out; in case 
[2 arid -J, stones were removed. Case 2 died of anuria 2 days after operation; 
3, in spite of the tuberculosis, lived more than a yean 
'The ureter of the single kidney may open iuto the oppt»site side of the blad- 
der, or, more correctly expressed, the ascending kidney may cross the middle 
Hlioe and lodge in the lumbar region of the opposite side (Lyon-Caen and 
^Marmier^ BulL ci mem, de la Sac, anaL de Par., 1007, bcxxii, 400). 

The single kidney generally posscssses an abnormal number of vessels, 3-5 

[arteries and 3-4 veins arising separately from the large abdominal trunks. The 

els on the side of the ahsent kidney are entirely missing; rarely one finds 

limentary or obliterated vessels. An unusual number of vascular twigs 

[supplying the fat or connective tissue in the renal region points to the possi- 



310 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

bility of there being nidiments of a kidney somewhere in the tissues, and if 
there is a number of large obliterated vessels, it may be considered as an indj. 
cation that the kidney has existed and subsequently become destroyed by a 
pathological process. 

The size of the single kidney is often much in excess of the usual dimen- 
sions, although it may not be above the average. This compensatory enlarge- 
ment of the kidney is believed to have its cause, not in an increase in size of the 
individual glomeruli or tubules, as in compensatory hypertrophy of the remain- 
ing kidney after nephrectomy or disease; but in an increase in their number, 
i. e., hyperplasia of the individual constituents of the kidney, brought about 
during the fetal development. 



INSUFFICIENT DEVELOPMENT OF ONE OF THE TWO KIDNEYS. 
CONGENITAL ATROPHY. 

The rudimentary kidney is found in two groups : first, kidneys which de- 
velop from only a portion of the original anlage, and, second, kidneys showing 
the usual form and construction, though much reduced in size. The initial 
stage of these changes seems to occur in early fetal life. There is also usually 
a persistence of the fetal lobulation. The other kidney nearly always shows 
compensatory hypertrophy. 

1. Between the complete absence of one kidney and the rudimentary kid- 
ney are many transition forms, all of which, however, show ureter and vessels, 
though often quite insignificant in development, or obliterated. The size of 
such a kidney varies from 2 to 5 cm. in length, and 1 to 3 cm. in width. 

The rudimentary kidney may or may not have glomeruli and tubules; the 
pelvis and ureter are represented by a formless pouch at the end of a tube or a 
solid cord. The cortex may develop, but not to the extent of producing lobula- 
tion and subdivision of the medullary substance. We then find one solitary 
pyramid or perhaps two instead of the usual number. This would correspond 
to the embryonic stage found from the seventh to the ninth week. 

2. A kidney of abnormally small size may possess normal structures 
throughout, but more frequently there are present atrophic conditions of con- 
siderable extent, so much so that practically the entire parenchyma consists of 
scar tissue. Such cases stand physiologically on the same level with complete 
absence of the kidney. 

Whether these conditions are acquired or congenital can be determined by 
examination of the internal generative organs on the corresponding side. If 
the renal atrophy is of later origin the generative organs are usually unaffecteA 



MALDEVELOPMENT AS TO NUMBER. 311 

It is obvious that in operations on such a kidney it is of the utmost im- 
portance to determine whether the other kidney is present, and, if so, whether 
it is functioning or not. The presence of an atrophic kidney on the supposedly 
sound side must lead to serious consequences. Cystoscopic examination, deter- 
mining the absence or obliteration of the ureteral orifice, is the proper diag- 
nostic means. An abnormally large kidney, with compensatory hypertrophy, 
\rould suggest an atrophic kidney on the other side. Careful study, however, 
is necessary lest the hypertrophy be mistaken for a pathological enlargement 
rortunately such cases of insufficient development of the kidneys are compara- 
tively rare, and, according to Morris, it is found in only 0.02 per cent, of 
autopsies. Atrophy due to pathological causes, however, is more frequent, 0.72 
per cent, of autopsies showing this condition. 

W. F. Braasch (loc, ciL) noticed this atrophic condition 5 times out of 
36 anomalies. Polack (loc. cit.)^ in a series of 264 anomalies, notes this condi- 
tion 16 times. In one little girl he found the left kidney perfectly formed, but 
only about % average size, and composed almost entirely of sclerotic-appearing 
glomeruli. This organ was not functioning ; it was supplied with a ureter and 
was tuberculous. 

It is quite common to find a kidney, in every other way normal, deficient 
in quantitative function as compared with the healthy fellow. 

SUPERNUMERARY KIDNEYS. 

Although from time to time cases have been recorded where more than two 
kidneys were said to have been present, it is doubtful whether the observations 
have always been correct. We know that there are kidneys which are divided 
by a horizontal cortical column into two entirely separate organs with separate 
ureters (partial or complete). Such kidneys have a deep transverse groove 
so marked as to awaken the idea that we have to deal with two kidneys on one 
side instead of one. Some horseshoe kidneys are so markedly lobulated as to 
resemble a semicircle of three or four separate kidneys, especially if more 
than two ureters are seen to leave the parench>Tna. From the descriptions of 
supernumerary kidneys in the literature it appears very probable that the 
majority of them belong in this category. 

A true case of supernumerary kidneys would be that in which the existence 
of more than two anlagen remaining separate throughout the entire process of 
development and ascent could be proven. Double ureters with double orifices 
in the bladder doubtless develop as separate offshoots from the Wolffian duct, 
but they are so close together that the kidney blastema surrounds the ureteral 



312 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

ampullflB in one unbroken mass, which remains undivided during the entire 
period of the development ; and in the adult we find kidneys with double ureters 
appearing as elongated organs, displaying merely a deep transverse groove in 
the middle, although this may also be lacking. 

Supernumerary kidneys, as such, are, therefore, really not in existence, but 
appear as separate ureteral anlagen with parenchymal fusion of varying degree. 

Watson Cheyne {Lancet, 1899, i, 215) has reported an unquestionable case 
observed at operation (laparotomy). The left kidney was in its normal place 
and was normal in size ; the same condition was noted on the right side except 
that in addition to the normally placed kidney there was another 4 inches below 
it in the iliac fossa. Another case is that of Calabrese {Ann. d. maL d. org. 
genito-urin., 1908, xxvi, 1841). For a most interesting review of the condition 
the reader is referred to Gerard {Jour, de Vanat. et de la physiol.. Par., 1905, 
xli, 241-267). 

MALDEVELOPMENT AS TO FORM. 

Such abnormalities are produced in the earliest stages of development in 
three ways: there is abnormal growth of the ureteral bud and corresponding 
abnormal arrangement of kidney blastema around the ureteral ampulla, affect- 
ing one or both kidneys separately and independently from one another; both 
kidneys, being normal in their individual anlage, unite with one another 
before they pass out of the pelvic position; or, both anlagen are abnormal 
regarding ureteral channel and form of kidney blastema, and fuse before 
they ascend. 

The following are the most important representatives of these forms of mal- 
development : 

THE LOBULATED FETAL KIDNEY. 

While in the majority of kidneys the lobulation disappears to a certain 
extent after the fourth year, it may remain throughout life. The lobulation 
corresponds to pyramids or subdivision of such, the deepest grooves indicating 
pelvic divisions. The persistence of lobulation signifies one of two conditions; 
viz., (1) that the growth of the cortex during the postfetal stage did not take 
place vigorously enough to obliterate the depressions on the surface; or (2) 
that the cortical columns wore of such depth that the usual postfetal cortical 
growth was insufficient to fill the grooves. Most lolmlated kidneys have abnor- 
mal arterial circulation. The veins are more apt to be regular. Lobulated 
kidneys are more often found to be diseased than smooth kidneys, tuberculosis 



vWe vfflWSBiffr AS 1 



MABSETOCrTPSTENl^AS TO FORM. 313 

being especially frequent. On the other hand a pathological pr .^ess may ac- 
centuate the lobulated form. 

THE HORSESHOE KIDNEY. 

(Ren Arcuatus S. Uiigiiliformis.) 

Such kidneys are caused by fusion of the embryonic anlagen before their 
ascent out of the pelvis. Although the variations of this form of maldevelop- 
ment are great in number, they generally have the folloveing features in 
common : 

1. The fusion of the kidneys of the two sides takes place at their lower 
poles, because these are nearer each other than any other part of the kidney. 




Fig. 446. — Coronal Section op Horseshoe Kidney Shown in Next Figure. The 
pelves are represented plastic. The two kidneys, from a secretory standpoint, are 
independent organs, the fusion of the cortex at the bridge being merely a narrow strip 
of fibrous tis3U3. 

The time of fusion is at or previous to the seventh week of embryonic life (Fig. 
461). The position of the kidneys at that stage corresponds to the position of 
the two halves of the horseshoe kidney in the adult. 

2. The pelves of the horseshoe kidney are in front of the organ, because at 
the seventh week the kidneys have not rotated around their long axis (Fig. 
461). There are frequently divided ureters, making the anlagen longer than 
usiial, and when they enter into the position shown in Figure 461, their lower 
poles are nearer together than those of the shorter anlagen in a normal case, 
the mesoderm between them being reduced to a minimum. 




Fill. 447. — Horseshoe KniPffliY with Aortic Aneurysm. The aneurysm hjul 
wired. ^Vhe arterial supply was rliiefly derived from one renal artery, arisin 
iho modiiiii line. Tliere are ai*eessf>r>' \'e.ss^'l3 eominpj from the aorta near iUi 
cation^ and small branches from each eoirimou iliac. Tire bridge of the hor 
kidney was CouikI at the level of the aortic l>ifurcation. The renal pelves, as 
the ureters, are in front, (J. R H, AutoiDsy, May 22, 1900.) 




MALDEVELOPAIEKT AS TO FORM. 



315 



The bridge uniting the two halves of the hori^ei^hrH:* kifhiey preTents the 
Tit of the organ beyond the level of the aortic bifiireation. It is possible 
that the mesentery of the alimentary canal, together with the inferior mesen- 
teric vessel forms the main obstacle. At any rate, the horeshoe kidney doea 
not swing back into the hirabar pockets, and the two halves do not rotate around 
their long axis, turning hilum and pelvis toward the aorta and vertehral col- 
unm, as in the case of a norma] kidney. As a consequence, the arterial branches 
imter the parenchvma mostly behind the pelvin, Tims in liorscrthiH.^ kidneys we 
find the arteries coming from the aorta, either in one common trunk arising 
below the mesenteric arteries with several otlier smaller branches from the iliac 
arteries, or else, two separate trunks similar to the nornuil renal arteries 
only at a lower level. Besides thesc% however, there are nearly always 
smaller twigs coming from below and behind, derivations of the external iliac, 
internal iliac, etc. 

As to the fusion itself^ there are three degrees to be mentioned : • 

1. The connection nuiy Ik* a thin fibrous band without any trace of paren- 
chyma in its interior (Fig. 44<V). 

2. The bridge may be broad and consist of cortex alone^ the medullary 
aubstance not participating in its formation. 
This is the most frequent form of horseshoe 
kidney (Fig, 447), 

The bridge ia situated at the aortic bifurca- 
tion and, while its posterior surface is smooth 

and tlat, anteriorly it is lobulated and has a 

distinct depression in the middle. 

There are six separate arteries supplying 

the renal parenchyma, all of which enter be- 
hind the [Mdves. The pelves are separate, their 

lower calicj^s coming to within 5 em. of each 

other. The bridge has a perpenditMilnr zone of 

ourtieal substance in its middle, and this again 

appears divided by a septnm into a right and a 

left half^ making it evident that from the 

standpoint of secretion the two halves of this 

horseshoe kidney are independent organs. The 

horizontal axes of the two pelves are directed 
I outward and back, the two rows of ealices pointing, respectively, laterally and 
^ backward (Fig. 447). 






Fig. 448.— Unilateral Horse- 
shoe KmNEY, The left half 
is the larger» The ureter of 
the right kidney is seen to 
come from the bridge. (After 
Kuster.) 



316 



MALDEVELOPMENT OF THE KIDNEY AND URETER. 



and thick, so as to make it seem a portion of the smaller kidney. The horse- 
shoe kidney then presents an asymmetrical appearance on account of the distor- 
tions of the ureters and vessels associated with such forjns (Fig. 448 ) ( Marlmrp 
collection). While the left ureter is of the usual character found in horseshoe 
kidney, the right divides into three branches, one of which enters the small 




fi\¥. of bwtf f 



Fig. 449. — Horseshoe Kidney of Remarkable Type. There are four distinct kidneys!, 
the upper two lie in an approximately normal situation, with each hiium facing luetlian- 
ward; those of the two lower kidnevs face downward and outward. Each kidney has a 
separate pelvis and ureter, the ureters on same side unite near the pelvic brim. The 
blood supply of this horseshoe kidney is complex, as shown in the diagram. (From 
R. B. Oleson, Chicago.) 



kidney, while the other two go to the bridge. The bridge is thus design a teil as 
a portion of the smaller kidney. Its circulation, however, is derived from the 
branches of the larger kidney. 

For the bridge to possess an independent ureter with a separate orifice 
in the bladder is quite rare. It is worthy of note that the orifice of the bridgt* 
ureter appears on the normal phiiu* of the vesical trigonum, while the other 
ureter, though b(»longing to the higher renal segment, empties into an oritico 
below and medianward to the other. The same conditions exist as we shall 
see later in kidnevs having double ureters. The upper renal pidvis (H»rre- 
sponds to the lower vesi(!al orifice, the lower pelvis to the upper orifice. The 




K 450. — Horseshoe Kidney of REMAHfeLABi^E Type, Inst^?a<l of fusing at lower pole, 
the kidneys have become fused by the upper poles. The adreual bodie^a are hkcwise 
fused into one. Associated with thi^ anumaly, and probably the eau^e of it, was a hernia 
iothe left anterior portion of the diaphragm, aa well as a spina bifida. The aorta and 
the vena cava passed in front of the britlge of the horseshoe kidney. (From Max 
Broedera collection of embryos.) 

317 





MALDEVELOPMENT OF THE KIDNEY AND URETER. 

iiroters are then usually seen to cross each otljcr, A very complex form 
horsesihoe kithiey is shown in Figure 44i>, 

Horseshoe kidneys generally fuse helow, but oecflsionally the upper pcilos 

may be united* Fi^ire 450 is a drawing 
from a tlbse<^tiou of the ab*Jominal vis- 
cera of a atillboni baby, who^e kidnm 
had fused at their upper poles. The en- 
tire organ was sitnated in A cap»ci 
pocket behind the aorta and vena ea' 
and on top of the bridge was one la 
fused adrenal body. The^ri!* was a spini^J 
bifida and an enormous diaphragiuatii 
hernia on the left side. The large at 
dominal vessels were drawn csonsiderabl; 
in a ventral direction, owing to the trai 
tion on the celiac axis and superin 
mesenteric artery, caused by the in 
tines lodged in tJie left pleural cavit 
The hernial ring was situated in tl 
dorsal half of the left dome of the di 
phragm, and to it tlie mtestines we 
firmly adherent. The space Iwtweeu t^»^, 
abdominal vascular trunks and the lu^nj. 
bar vertebra* was appart*nlly sufficient ]«^ 
large to enable tlie kidneys to ascend in 
it. The fusion of the upiH»r p ' 
dently took ])lace after the ki'li 
passed out of the pelvis. 

According to the c^nnbined statisliof 
of Morris and Socin, the horseshiie kH- 
ney occurs in 0.08 per cent of en^ 
The statistics fumislied by these two 
authijrs togt»ther cover almost l*»,iKK) 
autopsy records. 
The other three forms of fusion to be described below occur still mote 
rarely, in fact they are of extreme rarity, Morris having found only 1 casein 
8,1TB antopsies. These are: the unilateral elongated kidney (ren i^hmtji^' 
tlie scutiform or shield-shaped kidney (ren seuiarieiLs)^ and the lump k- 
{ren informis). 



Fio. 451. — Um LATERAL Horseshoe Kn>- 
KEY. Both kidneys are on the left side 
of body and it is interest ing to note how 
the eirculatiun has adai>te<l itself to the 
abnonnal iof^oj^rapiiical condition of 
tlie kidney. The right renal pelvis is 
in front, one calyx coming from the 
bridge. (Path, Museum, J. H. H.) 



MALDEYELOPMENT AS TO FORM, 



319 



UNILATERAL ELONGATED KIDNEY- 

(Rpii EloDgatiis.) 

This is a forni in whieh both kiiliiey nTila^on fuse and ascend together into 
! himbar pocket. It eonsistg, then, of two yu|MTirapo8ed kidneys, the bridge 
oonn^'Cting them being formed by functionating renal parenchyma. 
The two principal forms are: 



Ao 



q"^ 



</ 



ftc. 452. — Two Cases of Sigmoid Kidney. The hilum of the lower faces in the opjKH 
site direction from thitt of thr^ iipptT iddney. (The right figure is from M. C 
Wintcmitz, J ohm Hop. Hosp. Bull.^ 1908, xix, 229; the left after Kiister.) 

H 1. Simple elongated kidney (ren eJo n gat us simplex) . — The 
^kidneys are one on top of the other, each hilum being turned toward the verte- 
bral column. The arteries of both kiiineys arise separately from the aorta^ the 
veins accompanying the arteries. The ureters" and pelves are separate, the 
upper passing in front of the vesstds of the lower kidney without crossing the 
lower ureter. It then passes obliquely across the pelvis to the other side of the 
bladder to empty in the usual manner. It has, however, also been observed to 
open into the blatlder on the same side. It seenjs probable that such cases are 




320 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

nothing but kidneys with double pelvis and double ureter, where the other kid- 
ney has failed to develop. Unilateral elongated kidneys are very long and 
narrow, their pelves being mostly on the anterior surface (Fig. 451). They 
apparently are instances where the six-weeks' embryonic stage persists. The 
two anlagen ascended not side by side, but one on top of the other, in which 
position they became fused. 

2. Sigmoid kidney {ren sigmoidevs) (Fig. 452 ) . — Brosike ob- 
served a case where the left kidney was in its normal place, with the hilum in 
its usual position; the other kidney, however, was on the same side just beneath 
the left, its hilum facing the other way. There was an oblique groove where 
the two kidneys had fused, in which was seen passing the ureter of the upper 
kidney. The ureter of the lower kidney crossed the sacrum and ran to the 
right side of the vesical trigonum. The vessels were separate, the upper 
having the usual arrangement, while the lower renal artery had a common 
origin with the inferior mesenteric. There was an accessory renal artery 
passing from the left common iliac to the caudal parenchyma of the lower 
kidney. 

The ureters in sigmoid kidneys may cross each other, in which case the 
crossing takes place in the upper pelvic region or in the vicinity of the iliac 
vessels. 

SCUTIFORM OR SHIELD-SHAPED KIDNEY. 

(Ren Scutaneus.) 

In this type, also, the fusion of both organs takes place very earlv, certainly 
before the kidneys have passed out of the pelvic stage, which corresponds to the 
age of four to six weeks. The fusion is extensive, involving the entire length 
of the kidneys, so that the result is a round, flat organ whose sides appear more 
or less lobulated. Such kidneys are found in low position and generally in the 
midline of the body, the sacral hollow being the favorite location. The scuti- 
form kidney usually possesses two ureters, rarely only one. There are two 
principal types, a round and a flat: 

1. The round form resembles a horseshoe kidney fused all the way 
up. In the central portion of the anterior surface are two depressions from 
which the ureters arise and into which the vessels plunge. 

2. The flat form appears to be more frequent. The ureters are on 
the anterior surface, while the vessels enter and leave the kidney from behind. 
The kidney shows marked lobulation. 

There are also unilateral scaitiform kidneys, which are found in a low 



MALDEVELOPMEKT AS TO T'USITION. 



321 



poaition ; the renal pelvis is in frfjut^ while the vessels enter from behind or 
from the aides, comiug from the iliac arteries, 

LUMP KIDNEY, 
(Ren informis.) 

Lunip-kidney (Fig, 453) is, as the name sifniifi^s, an irreg:iilar, shape- 
less maas, ooinposed of lobules of flitTerent size. Its poaitioii is dcscrihed as 
lieing just above the sacral proniontary* The ureters, 1 to 4 in number, are 

AorU 



Kml 



/ 






k.'^rH 



.»ri. 



lUr. 



.Ent.lu 



lllr. 



Hyp*>g 



Fig* 453. — Lumi' Kidnt.y (So-Called)* TIuh represents an extreme degree of fusion of 
the priiTiiiry deptit^. Tlie two renal pelve.s arc in front, as b conimun in all such anom- 
alies. The blood supply is derived from the nearest points of the aorta and ita 
branches. (After Kiister.) 

ehort and are most commonlv sitiiated on the anterior surface; the ves- 
sels are seen near the upper niar|rin of the organ, but may also be on the an- 
terior as well as the posterior surf ace. They enter the parenchyma in the 
depressions between the lobules. 



MALDEVELOPMENT AS TO POSITION. 

While abnormal position is noted with special frequency in kidneys of 
abnormal form, such as described above, it is by no means exceptional to find a 



322 



MALDEVELOPMENT OF THE KIDNEY AND TRETER. 



>? 



vc 



/•ctop^c K.jr< 



kidney of normal development in an tinusual position. Still, it appears that 
the same factors which prevented the kidney from reaching its normal position 
generally caused also a disturbance of its form. This disturbance may be 
slight or severe. 

Ahnornial position of one or both kidneys may, of course, be produced by 
pathological influences^ such as tumors, nephroptosis, etc., in which instances 
the examination of the length and course of the ureter may be of vahie in de- 
tenniuing whether the descensus is congenital or acquired. In congenital low 
kidneys the ureter is shorter and free from kinks and twists, its length being 

determined by the level at which the kidney 
has become fixed, while act]nired low kidneys 
have long and couv4)luted ureters. Further- 
more, the vessels of kidneys of acquired low 
position are much lengthened, while in con- 
genital forms they are short. In the follow- 
ing discussion reference will be made only to 
conge ni tally displaced kidneys. 

The factors causing the disturbance are 
conceded to be chiefly of a mechanical charac- 
ter, for it 18 evident that two kidneys fused 
cannot pass through the mesentery and its 
Vessels and attain tlie level reached by separate 
kidneys. Fused kidneys therefore remain ar- 
rested either just above the sacral promon- 
tory, or in front of the lower lumbar vertebrse. 
In the case of an '^elongated*' kidm\y the two 
kidneys slide one on top of the other into the 
same lumbar pocket, the lower kidney coming 
to lie in the iliac fossa or in front of the iliac 
vessels. If one of the two kidneys fails to 
ascend, it is usually found at the brim of the 
pelvis or below, filling the sacral hollow. The 
renal pelvis is seen in front, and the shape of 
the kidnev is altered to fit the bed in which 
it lies, flattened posteriorly and with deep an- 
terior grooves. The vascularization is also abnormal. Figure 455 shows a 
right kidney w^hich was found in the sacral hollow. Figure 456 shows a kidney 
which w^as found at a somewhat higher level 

A kidney in low position may easily be mistaken for a tumor, especially in 



Fio. 4M. — Ectopic Kidney on 
Left 8mE» with a Normal 
R I GHT Kidney, U is i n tere^ti ng 
t«> note the origin of the upi>er 
renal artery of the ectopic kid- 
ney, which, in its origin and 
course, resembles one of the 
arteries of the Wolffian botiy in 
the fetus. (From Path. Col- 
lection, J. H. H.) 



MALDEYELOPMENT AS TO POSITION. 



323 



f/ie female, and if, in the case of a pregnant woman, it is Bituated in the sacral 
itollow, it may become an oWaele to hirth* 

The kidney haa been found in several peculiar positionsj viz,^ near the 



f(M(«4 him) 




FiQ. 455. — Ectopic Left KmNEY with Abnormal Internal Generative Organs, In 

the upper picture the position of the kidnoy i« incttcatefl in dotted lines; also the short 
uret4^r k*ading to the aiitrrior renal pelvis. In the lower picturesr, an anterior view 
of the kidney and of the pelvis and its niniifi cations in the parenchyma are given, 
H natural ^e. (S,, J, H, H., April 8, 19050 




HALDEVELOPMENT AS TO POSITION, 



325 



Braasch, in his 3G cases, found 4 of ectopic kidney. Wo ha%'e observed 

S cases of ectopic kidney, 6 right-sided and 2 left*sided. In one of the 

I<*ft-8ided cases (a colored woman at the Camhrid^e Hospital, Maryland), 

pregnancy had twice been successfully carried to full term labir in spite of the 

tidnej, which was discovered accidentally during a laparotomy. None of these 



ly 






o. 457. — SKcno!i of Tumoe Shown is Previous Figure, The hemorrhagic infiltra- 
tion of the degenerated myoma, gives it the C(jlf>r of renal parenchyma. The coiled 
arrangement of the lighter areas suggests kidney cortex. This arrangement is prob- 
ably due to a collapse of the walls of the necrotic myoma. 



_ leys gave any 8;vTnptoms except one in the rij2:ht iliac fossa, which contained 
fwone, which was successfully renu>ved. An interesting parasitic uterine 
fibroid simulating ectopic kidney is shown in Figures 450 and 457, 

The Arrangrement of the Vascularization in Abnormally Situated Kidneys. 
— The arteries always adjust thenisehcs to the position of the kidney. They 
arise from the nearest aortic source. In extremely low positions they come 
from the common iliac, external iliac, (*rura], etc. It may even occur that the 
caudal artery may step into the service of a kidney which has not passed beyond 
the pelvic stage. Fused kidnevs mav have one large common artery arising 



there are several accessory branches coming from Mow. If the kidney ladf^ 
in front of the aorta the majority of the vessels enter its parenchymft from 
behind or from above. 



EMBRYOLOGICAL NOTES ON THE MALDEVELOPMENT OF 
imETER AND RENAL PELVIS. 



THE 




-! 



Fio,45.S.— Division of Renal Pelvis 
iNTt* Upper AND Lowkk Hhanches* 
The division is caused by an es- 
I)e€mlly deep column , of cortical 
substance (a), which has forced its 
way almost to the hilum. After 
the kidney ha.s unfolded itself, as 
shown in the fipirc to the rights 
the pelvis l>ccomes an extra-renal 
organ, ap|)earing at the liiluni as 
a dividtMi pelvic, thus simulating 
caeca of precocious branching of 
the ureter duhng the cmbrj^ooic 
stage. 



The nreter arises as a process from the hind wall of the lower end of the 
Wolffian duct. Its distal end divides into two branches^ which grow into the 
developing kidney blastema. Each branch divides again dichotoniously. ThU 

prueess is repeated until the caliees and 
straight nriniferons tubules arc prodiiecA 
At first the ureter opens into the lower end 
of the Wolffian duct, but later the coinmon^^ 
pierce is drawn nuire and more into the sintia^ 
nrogenitali.H, until finally Wolfiian duct anA 
ureter open separately into that cavity. Th© 
kidneys ascends into the lumbar rf^gion, 
causing the lengthening of the ureteral tulid 
From the Wolffian dnet in the male are 
developed the head of the epididymis, the 
vas deferens, the seminal vesicle, the ductujs 
ojacnlatorius ; while in the female this canal 
exists only in rndimentary fonn as Gart- 
ner's duct. 

1. If the Wolffian duct and ureter fail 
to shift anteriorly from the cloaca befon* 
the urorectal septum grows down to divide 
the rectum from the bladder, the urett* 
opens into the rectum. 

2. If the ureter does not separate itseli 
from the Wolffian duet but accompanies that eanal in its j*jurney candalwari 
there results abnormal connection of the ureter with those organs which ar 
from the Wolffian duet (in the male, vas deferens, seminal vesicle, and due 
ejaculatirrius; in the female. Gartner's duct). 

3. If the ureter does not remain isolated from the Afiillerian duct, i 
attached in women to the ti terns or to the vagina. 

4, If the ureter, after the sixth week of embryonic life, does not be 



KMBHYOLOmCAL NOTES. 



dctiLciied from the Wolffian duct but aceompanies that canal in its downward 

course, iheii the ureteral opening may be found in the sirnii^ nrogenitalia and 
the or^aiUii developing out of this, i, e., in the npper portion of the urethra in 
both eex(»s and in the vestibule of the va|jrfna in women, 

5, If the ureter separatfs froiu the Wultlian duct without opening into any 
cavity it boconies n blind canal with an atrophic or cystic kidney above. 

Several theories have }>een advanced explaining the doubling of the 
ureter, the most important being as f(jllows: 

1. Sappey. The ureteral aniage, instead of branching near the kidney 
blastema, branches sooner, thus forming a bifurcated ureter. 

2. Caudmont. The condition is brought about by a partial fiL^ing together 
of two kidneys. 

3. Deubierre, There is a double evagination from the Wolffian duct. 
The first and third views are the nn^re acccptabk*, although the first alone 

suffices to explain all the various |ihenoincna. As long as the actual process in 
embryos has not been oWrved, the question, of course, can not be definitely 
answ^ered ; nevertheless, if we In^ar in mind tlie fact that the division of the 
ureter into two branches has Ih^cu observed at any place Ix^tween bladder and 
kidney, and that, if entirely se{mrate, the two ureteral oritices arc either close 
together or more apart, we must come to the eonclusion that these transitions 
are all manifestationg of one and the same factor, only dififering in degree. No 
one will doubt that a ureter, doid)le from the middle of its course up to the 
kidney, must have developed through a prcctxMons brjuiehing of the original 
evagination before the ampidUc become embt*dded in the nephrogenic tissue 
(Figs. 458 and 100). The same nuiy safely be assnnied to have taken place 
in those cases where the division Is found nearer tlie bladder or even at the 
bladder. The division of (he original ureteral bud must then have taken place 
just after that canal branched off from the Wolffian dnct» Another plausible 
explanation of the varying location of the point of division may Ik? ihe siirmise 
that the lengthening of the embryonic ureter may take place unequally in its 
various jKirtions; viz., if the distal or «livided portion stretches while the 
proxinuil or undivided remains more or less anch(»red close to the bladder, the 
place of division will be found far ihnvxi. If the Icngtbening is more uniform in 
chara<'ter, tlie pbtce of division is found at a higher level In Figure 45f), g 
and h, the ureters were double from the brim of the pelvis up. In n (on the 
right side) they divide just outside the bladder, while in i, k, 1, m, and n, on 
the left, they are separate throughout their entire c*onrse- 

Such double ureters apparently either have their origin, as has already 
been indicated, and as w^e are inclined to believe, in tw^o separate evagina- 



Fig. 459. — Diagrams from Actual Cases, Showing Anomalies op Ureters and Renal 
Pelves. Above are cases where the ureter branches to form two separate pelves, just 
before entering the kidney. In the next row, the division takes place further down, until 
both ureters are separate in their entire course; the vesical orifices are close together or 
further apart, the lower one even reaching the urethra. In the third and fourth row the 
ureter branches outside the hilum at the point of first division into two, three, four, five 
and even six separate calicos, with or without the formation of a pelvis. 



328 



330 



MALDEVELOPMENT OF THE KIDNEY AND URETER. 



Ur. 



jSinglt pelvis 



tiona from the Wolflfiaii duct, or tlio division of the single bud was &o near the 
Wolffian duct as to appear as two si»paratc out|i;rowt.h9 (Fitjs, 400 and 4G1). 
At any rate, the process must date back to the third or fourth week of embryonic 
life, i, e,, before the common duct {portion of Wolffian duct between kidney 
hud and urogenital sinus ) beenmos widened and drawn into the sinus. While 
the lower portion of ihc Wtdtfian duct is ihiin utili;ied in the promotion of the 
growth of the lateral porti<»n uf the urogenital sinus, the posterior wall of the 
urogenital sinus grows vigorously in a downward direction, carrying wnth it 

- the oritiee of the Wolllian duct. The 

orifice IS thus caused to travel down- 
ward and mcdiaTJwarc! until it be- 
comt^s pennaneutly situated in the, 
urethra in the male, \ivhile in the fe-« 
male the Wolffian duct continues to 
travel lateral to the Mullerian duct 
(vagina) do\ra to the outlet (oblit- 
erated Gartner's duct). 

During this process of expansion 
and simultaneous downgrowth of the 
Wolffian common duet, the ureters] 
are thrown off in order to beoome| 
attaches] to the bhidder along the 
lino marked by the travel of the 
Wolffian duct. The lower ureter 
reaches the bladder first (Fig. 461), 
usually in the plaec w^here the normal single urcler is found, while the upper 
continues its downward shifting together with the WoMan duct meaially X^ 
the first attached ureter, until it also reaches the urogenital sinus. The 
Wolffian duet, minus the ureters, continues to shift to a still low^er level. If 
the tw^o ureters iire liberated in quick succession tbev will be found close to- 
gether in the bladder; if a longer interval prevails they are farther apart, so 
far that the upper ureter may be carried even to or below the internal urethral 
orifice. 

The process is comprehensively shown in the diagrams of Figure 401. 
The pictures also make it clear w^hy the iireters cross each other and why 
the ureter coming from the upper part of the kidney has a vesical ori- 
fice below an<l medianward to the orifice of the ureter coming from the 
low^r part of the kidney. Figures 402 iind 4G3 show a case of double ureter 
in an adult 



c^^ yy 



i V i d e ct p e I V J s 

Fig. 460. — Diagrams iLLusTntiTiNG the Ori- 
gin OF A Divided Renal Pelvis as Com- 

PAKKD WITH THAT OF A 8INGLE PELVIB. 



rfB. 



5IALF0RMATI0N OF RENAL PELVIS AND URETER OF LESSER DEGREE. 331 



MALFORMATION OF SENAL PELVIS AND URETER OF LESSER 

DEGREE. 

Besides these striking malformations just described there is a vast num- 
l3er of minor degree, many of which do not become recognized until a care- 
ful examination has been made. These concern more the upper part of the 
Tireter and its branches, the calices. Since they are of great importance in 
surgery they have been taken up more fully in Chapter IV. In the light of 
embryological knowledge, however, they are also of considerable interest 

1. Malformation as to Position. — While the usual place for the renal pelvis 
is on the mesio-posterior region of the hilum, it is by no m'^ans always found in 
that position. We know that the kidney rotates around its long axis during the 
ascent out of the pelvis, and at the eighth week of embryonic life it has com- 
pleted this rotation (Fig. 455). Insufficient rotation or a failure to rotate 
leaves the renal pelvis in a mesial or even anterior position. Such forms are 
pictured in Figure 455 and Figure 459, t-w. The greater number of vessels 
then enter the kidney from behind. 

As a rule, the pelvis enters the hilum in the middle third of the kidney or 
just below ; in cases of especially long kidneys, however, the pelvis may run 
along the entire length of the organ, giving off several major calices in more 
or less regular intervals. Such forms are probably due to precocious divisions 
of the ureter. 

The pelvis enters the kidney sometimes very near the lower pole, and it 
Beems as though this condition is brought about by a more vigorous development 
of the cranial half of the nephrogenic tissue and of the invading ureteral 
branches. 

The position and length of the ureter are dependent upon the position of 
the kidney. A kidney in congenital low position has a short, straight ureter 
and a ventral renal pelvis, which is a persistence of the sixth-week stage. 

2. As to Form. — The usual arrangement of the upper end of the urinary 
tract is a single pelvis at the posterior site of the hilum. This pelvis may be 
intrarenal, but is usually extrarenal. It follows that the division into major 
calices may be found either within the sinus renalis, just outside the hilum, or 
acme distance from it. The number of calices varies between 2 and 6. In 
Figure 459 is pictured a series of abnormal forms of pelvis and ureter, which 
serves to illustrate the great diversity which is found in the form of the upper 
end of the urinary tract 

The ureter frequently divides into two branches before entering the hilum 



Fig. 461. — ^Foim Diagrams Illustrating the Dbvblopment op a Kidney with Dividbd 
Pelvis and Double Ureter. The figure shows why the ureters cross and why the 
upper pelvis and ureter drain into the lower vesical orifice, while the lower pelvis and 
ureter drain into the upper vesical orifice. 

I. The double ureter starts from the Wolffian duct either (a) as two separate anlagen, 
(b) and (c), or as an original single anlage showing a precocious branching which resembles 
a double anlage. 

II. Through expansion of the lateral portion of the allantois, the lower Wolffian duct 
becomes dilated and the lower ureter (c) is the first to reach the allautois. The Wolffian 
duct (a), carrying the upper ureter (b) with it, shifts with the urogenital sinus, in a down- 
ward direction, between the allantois and the rectum, as shown by arrows, until the second 
ureter (b) also becomes implanted in the bladder, but further down and more mesially 
than the first (c). 

III. We here see a continuation of the same process of advance of the Wolffian duct 
with a greater separation of the duct from the ureter. 

IV. The Wolffian duct continues to travel downward with the advance of the uro- 
genital sinus and finally becomes permanently lodged at the neck of the bladder (a), in 
the male; in the female, it continues still further down. This last picture represents the 
final arrangement, as seen in the adult. Note that the original order a, b, c, as shown 
in first picture, is now reversed to c, b, a, at the bladder. 



332 



334 



MALDEVELOPMENT OF THE KIDNEY AND URETER, 



(Fig. 450, a-n). The lower division is generally the larger^ and may not infre- 
quently become distended to form an actual pelvis, while the upper division 
remains small and appears like the contimiation of the nreter (Fig, 459). A 
division in 3 branches is seen in o-s. Thin appearance is gonietimes simu- 
lated by the first form, i. e., division into 2 branches, if i branch divides 
again before entering the hi him. The lower branch ia known to do this oftener 
than the npper. Division in 4 branches is shown in t-v, w has 5, wliilc x 
has (> well developed catiees. Such nnmcrous divisions are often seen in 
horseshoe kidneys and other fused forms; the individual branches then invade 
the parenchyma in many places and often considerable distances apart from 
each other. 

In these eases of ureteral division outside the hihimj including the double 
ureters, an actual pelvis is often lacking, although the point of division may be 
marked by n dilatation of the ureteral lumen (Fig, 4ri9, a and f). 

These forms of ureteral division outside the hilum may have their origin in 
a twofold manner: 

1. Through a precocious branching of the ureter similar to that producing 
a double ureter, only the division is quite near the kidney aiilage. (See Fig, 
45t), ) Through this the more pronounced forms are produced, 

2, Through espeeially deep inginiwth of one or several transverse cor- 
tical columns during the fetal stages and subsetpient unfolding of the adult 
kidney, by means of which meehiinical priK^pss the pelvic divisions be- 
come disloilged downward and appear at the hilum. Figure 77 illustrates 
this intluence of the cortex upon the shape of the pelvis, and it seems as 
though in this manner the majority of divided pelves of mild degree are pro- 
duced. 

In examining embryonic kidneys after the second month a transverse cor- 
tical column is often seen extending across the entire ki<lney and projecting far 
into the sinus renaUs. This wedge of tissue divides the ureteral branches into 
two main bundles and the pelvis into two main branches. After the kidney has 
unfolded itself in the adult, the site of division becomes dislodged to a lower 
level and appears well outside the hilum. 

If there are two or more cortical wedges gi*owing into the ureteral branches 
the division of the pelvis nmy be into three or more calices. 

Ureteral divisions and divided pelves outside the hihim occur, according 
to our experience, in ahrmt 28 per cent, of cases, and since the surgical sig- 
nificance of that condition is of considerable importance, a careful inspec- 
tion of the kidnr'v and its pelvis at the site of the hilum should be made 
before every nephrotomy. 




336 



MALDEVELOPMENT OF THE KIDNEY AND LTRETER, 



Until quite recently, so far as surgery ia 
concerned, the anomalies of the kidney and up- 
per ureter were regarded as merely aceident«l 
and usually uniniportaut findings. As a rule, 
unless some pathological process set^ in, these 
kidneys give no symptoms, Rovsing (Ztschr, 
f\ UroL, 1911, \% 586) has reported S symmet- 
rical horseshoe kidneys which caused pain by 
pressure on the nerve roots. The treatment for 
this condition is simple division of the bnd|^ 
connecting the halves. On the question of 
pathological prcx*esses in an anomalous organ 
too much information can not be acquired. 
Here the careful iirological examination with 
the eollargol injection is indispensable and 
leads to dofinite conclusions. 

A splendid consideration of the surgical 
possibilities is to be found in the paper of 
Dr. Charles Mayo (Ann. 8urg,^ 1913, Ivii, 
511). 

In many sections of this work the question 
of the confusions in diagnosis, due to double 
ureter and pelvas, has been dealt with, and it 
need not be considered here. The usual ar- 
rangement is shown in Figures 462 and 463. 



Fig. 403.'-'KmNEY with Double 
Ureter and Two Opentnos 
IKTO Blai>der. The bladder 
is shown in sagittal section, 
with a Hjx'fuliini introduced in- 
to the urethra. The lower ori- 
fice, almost at the neck of the 
bladder^ leads to the upjxsr pel- 
vis; it is also nearer the middle 
hne. The other orifice is in its 
' nonnal position and usually 
corresponds to that of the 
opposite ureter. 



One other interesting and important group 
of abnormalities remains — that of the opening 
of ureters outside the bladder. 



URETERS (SINGLE AND SUPER- 
NUMERARY) ^^TH ABNOR- 
MAL ORIFICES. 

It is about this class of anomaly that in- 
terest should center, as sometimes in these cases 
a dia^osis can be made intra vHnm and, if 
made, may result in operation and permanent 

cure. 



I 



URETERS (SINGLE, SUPERNUMERARY) WITH ABNORMAL ORIFICES. 337 

The symptomatology of this condition is, of course, extremely varied, de- 
pending on various factors, the position of the orifice being, of course, the most 
important The most characteristic symptom of a great many of these cases is 
a peculiar variety of incontinence, that is, a constant dribbling of urine, asso- 
ciated with voiding from the bladder of larger quantities of urine from time to 
time. If this is the case, a careful cystoscopic examination of the bladder 
should be made, together with a thorough scrutiny of the external genitals, to 
determine the site of the abnormal orifice, if it should exist. If it is found, its 
exact position should be definitely determined, and, with catheters and bougies, 
we should ascertain the length and direction of the canal which ends at this 
orifice, whether it leads from the kidney region, whether the fluid flowing from 
it is or is not urine, whether the canal is uniform in caliber or sacculated, and 
whether it is in conununication with the bladder, which last may be easily 
determined by injecting milk or colored fluids into the orifice and seeing if the 
urine flowing from the bladder is affected, and vice versa. Of course the ure- 
teral orifices should be carefully searched for in the bladder, to determine 
whether the abnormal orifice is of a single or of a supernumerary ureter. 

The fluid from the abnormal orifice should be carefully measured so that 
the daily capacity may be known, and it should be carefully examined for pus, 
as the location of some of these abnormal openings is such as to render infection 
extremely easy. 

One should determine as well as possible whether the canal which opens at 
the abnormal orifice is at all constricted in its course by formations encroaching 
on its lumen, by peculiar twists or angles in its course, or, what is most com- 
mon, by passing through muscular tissue which may narrow, or even for a time 
close the lumen and thus cause a light grade of stenosis. Such stenosis, of 
course, results in hydroureter and hydronephrosis, of greater or less extent, 
according to the position and extent of the obstruction ; in some cases this is 
so great as to form an appreciable tumor, and in many cases it results in more 
or less complete atrophy of the kidney substance. 

Of course all the above points can be determined in comparatively few 
eas^ as in many instances the peculiar variety of incontinence mentioned 
above, which is usually the sole symptom that calls our attention to the 
condition, is wanting, and it is only at autopsy that the condition is deter- 
mined. 

These abnormal openings may be either of a single or of a supernumerary 
ureter, and may occur, of course, in either the male or female sex. 

For convenience we have divided and subdivided these anomalies as 
follows: 



338 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

I. In the male genitourinary apparatus. 

1. In the bladder. 

2. In the urethra. 

3. In the seminal vesicle, vas deferens and ductus ejaculatoriua. 
II. In the female genitourinary apparatus. 

1. In the urethra. 

2. In the vagina. 

3. In the vestibule of the vagina. 

4. In Gartner's canal. 

5. In the uterus or tubes. 

III. In the bowel. 

1. In the rectum and cloaca. 

2. In the intestines. 

3. In the urachus and amniotic cavity. 

IV. In case of congenital absence of the bladder. 

1. In the urethra. 

2. In the vestibule of the vagina. 
V. Blind endings. 

The limits of our space make it necessary for us to consider only the more 
ordinary conditions found in the female. 

OPENINGS WITHIN THE FEMALE UROGENITAL APPARATUS. 

This is the subdivision of this subject which, of course, appeals to us much 
more than either double ureter or abnormal openings of the male ureter, for, 
besides the fact that we are devoting ourselves mainly to the urinary disorders 
of women, this abnormality, in contradistinction to the other two just men- 
tioned, should be diagnosed during life and the condition entirely cured by 
operation. 

The symptoms, namely, the peculiar form of urinary incontinence and the 
concomitant skin affections in the region of the vulva, as well as the dangers 
of infection, and the utter misery which many of the women suffering with 
these abnormalities must endure unless relieved by operation, warrant us in 
going into these conditions in detail. 

The abnormal openings of the female ureter hitherto reported, consist of 
openings into the urethra, the vagina, the vestibule of the vagina, Gart- 
ner's canal, and the uterus and tube. A moment's consideration will show that 
in almost all of these that most unpleasant symptom — constant dribbling of 
urine — will be present if the kidney is capable of secreting, and this should call 



URETERS (SINGLE, StTPERNrMERARY) WITH ABNORMAL ORIFICES. 33^ 



our e8iw?eial attention to the case and cause us to make a very careful examina- 
tion of the genitalia, urethra, and bladder. 

If the diagnosis is made correctly, an operation may be performed and 
complete relief obtained ; if a wrong diagnosis is made and an operation at- 
tempted the patient will probably die of infection or uremia due to closure of 
the canalj from a wrong interpretation of the symptoms, while if the diagnosis 
is not made, the patient, living in a state of constant wretchedness, is always 
exposed to the dan^ertt of infection^ pyi>nephrosis, and death. 

Dpeaing of the Ureter into the Female Urethra, — Although but few cases of 
this anomaly have been reported, they are, nevertheless, of much greater signifi- 
cance than the correi^pondiug condition in the male, as, owing to the short 
urethra and the consequent greater tendency of the anomalous ureter to opc*u 
below the sphincter, urinary incontinence may occur and the case be recognized 
during life. 

(A) Of thk Sinolk Uuetkr*^ — One such ease has been reported by Thilow, 
The case was that of an old woman who had constantly suffered from involun- 
tary passage of urine, and at autopsy it was found that the right ureter passed 
by the blailder and oi>ene<l into the urethra. 

(B) Of a SuPEKNi merary Urktkr.- — Cases of this kind have been re- 
ported by Kriaeh, Kolisko, Tauffor and Velits, and Obici. 

In Erlach's case tlu- woman died of thrombosis of the right spermatic vein, 
and the autopsy showed that the right kidney had two jielves and two ureters, 
one ureter opening in the normal place, the other (the lower) passing below the 
sphincter and opening directly into the urethra* being markedly dilated just 
above the orifice. Although this ureter o]X'ned below the vesical sphincter there 
was urimirv continence, 

Kolisko's observation was made at autopsy on a woman 21 years old, who 
had died of endouietritis following preguttncy, and had never had any urinary 
symptoms. The autopsy showed a normal kidney and ureter on the left side, 
while on the right side the kidn<\v had I wo distinct |>idves, from the lower of 
which ran a ureter c:f nnruuil size oprning in the usiuil plaot* in the bhidder, 
while from tln^ npjHn\ which was nuirkedly dilated, ran a widened ureter open- 
ing into the urethra just beh>w thfi internal nn^tljral oritice, after forming a 
eystdike dilatatiou in its course beneath the vesical mucosa; when filled with 
fluid this cyst would completely close the urethral orifice. The portion of kid- 
ney corTcsponding to this ureter was much atrophied and had but little secreting 
substance. 

The case of Tanffer and Velits is of great interest from the fact that the 
condition was recognized and an operation performed, with a perfect result 



340 



MALDEVELOPMENT OF THE KIDNEY AND TOETER. 



^ W 



The patient was a 14-year-old girl who, since birth, had suffered from constant 
dribbling of urine, A cystoaeopic exaniination showed that both ureteral open* 
in^s were normally situated in the bladder, and that there was no evidence of 
any coin ninni cation Iwtween the two nreters on the left side. On the left side 
of the posterior wall of the urethra an o|M*niny was secni, through which a ure 
teral catheter eonid be introduced backward and to the left for quite a disttBce, 
anil through which urine flowed. Tauffcr |>crf<jnned epirysfotoniy, introdur^l 
a knohhed sound into the third ureter, pressed ihe kiiobl>ed end toward the 
bladder cavity at the level of the normal left ureteral ojjcning, cut down upoa 
the sound, so that it appeared in the bladder cavity, and sutured the ureter to 

the bladder ; the s!ipcrtluuU8 distal portion of the aV 
norniid ureter was treated with the Paquelin e^iutery 
and obliterated. 

The girl made a complete recovery and the drib- 
bling of urine ceased entirely from that time forth. 
Oliici^s case was that of a w^onian dyiDg of puer- 
peral fever, at whose autopsy a doubling of the upe- 
ters was found on both sides; on the right they both 
opened into the bladder at the normal Bituation^ 
while tlio supt*rnumerary b'ft ureter bored its way 
thraugh the bladder wall and opened into the 
urethra, forniing tlic* usual fvst-lik(» dilatation in its 
passage through the bhidder wall just b«,*fore its 
urethral orifice was reached. Xo mention was made 
of any previous urinary svinptoms. 

A case of this kind relic vi-d by a very simple 
proeednre is show^n in Figures MW and 405. A wide 
opening with the cautery diverted the urine into the 
bladder. 
One of xis ( Burnam) succeeded admirably in relieving two eases. In each 
^here was a widely dilated canal running in the spacx' between the vaginal wall 
and the vagina and emptying into the urethra. In the one case there wia 
continuous dribbling of urine of good qinility, containing abundant indigih 
earniiu on mibeutiineous iujecticm. In the other ease the ureter w^ajs alnjofll 
fnnctionless, now and then discharging but causing a great deal of pain at the 
neck of the bladder. The first was in a young girl of 15 and the 8<^ctmd in a 
woman of *10. In each case the same plan was pursued. The ureter, in each 
case a supernnnierary organ from the right side, w^as opened longitudinally 
through the vaginal wall. Then an opening, also in a longitudinal direction. 



Fig. 464.— Speculum Vjews 
OF Uhetuiial OaiFlCE 
OF Ureter. The figure 
to the left shows it eon- 
tracted, that to the right, 
relaxed ; demonstrate 
ing the end of the proc- 
ess of jx'ristalsis. The 
greatly dilateiJ ureter 
opened in the middle of 
the urethra and readily 
admitted a No. 10 Kelly 
speculum (i.e. IQ nun. 
diam.). (From Guy L. 
Humier; P., J, IL H., 
Mareh 4, IiM)(J,) 




Fio. 465. — Sagittal View of Method fob Treating Dilated Anomalous Ureter 
Opening into Urethra. Tlie course of the urctt^r was bo close to the blatlder that by 
pressing invvant with the finger in the vagina, the ureter waa brought out as a distinct 
prominence in the bladder, emphasized by distention. Through the speculum in the 
urethra, Dr. Huimer introduced an electric cautery knife into the bladder and made an 
^^ ope^ng through its walls into the ureter, establishing a new intravcj^ical orifice. Tlie 
^m urijie, which had pre\iou8lv dribbled from the urethra, then emptied normally into the 
■ bladder. (From Guy L. Hunner, J. H. H., March 4, 1907.) 

the severed end toward the urethra were carefully closed, and, finally, the 
vaginal wall. 

Opening of the Ureter into the Yagina. — These ea^^s and the cases of the fol- 
lowing group have furnished the greatei?t numlw^r of examples of oj>erative inter- 
ference, as the cardinal .syujptom^ the constant dribbling of urine, is present in 




342 



MALDKVELOPMENT OF THE KIDNEY AND URETER. 



all of them, and should lead ua to make a most careful exami nation, which 
will in time always be rewarded bv fbe ei^tablishment of a correct diagnoeig, 

(A) Of a Single Urktkr, — Palfyii, Depaul, Davenport, Emmett, &&d 
By fort have each reported one ease of this anomaly. 

Palfyn found a series of anomalies in a non-viahle fetus, namely, two uteri, 
two vai^ina*, the right va^niia opening into tlio rtx-tiinu and the left vagina 
receiving the single ureter whit4i rame from the two kidneys, which lay eidebv 
side and partly fnscd in the saenil hollow. 

DepaiiFs case was of a somewhat similar kind; he found two completely 
separated uteri and vagina*, atresia ani, openings of the large and small intea- 
tines and of both nreters in the abdominal wall, the right nret4:^r, which waa 
markedly dilated, eomninnieuted witii the right vagina by a very small ojiening. 

Davenport eorreetly diagnosed a ease of this nature in a woman 29 yeafS 
old, who liad snlfered during her whole life with ineoutinenee of nrine, and had 
been absolutely shut ntT from a partieiyiation in the nsnal pleasures of life. Be- 
sides this ineontinenee, the patient voluntarily voided large quantities of nrinc 
from the bladder from time to time, and she herself had noticed that urine 
seemed to triekle cfJiistantly from the vagina. 

By examination it was found that she had a ureter opening into the va^ni. 
Davenport cnt away the ureter from the anterior vaginal wall and inserted it 
into the bladder; a second oj>eratioTi was f<*mid necessary to close a vesical fis- 
tula. The f>atient had a complete recovery and was entirely ciir^d of all her 
symptoms, 

Byfort's case of opening of the nreter in the vagina was operated on sncceea- 
fully according to Davenport, who cites the case, ^H 

Emmett's case was one of the ureter opening in the upper part of the ^(^ 
gina in a 30-year-old wt>man w^io had always suflFered with urinary inconti- 
nence. Emmett detennined to perform ureteroplasty, i. e., to form a canml 
along the upper surface of the vagina to a jMiiiit in the base of the bladder 
where the wall was thinnest, and he had succeeded in constructing his canal 
from the vaginal opening of the nreter to a point where the bladder could have 
been opened when the patient, unfortunately, died of an intercurrent pneu- 
monia. The reason, of course, for this extremely difficttU operation was that 
the ureter of>ened so liigh in the vagina that it was imiiossible to insert its 
distal end into the bladder walK 

(B) Of a Supkrnumerary Ureter, ^ — Alsl>erg found, in an 18-year-oId 
girl, who had always suffered with incontinence and constant trickling of urine, 
a fistula opening in the anterior vaginal wall, connef?teil with a small ^'csicle 
which lay beside the bladder. He regarded it as a persistent Wolffian duct, and 



URETERS (SINGLE, SUPERNrMERAKY} WITH ABKOHMAL ORIFICES. 343 



I 



extirpated it as far as the parametrium. The patient died of pyemia, and at 
antopfij it was found that this fistulous tract was a supenuniii^rary ureter lead- 
Ing to the right kidney, while the h'ft kidney also exhibited duplicity of the 
areter. 

Milton reports a case of the congenital opening of a fine canal into the 
figina, from which there was eoiistaiitly voided an albuminous fluid fre« from 
orea. Milton, therefore, reported this as a persistent Gartner's canal. A 
Hreteral l>ougie, which he, to prevent thii^ flow of fluid, iutroduced into the 
bladder^ could be introduced up to the renal origin, and the case was undoubt- 
edly one of a superuumerary ureter from an atrophic jwrtion of the kidney 
opeuiug into the vagina. 

Conitzer reports a case of hi lateral duplicity of the ureters on the left side, 
both opening into the bladder in the normal position ; on the right side only the 
lower one did this, the other, arising from the atrophic upp^T^r portion of the 
kidney, opened into tbe vagina in two places, with a sac-like dilatation just 
before the end of its course. The fluid voided through this canal contained no 
urea, and tlie canal was, therefore, regarded as a persistent Wolthau duct ; after 
an unsuccessful attempt at extirj>ation of the cyst, a laparotomy was performed, 
at which the condition described above w^as found; the patient died from the 
effects of the opt^ration. 

Opening of the Ureter in the Vestihnle of the Vagina.^As in the preceding 
group, these cases are of especial intercut Ijccause they are often diagnosed 
during life, and have been operated on with success. 

(A) Of a Single Uretee. — Such cases have been reported by Maxson, 
Baker (two cases), Schwarz, Schrader, Bousquct, Massari, Soller, Bois, Mad- 
den, and Colzi. 

Those of Schrader and Bousquet were cases of absence of the bladder, and 
will be treated in the ai^propriate class. Baker's first case was that of a 
22-year-old w^oman, who had always suffered from incontiuonce, who exhib- 
ited a ureter opening in the vestibule of the vagina, he low and to the left 
of the urethral opening; a chemical examination showed the fluid which wa3 
passed through it to be urine, but no connection could he shown hetween this 
canal and the bladder. An operation was perfonued, at which this canal 
was slit up 1% centimeters and the ureter then inserted into the bladder in an 
opening artificially made 3 centimeters from the neck; the ureter was then 
covered with the vaginal mucous membrane. The patient ever after had 
normal retention of her urine. 

Baker's second case wa.^ in a girl of 18 years, who had suffered with partial 
urinary incontinence since birth, and whose left ureteral orifice was found on 




M4 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

«^\Miuiiiiitioii to be situated in the vestibule of the vagina close to the external 
urt^U^nil luontus. 

MMi4Miiri*8 case was a child 4 years old, who had been operated on at the 
H|(tt of months for a vaginal atresia of the anus, and had always had inconti- 
iioiuHt of urine. 

'J'ho condition was not diagnosed during life, as the incontinence was 
thought to 1x3 due to an atonic condition of the bladder walls, but at the autopsy, 
tho chiUrH death being due to a second operation (a repair of the recto-vaginal 
fUtiihi h'ft from the first operation), the following condition was found: From 
u fuMcd kidney whose left portion was atrophic, ran two ureters, the right one 
oponiiig in the normal place, while the left one, constricted and twisted in many 
IKirtious of its course, opened in the vestibule of the vagina by a very fine open- 
ing in the fold of the prepuce. The vagina was bipartite. 

In Seller's case, a girl 18 years old, who had always suffered from constant 
trickling of urine, the ureter opened to the left of the external urethral orifice, 
as a ureteral bougie could be introduced for a distance of 10 centimeters up 
this canal. The introduction of fuchsin solution into the bladder showed that 
it had no communication with the ureter nor with the abnormal opening, and, 
after complete emptying of the bladder by catheter, the urine continued to come 
drop by drop from this abnormal opening. 

In Bois' case there had been constant dribbling of urine, although the urine 
was also voided normally, and an examination showed that there was an open- 
ing beside the external urethral orifice, through which urine came drop by drop, 
and into which a sound could be passed for a great distance. Examinations 
made with sounds and with colored liquids showed that there was absolutely 
no communication between the bladder and the abnormal ureter. The woman 
having agreed gladly to any procedure which might promise her some relief 
from her miserable condition, Bois performed the following operation. A per- 
manent communication was established between the cavity of the bladder and 
the abnormal ureter at a level with the base of the bladder, this being done by 
introducing a tenotome with a knot on its end into the abnormal ureter for a 
distance of 4 centimeters, a catheter with a gutt(»r being introduced into the 
bladder at the same time; the uretero-vesical septum was then cut. This open- 
ing was kept open by having a knobbed sound passed through it every day for a 
week; finally the useless i)eripheral portion of the abnormal ureter was to be 
treated as a simple fistula and extirpated, but this part of the operation was 
postponed until a later time because of the discovery that the patient had 
become pregnant. 

In Colzi's case the characteristic symptom, constant dribbling of urine with 



URETERS (SINGLE, SUPERNUMERARY) WITH ABNORMAL URIFICES. 345 



regular voiding from timr to times liiid l«*<^''i pn^sent from birth, and an exam- 
ination disrlosfd the fat^t that the ahnornml 4>j>etiiiig was just l>eside the hymen. 
Through this opening a Bound eon hi be introduced for 30 centimeters, and 
further examination with eoh>red flnidft, et«\, showed that there was no com- 
munication k^tween this ureter and the bladder. There was a marked dilata- 
tion of the alinormal ureter one em, alK)ve its orilice. From the bladder 700 
c. c. of urine were voided daily, from the abnormal orifice 600, and the chemical 
and physical properties of the urine from the 2 sources were practically the 
same. 

The op<?ration was as follows: The patient being put in the lithotomy 
position^ the prevesical space was exposed by making two incisions, one bow- 
shaped, so made that the top of the l>o\v was over the juncture of the labia 
njajora; the other, a vertical incision, running from the top of the curved in- 
cision upward over the mons veneris, and cutting the nx>ta of the clitoris. Tlie 
urethra and vagina being pressed downward, the lower portion of the pubic 
arch was chiseled away for a distance of l\(* centimeters. The bladder was 
then laid free on its left side, and a T-shaped incision made at the plac« 
where the ureter usually enters; the peripheral portion of the abnormal 
ureter was tlien freed from its attachments aiid removed by knife aud cautery, 
and tlie i>ro|)er end sutured into the T-shajx^d opening in the bladder with fine 
silk ; the flaps of the T-shaped %*esical incision were then closed over it so that 
fiome approach to a sjdiincteral condition might Ix^ obtained. A catheter in the 
bladder and a sound in the ureter naturally aiiled the opi*ration; hc»aliiig took 
place per prlmatn. The patient was relieved of all her unpleasant symptoms, 
and a cystoscopic examination showed a sufficiently wide ureteral opening of 
elliptical form, tlirough which the urine flowed with perfect ease. 

In Maxson*s case, tlie diagnosis of a nreter of>ening abnormally just 
beside the external urethral orifice was made bv careful examination, the use 
of sound, etc., in a girl who had always had the characteristic symptom of 
incontinence with voiding of larger quantities of urine at intervals; the opera- 
tiun consisted in dissecting the ureter up to the walls of the vagina, cutting off 
the unnecessary portion, and at a c^uivenient place turning it into the bladder. 
The bladder opening was made by the help of a catheter introduced into that 
organ, and the ureter was drawn into the vesical opening by means of a auturo 
withdrawn with the catheter, and sutured to the vesical wall with cat-gut liga- 
tures. The vaginal wall was finally closed over the former site of the ureter 
and a pennanent catheter left in the Madder- The healing was per primam, 
and the patient completely recovered. Two years after the operation aha was in 
perfect health, voiding her urine absolutely normally. 



346 



MALDEVELOPMENT OF THE KIDNEY AND URETER, 



In Scbwarz's case, operated on by Wolllor, where the UBiml symptomi* wert 
present^ and where absence of commiinieatton between bladder and abuoriiial 
ureter was demonstrated bj the usnal methods, the operatiou was of ]Dti?reit 
becanse of the novel iiistniment employed, a peeuliar varietv of clamp (miioli 
like Dupnytreii's), one link of which was introduced into the bladder, the other 
into the abnormal ureter. Then, when the proper place had been reached, the 
two Hides were screwed together (see diagram)^ so that an o{)ening was made 
betvvef*n the bladder and the ureter bv slongliing away a sufficient portion 
of the intervening tissue. The operation was not very successful, although 
after a few months the patient had practically very good control over her urma* 
tion, not dribbling except after violent exertion or after partaking of larjs^e 
amounts of fluid, and only voiding the urine every three or four hours. The 
eecond part tjf the ojKtration, the obliteration of the distal portion of th^ abnor- 
mal ureter, was not performed, 

Ifaddnn'a ease was that of a girl of IG, who had suffered with oonitant 
dribbling of urine, with voiding of larger quantities at regular inten'ala. An 
examination showed a small opening in the vestibule of the vagina, \^ an 
inch above the meatus, from which urine oozed drop by drop, and into which a 
catheter could Iw passed in the direction of the right kidney. Operative inter- 
ference was discussed, but w'as not carried out. 

(B) Of a StJPEBNUMERAHY Uretee, — Cases of this abnormality have been 
reported by Baumm> Joaao^ and Albarran (2 cases)* 

Josso's case was of a three- w^eeks-old girl, in whom a dilated snpernitmerary 
right ureter opened near the external orifice; this abnonnal ureter came from 
the npfier j>ortion of the kidney and was widened and twisted, while the ureter 
from the lower portion w^as slender and opened in the normal place. The left 
side w^as normal. 

Baunim*a case was of an 18-year-old girl who had suffered from birth with 
the characteristic symptoms, constant dribbling associated with the passage of 
larger quantities of urine at Iniiger intervals* Examination showed that there 
w^as an opening in the vestibule of the vagina near the urethral openiiig, from 
which urine came drop by drop and through which a ureteral catheter could 
be introduced for 25 centimeters. Just back of the outlet this canal showed a 
distinctly dilated portion. While 1,100 cubic centimct<'rs were voide*! daily 
from the bladder, only 200 were voided through this abnormal opening, and the 
physical characteristics of the two urines were distinctly different. It wii 
established, by closure of the abnornial opening with a drawing suture an<i the 
denionst ration of marked swelling along the ureter's course, that thi^ ureter 
had no communication w^ith the blaiider. 



CBETERS (SINGLE, SUPERNUMERARY) WITH ABNORMAL ORIFICES. 347 



The operation was aa follows: Sectio alta was perfornied ; the 2 
normal ureteral opeoings in the hladder were seen ; a large window was cut in 
the dilated portion of the third ureter, into the wall of which was inserted a 
circular row of silk ligatures; Baumm next sutured this to the walls of a small 
apening made in the bladder near the normal right uretera! opening, and the 
Uadder incision was closed with a double row of silk sutures. 

The of^eration was completely successful, and the passage of urine remained 
completely normal except for the passage of a urinary concretion five and one- 
half months afterward, 

Albarran's two cases were in young girls, each aged 20 years, who had 

ilEffiefed with the characteristic variety of incontinence all their lives, and in 

irkma all general treatment had proved of no avail. In one, besides the 2 

Donaal o|>eniDgs of the ureter in the bladder^ clearly shown by eystoscopic 

examination, a small cribriform opening was visible in ihe vestibule of the 

vagina, from which the urine came droji by drop, while vaginal examination 

demonstrated a dilatation of this supernnmerary ureter jnst behind its outlet. 

Albnrran twice tried to dissect out this supernumerary ureter and suture it into 

the vesical wall, but the operation failed both times because of the extreme 

tliinneas of the vaginal wall ami the consequent formation of a persistent fistula. 

In the other case a supernumerary ureter was discovered terminating in a 

little intervesico-vaginal pouch, which in turn opened into the vagina and vulva, 

H \^'Iiile by eystoscopic examination the two normal ureteral openings in the blad- 

^ der were easily seen. Albarran performed se c t i o alta, introduced sounds 

into both normal ureters, isolated from the vagina the su]jernumerary ureter, 

resected its blind end, and sutured the urethra into the bladder's posterior wall, 

just behind the trigonum. The catgnt sutures not holding, a second operation 

was performed, in which a double row of sutures was employed. The success 

of this second oiieration was complete, and the patient had no further trouble. 

OpeniEg of the Ureter in Qartner^s Duct — ^Tangl has reported the oidy case 

of this nature, which showed the following anomalies: congenital atrophy and 

dystopia of the left kidney, opening of the left ureter into the persistent left 

^Gartner's duct, which ended blindly at both ends, uterus bilocularis 

annicolis. The canal evidently corresponded to a persistent Gartners 

canal, as it coursed for its whole length in the vaginal and uterine musculature 

and was lined with high cylindrical ciliated epithelium* 

k Opening of the Ureter in the Fallopian Tube or Uterus.^— Yeau mentions this 
apoSBihility, and relate?* that it has been reported in a few cases of non-viable 
uses where many other congenital abnormalities were also present. 
According to him a tubal orifice is somewhat less uncommon than a uterine. 



^ 




348 MALDEVELOPMENT OF THE KIDNEY AND URETER. 

Clinically, of course, these openings are of no interest whatever. 

Opening of the Ureter in the Rectum and Cloaca. — Oerster reports this ioter^ 
esting anomaly in a child dying shortly after birth. The left ureter did not 
reach its normal vesical ending, but opened in the blindly ending rectum.. 
Through the consequent stasis the kidney showed a hydronephrotic condition -^ 
which, of course, had developed during fetal life. 

Oberteufer and Bevolet report the case of an abnormal fetus where cloao^ 
formation with splitting of the bladder was to be made out, the two vasa defer-^ 
entia opening into the split bladder, the ureters opening into the rectum ; while 
Saviard reports the case of a newly born girl who showed externally no geni- 
talia, but only a cloacal opening, into which the two vaginse opened ; the left 
vagina received the urethra, while the single ureter coming from the two kid- 
neys lying side by side in the sacral hollow, opened into the cloaca. 



BIBU06RAPHY. 

Baker, W. H., "Malpositions of the Ureter," iVeii; York Med. J,, 1878, zxviii, 

675. 
Bostrom, E., Beiir. z. path. Anat. d. Nieren, Freiburg and Tiibingen, 1884, 

Hft. 1. 
Davenport, Amer. J. Obst. (Tr. Amer. Gyru Asso.)^ 1890, xxiii, 1122. 
Forster, "Die Missbildungen des Menschen," Jena, 1865. 
Guessarian, "Incontinence d'urine chez la femme par anomalies de developpe- 

ment des organes genito-urinaires," These de Paris, 1898. 
Maxson, W. H., "A Truant Ureter," Med. News, 1896, Ixviii, 323. 
Schwarz, C, Beitr. z. hlin. Chir., 1896, xv, 169-244. 
Secheyron, L., Arch, de tocol. et de gyru, 1889, xvi, 264; 335. 
Spaletta, Ann. d. mal. d. org. genito-urin., 1896, xiv, 181. 
Veau, Gaz. des hop., 1897, Ixx, 353. 
Weigert, C, Arch. f. path. Anat., etc., Virchow, 1877, Ixx, 490. 




STRICTURE AND OTHER DISEASES OF THE URETER. 

The discovery of ureteral stricture duriiifij an urolngical examination is too 
conuuon to jiistity not giving the siihject ^>parate consideration, althougli 
in most instances it is but a symptom, being part of a process involving either 
kidney or bladder, or both. Stricture of the ureter is an extremely common 
complication of kidney tnbercnlosis. The first two cases of kidney tuberculosis 
in the Gynecological Department of the Johns Hopkins Hospital, May, 18J)0, 
were diagnosed ureteral strictures, the true condition not being recognized for 
some weeks; neither patient had vesical involvement^ Ixith snrvived neph- 
rectomy, and both are still living. Strictures due to chronic pyogenic pyelo* 
nephritis are very common. Those following inflammatory reaction or ulcera- 
tion about a ureteral stone are very frequently ol»served and treated. Rare 
strictures are those due to new gi-owths, primary or secondary, of the ureter 
(see Chapter XXV). The rare involvement of bilhar/Josis is treated by 
Goebel (Deui. Zisehr, /. Chir., lOOH, Ixxxi, 288), Syphilis may definitely 
cause stricture, and the affeetion is probal»ly not nearly so rare as supposed. 
Hs treatment is antilnetic, both general and local. See Proksch {Arch. f. 
DermaL u. Sijiih., 181)0, xlviii, 224). 

Cyst* of the TTrcter, — ^Exeellent reviews of the question of ureteral cysts are 
to be found in the articles of t\ Sinnreieh (Ztschr. f. Ileilk,, 1002, xxiii, 91) 
and Marckwald (Munch, mrrf. Wchnschr., 1808, xlv. 1,040). The latter ob- 
server has aecurately descril>ed the pathological changes met with in the so 
called epithelial cysts of the kidney pelvis and ureter, and has given the name 
ureteritis cystica to this rather rare condition, which is particularly likely to 
occur in early life. The cysts are invariably multiple, rarely larger than a 
pea, and apparently formed by the breaking down of the center of epithelial 
nodules* For this condition, which rarely gives symptoma, there is no recog- 
nized treatment. They appear in intra-nterine life; occasionally, as in cases 
referred to by Paul Wagner ('^Handbuch der Urologie/' ii, 356), they may 
give rise to clinical svmptoms. Saltykow {Beiir. z, iHiih. Anat, u. z. allg. 
PaiK, 1908, xliv, 393) believes that the ureteritis cystica comes from a definite 

340 



Fig. 466. — Determination of Distance of Stricture of Ureter from Vesical Orifice. 
Ureteral catheters are introduced on both sides, each catheter being pushed up as far as 
it will go. The little rubber sleeves are then pushed up to the external urethj-al orifice, 
while the catheters are held firmly in their relative positions and simultaneously with- 
drawn, as shown in picture. The distance between the ends shows the distance of the 
stricture from the upper part of the renal pelvis. 



350 



352 



STBICTURK ANT> OTHER DISEASES OF THE URETER. 



inflamiiiatory reaction in the so-ealled Enmn's epithelial nests, and that the 
colloidal eonteiit comes fnmi the bkK>d» Llevin ( I. I>. IJuim, 1(109, ''Ucl^r 
ITreteritis cystica; zur Kcnntnis ihrer GenesH?**) thinks ihsit th<'y come from 
definite glands of tht" ureter. In addition Uy these cysts there are the so-ealled 
paranephritic cysts, which usually coinicet by small openings witJi the ureter, 
A case of this kind has been described by Israel (Chir. Kiln, der Nierm- 
krankheiien, 1901^ 354). A third type of cyst is that of dilatation in one 
portioti of the nreter* This dilatation is usually of the vesical end of the organ 
and leads to the well-known pouting into the bladder (Figs, 471 and 472). 

The treatment of cysts of the urcler which 'give s^Tiiptoms is, with 
the exception of the dilatations at the lower ureteral end, entirely by formal 
surgical procedure^ an<l is directed towartl relieving obstruction. 



The common kinds of strichire are inflammatory, traunuitic, and congenitHl 
and it is convenient to classify tliem according to these causes. They occur 
about in the order of fretpiency given, 

Infiammatory Strictures. — Tlu*se are very connnon, may lie located at any 
point of the ureter, but are fuiind espocially at its vesical end. 31 any eases of 
chronic pyelitis are assm-iated with ureteritis, and stricture formation results 
from the inflammation. It is not uncommon to fin<l the condition bilateral. 
Gonorrheal infection is a common cause, many cases being on record; as early 
as 18f*4, one of us (Kelly) treated successfully a ureteral stricture and pyo 
nephroais of 150 c. c. by dilatation and irrigation {'^Operative Oynecolog\%" 
i, 534). Although a secondary development, the strictures in such cases 
assume primary importance^ for the infection cannot be relieved so long as 
they exist. The symptoms are principally those from the asaticiated involved 
bladder and kidney. 

Diagnosis. — The diagnosis rests on a most careful urological examination. 
Stricture is suggested, n^it proven, by a ureteral catheter nu'cting an impassable 
obstruction, for in many cases the obstruction is but a kink or a mucous mem- 
brane fold of the ureter. Such obstruction in tlie jiresence of infection is very 
suggestive of true stricture, especially if a eoniparative functional test shows 
reduction of secretory power. Most conclusive is the demonstration of a dilated 
pelvis and ureter. This can easily Ik? carried out as show^i in Figures 266 and 
2G8. Absolute demonstration is made by the injection of 10 per cent collargol 
solution, and the X-ray, which shows the location and length of the stricture. 
The lo<'ation of the vesical end of the stricture is readily obtainable by meas- 
urement, as shown in Figure 40(3. The average length of an adult ureter is 
28 cm. (see Fig. 130). The caliber and rigidity of the stricture can be demon- 





t. 467.^ — SsRiEB or Catheters or Bougibs Used to Dilate Stricture of the Ureter. 
An ftUisator forceps, as shown in cystoscope^ can he introduced into a dilated ureter for 
the purpose of graflping a stone. 

Treatment. — The treatment depends on the location of the stricture, its 
Itent, and the condition of the kidney eoncemed. Primary uretero-uretero 

ftomosis is prartically never pos.sible, owin^ to infeetiun. In every case 
Hlatation by graduated bougies, shown in Figure 467, should be carried out 
wfitli lavage of kidney (Fig, 309), and abundance of urotropin and water to 




[354 STRICTURE A^^) OTHER DISEASES OF THE 

clear up tlie infection. It is possible to dilate a ureter by the graduated 
boiijj;ies to IG nuu. in a few weeks and without general anestlicsia. With long 
strictures at the vesicul end of the ureter there is a tendency to recurn^mH'; 
under such circnmstanecs u r etc ro- vesical auastomosifi offers the liost result**. 

This operation, shown in Figure 461), can be easily carried out throng a 
oni8ele-s]>littiiig extraperitoneal iucieiion and, if desirable, under local anoi- 
thcsia. I'efnrc doing this operation, the suture material Ix^ing catgut, errry 
effort should bo made to secure as much freedom from infection as poesible. 




r^^' 



Fig. 468. — Measxtring tue Yimcw Needed to Wititbr.\w a Renal Catbstbb Hjuj» i 
TKB Bits of a Stkiiti red I iU!:TEit. By usiog the stime suted catheter on guoocMJ^ii ^-^ 
days and registering the pull, any dilatation of the stricture can be determined. ^ 

When the ureter alxjve tlie stricture i.^ greatly dilated, and if the kidney f mm *^>. 
tion ift greatly and permanently impaired, the best treatment is iicphn>etom^^. 
This is esjjeeialiy true of strictures in tbi' middle third of the ureter due ^o 
stone. 

Traamatic Stricture* — Traumatic stricture of the vesical end of the ureter 
following the injuries of labor and of eiirgical oiM?ration» especially the 
Wertbeim operation for cancer of the cervix uteri» is quite common* As ^ 
rule, the trauma has so interfen d w^ith the blood supply of the orpin that theft 
are lateral nerrtisis, a contitnHins leakage of urine, and uretenwaginal fistub. 
The spontaneous Inhaling of such a fistula, almost invariably, means stricturr 
For the Ireatment of such fistulas see Chapter XXXIIL As a rule, tlie Uvr 




IG. 469.— Uretebo- VESICAL Anastomosis, by the Transperitoneal Rol-te. Tlie end 
of the ureter is Bplit, as aliown^ and a traction suturt; applied, drawing it through the hole 
in the bladder, aa indicated. The second and third fi^ure^ show the ureter fixed into the 
bladder by interrupt^^d catgut sutures. 

lis Fiipposcd to varj in its dpvehipment from a few months to year*^ after the 

linjury, A full account of the condition is given by K. W. Monsarrat (Wien. 

led. Presse, 1905, xlvi, 1593), When very loiio', tlio only treatment is by 

station throuiErh the bladder or directly by operative exposure through the 

The ideal treatment, where possible, is resection and end-to-end auas- 

tomosia (Fig. 470)* 




356 



STRICTURE AND OTHER DISEASES OF THE URETER. 



IV 



Congenital Stricturcfi,^ — Congenital narrowing or complete closing of the 

ureter is not a rare condition (Chapter XVII). Omitting from consideration 

the conditions of entire or parhal absence* and those of exlravesical opening of 

a ureter, tliere reiriains qnitt* a prei^entalile group. Dr. 

John Uottomley (-l^^^k Surg., tiMO, lii, M^7 ) collected 5G 

caaes from the literatnre. lie observed the followng 

points : 25 were males, 1 females^ 1 5, sex nut stated ; left 

ureter, 27 times; right ureter, 17 times; both ureters, 10 

times; upper ureter, 8 times; vesical end ureter, 38 times. 

Only 19 cases gave subjective symptoms. 

Of considerable interest in conneetinn with kinhs and 

valves is a recent publication of d. Eiiglisch (Wiener miuL 

Wchnschr,, 1011, Ixi, SJiSD), who finds in the ureters of 

live months' fetuses nnirked kinking mid foldings of the 

mucous and muscular coats, while the fibrous coat is quite 

sraooth. At the vesical end, well nnirked cysts were fre- 

qnently observed. 

Kinks of the nreter may he dne to movable kidney and 

i'la. 47U.— -b N D-T o- ur^.i;^.^ or to any condition, such as an inHanmiatory bowel. 
End Anastomosis i . i ^ i " 

OF Cut Ureter, which fixes the organ. 

The longitudinal The occurrence of valves in the nreter is pictured by 

slit in the lower j^^^,^^ -j^ |^jg "Traite deg maladies des reins/' Paris, is;n ; 
Simon (/'Chinirgie der Nieren," 1S76, 2 Theil) sug- 
gested removal of the valves. Dr. Christian Fengcr 
(Chkatjo Med, Bpc, 1893, iv, 155) reports a ureterotomy 
for such a stricture. 

In the upper nreter the ])ossibilities are resection and 

to the left, atjd anastomosis, plastic widening of the canal, and dilata- 
the two ends are ,. ^ - /t^ n \ ^ i -ii * \^ 

unit-cd bv inter- ^**'^^' '^^*^ ^^f ^^^ (Kelly) operated with great success b\' 

mptcd catgut su- this mc^thud in a ease reported in the Johns Uophins II os- 

tures, as shown in pHal Bullet m, lOOG, x^ni, 173, 
We quote verbatim : 

**Mr. R* A. W,, age 43, was under ray care for on 
month, from Juno 10, 1900. He had had repeated attacks of severe pain in 
the left side, seriously interfering with his occupation, which was that of an 
E%^angelist. These attacks began January 8, 187^^ when he had a long spell 
of aickness, associated with a bowel trouble thought to be intnsguseeption. The 
attacks were clearly renal in their origin, and nothing was found by a physical 
examination or an examination of llie urine, I exposed the left kidney and by 



section permits 
easier invagina* 
tion of the upper 
portion. The 
traction sntare is 
placcil as shown 
in the drawing 



the right-hand pic- 
ture. 







PROLAPSE OF VKSICAL KND OF UHETKR INTO BLADDER, 



357 



rotation broiiglit into view a large hydroucphrutic pelvis of about the same size 
as the kidney itself. It was fusiform in shape and extended down below the 
lower pole of tbe kidney a short distance beyond the pelvis. The nreter, which 
began normally, suddenly eontraeted imtil it was only about 2 mm. in diameter 
at a point 2 cm. below the pelvis. There %vere no signs of any adhesions, or evi- 
dence of previous inflammation. The pelvis of the kidney, however, was tliiek- 
walled, owing to physiological hypertrophy. 

"Treatment: Realizing that it was impossible to do any plastic opera- 
tion on so delicate a structure, I 
tried that which seemed to he the 
only feasible plan. I incised the 
pelvis of the kidney about a centi 
meter above the ureter, and then 
ihnmgh this orifice I introduced 
metal cathetprs which I have liad 
made for dilating strictures of the 
lovrer end of the ureter ; with these 
I gradually dilated the stricture 
unril a catheter about 5 mm. iii 
diameter was passed with some ap- 
parent rupture of the inner coats of 
tk ureter (Fig. 201* ). The 
wound in the pelvis was then closed 
TPiith fine silk and the kidney re- 
tamed to its position, with a small drain. He made a perfect recovery from 
tie operation, and has never had any pain from that clay to this,'^ 

Prolapse of the Yeaical End of the Ureter into Bladder, — This very interest- 
ing condition is well shown in Figures 471 and 473. Bhimer's cases are espe- 
cially extraordinary. At the time of his publication (JoIiThS Hopkins Hospiial 
^■Bulletin, 1896, vii, 174) he was able to collect 13 eases from the literature. A 
iios^t interesting case is that shown in P'igiire 471. One of us (Kelly) reported 
a case successfully treated (Johm Hopkim Hospital BuUeiin, 1906, xvii, 173). 
*'A number of cases of tliis extraordinary condition have been reported, but 
^^lo far as I know no other ease has been diagnosed and treated intra v i t a m. 
^pbc patient of whom I now speak, Mrs, J. W. F,, came to me through the 
Htourtesy of Dr. P. M. Hicks, of San Antonio, Texas. She had had one child 
nine years before, with a difficult instnnnental labor associafed with a bad 
laceration. About six montlis beft^ro she was seeu she bad suffered with a bad 
attack of lower abdominal pain, accompanied by a temperature of 102^ F,, and 



Fio. 471.— Prolapse of RmuT Ureter into 
Bladder^ Forming a Cyst. Note the 
small orifiec. (Mrs. P. From G. L, Hnn- 
ner, Union Protes. M,, Oct., 1906,) 






STRICTURE AND OTHER DISEASES OF TEE ITIETEIL 

much tciuleniess in tbe right Fide. Since that time she continued to complain 
of backache and much pain in the lower abdomen. Vaginal examiualioQi Dr, 

Hicks wrote, revealed a 
retroflexed utenift and a 
somewhat fixed tender mut^ 
II bout the size of an 0gg in 
tbr right ciil-de-sac, 

* November 18, 1TO4, I 
made an abdominal in* 
cisiHu and fonnd li*»ili 
ovaries small and aclerotie, 
2\U cm. by 1 cm.» and S 
by 1 cm., and the ureters 
appeared normal. The ap- 
pendix was removed and tbe 
uterus suspended. She made 
a good recovery from this 
operation, but continued to 
have more or less discomfort 
in the lower abdomen, Tpon 
a careful bimanual examina- 
tion, November 23, 1{K)4, it 
w^as impossible to feel any- 
thing upon tbe left aide, 
while the ureter could Ik* felt 
on tbe right through tlio 
somewhat senile vaginal 
^valL Upon making a vodical 
examination in the knee- 
breast posture the bladder 
distended well, the posterior 
Willi dropped 6.5 cm. from 
the anterior wall. Through 
a No. 10 speenlum a curious 



Fig. 472* — Prolapse of Vesical End of ITiIbter 
INTO Bladder, Dub to Strhtture Induced by 
Cystitis, The prolapse an the right side is moder- 
ate, that on the left enormous. Note the positions 
of the ureteral orifices on the prolapsed sacs; also 
the thickened and diseased bladder mucosa, and 
the pseudo-^liphtheritic patches on the mucous mem- 
brane. The large prolapsed sac hangiiig out of the 
neck of bladder wm curled up in the cavity. 3^ 
natural size* (From George Blumcr^ Johns Hop. 
Hosp, Bull., Sept. -Oct., 1896.) 



teat of tissue could now be seen hanging do^vn into the bladder from its base on 
the right side, occupying tb6 position of tbe ureteral raons. This at first iip- 
{tf'ared as a short truncate cone about 1.5 cm* in diameter at its base, and 6 mm* 
f rnni base to apex. From tbe apex clear urine fell steadily drop by drop. While 
in the act of watching it a remarkable transformation took place; the cone bc^aa 




PROLAPSE OP VESICAL END OF URETER INTO BLADDER 359 

to swell, and in the act of swelling was forced down into the lumen of the blad- 
der ; as it continued to grow larger, its walls appeared paler, thinner, and clearer, 
until, at the maximum, a few red vessels could be seen coursing over the surface, 
which looked like a large cyst as big as the end of the thumb, full of water. With 
this distention the flow of urine increased in amount. Numerous translucent 
areas were visible scattered over the now hemispherical enlargement, which was 
from two to three times the size of the eminence originally observed and more 
rounded in form. Following this distention the cyst collapsed to its former 
size. As I continued to observe it, I noted a periodicity of from 5 to 10 sec- 
onds between the intervals of advancement and retraction, of expansion and 
contraction. 

*'Tlie ureteral orifice could fortunately be seen on the anterior, inner, or 
urethral side of this mens, faintly outlined, forming a narrow slit not open at 
any time. The left or opposite ureteral orifice lay in a red mucous vesical fold 
not prominent in its normal position. When the mucous tissues about the right 
ureteral orifice became distended, the narrow opening, instead of advancing 
toward the median line of the bladder, remained relatively nearer to the base 
until the orifice came to lie wholly on one side. We had here manifestly to do 
with a stricture of the vesical orifice of the ureter affecting only its mucous 
surface. 

"Treatment: The treatment was very simple. I took a delicate 
pair of vesical scissors, working on long parallel handles like an alligator 
forceps, and introduced one of the points into the ureteral slit-like orifice 
when the sac was fully distended and cut a slit 5 mm. in length. Fifteen c c. 
of urine at once gushed out, and later 60 c. c. escaped, about half of which was 
estimated to come from the bladder, when the patient assumed a kneeling 
posture. When examined five days later, the right ureteral orifice appeared 
stellate, widely opened, seated on a red papillary eminence. On intro- 
ducing a searcher the margins could be readily lifted apart. The opening 
now looked like a black hole in the bladder wall, instead of a slit situated 
on the side of a cyst The patient was discharged well, February 9, 
1905.'' 

C. Adrian has reported a case of intermittent cystic dilatation of the vesical 
end of the left ureter (Arch. f. klin. Chir,, 1906, Ixxviii, 588). The patient 
had had dull pains in the upper abdomen and in the region of the right kidney, 
becoming more distressing upon standing or walking; these finally became so 
intense that she could not sleep. A diagnosis was made when the cystoscope 
was used ; this revealed an intermittent cystic dilatation of the vesical end of 
the left ureter. The condition was relieved by making a suprapubic opening 



360 STRICTURE AND OTHER DISEASES OF THE URETER, 

of the bladder, with an incision into the little mucous tumor, with a suturing 
of the vesical and ureteral mucosse with fine catgut. 

Adrian calls attention to 52 cases of dilatation reported in the literature, 
in 12 of which the diagnosis was made intra vitam. (See further litera- 
ture in article by Th. Cohn, Beitrdge z, Iclin, Chir., 1904, xli, 45.) The cystic 
prolapse may be very small, or it may reach immense size. 

In the large cases it would probably be preferable to do a suprapubic cys- 
totomy and resect the cyst, although the simpler procedure is always to be tried 
first 



CHAPTER XXX. 
ANATOMY AND TOPOGRAPHY OF THE FEMALE BLADDER AND URETHRA. 

THE BLADDER. 

The bladder is a capacious muscular pouch, situated in the anterior hemi- 
j-phere of the pelvis, designed to receive and accumulate the urine from the 
kidneys, which it discharges from time to time by way of the urethra. Owing 
to the yielding character of the wall, its capacity in a state of physiological 
distention varies considerably, as shown in the following: 

Minimum Maximum Average 

Adult Male 240 c. c. 1,140 c. c. 710 c. c. 

Adult Female 200 c. c. 1,020 c. c. 650 c. c. 

These figures are exceeded in exceptional cases, and a capacity of 3,000 to 
4,000 c. c. and even more is noted without rupture. 

An empty bladder in the state of muscular contraction is spherical, pear- 
or egg-shaped, with its upper narrow extremity leaning against the svTnphysis, 
the lower round end resting on the pelvic floor and vagina. Its length is 5 to 6 
cm. ; breadth, 4 to 5 cm. ; depth, 2 to 2.5 cm. In the relaxed condition, espe- 
cially in the more thin-walled female bladder, the vertex, with the fundus uteri 
rtsting on it, drops down onto the base, giving the bladder a peculiar gibbous 
appearance. It is Y-shaped if seen in sagittal section, the stem of the Y being 
the urethra. The longer anterior arm of the Y rests against the symphysis,, 
while the shorter posterior arm lies on the upper vagina and cervix. Pos- 
teriorly the bladder is somewhat flattened against the cervix. 

In distention the vertex is gradually lifted up from the base, which 
first expands backward and downward, while the lateral bladder walls expand 
toward the pelvic walls on both sides. Owing to the limited space in the pelvis 
the transverse diameter reaches its maximum sooner than the other measure- 
ments. The upper half and a part of the posterior portion are covered by peri- 
toneum, and, as distention proceeds, the vertex rises over the symphysis, carry- 

361 



362 



TOPOGRAPHY OF THE FEMALE BLADDER AND URETHRA. 



ing the line of the peritoneal reflection upward; this exposes the extraperi- 
toneal suprapubic portion of the bladder, so imi)ortant to the surgeon. The 
bladder is now ovoid, with the long axis pointing to the umbilicus. In exces- 
sive distention the vertex rises up to 
the level of the umbilicus, and the 
line of peritoneal reflection is 8 to 
9 cm. above the symphysis. 

The bladder develops from 
tho allantois and cloaca of the em- 
bryo (Chapter III). The down- 
ward growth of the urogenital sinus 
divides the cloaca into anterior and 
posterior portions. The anterior 
becomes the base of the bladder and 
urethra, the posterior, the rectal 
ampulla. The upper end of the 
spindle-shaped allantois lies in the 
umbilical cord. While the bladder 
in the newborn is largely an ab- 
dominal organ, after birth it rap 
idly descends into the pelvis. It 
changes in shape from a spindle to 
an ovoid, becoming still rounder 
and lower in the adult. The ob- 
literated allantoic duct is now seen 
as tho fibromuscular urachus run- 
ning between the two obliterated 
hypogastric arteries on the inner 
surface of the anterior abdominal 
wall from symphysis to umbili- 
cus. 
The peritoneal covering is limited to the upper surface, but dips 
down slightly on the sides and behind, forming fossa? on the two sides between 
bladder and pelvic wall, round ligament, and uterus. The lateral paravesical 
fossae are crescent-shaj)ed and traversed by the converging obliterate<l hyiH> 
gastric arteries. Light peritoneal folds traverse the top of the bladder in a 
transverse direction. There are also a few longitudinal folds in front. In a 
state of distention these folds and fossa) become obliterated (I'igs. ^".'J and 
474). 




Fig. 473. — Distended Bladder and Its To- 
pography IN Relation to Peritoneum, 
Intestines, and Pelvic Bones. The 
dotted line below marks the position of 
the symphysis. 




Fic. 474. Anterior View of Distent>ed Hardened Hi^DpfcR. Wmdows are cut out 
of the anterior and the left Int^^ml walb. The distribution of tlie muscle fibers U ahown, 
as well m the peritonea! reflection. Through the middle window the base of the bladder 
and trigotiuin are exix)sed, and tlirough the side widow, the left comu. 



marked in the prevesical ure«, the so-called gpaec of Rctzius. With the body in 
the upright posture the internal urethral orifice is at the lowest point of the 
bladder, about 2,5 cm. back of the pubic bone. 

The recto-vesical fascia (Figs. 474 and 476) resting on the levator ani is 
especially strong in front, forming the anterior true ligaments of 
the bladder, two strong bands passing on either side of the urelhra from the 
lowest portion of the synipby,sis to the net»k of the bladder. Similar ligaments 
can be ditfcrentiattHl in the lateral part of the fascia. These run from the 
white line of the olitiirator fascia to the lateral region of the bladder, the so- 
called eornu. There arc also two posterior ligaments^ which pasa from the 



364 



TOI*OGRAPHY OF TOE FEMALE BLADDER AND URETHHil. 





iioc*k of the bladder around the %'agiim and through the broad ligainenU bick 
to the fasria covering of the M. pvriformis. 

The interior of the distended bladder is smooth except for 
a few nincoiis folds at the trigonnm and internal nrethral orifice. The iuii^*le 
btmdles of ibe bladder become stivtelied and separated from one another, letv» 
ing little intergpacea through which the inner coats slightly protrude. These 
little i>its on the nineuns surface may increase in size and heeome henii» or 
diverticula of various dimensions. 

In the contracted bladder the loosely attached mucosa is thrown into 

numerous folds and 
wrinkles^ running mostly in 
a 1< )ugi tud i nil 1 d ire<*t urn. 
The internal urethral ori- 
fice is in the lowest p«irtion 
of the blu<ider; it is cres- 
cent-shaped, concave toward 
the front, and shows deli- 
cate nuicons folds rudiating 
from the urethra upward 
and back into the trigonura, 
which begins at the orificei. 
The upper limit of tie 
trigonnm is marked by i 
line connecting the two uit- 
teral orifices. The trigimal 
region, being less mobile 
than the rest of the blad- 
der, remains comparatively smooth. The suhmucosa here being almost lack- 
ing, the nincosa rests directly on the mnscle. The size of the trigonum i* 
less aifcctcd in contraction and expansion than any other part of the bbidder. 
The two ureteral orifices are little slits, oblique, oval, or crescent-shaped, open 
below and situated about 3 cm. apart on a transverse muscular ridge, the 
plica u r e t e r i c a. Lateral to the nreteral orifices this ridge curves slighdj 
upwardj foltowing the course of the intramural p^l^tion of the ureters. Back 
of this ridge is lli*' rrtrotrigonal fossa, a shallow recess which becomes more 
marked on moderate distention of the bladder. On each side of the bladder ia 
found a shallow pf>cket, the so-called cornn, also best seen in moderat**d disten- 
tion. The location of these cornua corresponds to the lateral ligaments aboTe 
described. 



SubmucoM 



rcuLar 






Fig, 475. — Section of TitE Bladder Showing General 
Disposition of Coats. Only a very few libers of the 
inner longitudinal layer are cut in this S4fction. 
X 12. (After riersol/'Iiunmn Anatomy/* 1907.) 




THE BULDDEB. 



365 



^s, 



Stmcture of the Blad- 
der* — There is a serousj 
lusculiir, 8ubimicoiis, mid 
^tiiueeus coal riehly snppli^-d 
by blcKxi-vcssels, lymphat- 
and nerves. 

The serosa consists 
of peritoneiiin and a loosely 
constructod, subperitoneal 
Hkyer of eonnoctive tisBuef 
^Rhe fiberi? of whidi ponnit 
Hgreat mobility of the peri- 
Htooeal membrane. The 
muscle coat (Fig, 
477 )y consisting of un- 
I striped muscle fibers, can 
Bl>e divided into thin outer 
I and inner longitudinal lay- 
,er8 with a strong circular 
lyer between. The direc- 
ion of the bundles, how- 
Ter, is quite irregular, the 
biuidles of the same layer 
ften intersecting one an- 
other, but, on the whole^ the 
rangement is as indi- 
ftted. The bladder nius- 
ties consist of relatively 
oarse bimdlca, which be- 
ome heavier still at the 
of the bladder. In 
the trigonnm the muscular 
Klayers show the greatest 
Bihickness and strength, the 
Bindividual fibers^ however, 
being more delicate and 



FlG. 476. — Relations of Urethra and Trigonum of 
Bladder as Seen from Vaginal Side. A longitu- 
dinal incision has bvLm nuulv tiirouj^li vagioal widl^ 
from the external urethral orifice to the cervix, whii-.h 
is drawn aside, exposing the urethral ridge atid the 
trigotium. The crosses indicate the internal urethral 
and the two ureteral orificos. 



t closer together than in the rest of the bladder. From this mnsculutnre arises a 

Pthick ring muscle around the internal urethral oritiee, the involuntary '*sphiuc- 

ter vesicae,*' The aubmueosa is more hx^sely attached to the muscle coat 




Fig. 477. — ^Musculature op the Bladder and Ubbthba. 

a. Diagram showing direction and disposition of muscle bundles composiEig Mm 
voluntary sphincter of the urethra (sphincter urogenitalis) ; the u])pertiioirt bundJei (1) 
surround the urethra, the terminal fibers passing in an upward direction id the viaeof J 
vaginal septum. Other fibers form a complete ring muscle (see abo little figun; (llfl 
below). The middle bundles (2) surround the urethra in front, pausing over ooto Um 
vagina and becoming inserted in its lateral musculature. The lowermost btmdkft CQ 
surround both the urethra and the vagina, terminating in the recto-vagirml ^'p4imi. 
(See little figure 3 below.) The urogenital sphincter terminates at tfie j unction of the ^ 
external and middle portion of the urethra, the lowermost portion lieing embraead 1 
the M. bulbo cavemosus with the erectile tissue of the bulbi vest)l>tili intern; 

b. Dissection of the muscle coats of the bladder and urethra. A little siquan? 1 
been cut in the outer longitudinal layer of the bladder muscle, expo.shig the filitvs ofl 
the middle circular coat. The voluntary sphincter of the urethra i^ s^hown tti llai 
entirety. A portion of the pelvic fascia and the triangular ligament is remiomd m] 
order to expose the urethrar 

c. Diagrammatic representation of the involuntary sphmcter of the urettoi^ IliftJ 
M. sphincter trigonalis. As shown in the figure, the fibers of this sphincter 1iav« ti 
origin in the muscle bundles of the trigonum, the fibers passing obliquely dowiswanl i 
forward and surrounding the internal urethral orifice in an oblique direction. The Imm 1 
circular fibers of the urethral sphincter are inserted in the latertil vaginal walL Th 
fibers of the inner longitudinal muscle coat of the lower urethra are relatively strong mti 
taper as they end, only a few reaching as far as the bladder. 

d. Injection of the erectile tissue of the urethral submucosa. 



366 



368 TOPOGRAPHY OF THE FEMALE BLADDER AND URETHRA. 

than to the mucous membrane. Its elastic tissue fibers permit the great char 
iu the arrangement of the mucous membrane incident to expansion and contrac- 
tion* At tlie rejirion of the trigoniini tlie HiilnniUNiHa is thin or wanting. The 
mucosa is a soft, smouthj^ orange-pink membrane covered hy a transitional 
epithelium similar to that of the ureter, renal pelvis, and upper urethra. The 









'♦Wf*i /iJi 



^i, 



Bl. 



Fio, 478.— TuE AiiTEHiAJ. CmcuLATioN OF THE Bladt>er and Uretbtia as Seen from 
THE 8101:. Thn origin aiul course of tlie Hiipprior, niidfll<% :uil1 iiifcTior vesical arteries 
are shown ^ tdso twigs ( (jniitig from the utt^rint' ^lrl,cr>^ The urethral arteries are de- 
rived partly from the inferior ve^ieal and partly from the vaginal; Im^Iow^ they proceed 
from temiiiial liraiieheii of the internal pudic artery. 

superficial layer coitaists of ihittened polyhednd cells, while deeper dowTi they 
arc cliih-shaped or cylindrical. In di^tmtiuii nf the bladder the cells Hatten out. 
bnl (io nut lose their connection with one another. 

The arteries are bilateral, coming from the rijxht and left iliac (Figs* 
478 and 470). On each side there is an inferior vesical artery coming 
from the anterior or posterior division of the internal iliac and running to the 
base and neck of the liladdcr and upjwr urethra. The middle an d supe- 
rior vesical arteries arise from tlie hypogastric urtcry before it Ix^comes obli- 




THE BLADDER. 



369 



[ temtcd and run to the aides and top of the bladder, tlie superior vesical supply- 
ing the anterior vesieal region. Thero arc also twigs from the uterine and 
yagirml arteries. The lower half oi the VJadder is rieher in hluod supply than 
the top. In the riiiilrarted bladder the artprirs assume a very tortuous course, 
whit'h becomes straight iti the state of maxiiiuun physio!ogieal distention. 

The veins form a eoiujilex network around the sides, base, and neck of 
ihe bladder, draining iulu the lateral pelvic veins, mostly the internal iliac. 



,1/; 



vu 



-^ »<i^* 



|Fi«. 479, — The Arterl\l Circulation of the Bladder as Seen fiiom in Front and 
ABiiVE. The vesico-uteritic j^jcritotieuni has hreu rcniovt-d, exposinjyf the v^iacular trunks, 
Not4? the course aufl dirstriljutiorr of the niidtlle vesical arteries. A tran^ver^c nick 
hflsbeeu nmdc thruugh tiic ura( hus, in order to show the origin of the anterior peritoneal 
WmIb coming from the inferior veijical circulation. 



The lymiihatics appear na a delicate network in the suhmueosa^ tlie 
collecting channels of which receive a few tributaries from the jnuscle coat, or 
else the lymphatics of the latter follow an iridepeuilent cunrse. The lymphatics 
everywhere accomijany the blood vessel,s autl drain bilaterally into the internal 

»Qiac chain of glands. The infi^rior lymphatics oceaaionally traverse small 
intercalate*! lymph nodes. 
The nerve sn|»()ly ly also bilateral; it is derived from the hypogastric 
plexus of the sympathetic and the third and fourth, rarely the second, sacral 



370 



TOPOGRAPHY OF THE FEMALE BLADDER AND URETHRA, 



nerves. Tliese unite to fonu the pel vie plexus tind its ganglia, extending on 
either side to the base of the MadJer, The vesical nerves arising from this are 
mainly non-medullated. 



THE URETHRA. 

The female urethra ia from 2.5 to 3 cm. long, of considerable thickness, 
10-12 mm., and posspasses great elasticity. The mucous surface is thrown into 
longitudinal folds, which give the lumen a star-shaped appearance; for this 
reason the canal is capable of considerable distention without 
injury to its coats. The urethra ia gently curved around the 
lower !»order of the symphysis, the fnnncl-shiiped vesical end 
being about 2.5 em. back of the symphysis, the external 
orifice only 1.5 cm. away from it (Fig. 47*))- The latter is 
the narrnwest portion of the tube. The M. levator ani, skirt- 
ing the urethra on both sides, dividts it into a short pelvic 
and a longer penneal sec*tion. In front and on the sides it 
borders on the putlie venous plexus, the urogenital trigonum 
(triangular ligament), which it perforates, the corpora 
ciivf rnosa of the clitoris, and the bulbi vestibnli. Behind, 
thu urethra is attached to the anterior vaginal wall, being 
more intimately comaected below than above. Situated on a 
round promiuence the extremal orifice or meatus is a vertical 
slit with more nr less distinct lateral ridges, the so-called 
urethral Inbia (Fig. 480). Sometimes the oritice has the 
form of an inverted Y, a crescent, star, or a cross. On either 
side, just within a meatus, are found the delicate paraurethral ducts of Skene's 
glands. 

The urethral mucosa (Fig, 477) shows many longitudinal folds, the 
largest of which is in the midline of the posterior wall. On each side of this is 
a parallel fold joining the middle one near the external orifice. The mucous 
membrane has a stratified squamons epithelium which, near the bladder, be- 
comes transitional like the vesical epithelium, and below resembles the vaginal 
epitheliimi. The urethral glands, more numerous below, are of the branching 
tubular typ<^ The sulnnucosa carries numerous vascular papilla3 containing 
l\'Tnph nodes. Lying close to the mucosa is a cavernous vascular network, the 
''corpus apongiosimi urethne,*^ emlxnJded in the submucous areolar tissue. This 
venous plexus extends a short distance into the muscle coats. These are of the 
UBstriped variety and consist of a thin outer and inner longitudinal and a thick 



Fia, 480. —Ure- 
thra Showtno 
Pronounced 
Labia. 




THE URETHRA. 371 

middle circular stratum. They are continuous with the trigonal musculature 
above, and are known as the involuntary sphincter of the urethra. The sphincter 
fibers are strongest near the bladder, getting progressively thinner and ceasing 
altogether in the lower third of the urethra. The inner longitudinal muscle, 
however, is strongest at the external orifice, only a few delicate bundles reaching 
the inner longitudinal bladder muscle. Outside of these three unstriped muscle 
coats are bundles of striped muscle fibers, the M. sphincter urogenitals, the 
''voluntary sphincter of the urethra." The bundles describe a definite ring 
muscle only around the upper urethra. Further down they merely form a semi- 
circle around the urethra in front, terminating in the lateral vaginal wall, while 
at the lower end they include both urethra and vagina (Fig. 477). The fibers 
of this voluntary sphincter are strongest below, ceasing near the bladder, the 
exact reverse of those of the involuntary sphincter. The urogenital sphincter 
does not extend to the external urethral orifice, its place there being taken by 
the M. bulbo-cavernosus, which surrounds urethra and vagina in a wide circle. 
Between it and the urethral orifice are the bulbi vestibuli. 

The arteries of the urethra are derived from three sources on each side ; 
the upper urethra is supplied by branches of the inferior vesical artery, the 
middle portion by the vaginal, the lower by branches of the internal pudic 
artery. 

The veins drain above and behind into the vesico-vaginal plexus, below 
and in front into the internal pudic plexus. They freely anastomose with the 
cavernous veins of the body of the clitoris and the bulbi vestibuli. 

The lymphatics drain upward into the hypogastric lymph glands and 
downward into the inguinal lymph glands. 

The nerves come from the pudic and the genito-femoral, carrying sen- 
sory fibers and motor fibers for the voluntary sphincter and the vesical plexus 
of the sympathetic, which supplies the involuntary muscle coats of the urethra. 



CHAPTER XXXL 
DIVERTICULUM OF THE BLADDER. 

A vesical diverticulum is a congenital pocket, loculus or sac of variable size, 
communicating with the cavity proper of the bladder, attached to its periphery, 
and lying below or at one side of, posterior to, or al)ove the bladder. Not infre- 
quently the added contents of several diverticula, or even a single diverticulujn, 
may be even larger than the cavity of the bladder itself (one was a gallon in 
size). When it is situated near a ureteral orifice, a customary location of 
the diverticulum, this may open into it, or the ureter may, with growth of 
the sac, be drawn down into its cavity (Young), constituting an important 
variety. 

The opening of communication varies from a wide mouth to a narrow sinus. 
The cavity is flat or sub-spherical, according to its size, location, and varying 
degrees of distention. If much pressure is habitually exerted in voiding urine 
the cavity may appear more or less diffusely distributed around the bladder as 
it moulds itself to the contiguous tissues. An interesting diverticulum, which 
differs generically from all others, is due to a patent urachus, which forms a 
pocket between the anterior abdominal wall and its peritoneum. We may ex- 
clude here diverticula extending out into an inguinal hernia, although this 
extension, too, may characterize a true diverticulum. 

OCCURRENCE. 

Diverticula, as pathological entities reipiiring trentmont, are generally found 
in men, and therefore belong mostly to the })rovince of the male urologist. In a 
group of 17 cases collected bv Van Dam (Bcifr, z, I'lin, (liir,, liV13, Ixxxiii, 
320) there is but one (Pean's) allotted to the female sex, and tliat is in a meas- 
ure doubtful, as the patient, a girl of 15, liad a supornuinerarv urethra opcniing 
into a sac without a ureter, which communicated bv a narrow opening with the 
bladder. Other cases in women an*, the followini::: 

(1) W. Alexander reports on(* (Llrcrpool Mecliro-CIilr, Jour,, 1884, iv, 
253) in a woman, 40 years old, admitted to the hospital **on account of her 

372 



OCCURRENCE. 373 

womb coming down." She had had six children, the youngest six years old. It 
was after this last birth that the womb came down, but it caused no distress 
until two years before her admission to the hospital, when she had painful mic^ 
fiirition and a swelling which troubled her most w^hen standing. A globular 
tumor projecting from the vulva was attached to the anterior vaginal wall by a 
rather narrow neck. Two calculi were found and excised from this tumor, and 
later the anterior vaginal wall, which was lax, was removed, laying bare the 
base of the bladder. The bladder cyst or diverticulum which arose at the 
trigonum near the urethra was then tied oif at its neck with strong catgut and 
excised, when the rest of the wound was sutured and the patient recovered 
i^ith a small fistula. 

(2) A large diverticulum, filled with papillary excrescenijes, in a woman, 
59 years of age, is reported and figured by Hofmokl (Arch. /. klin. Chir., 
1896, Ivi, 202). The patient died with an infection of the sac and lobular 
pneumonia, and at the autopsy an opening was foimd above the left ureteral 
orifice leading through a passage 1 cm. long into a fluctuating tumor almost the 
gize of a child's head. On opening the sac it was found filled with pus, and ita 
walls, which were greatly thickened and made up of muscular tissues, were 
covered on the inside with soft polypoid excrescences. 

(3) A case of congenital diverticula is described in Kelly's "Operative 
Gjnecology," 1898, i, plate ii. There was an opening in the bladder, 1 cm. in 
diameter, leading into a basin-like cavity, 1 cm. in depth, posterior to the right 
ureteral orifice and near enough to be mistaken at first sight for a large ureteral 
opening. With the contraction of the bladder the oval opening into the diver- 
ticulum closed down to a line with radiating folds (Fig. 481). Buerger (Uro- 
logic and Cutaneous Review, 1013, xvii, 135) has made the same observa- 
tion on the contractility of the orifice, and quotes Durrieux's thesis, Paris, 
1901. 

We have seen another case in a woman 47 years of age, in the posterior wall, 
where the narrow-mouthed pocket, about 2.5 cm. in depth, was filled with 
small stones. 

True diverticula, as a rule, occupy the lateral walls of the bladder and are 
apt to lie outside a ureteral orifice. They are lined with mucosa and have well- 
developed muscular layers. A further distinction is between diverticula, which 
are completely pre-formed and show all the normal tissues of the bladder in 
their due proportions, and those in which the pocket has become greatly en- 
larged after years of pressure, and there is little or no muscular tissue in the 
wall, due perhaps to a prostatic or other urethral obstruction associated with 
back pressure in urinating. 



Etiologiciilly, diverticula arc usiuilly forrnrd from small preexistinj? pouches 
or htruiib in thu lilaJder, wliit-h lux-uine enlarged by pres^surej and later come 
into prominence through stagnation of urine and inflammation, or by concealing 
a stone or a iieopiasm, or by exercising damaging pressure on a ureter* It is 
because of tlie absence of these ciiuses that we rarely see large diverticula in 
women. Hodgson {Glasgow Med. J,, 1857, iv, 29 ) long ago recognized tlxat a 
common cause of a diverticuhnn was to be found in a prostatic or a urethral 
obstruction. I{. Harrison reports a case due to violent muscular effort made in 
the act of b*^ing thrown from a horse* 



SYldPTOMS. 

The symptoms of a diverticuhim are often obscure and its discovery acci- 
dental. The symptoms may be nothing more than pain and difficulty in mic- 
turition which are prolonged, and thus often attributed to the common coinci- 
(h'ut enlargement of the prostate or to a stricture* Anotlier and more charac- 
teristic symptom is that the patient urinates, and, after emptying the bladder, 
in a short time has to urinate once more (mirturiiion en detix temps). The 
pain may be unilateral over the site of the aac, where there is also a marked 
tenderness; or there is complaint of a sensation of not emptying the bladder in 
spite of a continuance of etlort with tenesmus, and, at tlie end, the passage of 
pus. More rarely the first sensation is pain in one kidney, owing to the pres- 
sure of the full diverticulum upon a ureter. This leads to hydronephrosis or 
pyonephrosis and fever, and may even destroy the kidney. 

If the bladder is washed out it is difficult to gii:^t it clean. If the divertic- 
uhun lies low and has a small orifice, it nevtr empties itself well, and the urine 
stagnates. 

Occasionally the hiatnry is marked by hemorrhages, w^hich may be relieved 
by the insertion of a drainage catheter (Harrison). 

1>. W. Graham (.inn, Surg,, 1003, xxxvii, 470) had a patient over 70 years 
old uuiible to vtdil, yet feeling that the Itladder was fidl. The catheter at first 
brought nothing away, but after the j>atient walked around a bit, it was reintro- 
duced, and a tpiart of urine escniped. At the autopsy a small, thick-walled 
bladder, resi*mbling a uterus, was found; in tlie left post^^rior wall there was a 
cican-ent, sharp opening the size of a lead pencil, leading into a cavity lying 
behind the bladder and tilling the pelvis. 



1 



376 



DIVERTICULUM OF THE BLADDER. 



As many of the patients are elderly men with enlarged prostate and cystitis, 
it is evident that these conditions must often obscure the symptoms arising from 
the diverticulum. In one case (Young) of a man 82 years of age, the first 
symptom was felt when a dumb-bell calculus, lying half in a dilated urachus 
above and half in the bladder, broke oif and fell to the base of the latter. Cys- 
toscopically the stone could be seen lying at the base of the bladder, while, at 
the vertex, was the projecting bar which had connected it with its fellow, still 
buried in the tissues above. 

DIAGNOSIS. 

Various conditions to be borne in mind and distinguished are these: first, 
broadly, the congenital and the acquired diverticula. In the congenital forms, 
at least while they remain small, one finds the various constituents of the 




Fig. 482. — Diverticulum of the Bladder. The figure to the left shows a sagittal view of 
the fully distended and partially emptied bladder. The drawing to the right shows a 
speculum view of the diverticula in a partially distended bladder. (H., Oct. 19, 1903.) 

bladder wall, namely, mucosa, fibrous tissue, and musculature ; these layers are 
also found when a stone has caused a part of the bladder wall to pout out from 
the main cavity. When, however, a largo sac is due to a pouting out of the 
mucosa with the cellular tissues between the muscular trabecule, muscle may 
be wanting (Cruveilhier). It is also wanting when an abscess from the outside 
ruptures into the bladder. In a woman this may be a tubal abscess, or a sup- 
purating dermoid or other ovarian cyst 



Note alsOj in a woman, not to mistake a pouching^ of the base of the bladder 
down toward the vulva (evstoeele) for a diverticulum. If the patient has a 
lax outlet, plus a iibroid tumor which chokes the pelvis, a part of the bladder 
may expand upward into the abdomen and a part downward toward the pelvic 
floor of the outlet, tlu^ com|)resse(! part Ijetweeu reuiaininir narmw and slit-like, 
thus itiaking a saddle-bag or hour-gla.ss liladdf r ; tlos doc8 not eonstitute a diver- 
tH'ulnm, 

E. Fuller (Jour. Cut, mid (ien.-UritL Dis., 1000^ xviii, Tj^I) has described 
2 eases of a eougeuital anomaly wbieli ean pcrhajjs br; best described by ealliug 
it an b<inr'glii^s er>j(fractir»ii, iu which the waist of the glairs lies between the 
ureters and tlie urethra, uuiking a sort of a vcstibulo of this part of the tri- 
goinnn. 

Oue must further distiuguish the rare ca&es in which there is a septum 
extending iuto the bladder from its posterior wall. This may divide the organ 
completely in two, iucludiug the neck of ihe bhidtler and the urethra* The 
peritijuenm usually shows a det*p depressii^n in which the rectuui lies; 
line ureter or, if the duplicature exteuds above, two uretei^ open into each 
linff of the bladder. These conditions have nothing in common with di- 
verticula* 

The iliaguosis may be made incidentally in the course of a routine cysto- 
scopic examination (Fig, 482), The diverticulum *>ftcii dcx*s not attract attcn- 
tifpu until the urinary staguation within the sac produces a diverticulitis, 
(.ituiorrhea is iu this way a frequent proviH^ative factor, converting an iumx'uous 
congenital malfornnition into a dangenais and distressing pathological condi- 
tion. The contents of the sac nuiy be so utt<*rly different from the bladder 
urine, so foul and so full of pus and debris, as to present the appearance of an 
abscess. Suspicion ought to l>e amused when such a condition has bet»n noted 
for a long time. A diverticulum ought to be suspc^cti^d when it takes two acts 
of uriiuition to empty the bladder, a considerable amount coming away tlie 
s4*cond tinte, A catheter may l^e used twice at a brief inlLTval to demonstrate 
this point. One may also draw off two differtrnt kinds of urine with a soft 
catheter. If a patient has constantly considerable residual urine a diverticulum 
slionld he thought of^ and, indeed, it should he 8U8jM?eted in every vesical condi- 
tion where the act of uriiuition is seriously disturbed, and the ease pr*>ves to l»e 
in some way peculiar and jnixzling. Sometimes one can inject more water into 
the bladder than can be drawn off immediately afterward (Gutlirie, **()n the 
Anatomy and J)i8t»ases of the Urinary and Sexual Organs," 18*ir.). One pa- 
tient was not rc^licvt^d until, after urinating, he pressed inside the left ischial 
tuberosity, when he could pass two or tliree ouBces more (Best). 



378 



DTYERTICtJLUM OF THE BLADDER. 



Sometimes a vagiie enlargement, more or less tender and resistantj can be 
felt per rcK^tntn or above the symphysis. 

The eystoseope is the reliable means of making a positive diagnosis, reveal- 
ing the opening of a pouch or of several pouches, A ureteral catheter, ao 

introdncc^d into 
the diverticulum, 
will empty it of its 
altered urine and 
remove all donbt. 
In the smaller di- 
verticula the 
mouth of the 8ae 
may contract, di- 
late, and contract 
again under obser- 
vation. It is easy 
to mistake the 
opening for a di- 
lated ureteral ori- 
fiee. If the sac is 
full and the blad- 
der comparatively 
empty, the wall of 
the former may 
bulge and give the 
liladder a gibbous 
form. R. Ilarri' 
son distinguishoB 
earefully lietweeu 
a pocket or pouch- 
ing out of the 
bladder which de- 



Fio. 483. — DfiMoNSTa^TioN of Uivkrticulum by Introduction^ 
OF Catheter* Left side, ureter cat heterized ; nomiaU Right 
sidt\ catheter enters a diverticulum through an orifice resem- 
bling a ureteral orifice and coils up within it- The right ureteral 
orifice was vi.sil>Ic and catheterized separately, (From Alfred 
T. Osgood, New York City,) 



velops somewhere in the basal portion, generally behind tho trigtmum, in or- 
der to aeeommodiite a calculus, and a true saccuhitiouj by whieh, he says* "it 
is generally understood that a limited portion of the mucous membrane has 
become herniated or prolapsed through the interspaces of the muscular network 
supporting it." 

Sometimes a clever country doetnr examines his patient, feels a click and ^ 
diagnoses a stone; if the expert is unable to eonfirm this by a careful explora- 




TREATMENT. 379 

tion, he should always think of a diverticulum and look for it. An X-ray 
picture will here prove decisive. Always investigate carefully any spot in the 
bladder where, unexpectedly, a little pus oozes out or is lodged. In an open-air 
cystoscopic examination this may trickle down the wall of the bladder, pointing 
in no uncertain way to the orifice above, and pressure may make the pus ooze 
out a little more freely. 

In doing a lithotrity, especially in the old, where there has been 
much vesical disturbance extending over a considerable period, always bear 
in mind the possibility of another stone lodged in a pouch or in a diver- 
ticulum. 

An X-ray picture may show the diverticulum like a second sphere clinging 
to the wall of the bladder. A good way to take this picture is to inject a heavy 
bismuth emulsion into the diverticulum and then introduce a solution of less 
specific gravity into the bladder, say the iodid of silver emulsion 2 to 3 per 
cent. If the sac is overshadowed by the bladder, tilt the patient well over 
to the opposite side in making the picture (Lerche, Fig. 488). 

A fine way to demonstrate the diverticulum is to introduce a shadow cathe- 
ter, or a stiletted catheter, and push it in until it coils up into the cavity, and 
then to take a radiograph (Brown-Osgood) (Fig. 483). 

In a case of our own, a woman had a diverticulum choked with small stones 
in the posterior wall of the bladder ; also a cystitis, which had kept recurring 
in spite of treatment. In searching for the mysterious cause we caught sight of 
a stone sticking in the orifice of the diverticulum (Fig. 484). 



TREATMENT. 

The various methods of treatment are : 

(1) None at all where the condition provokes no trouble. 

(2) Palliative treatment by irrigation and sterilization of the bladder in 
those who are too old, ill, or feeble to stand any operation. This is good pre- 
paratory treatment for an operation in most cases. 

(3) Removal of complications by crushing a stone, or by draining or re- 
moving a pus kidney, produced by the pressure of the diverticulum. 

(4) Incision of the orifice leading into the diverticulum, most suitable in 
little finger-tip pockets with contracted orifices. 

(5) Excision of the mucous lining of the pocket with denudation, suture, 
and closure of the margins of the orifice (Pousson). 

(6) Extirpation of the diverticular sac, when necessary transplanting a 



380 



DIVERTICULUM OF THE BI.ADDER. 



ureter. This is done either (a) extra vesical ly, (b) transvesically, ••r (r) by a 
combiimtirm of both mefhods. 

Treatnient ia urgent when the divertieiilnm creates syaiptoms due to stag- 
nation and cystitisj or when it presses upon a nreter and affects the function 

f'0 



\ 



\5 



\ 



v--:4.#^i 



O 



Vft«ieal 



Fig. 484. — Method or Treating Divebticiil.\ Through Open-air Cystobcope. In this 
ca*sc a st^nn h being removed, Loral applirations may be made, the neek of the diver- 
ticulum enhirg(^d, and similar manipulations carried out with great eiise. 



of the kidney, or wlif^ii it eontaiiis one or more stonc^s. In tbone who are too 
feeble for operation, t!ie best treatment U to wasli ont the bladder and to keep 
it clean, if possible each time eatheteri^Jng and washing ont the diverticulum. 
When a stone in the diverticulum causes the trouble, and the orifice is large 
enoup:h, our own plan of treatHient can 1k' used in women and, we doubt not, 
(leeasionally in men ( Fig. 484 ). We distend the bhidder with air, using a long, 
open sjieeulum, with the patient in the knee-breast posture; then with a suitable 




TREATMENT. 



381 



Fig. 485. — Papilloma in Divertjo 
ULUM. (P>om Leo Buerger, 
*' Congenital Diverticulum of 
the Bladder with a CoDtractile 
Sphineleric Orifice," Urologic 
and Cutaneous ReHtrWj March, 
1913. Lent by Buerger, N. Y.) 



I 



alligntor forceps the stone is picked out of the eavitj and removed. The orifice 

mi be enlarged by incising it at several poiiitii with a cautery. If the stone is 

larij;!', Vouu«!;'s plan of litbotrity may be used. 

In a bad case it may be necessary to treat tlie 

blaJder first by draining it, and to o])enite 

upon the di verticil him later. If the divert ic- 

tiliim is the seat of a papillrmia ( Buerger and 

ijtliers, Figs. 485 and 48*1), this can be 

treated and destroyed by fulgiirationj or bet- 

ter^ by eJrtirpation, 

Before surgical treatment it is important 

lokiiow the general state of health and to esti- 

mate that imponderable factor called vitality; 

ilso to know the precise condition of the iire- 

thra» bladiler, ureters, and both kidneys, as 

well as to detennine whether the diverticulum 

jg^ngle or muIHple, whether a stone or a new 

pniwth is present, or whetber the case is one of diverticulitis and nothing more. 
The size of the diverticulum will have been determined by the injection and 

the X-ray (Fig- 487), By means of the eystoscoj>e the exact location of the 

orifice is known. In the presence of a stricture or 
livpertrophy of the prostate, it is s<»melimes wiser 
to remove the lowivr obstruction and to drain the 
bladder as a preliminary step. It is better at first, 
simply to relieve the symptoms, than to nm the 
risk of attempjting a little more than the patient 
will stand. WHien he gets stronger, then the sac 
can be enucleated — ** two-step operation/* 

Van Dam recommends an extraperitoneal ex- 
tirpation w^hen the divertieuliim lies in front of 
thi" bhidder or lateral to it. Wlien posterior, it is 
best extirpated transvesical ly by inverting it into 
the bladder, amputating it, and sewing up the 
orifice. It may 1k^ necessary to open the peri- 
toneum to bring about the inversion. When it is 
hiti*ral, and the ureter is in the wall, it is best to 
exhVpate extravesically from an anterior position, 

or, if tills does not work, to use a combined extra- and intravesical method, or 

ptTcbaiice a purely transvesical procedure. Ponsson'a method (sec below) Van 




fto, 486. — DrVERTICULUM 

Closed; Sphikcteric Ac^ 
TioK OF TttE Orifice. 
(From Tipo Buerger, '^Con- 
genital Divertieulum of 
thi* Bladiler with a Con- 
tractile Spfii net eric Ori- 
fice,*' Vrdogic and Cvf 
ianenu* Review ^ March, 
1913.) 



382 



DIVERTICULUM OF TOE BL.VDDER. 



Dam reserves for diverticula too firmly fixed to the surrounding parts to permit 
extirpation* 

In making (he alMlnmiiial ineision to roa<?h and effect a radical removal of 
the diverticnluni, one may make one of four openings: (a) vertically in 
the median line, or (h) and (e) laterally through one of the recti muscles, or 
(d) horizontally through tlu* fascia parallel to the puhic rami; the recti muacles 
are then pulled apart until the bladder is well exposed and can be handled in 
the attack upon the diverticulum. It is of the ntmost advantage to introduce a 

catheter into the 
ureter to keep it 
from being cut or 
caught in the su- 
tures or ligatures 
(Chute), and to 
insi»rt a rubber 
balloon into the 
d i v e r t i c u 1 u m 
either through the 
urethra ( l>erchej 
Ann. 8urg,, Feb., 
1912, Fig. 488^ or 
through a supra- 
pubic vertical in- 
cision in the blad- 
der. 

A\Tien tlie ure- 
teral orifice lies in 
the diverticulum, 
if it ia not ti»o far 



Fig. 4S7, — Diverticula of the Urinary Bladder with Hpecial 

ilEFERENCE -IXJ R^NTOENMlAY DIAGNOSIS. (From Jolui M. 

Garrutt, Surg,, Gyn, andObst, 1911, xiii, 292 ) 



ray from the opening, it may be left attached to the margin by a tongue of tis- 
sue embracing the ureteral opening, then, after rtmioving the rest of the diverti- 
culnm, thia tongue is sutured into, and helps to close the orifice (Young ), 
With a ureter at the liottum of a deep diverticulnuL cut around its orifice and 
transplant it into the bladder after extirpating tlte rest of the diverticuhim. 
Drainage, vesical and cxtravesical, ought to he used lil>erally. 

Hemoval of the Sac*- — When the diverticulum is marked out by the inflated 
rnbbcr ball<Hin (Lerehe), it can Ire graspt-d like a linn cyst and gradually lifted 
and dissected out of its hed^ taking great care not to hurt a ureter, and catch- 
ing all %Tssels as they appear, and tying them at once. 




TREATMENT. 



WTien it is adherent to the pc?ritoneinii, this should he carefully detached to 
[ivoid injury. If, however, it is oprofcl, it .should be closed immediately with 
a fiiie suture; this fart tmghf. not Ht*ri*tuslv to eoHijdifate the recovery. On 
reaching the neck of the bhc it shtniM hv clamped hctwcen t\vo forcc|t8 and the 
sac remnve<l. The vesical wound h then carefully jiacked off and closed with 
a close, fine, continuous, catgut suture, am! the wound area is further inverted 
into the bladder 



with two othrr 

avers of sutures, 
|.(Mie of which 

aght to be of 
lither fine chro- 

lic gut or tine 

P o u s s o N ' a 

R O C K D U R l: . 

AXhm the di- 
verticulum cann«>t 
freed and cnu- 

Seated, and when 

it is too large, or 
wk'ii it contains a 
stniii' which has to 
be removed 
tlirotigh u supra 

Ipubic vesical inci- 
sion in a fe4:*ble old 
patient, a safe 
plan of treatment 
ifl to sterilize the 
cavity with stron*^ 
iocHn solution fol- 
l<»wetl by alcohol 
or with a 20 per 
cent, nitrate of sil- 
ver, followed by alcohol — and then to treat it by Pouason's procedure (Ann. 
!d,mal d, org. geniio-urbu, rJUl, xlx, 11:52). This w^as applied in a vigr*rou9 
xm\ of 78, wdio had sutTered for two vears from dvsnria and hvpertrophy of the 



Fig. 488.— Hadioghaph of Diverticulum and Bladdee Taken 
FROM THE LBtT SiDE. Male, 38 years old. Sjimptoms, pain in 
lett abck»nioii and incomplete urination with second action short- 
ly after first. Diagnosia renal colic and gontjrrheal cystitis. 
Residual urine 200 c. c. with nmt'h pns and slhnc; no tenderness. 
Cystoscopy showed a large diverticular orifice. Radiograph 
taken after introduction of 4(H) (*, e, of a 5 per cent, solution of 
collargol into the bladder auii with patient turned about 35° to 
show the diverticulum. The diverticulum appears iu rounded 
outline pressing against the pelvis on the left Hide of the picture. 
The dark shadow in upper part is eollargol in bladder. tWilliam 
Lcrche, Ann. oj Surg., 1912, Iv, 285.) 



384 DIVERTICULUM OF THE BLADDER. 

gation and sterilization, a suprapubic opening was made and three calculi not 
larger than a small cherry removed. As Pousson was about to close the bladder 
a little pus was seen oozing from an orifice 2 cm. behind and above the ureter, 
and here a pocket was found containing a stone. After evacuating, irrigating, 
and sterilizing it with a solution of cyanid of mercury the mucosa was can^ 
fully curetted away, the margin of the opening denuded, and approximated with 
three catgut sutures. Lastly, the bladder incision was closed and a Pezzer cathe 
ter introduced by the urethra. The patient made a rapid recovery. 

If the patient is too weak for any extirpative operation, the opening mav be 
cut through with the cautery to enlarge it, giving free exit to its contents. If 
the septum between the diverticulum and the bladder is thin, this may be 
divided to a considerable extent. The sheet anchor of subsequent treatments 
rests in keeping the bladder clean by frequent irrigations. 



LITERATURE. 

Fundamental in the literature of diverticular bladders is the paper by J. E 
Targett {Brit. Med. J., 1803, ii, 218), with 15 illustrations of specimens from 
the various London museums. Targett cites several cases in which the sacculus 
is the seat of malignant disease, epithelioma, sarcoma, and fimbrialed papil- 
loma. He deals with the subject of false diverticulum or abscess cavity opening 
into the bladder and mentions a variety characterized by the extension of the 
sac between the muscular layers of the bladder wall. 

Important papers and monographs are: 

II. Harrison, Inlernational Clinics, 1894, iii, 243. 

J. Englisch, Wiener Klinik, 1894, xx. Heft 4, 91-120. 

Pagenstecher, Arch. f. Min. Chir., 1904, Ixxiv, 186. 

Young, Johns Ilophins IIosp. Reports, 1900, xiii, 401. 

E. M. von Eberts, Ann. Surg., 1900, 1, 883. 

Fischer, Surg., Gyn. and Ohst., 1910, x, 156. 

Lerche, Ann. Surg., 1912, Iv, 285. 

Chute, Trans. Amer. Ass. Geniio-Urin. Surg., 1911, vi, 86. 

J. M. Garratt, Sxirg., Gyn., and Obst., 1911, xiii, 292. 



386 



EXSTROPHY OF THE BLADDHR. 



long series of cases that an exstrophy occurs four times in 116,500, The di^ 
treasing condition thus created arises from the failure of the tissuea of the em- 
bryo, which go to fomi the abdominal walls, to meet in tho mctdiun lim% ii drfect 

in the prevertebral UminxH 
aiuilogons to hare-lip, clift 
palate, congenital oniphjUb* 
ccle, and spina bifida. In i 
vesical exstrophy the aih 
terior wall of the urethra it 
mIso wanting, while tiie 
short rudimentary penis 
lies wi<le op<»n with its ci* 
pused reddened posterior 
urethral mucosa, and tko 
j>ri'ptiee hanging below a 
Inffre, useless tag of ^^ 
dnridant skin. In a gtfl 
liiihy the clitoris and th** 
MyniphiP are bifid and trclt 
displaced laterally (Fig, 
4iMV). A woman with «t- 
stra[>hy 18 nfti>n s<*xuttlh 
l>erfect, capable of nortoal 
relations and conception. 
There is no sntii physic, and 
tlie pubic rami are always 
more or less widely 8cp4- 
rated, even as much as IS 
em. Above the bladder o 
triangular plane of smo^^h 
skin closes the abdominal 



Fio. 490. — Exstrophy of the Bladder in Girl with 
Phol.\P8B of the Rectum. Note the deep fissure 
at the site of the 8>Tiiphy&iis, the bljia and clitoris on 
either aide and the exsirophied bladder lying just 
above. 



radP 



wall and represents the region of the navel, which may be hemiate<l. 

Concomitant iiipuiiial herniir are often found, and in the nit»re distrus 
eases there is aLso an extensive prolap.^^e of the reetum to complete the niiseral 
pieture of a wretehed specimen of the gens humutui who^ while able like onliiir 
ary, normal individuals to eat, enjoy, and to digest foixl, is utterly incapable of 
eontrolling the exeremeirts, the waste tluidj^, and the ashes of combustion of the 
body; until they can l)c deposited privately and without offence iu a suitable 
receptacle, according to the universal eustoms of all races. Extreme cases have 





491.^ExsTR<jf»HY OF Bladukk in Adult Female. The liiagrjini alttive pointsi out the 

btopogmphy t>f thtt case. Note wide separation of tlie puhir IxjiieH and refti musclas, low 

> posttioti of the umbilicus, and bifurration of the elitoris. The halved flitoris b iittached 

on either side to the top of the labium minus, the vaginal inlroitus is seen between the 

labiiif and the bladder is everted. The greater rigidity of the trigonum and iti^ attach- 

toent to the vagina holds it io place to a greater extent than the rest of the bladder, hence 

J the characteristic T-shaped folding. Note the small surface area of the bladder mucosa; 

'this is characteristic of the eoiuiition mnl m due to the fact that it has never been dis- 

teodecl, (Patient of G, L. Iluimer. C. H. and Inf., March, 1905.) 





Fig. 492*— Kxtbnsive CANrEu hf IJxstrophied Bl.m i- fhe grnrnil amingeinfiii 
the parts is similar to that in Figure 49L (Qyu. fcJervice, J. H. H-, No. 491^1, Jsa. 

18980 

Yc^ty bludtler wljieh, hi infants, toUk cnit liki^ a lar/i^e, fleshy tinuor iifHUi cryi 
The mass is cxqiiisiti^Iy tender to toiK-h* The everted ureteral orifices ofi 
stand out like little teats alternately spouting their jets of urine and keepii 
the fmtieiit constantly wet and foul, rrnderinjL; liini, as he grows up, utterly uai 
for all social relations. The surrounding skin is often eczematoiis and exi 
iated and inerusted with urinary salts^ adding greatly to the poor viclitti*8 





TREATMENT. 389 

tress. There is often a marked hydro-ureter and hydronephrosis. One ought, 

for this reason, not to catheterize the ureters for fear of provoking an ascending 

infection, pyelonephrosis, and death. Many of those patients — Neudorfer says 

nine-tenths — die under 7 years of age. Berger found that, of 74 patients 

\)om with an exstrophy, only 23 passed the twentieth year of life, the others 

dying of pyelonephritis. Occasionally one is found to live to extreme old age. 

As they grow older they are liable to develop canccT of the chronically irritated 

mucous surface, where one often finds isolated thickened patches of pavement 

epithelium, while in other parts an actively secreting cylindrical epithelium has 

fonned. 

Dr. Guy L. Hunner had a case of a young woman, 26 years of age, who 
developed a papillary adeno-carcinoma Rhont 2i/> cm. in diameter, and with a 
pedicle about 1 cm. across. In such cases a radical operation (removing the 
cancer) is, of course, imperative. A cancerous change in the exstrophied blad- 
der is shown in Figure 492. 

TREATMENT. 

Aside from surgery there is no relief from the wretched condition which 
compels the poor victim to live continually in a puddle of his own secretions ; no 
mechanical device has yet been discovered which effectually catches the urine 
and keeps the person clean. The best that can be done is to wear diapers, 
changed at frequent intervals through the day. 

Surgeons, therefore, naturally began early to devise means to overcome the 
many technical difficulties of the situation, and there are few more interesting 
illustrations of inventive ingenuity in surgical art than can be found in the 
rarious operations, each one correctly labeled with the name of an originator, 
devised to remedy nature's deficiency in the face of well-nigh insuperable 
obstacles. 

Inasmuch as exstrophy of the bladder owes much of its distressing char- 
acter to the exposure of the highly sensitive vesical mucosa as well as to the 
foul condition of the patient bathed in his malodorous excretions, so have the 
?urgieal operations varied, according as they attempted to relieve one or both' 
of these conditions by a plastic operation designed to effect a restoration of 
the bladder cavity and construct a urethra, or by the transplantation of the 
ureters and the diversion of the intestinal tract, coupled with an ablation of 
the troublqsome bladder. 

The earliest plastic procedures deserve consideration because they so long 
taxed the ingenuity and engaged the undivided attention of surgeons, and 



390 EXSTROPHY OF THE BLADDER. 

further because every one who sees a case for the first time is tempted strongly 
to see what he can do by a plastic operation; nor can it be said, as some claim, 
that they must to-day be relegated to the surgeon's waste basket, for our adult 
patients are apt to demand recourse, and we think rightly, to a procedure which 
will not endanger life, promising to be content if they can be rid of the extru- 
sion, catch the urine, and escape the wetness and the smell. 

Among the factors which will influence the choice of an operation or coiujk?! 
the operator to modify his procedure are: (1) the ill health of the patient, 
which will naturally check any prolonged aggressive procedure; (2) the age 
of the patient, for greater risks to secure continence will be taken very early in 
life, while an adult will naturally demand a procedure involving the least risk 
to life; (3) if carcinoma of the bladder has developed, a more radical extir- 
pative operation will naturally be demanded. 

If the patient has double hydro-ureters, the risks of an ascending infection 
are enhanced; a pyelonephritis of one side may call for extirpation of the 
affected kidney, and the most careful treatment of the remaining one. 

Calculi have been found impacted in the ureters. Dr. Q. Woolsey removed 
2 large calculi from the right ureter and 5 from the left, in a boy 3 years old; 
he removed them by lateral incisions and then did a Maydl operation. The 
Trendelenburg operation ought not to be done after the eighth year. 

Classification of Exstrophy Operations. 

I. Plastic Operations ox the Bladdeb. 

(1) Covering in the bladder by skin flaps taken from its sides; 
skin turned in onto the bladder. (Roux, Pancoast, Ayres, Wood. 
Maury.) 

Skill slid over the defect with its raw surface next to bladder. 
(Thiersch.) 

(2) Dissecting out the bladder without opening the peritoneum, 
and suturing its edges together. (Czeniy.) 

(3) liupture of one or both sacro-iliac synchondroses to i^ermit of 
the easy approximation of the tissues in front with denudation anJ 
closure of the fissure. (Trendelenburg.) 

(4) Keinoval of the entire l)lad(hr, with implantation of the ure- 
ters into the base of a newly made urethra. ( Son nen burg.) 

II. Implantation of the Ureteus into the Intestinal Tract and 

Ablation of the Bladder. 

(5) Simple oblique implantation of the ureters with the formation 
of a j)rotecting mucous apron (Fowler), or an oblique implantation 
after the method of a Witzel gastrostomy. (Stiles.) 



TREATMENT. 391 

(6) Forming a spur or a cloaca in the sigmoid, into which the 
ureters are implanted by amputating the bowel and closing the lower 
end and anastomosing the upper end at a lower point. (Miiller.) 

(7) Excision of the bladder wall, all but an oval strip at the 
trigonum holding the ureters; this is then implanted into the sig- 
moid flexure. (Maydl.) 

(8) Extraperitoneal implantation of the separated ureters with a 
button of surrounding mucosa into the rectum. (Lendon-Peters- 
Bergenhem.) 

I. PLASTIC OPERATIONS ON THE BLADDER. 

1. Dissecting up and Turning over a Skin Flap. — These earliest attempts 
simply endeavored to correct nature's deficiency through closure of the defect 
by taking the nearest plastic material at hand and constructing an anterior ves- 
ical wall out of the neighboring skin. The older surgeries are replete with dia- 
grams of the various forms of flaps recommended as most likely to accomplish 
this almost impossible task, while the abdominal walls were attacked by relax- 
ing incisions made to relieve the lateral tension which served to pull the wound 
apart and extending down even to the deep fascia. Often even the hyper- 
trophied preputial flap has served a similar purpose, after perforation to let 
the glans penis through the hole, when the flap was pulled up and used to help 
construct the lower anterior wall. Maury, an assistant of the elder Gross, took 
his principal flap from the perineum and turned it up over the hiatus, making 
a button-hole below through which he drew the penis. 

Such well-intended efforts often failed, and when only a partial union took 
place the secretions became more foul and ammoniacal and the parts more 
painful than before from the constant irritation of the hairs incrusted with 
urinary salts. To avoi*d this most serious objection, Thiersch and Billroth 
detached long flaps at the sides, let them granulate freely, and then slid them 
over the opening with the flesh surfaces toward the bladder. This, too, was 
difficult and subject to repeated failures and, of course, did not in any degree 
relieve the incontinence. J. M. Batchelor presented a case at the Southern 
Surgical and Gynecological Association at New Orleans {Trans, So. Surg, and 
Op, Asso,, 1907, XX, 531), in which he had used Thiersch's method for closing 
in the defect in an adult woman. The result gave comfort and entire relief 
with the wearing of a urinal. 

2. Bissecting ont the Bladder without Opening the Peritoneum and Suturing 
ItiEdgcs Together.— G. B. Schmidt (Beitr. z. klin. Chir., 1892, viii, 291) has 



302 



EXSTROFMIV OF THE BLAPDER. 



VmicaI fnuco»a 



►^, 



iS^-^u^^sH 






"^^ 



/ 



^ F 



y^ 



.Bridge made by 
pre vr Qua optrMion 



(IrvisfTl tbo plan of tlt'l aching the vci^tcal mucosa from thu uiulerlying tifl 
witluuit opeiiiji^^ tltc perituiunim, but leaving tht^ bladder attadied by its mid 
and inferinr pnrtions. The detached margiDs of the or^ua are thcu aewi4 
lugetber so as to ffrrni a diiiiinritive oavity, the raw area thus create<l Ijeing 
covered witli two bridging flapy takt^ii from the sides. The next stage i» union 
of the tissues so as to form a urethra and a neck of the bladder in such a man- 
ner as to secure an elastic 
closure for the canaL 

Sebnudt describes an opera- 
tion upon a little girl 2 yean 
old. The incision throtigh tbt» 
bhidder wall was made on all 
sides, Y2 ^^^* from the miicoua 
margin. This was then ilia- 
sected up for 1^4 <^in,, and 
united from side to 8i<le with 8 
catgut Lembert 8titx»h<ss, form* 
ing a clom^d cylinder narrowed 
below to fit the urethra to be 
made substHpicntly. The raw 
surfaces of the bladder were 
covered with Tliiersidi flaps. 
The urethral canal was then 
constructed and connected with 
the bladder cavnty* This 
method pro\^des a good drain. 
tuf'ks away the irritated blad- 
der, enables the patient to keep 
dry, and sometimes enj*ureit g 
small degree of continence. It 
serves as an altenintive to 
Sonnenberg'g methcKJ, 
Perhaps as good a resnlt a^^ can Iw hojKMl fiir from a fnirely plastic operation 
is illustrated by a patient from v. Hacker's Clinic (G. Lotheis^^en, /?ri7. e. Wink 
r'Air, 1J)00, xxviii, 528). A boy 12 years old was opt^rated upon by [leeliui; 
out ihc hhnlder free and suturing its margins together without oiieuing the 
|icritonenm (CVeriiy), associating with thi^ the complete detachment of hioth 
recti with a |>i<Te of the piilor hime (von Schlangc), and attaching them afresh 
to the inner surfaces of the pnbic rami. The opening was narrowed and 



Initfowtewt '. 
in urethra 



Prep. 



Fin, 4i)3.^0PER.\Ti0N FOE Exstrophy of the 
Bi^DDER TN Malk SoajEiT. At prc^nons opcm- 
tiun urctlini had hccn fonned. In the original 
state there was €omi>letc cpii<padias. The blad- 
der is being ilis.S(M"ted free from the skin, fa.scia 
and mui^('lei5, and put^ticil l)aek into the alMJominal 
cavity; which i;^ not ti|x*jicd. The dotUd Unc 
indicates the length and po.sition of the splitting 
incision. (H. G,, San,, Jan., 16, 1899.) 



TREATMENT, 



303 



ladder was closerl* After a rePOTistru«*tion of thf; nr<:'thra and tho flosiirn of 
ItistulsG the patient finally scfured a passive eoiitiiienef% and could hold his urine 
' wilh a suitable pressure apparatus ftir hours, hi urinating, he assunjer! the 
feminine squatting posture. At ni^ht he had to bn wakened repeatfHlly to ki^p 
hiin dry. The urine would ^usli ont whenever the poor vietim lanphed, or 
coughed, or snec*zed, or stn»u^Iy contracted the akloininal uxuBcles. At the 
YCry best, after interminable 
operations, one secures a coiiti- 
ueuce of the urine lastinf^ hut an 
boitr or two, often in a particu- 
lar posture, lying on the back. 

A fairly sueeesaful attempt 
is shown in Figures 493, 494, 
ninl 495. 

3. Approximation of the Mar- 
gin by Rupture of the Sacro-iliac 
Joint.— Perhapa as much as can 
\ie secured by phistic surgery has 
been attained by F. Trendelen- 
burg (Arch, /. Mln. Chir., 1892, 
xliii, 394), who, noting that the 
chief cause for the repeated fail- 
ures lay in the extreme tension 
of the margins of the wound , due 
to the wide separation of the 
ends of the sympliysis, boldly 
chiseled through the sacru-iliiic 
joint on one or on both sides, and 
then put the patient in a ham- 
mnck sling with the %vcights pull- 
ing in opposite directions across the body, so as to force the pubic bones to come 
togetlier. The margins of the opening were then freshened and united^ restor- 
ing the bladder as well as the penis, whieJi l>ecame lengthened as the side pull 
was taken off* Especial care was taken to restore the mus^cidatnre at tlic neck of 
the bladder above and below the sphincter region. Trendelenburg divides his 
proeedure into three steps: 

(1) Separation of the sacro-iliac joint in order to approximate the l>unes 
in fnait at the symphysis. 

(2) Closure of the vesical cleft by broad denndatinn and suture. 



un Mnd fascia 
bladdeir 



Fio. 494. — SiTTTKivrt of Freed Bladder, as 
Shown in Last FroimE. Note that sutures 
do ntit pierce tlic mucous membrane. 



394 



EXSTROPHY OF THE BLADDER. 



(3) Closure of any persisting fistulse. 

This procedure ought not to be done in a child over eight years of age. 
The operation rarely succee<ls wholly at once, and has not established itself 
as a prociedure which can be counted upon to yield results commensurate with 
the risks of life and the tedious operations which too often end in a reposition 

of the bladder without con- 
.-^/--^ 



ekfped 



tinence. The judgin(*nt of 
Tx)theisen in v. Hacker's 
Clinic (1900) is: '^In 
allgemeinen hiilt man houte 
Trendelenburgs Vcrfahren 
fiir zu umstandlich imd zn 
gefahrlich." 

4. Extirpation of the En- 
tire Bladder with Implanta- 
tion of the Ureters into the 
Base of a Newly-Made Ure- 
thra. — Sonnenburg ( DLsrh . 
ined. Wchnschr., 1 S 1) , 
219), recognizing that th»' 
best that could be done in 
the vast majority of cases 
after repeated operation? — 
operations which even en- 
dangered life — was to tuck 
in the bladder, dcvise<l the 
plan of extirpating the bla<l- 
der mucosa and implantinir 
the ureteral ends into a 
longitudinal slit in the up 
per urethra and then fittiiii: 

the patient with a urinary reservoir. He treated 7 patients in this way without 

a deatli (Fig. 490). 

The Sonnenburg operation is best adapted to an older patient where 

tliere is some impairment of the function of one or both kidneys, and where 

the risks of implanting the ureters into the bowel seem to be unjustifiably 

great. 

An a(liniral)le case in point is that of Dr. J. "R. Eastman (/. Am, ^feL 

Asso., 1900, xxxiv, 110»>), where a boy of 1*3 had an exstrophy, and the urine 




Fig. 495. — The Last Step in the Operation Shown 
IN Two Preceding Figures. The sutures in the 
IJadder are tied, and sutures to approximate the 
alxlominal wall arc placed. Above, an opening has 
been left into the bladder, to prevent distention of 
the organ until the repaired part is healed. Note the' 
separat ion at the symphysis partly replaced by fibrous 
bands, as shown. 



TREATMENT. 



sm 



f?om the left kidney contained blood casts, also epithelial and granular easts, 

while the right side was not nornml The ureters were detached from the extro- 

Bfrerted bladder and implanted into a groove made by a median sagittal incision 

OB the dorsum of the clubbed episf>udiac penis* The raw surface of the bladder 



ho, 496. — 8oNNE^fBUHG*s Method of Treatment of Exstropht. Patient 9 years old 
when operated upon ; shown here 18 yefirs after an operation which consisted of re- 
moving the bladder and transplanting th^ ureters into the upper urethra. ("Hand- 
buch der praktischen Chirurgie/' 19a3, iii, 7290 

mucosa was then cut away and the margin of the defect snugly sutured over the 
twoareters. On account of a gangrene of the end of the left ureter, that kidney 
w»5 removed, the boy reeovered and was able to keep dry while wearing a 
urinal with a cup-shaped attachment fitting snugly over the defective area. 
The patient lived for six years, dying finally of an ascending nephritis of the 
rernaijiing kidney- 




396 EXSTROPHY OF THE BLADDER. 

II. VARIOUS METHODS OF IMPLANTATION OF THE URETERS INTO THE 

BOWEL. 

A large group of operations has in recent years come into favor which 
rejects at once any effort to restore the parts in situ and attacks the problem 
with the idea of reflecting the malformed tissues, sacrificing the bladder and 
dissecting out the ureters, which are implanted in the intestinal canal at some 
point. Many surgeons insist that if any operation at all is done, it must be one 
of this group. If a carcinoma develops in the bladder mucosa then the bladder 
must be extirpated and the ureters implanted into some part of the bowel. 
The imminent danger is that of an ascending infection causing a pyelonephritis. 

The advantages are the removal of the irritated bladder with its liability to 
cancerous degeneration; the utilization of the intestinal tract as a urinary 
reservoir; and the entire comfort the patients have as the bowel learns to 
tolerate the urine for longer intervals. 

The various operations may be divided into two classes, namely, those in 
which the operation is transperitoneal, and those in which it is extraperitoneal. 

5. Simple Obliqne Implantation of the Ureters with the Formation of a Pro- 
tecting Flap. — George Ryerson Fowler (Am. J. Med. Sci., 1898, cxv, 270) 
successfully planted both ureters, cut off obliquely, into the rectum, utilizing 
the circular fibers of the bowel so as to form a fold and to compress and protect 
the ureters obturating the orifices during the passage of feces (Figs. 497 and 
498). 

Fowler's operation was done on a boy of 6, who lived to adult life, when 
he was lost sight of. Fowler says further: "The operation is performed as 
follows. The abdomen is opened in the median line, with the patient in the 
Trendelenburg position. The anal sphincters are dilated and the rectum thor- 
oughly cleansed preliminarily. The ureters are identified in their relations to 
the vessels, the jx)sterior layer of the peritoneum incised for a sufficient extent 
to expose them freely, and the ureters traced to their terminations upon the 
bladder-wall, from which they are detached. The ends of the ureters are cut 
off obliquely. 

"A longitudinal incision, 7 cm. long, is now made in the anterior wall of 
the rectum, only the serous and muscular coats being included in this incision. 
These structures are dissected laterally until the mucous coat is bared and a 
diamond-shaped space in the submucous space exposed (Fig. 497 A). The 
edges of the incision are retracted by thread retractors, and a tongue-shaped flap 
of mucous membrane, with its base directed upward, is cut from the mucous 
membrane in the lower half of the diamond. The tongue-shaped flap is doubled 



TREATMENT. 



307 



Ifpon itself in mi u]nvarcl direftioii in sut'li n niaunor that one4ialf of its mueoiis 
iirfaee preseuls aiiteriorly, when it is semired hy ouv fir two eatgnt sutures. 
flwp-valve is thus seeiuTil, hc^tli siilos of wbiph are cnvfTed with mucous 
ciembraiio. 

**Thc nretera are now (ilarcd in tlic iDcision, bo thiit thcnr ohliqiiely cut muh 

jeupon the prt!si*iiting inneoiiM nu'iiil)nmo surface of the Hap (Fig. 497, li). A 

W fine catgut sutures serve to seeure the un^terj^ iu ponitinn in the space repre- 



Fio. 407, — G. R. Fowr.ER'8 Case of EFisi'Ai>iA«. Child mx years oM, Uvvd in aihill lift 
and was then lo«t sight of. (Artier\ Jour, Med, Scu^ March, 1898,) 



in the upper half of the diamond, care being taken that these sutures 
tlo not invade the lumen of tJie ureters. The flap-valve and attached ends of 
lie ureters are now pushed into the cavity of tlu^ rectuTu, and the rectal uviuud 
cWd in the following manner: The gap in the mucous memhrane left by the 
reflected half of the tongue-shaped valve is first closed by a row of catgut 
sutures (Fig. 408 A). The original wound in the rectal w^'dl is closed by fine 
silk sutures, the upper two or three of these being likewise iitiliz«^d for still 
furtlier sr^curiug the ureters for tlu^ distance wdiich they pass in the submucous 
Mice in the upper half of the diatooarl (Fig. 408 B). The abdominal \vtniu<l 
U »ow closed. 



398 EXSTROPHY OF THE BLADT^ER. 

^^A remarkable fact, bruught out by the after-history of this caae, is the 
maimer in which the bowel performs its ^louble tunftion as a receptacle for 
both feces and urine. While urination taki'.-^ jilaee at about the normal inter- 
vals, defec*atiun likewise takcH place at normal intervals, although the former 
occurs abcmt once in six hours^ while the latter oc<nirs but once claiiy. The 
movement is generally tVtrnietl, arnl is not njixcii with or accompanied by urine, 
as far as |rross a pfn^a ranees {-an dt'ffrniiue/' Scr also 8tiles' methml of implan- 
tation under Kpispath'as. 



Fig. 498. — G. R. Fowleb's Cask of Epispadias. Child lived to adult life and then lost 
sight of. (From Amcr. Jmir. Med, Sri., March, 1898.) 



6. Forming a Spur or Cloaca in the Sigmoid, into Which the Ureters Are 
Implanted by Amputating the Bowel, Closing the Lower End, and Anasto- 
mosing the Upper End at a Lower Point — GrrHnny operated by turning the 
ureters with their vesical nritiees ioto a blind end of the reetnm after ampu- 
tating the bowel. The npper end waR then implantrd inro itself at a point just 
above the sphincter rofrion. This method is interesting on papc»r, but difficult 
and dangerous in praetiec. 

Borelius of Lund (Cenirlhl, /. Chir,, 1D03, xxx, 7R0) proposed an anasto- 
mosis of the sigmoid into itsflf, leaving a projecting lor>p thrown ont of use. 




TREATMENT. 



thus Bhort-circuiting the passage of frcal laaU'rial and protecting the ureters, 

vhicli were trangipl anted, as in a Majcll operation, into the IcMip of the boweL 

7. Excision of the Bladder Wall, All but an Oval Strip at the Trigoniim 

Holding the Ureters; This Is Then Implanted into the Sigmoid Flexnre. 

— Maydl (Wiener med, WehfMchr,, 1804, xliv, and ISOT), xlvi, first operation 

iooe in 1892) reported 2 casea treated by the insertion of both nreters with 

thewnnecting elliptical piece of the trigonum of the bladLlor into the sigmoid 

Hexiire of the colon. He operated snece^sfully on a young man 20 years of 

ggc and a girl of 12, The basic idea in this operation is to disturb the ureters 

ilmI the protective apparatus about their orifices as little as possible, so as to 

minimize the risks of an old ascending infection. The Maydl operation was 

such an improvement over the older plastic procedures and ordinary straight 

implimtations that Stoeckel unhesitatingly says : **If we conclude to operate in 

actseof bladder ectojiy we ought to use the Maydl prtK^edure/' 

The ectopic bladder mucosa is excised and the abdomen opened; an ellip- 
tical piece of the trigonum, including the intact ureteral orifices, is spared and 
tbon sutured exactly into a long longitudinal incision in the prominent part of 
the easily exposed sigmoid flexure. Even after this operation, however, the 
patient may die of an ascending infection, either promjjtly or some months or 
Tears later. 

It was Tuffier who first, in 1890, finding that the implantation of the cut-oflF 

BreUT^ led to pyelonephritis, argued for the preservation of the ureteral orifices. 

Whitacre {So. Surg, and Gyiu Trans., 1009, xxii, 530) gives a clear de- 

dcription of a successful Maydl operation on a young woman 21 years of age. 

After dissecting the bladder away down to the trigonum^ an elliptical area 

Ldiucous membrane, including the ureteral orifices, WU niches in diameter, 

I left intact* This was then dissected nj^ from below and the ureters suffi- 

^ieDtly exposed to give the necessary mobility. The abdominal cavity was then 

low down and the sigmoid flexure brought into the wound. The gut 

then grasped in a gastro-enterostomy clamp and dioroughly protected by 

paze sixjnges. The ureter, bearing a seguient of the bladder, was then placed 

alongside the sigmoid mid a preliminary continuous silk suture used to unite 

tie outer eon neclive tissue pnrrion nf the wall of the bladder to the peritoneum 

3f the gut. A sutiicient incision was then made in the gut and a continuous 

|gtit suture passed through all coats of the gut and of the bladder in a manner 

entirely analogous to that used in making a lateral anastomosis of the hollow 

Tistera. This row of sutures was continued entirely around the fragment of 

the bladder and the opening into the Ijowel, so that the raueous surfaces of the 

bladder bearing the ureters became continuous with the lining mucosa of the 



400 



EXSTROPHY OF THE BLADDER. 



sigmoid. The result was that tho patient left tliL* hospital on the 23rd day with 
the wound healed and able to retain her nrine in the rectum for 2 or 3 hours, 
and was well 2 years later. 

Zesaa (DLsrh, Zhchr, /, Chir,, IDOt), ci, 233) collected 97 Maydl opera- 
tions and found that 2<> died after tho operation: 13 of pyelonephritis; 5 of 
peritonitis; one of pneumonia; 3 of urinary infiltration; 2 of kinks in the 
ureters. The author prefers to put the case the other way ahcjut, and to say 
that, out of 97 cases operated upon for this distressing condition, 71 lived 
and were relieved of their disahility. The continence is rarely established 
immediately, 

8. Extraperitoneal Implantation of Intact Ureteral Orifices into the Eectum 
(Peters^Bergeohein ). — Rergenhem was the first operator who did an extra- 
peritoneal implantation of the ureters into the rectum (CentrlbL f, Chir,, 1896, 
xxiii, 389). 

Bergenhenrs patient was 35 years of age and had an exstrophy mcasuritii^ 
6x4 cm., with a separation of the symphysis of 9 cm. All the surrounding 
parts were in a distressing condition of eczema and furunculosis, and there 
was a malignant adenoma of the bladder wall, A month after excising the 
tumor the entire bladder was extirpated. A transverse periueal incision w^4^_ 
then made to aflford access to the ureters in front and the rectum hchiiul; hy |^H 
hlunt dissection the ureters, marked out by catheters, were exposed and freed ; 
this was not <huie without some small rents in the peritoneum, which were 
immediately closed. A little of the vesical mucosa was left around each ureteral 
orifice, and the ureters were brought down into the perineal wound. Two in- 
Mions were now made through the wound into the rectum and the ureteral 
pening conducted through these into the VmjwcI and attached with a few 
sutures. The raw vesical area was then sutured together as much as possible 
and covered by Thiersch flajrs from the sides. In the after-treatment a large 
drainage tube was introduced into the bowel and the perineal incision was 
tamponed. 

When, after 6 days, the tube was taken out, the patient had attacks sim- 
ulating uremia, disappearing on rein trod uct ion of the tube. In time, however, 
the tulw? could be left out, and it was only found necessary to empty the new 
urinary cloaca at intervals of 3 to 4 hours by day and a couple of times at night. 

The second operation of this kind was done by P. Pozza of Italy {Oazz, d, 
osp,, Milano, 1S98, xix, 293). 

George A, Peters of Toronto (Brit. Med /., 1001, i, 1,538), and T.eudon, 
of Adelaivle, Australia, also originated a plan of extraj>eritoiieal transplantation 
of the ureters into the lower rectum; there is a clear description of the opera- 




TREATMENT. 401 

tion by H. S. Newland in the British Medical Journal, 1906, i, 964 (Lendon's 
paper is in the same number). 

Peters' account is, in part, ao follows: A boy over 5 years old had an 
exstrophy of the bladder; the symphysis pubis was about lVi> inches. Along 
with this there was a procidentia of the rectum, the apex of the tumor during 
the straining reaching eight inches below the anal ring. Dr. Peters first re- 
lieved the rectal procidentia. 
[ Three years later, July 15, 1899, the exstrophy of the bladder was treated 

* as follows : the rectum was emptied and the sphincter stretched ; a sponge 
attached to a tape was pushed high up into the bowel, preventing the passage 
of fecal matter and raising the anterior wall of the rectum toward the bladder. 
A small soft rubber catheter was next inserted about two inches into each 
ureter. A silk suture was then caught through the extreme end of the ureteral 
papilla and passed through the substance of the catheter to prevent its slipping 
out. The distal end of the ureter, with a goodly rosette of bladder muscle 
and raucous membrane, was then dissected free, using the catheter as a guide. 
.As soon as the bladder wall was cut through, the lower end of the ureter was 
detached by a blunt dissection. After isolating both ureters in this way, the 
^^vhole bladder tissue was cut away without injuring the peritoneum. 

The next step was to expose the lateral aspects of the rectum below the 
jjeritoneum. The deep dissection was surprisingly easy, as by pressing back 
tie retrovesical cellular tissue the anterior and lateral walls of the rectum were 
exposed. This part of the operation was also facilitated by an assistant insert- 
ing his finger into the rectum and lifting it into the wound. 

The final step in the operation was the implantation of the ureters into the 
lateral walls of the rectum above the internal sphincter, care being taken not to 
link the ureter. The opening was made high enough to permit the ureter to 
project slightly into the luinen of the bowel without tension. The proper point 
of anastomosis having been decided upon, an assistant passed a pair of slender 
forceps through the anus, pressed them against the spot selected, and lifted it 
into the anterior opening. 

The wall of the bowel was then incised on the projecting forceps, making 

the incision just large enough to admit the catheter and the ureter, but not tight 

I enough to press injuriously upon it. By means of the forceps, pushed through 

k the little opening, the catheter with its attached ureter was drawn into the rec- 

1 turn on either side, when both ureters projected about ^4 ^^ ^^ ^^^h into the 

1 bowel. The sponge plug was then withdrawn. Dr. Peters saw no necessity 

I for stitching the ureters into position, and left the catheters in position two or 

I three days, or until they came away of themselves. No plastic operation was 



402 



EXSTROPHY OF THE BLADDER. 



done oil the abdominal wall ; the wound was simply protected by a moderately 
firra packing uf iodoform gauze, which aflForded efficient drainage and, at the 
same time, supported and splinted the delicate ureters in their new position; 
the wmnnd healed entirely by granulation, leaving a smooth, firm sear. One 
and a half years after the operation the boy was in perfect health, there was no 
prolapse of the bowel and no disturbance of the function of the kidney. Upon 
rect&l examination, the month of eaeh ureter was found to have a salient papilla 
the size of a little linger. The rectum was continent, and he was able to play 
from 1 to tJ boors without urinating, and, while in bed at night, he could go 
from 6 to 8 or 10 hours without an evacuation. 
The advantages claimed are the following: 

1. There is no danger of peritonitis. 

2, A promineut natural papilla is secured, the natural manner of de- 
bouchement of a secretory duct upon a mucous surface, and the one atfording 
the best possible protection against an ascending infection. 

3. The ureters are further protected against infection or sloughing by 
remaining in their natural envirounient almost to the point of iraplantatioiL 

4, The operation is easy, and free from shock and exhaustion, 
Lendou's ease was that of a boy of 10, upon whom he operated May 12, 

1809. The method was similar to that of Peters, except tliat no catheter was 
inserted into the uret-er, the end of the ureter being seized by a pair of for- 
ceps and drawn through the oyjening into the rectum, where it was the intention 
of the operator to hold it in position by a pair of clip forceps. The left ureter 
became permanently attached and discharged its urine into the bowel, but the 
right ureter, from which an assistant removed the forceps, worked back into 
the cellular tissue and necessitated a Mayd! transj>eritoneal operation, setting 
it into the sigmoid flexure* 

Newland {Brii. JlIetL -/.. 1000, i, 964) had a case, a boy 7 years of 
age, operated upon ilarch 21), 1904. Catheters were inserted about 2 inches 
up Ixith ureters and stitched to the papilliie. He then made a circular incision 
as large as possible thmngh the mucous membrane around each papilla and 
deepened it until the bladder wall was completely cut through. After freeing 
the ureters from the cellular tissue and thoroughly cleansing the bowel, an open- 
ing was made at a point alMjut IV2 inches above the anus by means of a forceps, 
and the catheter was pulled in, the ureter following. The rosette of vesical 
mucous membrane passed through the wound into the rectum, much as a button 
passes through a button-hole* With a large rosette and a small rectal wound, 
there is no danger of the ureter slipping out of the rectum, and there is no 
necessity for a restraining suture. The wound left by the transplantation of 




FISSURA VESICA SUPERIOR. 403 

the ureters was gently packed with iodoform gauze. The boy recovered, grad- 
ually acquiring control over the flow of urine until, at the end of a month, he 
remained dry all day and only occaisionally wetted the bed at night. 

J. J. Buchanan (Surg., Gyn. and ObsL, 1909, viii, 146), in a most pains- 
taking collection of cases operated upon by the Bergenhem method, finds that 
in 26 extraperitoneal rectal implantations there were three deaths, a mortality 
of 11.5 per cent., two being due to ascending infection. 



FISSURA VESICiE SUPERIOR. 

11. Braun (Arch. /. klin. Chir., 1892, xliii, 185, of Festschrift f. Prof. 
Thiersch) describes a girl 15 years old who had a fissure of the upper part of 
tie bladder toward the umbilicus, which was exstrophied, dry, and shining^ 
6x7 cm., while the lower basal part lay in its normal position with a normal 
urethra. The clitoris was bifid and the symphysis wanting. The. defect was 
covered in with long Thiersch skin flaps taken from the sides in four opera- 
tions. Braun cites another case — from Froriep — an autopsy in a boy three 
weeks old. 



CHAPTER XXXIII. 
VESICAL, URETERAL, AND URETHRAL FISTULA. 

VESICAL FISTnUE. 

Vesical fistula is an abnormal opening between the bladder and a con- 
tiguous organ, associated, as a rule, with incontinence of urine, owing to its 
more or less continuous escape by the fistulous opening. 

Entero-vesical fistula is an opening between the bladder and the 
bowels, either the vermiform appendix, the ileum, the sigmoid flexure, or the 
rectum — when the contents of the bowel may empty themselves into the bladder 
and out through the urethra. If the fistula is a small one, the chief incon- 
venience suffered by the patient is the escape of gas from the bowel into the 
bladder. Fistulse may form between the bladder and the uterus, known as 
utero-vesical fistulse. They may also form between the bladder and 
the vagina, and these, the commonest of all, are the well-known vesico- 
vaginal fistula?. 

An opening from the bladder onto the surface of the skin above the symphy- 
sis may follow an operation upon the bladder at that point or an injury such 
as a pistol shot, and is called vesico- hypogastric fistula; we will 
not include here cases in which there is a sinus from a pelvic abscess, a dermoid 
cyst, a suppurating ovarian tumor, or an extra-uterine pregnancy opening into 
the bladder. 

ENTERO-VESICAL FISTULAE. 

Vesical fistula*, uniting the bladder with some part of the intestinal tract, 
are often due to the perforation of the bowel by some sharpjvointed body, such 
as a pin or a spicule of bono, which then penetrates the bladder and forms an 
avenue of communication between the bowel and the bladder, and may itselr bo- 
come the nucleus of a vesical calculus. In this way, a connnunication has been 
established between the bladder and the vermiform appendix by means of a 
pin which has been swallowed, has wandered down the appc^ndix to its tip, and 
then perforated the appendix and the bladder. 

Among other common causes of these fistula? are inflammatory processes, 

404 



TESICAL FISTULA. 



405 



PtsM. II. 



I 



espeeiallv of a tuberculous nature, in the ImiwpI or in some orpjnn lying between 
bowel and bladder. The destructive disease is in some cascis malignant and in 
some syphilitic. When, m is quite frequently the case, an infected ovarian cyst, 
a pus tube, or an infected extra- 
uterine pregnancy, opens into the 
bladder and the bowel, there results 
a long and tortuous fistulous tract- 
On tiie sillier hand, when the disease 
is priuiary in the bowT-l^ the opening 
is direct. In the male, niany rectal 
tifituUe folluw destructive disease of 
tbe prostate or seminal vesicles. 
Pascal (These de Paris, IDOO) has 
contributed an intereating study of 
this eontlitiou. He findn that the 
fistula may open anyw^iere into the 
bladder, and that the rectum is the 
commonest site of opening into the 
bowel. Tn ltt5 cases his fistuhe were: 
roetiil, 11*]; colon, 42; ileum, 2G; 
cecum, n ; cecum and appendix, 1 ; 
appendix vermiform is, 7. 

Such tistulte comuinnly set up an 
intense cystitis, and are readily dis- 
tinguiBhed by the discharge of flatus 

and fecal materials by the urethra. Bismuth given by the mouth will appear in 
the course* of 24 hours in the bladder, 

Treatnient. — Surh openings rarely heal spontaneously, and, if allowed to 
persi&t, sooner or later lead to death, through infection of tho bladder and kid- 
neys. For this reason the presence of .^uch an opening is a positive indication 
for surgical interference, the one exception being, pc^rhaps, advanced cases of 
malignant disease which cannot be cured. 

The treatment of an en tero- vesical tistula, excepting the recto- vesical, is to 
make an abdominal incision sufficiently w^ide to furnish a controlling view of the 
entire pelvis as well as the site of the tistula (Fig. 4J>9), and then to carefnlly 
w*all off on all sides with gauze and detach tlie adherent loops so as to expose and 
is(3late the fistulous tract, which may have been marked out previously by 
pasaing a ureteral catheter through the bladder wall into the bowel. 

The fistula is then carefully divided (Fig. 500) ; if it is necessary to aacri- 



FlO, 499, — FiBTULA BETWEEN SmALL INTES- 
TINE AND Bladder, View of adherent 
bowel through meclian al>doriiiiial in€iision. 
The i>osition of the fistula is shown by 
arrow. 



406 



VESICAL. URETERAL, AND TTRETHRAL FISTULA. 



\ 



/ 



\ 



/ 



K 



/ 



fice one organ on account of the clospnesB of the attaehnient, it is best to make a 
freer dissection of the bladder, sacriticiiig an oval area in its wallg, and cutting 
well out into its sound tissuea. This wound is then readily closed by fine silk 
sutures reaching down to the mucosa ; a secondj and even a third layer serves 

to draw the siirrouniling fascia over 
IVs. i-l/ ^ the tii'st line and insure success 

(Figs. 606 and 607). The bowel 
oi>ening is then dissected free on all 
sides down to the point of the en- 
r trance of the fistula into the lumen 

of the intestine^ where it is exeisi^d 
with beveled edges, when the bowel 
is closed by two rows of sutures in 
the usual way. Sometimes the fistu- 
\ lous ring can be sinipl y inverted into 
the lumen of the bowel and the open- 
ing closed over this, just as one in- 
verts the stiuup of the appendix and 
closes tlie hole. 

When the vermifonn appendix is 
attached U> the bhulder it may be a 
Pio. 500,— Adherent Bladder and Bowel better plan to clamp and divide it at 

Shown in Last Figure Separated. :* i- - ^, i *. *: a- •* i • 

zr . I r. ' * I *k ^^^ ^'''**' ^'^<J to tie ott its vessels m a 

The openiogt^ left uito both organs are j. . j. , , _ 

closed by suture, im stiown; or, if pre- direction from base to tip. This 
ferred, by continuous suture. makes it easier to deal with the vesi- 

cal fistula, which is marked out by its 
adhesion to the now movable appendix. A careful dissection can now be made 
^ovm into the bladder, am! a good closure secured with sutures — chromicised 
catgut or fine silk. 

After all intestinal fistula operations, it is a wise plan to insert a small 
safety drain, say about the svi^ of a cigar, wrapped in protective, into the abdo- 
men dt)wii close to the seat of the operation. If the wound remains sweet and 
clean, the jiroviBional sutureR, left for this purpose, can be drawn up and closed 
and tietl after the removal oi the drain on the fourth or fifth day. 

The above outlined plan is manifestly only applicable tu Himplo fistula*, 
where there is no serious disease of either bladder or boweb In the case of 
malignant disease, or of tuberculosis, the general plan may have to be altered. 
With an inoperalde cancer of the bowel the best makc*-shift is an enteroentero- 
anastomosis connecting a portion of bowel above the fistula to one below it and 




VESICAL FISTULA. 407 

preventing discharge of bowel contents into the bladder. In operable cases the 
diseased part of the bowel is removed and suitable measures to restore its con- 
tinuity carried out. In those cases where the fistulous tract passes through a 
pus tube, the sac of an extra-uterine pregnancy, or an ovarian cyst, the viscera 
are detached and treated as outlined, after which the primary trouble is suitably 
treated. 

Recto-vesical fistulae below the level of Douglas' cul-de-sac con- 
stitute a class in themselves and demand special consideration. Excluding 
those cases where there is gross disease of the affected organs, or, in other words, 
where there is a simple fistula, several plans have been advocated. The most 
surgical and satisfactory is the following: transverse incision parallel to the 
symphysis pubis, through the skin, fat, and fascia, separation of the recti mus- 
cles in the mid-line, freeing of the bladder extraperitoneally to the site of the fis- 
tula, separation of the bladder and rectum, and closure of each separately in the 
manner already described. Such a procedure is almost invariably successful. 
This class of case is found exclusively in the male. Much less satisfactory 
results are obtained by operations through the rectum or through a suprapubic 
opening in the bladder. I3oth of these procedures have been extensively em- 
ployed. 

VESICO- VAGINAL, VESICO- UTERINE AND URETHRO- VAGINAL FISTULiB. 

Vesico-vaginal fistulae, opening from the bladder into the vagina, vary in 
size from the diameter of a hair up to great, gaping holes, taking in the whole 
anterior wall of the vagina through which the opposite bladder wall prolapses. 

Etiology. — The causes which give rise to vesico-vaginal fistulsB are : 

1. Cancer of the cervix uteri, commonly. 

2. Syphilis of vagina or bladder, rarely. 

3. Difficult labor, commonly. 

4. Surgical operations, occasionally. 

5. Malignant disease of bladder, occasionally. 

Cancer of the cervix breaks through into the bladder late in its 
course. The surgeon occasionally makes such a fistula by injudicious and too 
^^igorous use of the curette as he removes the friable, cancerous tissues. The 
-patient's discomforts are so much augmented by the added distress of the con- 
stantly escaping urine and the associated foul odor that she will hardly forgive 
tte operator, as she generally holds him, and not the disease, responsible for 
Jxet condition. 

Difficult labor often gives rise to a vesico-vaginal fistula, as T. A. 



Fig. 501. — ^Exposure op a Difficult Vbsico-vaginal Fistula, Following Hysterec- 
tomy, a. Patient in Sims' posture, with a strong retractor introduced into the vagina. 
Note the distance of the fistula from the introitus. The absence of the cervix and the 
presence of scar tissue in the vault of the vagina always complicate the exposure of such an 
opening. In b the retractor is drawn forcefully in a dorsal direction, pulling the perineum 
and the posterior vaginal wall well out of the way. If this is insufficient, a Shuchardt 
pararectal incision should be made. Guy sutures, placed as shown, aid greatly in 
making the fistula accessible. (F. B., May 28, 1906.) 



408 



410 



VESICAL, URETERAL, AND URETHRAL FISTULA. 



Emmett and niaiiy others before him Liive loii*r 8iii(*e pointed out, from the 
inipautioii of the head of the child fur several hours in aiiv purtieidar part of 
the pelvic canal, eansing a pressure ischemia of the ba^e of the bladder, as it is 
squeezed between the head and the symphysis or the pubic arch. The trouble 
then arises^ not because forceps are used, but rather In^eause they have not bee-n 
used soon enough, or because of the failure to do a symphyseotomy or a 
Cesarean section in a lab<:>r almost impossible by the natural ways. Vesico- 
vaginal fistuhe thus commonly arise in contracted pelves or where the child is 
disproportionately large. 

Surgical operations, in these days, usually hysterectomy for caocer 
or for tibroid tumors of the nicnis, tjccusionally give rise to fistulte situated high 



y>y 



\\ 



Fig. 502. — Sagittal View or Vesico-vaginal Fistula, with Open-air Speculum in 
Urethra. The snmll diaj^niin to the right shows the speculum view of this fistula with 
the surround ill g bladder mucosa. (F,, March 3, 1900.) 

up in the vagina, small in size and lying close to the sear at the vaginal vault, 
just under the peritoneum. 

Symptoms. ^ — The cardinal symptom of this fistula is the leakage of urine 
from the vaf^ina over thr person, irritating the skin^ causing edema, inSamma- 
tioUj ulceralioiij and painful abscesses of the hair follicles, and disseminating 
from the person of the patient, wherever she may go, a foul, repidsive, urinous 
odor, making the room where she sits and the bed w^herc she sleeps like a j^est 
house. For this reason patients afflicted in this way coinmonly live a recluse 
life^ rarely seeing any one outside of the immediate tolerant family. 




VESICAL FISTUL7E. 



411 



Diagnosis, — The diagnosis of a vesicovaginal fistula is usually easy; it 
^^y he evident at once, upon retracting tbe positcrior vaginal wall (Fig. 501), 
^Wn the bright rod bladder mucosa can be seen pouting through the fistidoiis 
^^rifice. If the fistula, as is frequently the case, is not readily found, a couple 
of ounces of milk or water colored with an anilin dye, injcetcd into the bladder 
through the urethra by means of a catheter and a rubber tub© attached to a 
fimuel, will reveal its presence by the little point of colored fluid escaping into 



V^'t 



V!i»,v»| fi»»w>* 



» 



:u. SOS^^ExPOSTTKiQ OF Small Vesico-vaginal Fistula. Procedure rendered quite 
slxiiple by the fact that the ccr\ix and the anterior vaginal wall can be drawn almost 
o\it of the vaginal introitus. The figure to the right sho^ft^ the closure of this fistula 
i^th two layers of autures. (F,, March 3, 1*J0U.) 



tlxe vagina* It 18 frequently a valuable aid to examine from the vesical side by 

ka csystoscope, as shown in Figure 502. 
In the case of a minute fistula, it is often a good plan to put an absorbent 
-otton pack in the vagina, after filling the bladder with the anilin solution. If 
^li^erc is a fistula, the cotton in the vagina wnll be stained at the point of its 
^^cape. If the cotton collects clear urine, while the bladder nrine is strongly 
^•Dlored, then the fistula is ureteral, nut vesical. When there is much inflamma- 
^ioa ami the parts are tender, it is k^st to put the patient completely under the 
^lafliienee of anesthesia before making a thorough examination. 
^m Treatment. — The object in the treatment of a vesico-vaginal iistuhi is to 
^■^ose it firmly^ m as tg restore vesical continence. 



VESICAL FISTULA. 



Fig. 505. -Sickle- 
shaped Kkife; 
Sharp on Both 
Sides* It is 

very convenient 
in dissecting the 
b I a d d e r free 
from the vagina 
and also coa- 
venient in mak- 
i n g vesieo' va- 
ginal fistuiffi for 
purposes of 
treatment, (% 
imtural size.) 



Conditions of Success Common to All Plastic 
0PEJi.\TioN8. — ^Suecess in treutinijj a vcaico-vaginal fistula de- 
pends first, upon deiiling suitably with imy existing couipli- 
rations, tuid then upon securing a gCMid devindntion in well- 
vascularized plastic tissues, that the tissues can be splioted 
during the healing process in snug coaptation without undue 
tension. The approximation of the tissues must be main- 
tained by a suture material which will last at least S or 10 
days, the parts nnist be kept eleiin while the union is being 
established, and, as a rule, the bladder must be kept at rest 
by drainage* These genera! principles 
are attained in some cases quite readily, 
in others only by extreme care, remov- 
ing one or the other of the various pre- 
existing coinplioations. 

Posri HE. — The best posture is the 
one which renders the fistula most ac- 
cessible and at the same time is raogt 
convenient for the operator, his assist- 
ants, and the anestlictisl. The lithi»tomv 
or the exaggerated lithotomy (Simon's) 
is generally the mobt satisfactitry ; 
Sims' posture is sometimes exeellent; 
occasionally an operation can be done 
with greater ease and dispatch in the 
knee-breast posture tlum in aiiy other, 

Anksthesl\* — II any opr^rations can 
be done imder local anestheaia. Novo- 
cain, 2 per cent. a<|neous solution, to 
which a little 1 to 100,000 adrenalin is 
added, is ideal. In addition U^ infiltrat- 
ing the tissues about the fistuhu it is a 
great help to thoroughly inject the 
perineuuL This permits of retraction 
without discomfort. 

,,», ... , OCISSORS CURVED 

\\ here local anesthesia is not satis- qn tile Flat, for 

factory an ideal suhstihite is found in Paring Edges of 

the mixture of gas, oxvgcn, and ether Vesi co-vaginal 

FisTrL.E. (Ji nat- 



FiG. 506. — Delicate 



in snch general use. 



uralfiize.) 



414 



VESICAL, URETERAL, AND URETHRAL FISTULA. 



Opebation. — With the patient in a lithotoiiiy posture aiitl the posterior 
vaginal wall well retracted, the next step is to proeeed to hring the fistulous area 
down as iieiir to the i)biBerver as jx)8sible* This cau often be done by passing 

4 stout silk sutures 
through the tliickness of 
the vaginal walls in 
frunt of, auil behind, 

^ ^' ' fistula (Fig. 501). The 

fistula can now be 
pulled down and ex- 
posed for operation as 
readily as tliough it lay 
^^^^^ on the surface of the 

^ .VfcHSHll^^^^^.% ''^^lll, body. Oftentimes it is 

suflieient to catch the 
cer\nx with a stout 
tenneuluni forceps and 
haul it down to bring 
the fistula with it al- 
most to the vidva (Fig. 
fiOIi). On the othei 
hand, much is a 

Fig, 507. — Immbnbe V^esico-vaqinal Fistula, Involving ^ * r i_ 

Entire Trigonum, Including Sphincter Area, The perineum as far back as 

uretcmt orifices are still open in bladder. Figure I shows possibleC Fig. 501 b). In 

the separation of the bladder from the vagina. A deiiu- juj^jy castas great gain is 
ilatiou is carried all the way around the fistula. Figure II * j i i* i 

shows placing of the sutures. (Sreat care must, be taken "*^^^^*^ ^y iJ^aking a deep 

nut to include the Ijladder tiuicosa and to close the angles para-rectal incision 

perfectly* The sutures below include the mobilized blad- tbrouiih the perineum 
der; care being taken to include a large bite. In front* , • t- r*ii^' 

they include both bladder and vagina. (IL, Oct, 31, 1900.) ^^^ ;*^*^^^"^ ^^' ^ ^^^^^ '^'^^' 

This ia readily closed at 

the eud of operation. T5y these devices, by pulling the fistula d*nvn, and by 
hauling the perineum up, two inches or more can be gained. The plan nbown in 
Figure 504 it* frequently a very effectual uiie in exposing tlie edges of fistula. 

The instruments needed are a speculum, scalpel, mouse-tooth tissue forceps, 
delicate scisaors (Figs. 505 and 500), artery forceps, tine needles, needle- 
holder, and suture material, 

Dell u d a t iou. — The Ix-st method of denudation is the one which sacri- 



V 




VESICAL FISTULiE. 

fioes tho least tissiiej and this is ihmo by cuffing through (he vaginal tissues at 
viwh eiiil uf tho Mpeniiig down t(» thf l)lufhlt*r wnll {Fig. 507), then freeing the 
l*la(ltler on all Hides from the vagina by nnining a scalpel anniiid between tlieni, 
when the bladder can be hr« Might togi:*ther iis a separate organ wlthtnit any 
teuj^ioo being phxeed on the binding sutures (Fig. 508). 

Line of UniriiK — The tissues s^hould be lirought together in the 
direction in which tliey must iiaturjilly mid readily fall itit(j upposiiii*u. 
It is not necessary for tho line of bladder uiiioii to coincide with the vaginal 



Y'-M\- f 



■■\ 




¥tQ^ 508. — ^FwrvLA Shown in Last Fir.ruK, wirn Si^tuues Tied. The bhidder, loosc^neil 
poeteriorlyp i» mm <lrawh furwurd and \]w sutures titHl. Xti attciofjt is tkiw Ui t)c uumIc 
to cover over tlic raw l>lad(bT syrfrirt* witli llie scrirrcd find rijci*! va^i^ina, as nature will 
soon hide all truces of the opirratiun and there will be no visihle defect- 

line. Other thing's being equal, in all larger fistnhe a transverse or slightly 
obli([ue line of mitnre of the vaginal tiftsne is best (Figs* fiOO and 510, 511 
and r»1:?; also oHS, r>:>?l, r>::i4). It is, as a rule, more dittieult to draw the 
tissues togetlier in the diret^tion of the axis of the vagina than across ita 
axis* 

Suture. — Fine needles are nse^i for the sewing, and we prefer chromic 
catgut for the bluddrr, and tine silkworm-gut or tine silver wire for tlie vaginal 
wall With tlie bladder w^all iletaehed from the vagina, it is go<id to unite 
tho under raw surfaces of tlie bladder, throwing a ridge of tissue upwards into 




416 



VESICAL, URETERAL, AJTO URETHRAL FISTULA. 



t.lie viscus by 2 layers of fine ehroiiiic gut ; silk or linen tlirt*n<l may also be used. 
A tine silkwonn-gut or fine silver wire does well to hold the vaginal tissue!* 
in apposition, avoiding any dead spaces between the vesical and the vaginal 
planes. 

Wliere the surroimding tissues are nut iiivitlved atnl (lie niargins of tlie 



W 



Fii;. 51)11 —Paring Edges of Ves- 
icovaginal Fistula Phkfara- 
'HJRY TO Closure, Thr paiiont 
should L>e in the elevated iKTitieal 
posture. The aiit+nior vai^inal 
wall in whic!i the fistula lies is 
exi>osetl by a large pc>steriQr re- 
tractor and two stnall lutiTiil re- 
tractors, as shown. The amount 
of denudation is indicated by tlie 
o nth lie. 



Fig. 510, — Cluslue of \ esico-vaginai 
TULu\. Tlie paretl vagina! edges arc brought 
togotlior with interrupted transverse su- 
turt*.^, goitiK down ti>, but not including the 
nunous inemliranc of the bladder. The 
beMi suture material is tine silkworm gut 
or fine silver wire. The upi>er and hjwer- 
most sutures should tmite the tissues well 
bcj'^ond the opening. 



fistula ean be easily drawn together, then the classieal operation of Sims can be 
done with every assurance of success. 

In this a broad strip of tissue is removed from the edges of the fistiila on 
all sides, extending up to, but not ineluding, the mucous membrane of the 
bladdf-r (Fig. 500). 

The next step 18 to pass a scries of silver wire or silkwonn-gnt sutures nI>out 
five millimeters apart, which, when shotteil or tied, will serve to bring the 



VESICAL FISTULiE. 



417 



apposed raw surfaces into accurate apposition and splint them without undue 
tension until firm union has taken place (Fig. 510). 

Simon, the great German operator of a half century ago, was fond of 
passing alternate sutures at a greater distance from the edges of the wound, 
which served, when tied, to relax the tissues for 
the accurate work of approximation secured by 
the intermediate sutures. 

After-Treatmen t. — After suturing the 
parts together, it is always best to test if the sew- 
ing is water-tight by injecting an anilin solution 
into the bladder, say 150 c. c, to discover any 
weak points. If any are found, other sutures arc 
eanfully placed there at once, or the whole is 
ripped out and done over. If the operation is 
really well done, the operator can feel sure in ad- 
of the test that no fluid will escape. A 
mushroom catheter 





513), with a 
about 5 mm. in 



fiG. 512. — Closure op Vesico- 
vaginal Fistula, as in 
Last Figure, wrrn a Sepa- 

BATE LAYfcR OF SUTURES 

FOR THE Bladder. The 
buried sutures are of cat- 
gut. 



(Fig. 
stem, 

diameter, is inserted 
into the bladder 
through the urethra; 
through this the 
urine drains contin- 
ually into a recep- 
tacle at the side of 
the patient contain- 
ing some 5 per cent, 
carbolic acid solution. 



Fig. 511. — Closure op a 
Vesico-vaginal Fistula 
WITH Sutures Placed in 
Antero-posterior Di- 
rection Making a 
Transverse Line when 
Tied. The procedure is 
the same as shown in the 
last figure except that the 
line of suturing, when 
completed, is from behind 
forward, instead of from 
side to side. 



Once or twice a day the 
bladder is washed out with warm boric acid so- 
lution, and once a day 2 oz. of 1 to 1,000 or 
1,500 nitrate of silver solution is tlirown into 
the bladder after irrigation. A very valuable 
irrigation is tluit of 1 to 1,000 formalin solu- 
tion. After G or 8 days the catheter may be withdrawn. 

The bowels should be moved on the third day by giving a laxative the even- 
ing before. After this the food need not be restricted. 

A rest of 8 to 10 days in bed will be necessary according to the severity 
of the case. 



418 



VESICAL, URETERAL, AND URETHRAL FISTULiE. 



Vesico-Cervico- Vaginal Fistula. — ^When the fistula is in juxtaposition 
to the neck of the womb it is a vesico-cervico-vaginal fistula. This form may 

be superficial or, when there 
has been much destruction of 
the neck, throwing it higlier 
up in the midst of a mass of 
scar tissue, it is a deep vesico- 
cervico-vaginal fistula. These 
forms attracted much attention 
from the earlier operators, as 
they are not uncommon and, 
where one is limited to the sim- 
ple plan of denudation, ap- 
proximation, and suture, they 
may be difficult to handle. Jo- 
bert de Lamballe and many 
others after him sometimes 
denuded the posterior cervical 
lip and sewed it to the anterior margin of the fistula, in this way closing the 
opening and also turning the uterine orifice into the bladder, through which 
the patient was then destined to menstruate. 





Fig. 513. — Three Styles op Self-retaining Cath- 
eter. These catheters are made of soft rubber 
and should be about 25 cm. long. The third is 
the one commonly used; in order to be able to 
irrigate through it with greater ease, it is often 
best to cut the holes larger. 




Fig. 514. — Vesico - cervico - vaginal 
Fistula. Dissected free and ready 
for suture. 




Fig. 515. — Vesico-cervico-vaginal 
Fistula. The dotted line indicates 
the plane of the dissection made to 
mobilize the bladder by freeing it 
from tlic uterus. 



The best plan of treatment here is to grasp the cervix and pull it down and 
back; then to cut transversely between the fistulous orifice and the uterus, com- 
pletely severing the vaginal vault and the bladder from the cervix. After 




Fig. 517. — Closure op Vesico-tjterine Fistula, from Below, The sutures cloeing the 
denuded and mobilized hUuliler ure in plaee, ready to tie. 

front of the cervix to earry off any secretions, and the bladder is drained for 
from G to 8 duvs with a catheter. 




420 



VESICAL, URETERAL, AND URETHRAL FISTULJS. 




Fig. 518. — Vesico-uterine Fistula. The bladder has been completely detached from 
the uterus and can now readily be sewn up. The utero-vesical space may be drained 
or closed at once; the choice of procedure will depend upon the character of the oj)e ra- 
tion and the presence or absence of infection. 



Vksico-TTterine Fistula. — A vesico-uterine fistula opens from the bladder 
into the cervix and is not visible. It can be detected by the flow of urine from 
the cervix and by passing a probe through the bladder and across the fistula into 




Fig. 519. — Vesico-uterine Fistula Treated through Median Abdominal Incision. 
The bladder is separat<xi from the uterus and each opt^ning ('lo;?ed separately. A drain 
is inserted at the site of the fistula leading into tlie vagina. 



VESICAL FISTULiE. 



421 



the uterus and then touching it with another probe passed into the cervical 
canal. The i)hin of treatment here is to separate the anterior vaginal vault 
from the cervix and to dissect the bladder free up to, across, and beyond the 
opening until there is plenty of slack bladder tissue around it, when it is closed 
^th a fine needle and fine chromic gut in two or three layers. It is not neces- 
sary to close the uterine end of the opening, although this is a simple procedure. 
Kext close the vaginal vault down to a small opening and insert a little cigarette 
Jrain for a few days. See Figures 517 and 518, also 519-521. 

Yesico-Urktiiro- Vaginal Fistula. — A fistula at the neck of the bladder 
is always serious, as it may involve 
the entire destruction of the sphincter 
muscle and so condemn the patient to 
a urethral incontinence when the hole 
is closed, which is no less annoying 
than was the flow through the fistula, 
for no operation is successful from the 
patient's standpoint unless she secures 
perfect urinary control. 

In operating here it is most im- 
portant (a) not to sacrifice any tissue, 
(b) to avoid as far as possible intro- 
• ducing scar tissue into the wound area. 
Begin the denudation by splitting the 
vagina in the median line, starting at 
fhe fistida, and extending on down the 
urethra. Then, by turning over little 
flaps of vaginal mucosa on either side, a raw area is secured covering the an- 
terior part of the fistula, which is the most difficult to get at. Then the pos- 
terior margin is split in the median line up toward the cervix for about one 
centimeter, and the little flaps dissected up from the bladder mucosa out to each 
side until a wide area is exposed, and the anterior and posterior denudations are 
joined at the right and the left angles. 

The denuded and, to some extent, liberated bladder is now rolled forward 
^to the urethral portion, raw surface to raw surface, and sewed snugly there 
ith fine needles and very fine, continuous, chromic catgut suture. It some- 
i^iies is a great help to unite the median portions of the wound with a single 
iterrupted stitch. This same principle is also a good one in dealing with 
I'ge fistulae of the base of the bladder, where the wound can be divided up 
t vantageously by two or three fine interrupted sutures. The fine continuous 




Fig. 520. — Treatment of Vesico-utbrine 
Fistula by Abdominal Incision. The 
vesico-uterine fold of peritoneum (P-P) 
is divided, and the fistula (F) exposed 
and detached from the uterus, (von 
Dittel.) 



422 



VESICAL, URETERAL, AND UKETHHAL FISTUL/E, 



B 



fhi-miiic^ gilt .suture is tlicn used to etTect an awurate closurG from end to end, 
or rather from near the center out to one end and then back to the center, and 
then out to the upjjosite viul and hiiek again, when it is held at the starting 
point. By lining a tine needle and line suture the tiasne.s are not injured and 
the snhires ean Im? jilaeed elose tugether, inukitig a ni^>re seenre rlosnre. If ttiere 
is any tcninion two or three silkwonii-gnt snturos will relieve that and make the 
fine suture work more eifeetive. It is good to end up with the last row just 

uiider the vairinal wulK completely 
buried out of siiiht. In many large 
fistula^ it is possible to bring tlie bladder 
together, but not the vngimd wall Sueh 
a condition is shown in Figures 507 and 
508, 

When the sutnring is done at *>r 
close up to the neek of the bladder, or 
involves the urethra^ it is best to avoid 
using a peniument catheter lying in di- 
rect eontaet with the line of approxima- 
tion. In th( se cui^es it is good to make 
a stab wound in the median line through 
tlie bladder walls well above the sutur- 
ing area» draining in this way until tlie 
tissues are well united, when the cathe- 
ter is pulled out and the vesical opening 
rapidly closes of itself. 

Urethro-Vagixal Fistula.— See 
Urethral Fistula. 

No satisfactory apparatus has been 



Fio. 521, — Vebkto-uterinb Fistula 

C'losed by Operation from Above. 

The hole in the bladder is now sewed 

upand then the vesico- uteri no plica (P) 

i^ rt'siorech Finally the ahdominal 

incision is eloHe<l nmi the bladder 

drained with a nnishrdura catheter 

for a few days. If the opening into 

the uterus is low domi, it will jw>nie- 

tune« be bt^^t to split the eendx into 

the va^na and drain the wound area 

through it. 

devised for eol kiting tlie urine leaking 
from a vesieo-vaginal fistula when the [latient is up; lying in lx*d very good 
results are obtainable by inserting a large nuisliroom catheter (Fig, 513 J into 
the vagina and by tubing to e<mneet it with a eonvenitut reeoptacle. 

As, for reasons uf treafnn^nt, il is often tlt'sirablc to leave tistuhe open — an 
in some eases it h impossibk' to close them — it wuukl \k' u great eontribution to 
the treatment if a really practical nieehanical apparatus were in iiac. 

We have merely outlined the qnestion of operative treatment. Not every 
fistula ean be closed by the vaginal route, and it seems wnsc to add Bometbing 
as to the coniplications. Each case nuist be judged on its own merits, and, 
among difficult cases, no two operations will bo identical. 



¥ 




VESICAL FISTULJE. 423 

Complications. — The complications threatening the success of the operation 
may lie in the character of the fistula itself, which is either minute or extensive, 
or it may be that it is inaccessible, or that the surrounding conditions offer 
difficulties such as scar tissue, a ruptured perineum, pelvic inflammatory dis- 
ease, etc. 

The following is a categorical list of the more important complications met 
with : 

1. The fistula may be minute, as fine as a hair, rendering its discovery 
difficult. Once located the treatment is simple. 

2. It may be large enough to involve the whole base of the bladder and 
the anterior vaginal wall. 

3. It may be embedded in the unyielding vaginal scar tissues. 

4. It may be so high up in the vaginal vault as to be inaccessible. 

5. It may adhere to one or both pubic rami. 

G. The destruction of tissue may involve the anterior lip of the cervix, 
which is more or less completely destroyed (fistula laqueatica). 

7. It may involve the urethra at the neck of the bladder, and with it the 
vesical sphincter. 

8. The whole urethra may also be destroyed. 

0. Two or three vesico-vaginal fistula? may exist at the same time. 

10. A vesical fistula may be coincident with a veaico-uterine fistula. 

11. A vesical fistula may be coincident with a urethro-vaginal fistula. 

12. One or both ureters may be caught and compressed in the margins of 
the fistula. 

13. A vesical fistula may be associated with rupture of the symphysis 
pubis, and sometimes with necrosis of the \xme. 

14. It may be associated with a complete tear of the perineum. 

15. It may be associated with a recto-vaginal fistula. 

1(). There may be a coincident pyelonephritis, usually due to an a8cen<l- 
ing infection. 

1 7. There may be prolapse and thickening of the inflamed bladder wall, 
through the large fistula. 

18. There may l>e cicatricial narrowing of the vagina, especially at its 
outlet. 

19. There may Ih} more or less extensive vaginal and vulvar inflammation, 
with follicular abscesses and incrustations on the raw tissues. 

20. Vesico-vaginal may bo coincident with u re tero- vaginal fistula. 

21. Tli(»ro may be pi^lvic infianimatorv disease fixing the uterus. 

22. Fistula may follow hysterectomy. 



424 



VESICAL, URETERAL, AND URETHRAL FISTULJB. 



M*B IKj 




Perhaps the sim})le8t and most easily managed of these complications is the 
preliminary clearing up of infection in the vagina and around the fistula. It 
is indispensable to satisfactory results. 

Bad cases of vulvar and vaginal excoriations and inflammation and badly 
inflamed bladders often demand some weeks of preparatory treatment to get 
the tissues into proper condition for an operation. When the vaginal outlet is 
open, affording free ingress and egress to fluids, the patient may be kept in a 
warm bath for several hours each day, extending for a period of from oiie to 
several weeks. In some cases continuous tubs are of great advantage. Patients 
may lie on a canvas hammock, in a tub, out of the water, and by suitable 
apparatus a continuous irrigation with plain water or any 
desired fluid may be kept up. This plan of G. L. Humier^s 
often so ameliorates the local conditions that an operatioii 
can then be done successfully. 

The use of a stiff oxid of zinc paste over the excoriated 
skin and \nilvar parts relieves pain and promotes healing. 

In some of the worst cases we find that it is a good plan 
to put the patient under anesthesia, say once every 5 days, for 
4 or 5 times, and then go tb work and cleanse the internal 
parts, which we prefer to do in the knee-breast posture, 
vigorously scrubbing off all the incrustations from the 
vaginal and vesical surfaces; then applying carefully to all 
wounded surfaces a nitrate of silver solution, varying in 
strength from 5 to 10 per cent. Xo other plan will so speed- 
ily hasten the healing of the wounded surfaces and prepare 
the patient for the operation, Avliich can be done as soon a-^ 
the surrounding parts become normal. 

Let us now consider some of the more important and fre- 
quent of those complications. 

Vkry Large Fistul.k. — In some of the worst fistuliv the 
opposite wall of the bladder is found prolapsed through the 
opening into the vagina, where it appears as an angry, red, 
soni(»tinies strangulated and edematous mass, inflamed, uIcit- 
atci], or coated with gritty material. The general prepara- 
tions described above aj)ply here, and, in addition, the blad- 
der should be replaced and prevented from falling into the vagina by packinir 
it from time to time. At the time of th(^ opc^ration the bladder can be restonvl. 
and retained bv the posture of the patient, either the left hiteral or the kncf- 
breast i)ositi()n. A rubber balloon with a stem to it can also be inserted in tlir 



Fig. 522. — Large 
Fistula with 
Rigid Vaginal 
Walls. The 
bladder has been 
dissected free 
and sewn to- 
gether, as shown. 
The suturing 
should be close 
and in two lay- 
ers at least. 
With careful 
post - operative 
attention as to 
cleanliness such 
a fistula will 
heal without 
any approxima- 
tion of the va- 
ginal wall. 



VESICAL FISTULA. 



486 



I bladder cavity, the stem brought out of the urethra, and the bladder blown 

When the fistula is m large that the vapnal tissues cannot be imited, one 
must do as much as possible %vith the available tissues and leave the rest bare. 



» 



f iG, 523.^ — Dudley's Operation for Laeoe 

V'ESICO-VAGINAL FlSTCTLA WITH RiOID 

E[>G£a. The diagram shows left half of 
the bladder. The denudation includes 
the anterior part of the fistuhi, flf; on 
reaching the point d, in place of extend- 
ing backward to the cervix, it runs up- 
ward in a semicircular denudation in 
the bladder- Some of the sutures are 
alreiidy placed. As a result of this opera- 
tion, the part of the l>lattder behind the 
sutures, as indicated by df, m left out of 
the newly formed bladder and becomes 
a part of the vagina. 



FiQ. 524, — Dudley's Opehation Com- 
pleted. (See last figure.) The part of 
the anterior vaginal wall back of the 
suture is made up of vesical mucosa. 
Although the bladder appears much 
smaller in our sketch, its size was, in 
reahty, not greatly reduced. 



This uncovered area becomes covered 
with epithelium, so that in a short 
time it is impossible to recognize that 
the vagina has not covered the wound 
throughout as usual (Fig. 522), 

In tlie ease of a large fistula son^e 
of the older workers deliberately adopted tin* plan of closing as much 
82 possible at one sitting, and then elosiug the remaining portion in one 
or two more sittings* Again, Freund and von Rosthorn resorted to the 
extraordinarj expedient of bringing the uterus out into the vagina 
tkrongh an opening in front of the cervix, and sewing the bnre uterine 
body by its posterior face into the large vesical hole; or bringing it 
out topsy turvy through the posterior cul-de-sac and sewing its an- 
li'rior face into the hole and so plugging it up. We think to-day 
we can avoid such extreme measures by dissecting the bladder free 
from its surroundings and closing it separately, as described* Maeken- 



426 VESICAL, URETERAL, AND URETHRAL FISTUK®. 

rodt has been one of the most active propagandists for this operation in large 
fistulss. 



I ' 

Fig. 525. — Double VEsic(>-VA(ii\AL Fistula. I. When tho fistiilip lie close together 
and in the hiise of the bladder, it is then best to cut the liridj^e and throw both into 
one. (E., Oct. 19, lt)08.) 

An interesting and somotiirios very valuable plan is that of Dudley, shown 
in Figures 52»*{ and 524. It can yi(dd a perfect functional result. 

Minute Fistul.i:. — A little fistula soiuetiinos <:ives far more trouble than 
a big one. One reason for this is that the oj)erator frecpiently treats it too 
lightly, and does not make sutKciently extensive denudations. Frequently a 



VESICAL FISTULiE. 427 

little fistula is the residuum of many operations closing a large fistula. In such 
a case it often lies in the middle of a hard mass of scar tissue. In every 
small fistula it is best to dissect out the whole fistulous tract all the way to the 
bladder mucosa, thus avoiding the formation of diverticula or funnel-shaped 
processes on the bladder side. After the denudation is completed the closure is 
hest made with fine needles and very fine chromic catgut suture. While such a 







TiQ. 526. — ^Double Vbsico-vaoinal Fistula. II. Transformation of the two fistula;, 
shown in last figure, into a single opening, by incision through the bridge of tissue 
separating them. The edges of this fistula were then denuded and the bladder 
freed for separate suture as aheady shown. 

condition is usually cured, even if the patient is allowed to pass water from the 
first, the result is better still if a urethral catheter is inserted and allowed to 
remain in the bladder for at least 6 days. 

Multiple FiSTULiE. — Where there are multiple vesical fistute, usually one 
is large and the other small and close by. In such cases it is often well to 
tkrow the two or three into one, rather than attempt to close them up separately 
CFigs. 525, 526, and 527). , A separate fistula into the urethra, or into the 
xiteras, only complicates the case because it requires an additional operation 
to close it; preferably at the same time the vesico-vaginal fistula is closed. 

Inaccessible Fistula, — ^Where the fistula is high up in the vaginal vault 



428 



VESICiVL, UKETERAL, AND ITRETHRAL FISTULJE. 



A 



and cannot be reacted readily so as to do accurate work, and cannot be brought 
down by traction on the vaginal walls or by retracting the perineinn, it may 
sdnietimes be reached by cutting down the vaginal orifice laterally, thereby 
gaming one-half inch or an inch (Fig, 636), If it still remains too far away 

a suprapubic transvesical opera- 
tion can be done, as by Trendelen- 
burg (Figs. 528, 529, and 530). 
Li such case the bladder may be 
opened above tlie pubis by a trans- 
verse incision through skin, fat, 
and deep fascia. It is not neces- 
sary then to cut through the recti 
muscles. These can be readily re- 
tracted when the bladder is ex- 
posed in tlie lowest tissues beyond 
the symphysis, opened widely 
from side to side, and the fistula 
exposed* By means of gut sutures 
the opening can sometimes l>e 
dra\\ii up on a level with the skin 
surface of the abdomen. 

The edges are readily denuded 
uiid, in some cases, tJie bladder 
and vagina separated and closetl 
independently. In others, one has 
to rely on the vesical closure alone. 
The same precautions as to deli* 
cate instruments and suture materials must be taken as in other cases. The 
best suture material is catgut, and the suture should preferably be submucous, 
A continuous thread is preferable to the interrupted one, but is not always 
possible. 

When the fistula is secured the bladder suprapubic opening should be closed, 
care being taken with the perivesical fascia. The space of Ret2iu3 is best 
drained with a small piece of iodoform gauze surrounded with protective, ami 
the bladder should be invariably drained by leaving a mushroom catheter in^ 
the urethra for a week or more. 

To suit the individual case the procedures are most variable. 
When there is a vesico-nterine fistula or a vesico^utero- vaginal fistula which 
is inaccessible becauac of the fixation of the uterus by inflammatory disease 



0. 527.— Double Vesico vaginal Fistula. 
III. Applicatiun of the first bycr of sutures, 
closing the fistula .'^hnwri in tlui liisrt two 
figures. The Huture material^ of fine catfifut, 
first closes the loosened vesical tissues, after 
which the vagina is closal m by a second 
layer of interrupted silkworm-gut sutures. 





Fio. 529,— Treatmbnt of Fistula PitruRED in Last Figuke, thbouoh a Median 
Abdominal Incision. The blatjder was opentnl on its posterior surface in the nudlino 
down almost to the fistula. A dcnuflatinn wiis then made across the bladiter, m fn>ni 
of the fijstula, s(*paratin^ it and a small part of the bladder from the wst of the orKan^ 
as shown. Next tlie l>ladder wa>5 sewn yp fnim top to bottom^ as indicated by the 
stitchei^, leaving the fiistuhi and the Httle patch of surroundinR veisieal mucosa wholly 
outride. A vaginal drain was then pushed up through the fistula to prote<?t the pelvic 
cavity* 

429 



VESICAL FISTUL.^. 

only taking great care not to tear it iu the neighliorhDod of the fistulous open- 
ing, the loose bladder tissues can then he brought together and the fistula closed 
by an of»eratioii thrnugh the abdomeUj where an operation through the vagina 
must necessarily fail (Fig, 5*13). 

In one ease, where the uterus had already l>een removed (Fig. 528) 
and numerous unsuccessful operations had bc»ofi done from below, the abdomen 




Fio. 532.— Vbsico-vaotnal Fistula with Pelvic Inflammation. 11, Sagittal view of 

patient shown in liisl ti^rt*. The pelvic infliimmatory cornjitinri, holding the uterus 
fixrd mnl hiRh up, provcntf^l pnlliup; the fistula dimn iind ojHTtitiuK by any of the 
ordituiry lyrotrtHluri'S. \Vt^ were thus force<i to procccxl by rt^moviug thf uterus, with 
its tubes and ovarifs, through the abdomen, in order to free the vagina and be able 
to get at the fistula. 

was ofieneJ and, on failure to mobilize the bladder on account of the scar tissues 
on the pelvic floor^ the bladder was cut into in the median line and the fistula 
expostnL Tt still \mng im]Missible to detach it from the bt^l of cicatrix, the in- 
cision was confinuc^d arouml the fistula on both siiles in the form of a denuda- 
tion about live nuiL in width. The raw surfaces were then brought together 
across the pip and united hy suture. 

FisTiTLA AniiERKNT TO THK PlBic Ramfs. — A fislula adherent to the 
pubic ramus is l)est treated by dissecting the Idadder entindy free at this point, 
so that it can readily be drawn down into the vagina and sutured. It is a mis- 




VESICAL FISTULA. 



43a 



Ureters in the Marcin of tuk Fiisrr'LA i¥\g, 534). — Wlicn one or hotli 
ureters are in the nuirji^in of the fistula, ciiii|i^ht in the sear tissue, this eonsti- 
tutes a serious eooiplicatino* In the first plaee it lias usually interfered %vith 
the funetion i>f the kidney of the atTtx*ted side. Then, if ihe misplacement ia 
not noticed, the ureter may l>e eaught in the Butures and its lumen compressed 
ar closed. We have known one case 



in which hoth ureters were thus in- 
ehided in the approximate sutures 
azid the patient developed a pyelono- 
phritia aud died. The way to avoid 
this difficulty is to inspeet the mar- 
e^ins of the fistula narrowly, giving 
tlie patient 20 c. c. of 4 per eent 
iudigo-carmin intramuscularly, if 
necessary, to make the orifice more 
evident, Then» at the time of the 
o|K*ration, when the orifice is seen 
caught in the edge of the fistula, a 
catheter is passed up into the ureter 
for a short distance and the ureteral 
orifice is slit up on the bladder sirlo 
for perhaps a quarter of an inch. 
This was re<^omtnended hy Bozetnan 
and has heen done uniuy Hnies since. 
Fistula Close to tuk Pkhi- 
KEiTAf, — When the fistnhi follows a 
vaginal hysterectomy, and the open- 
ing, usually a small one, is lii^h up 
near the peritoneum, it is often a 
good plan to open the peritoneal eav- 



>;° 



*fD-vag 



fstula 



Fkj. 535.— Urethho-vaginal and Recto- 
VAUiNAL Fistula at the Same Level. 
When the rectal opening is embcddixi in 
scar tissue, and where previous operations 
have iM'cn done, it is sometimes well not to 
follow the simpler plan of iscilation and 
suture, as ilescribcd in the text, but to 
split through the enlirr s**ptuni up to, 
through, aud above tlie listula. See Fig. 
536. (Mrs. M., Jan. 11, 1902.) 



ity deliberately and widely from 
side to side a8 the very first step, thus freeing the bladder, and to draw its 
peritoneal portion dowu into tho vagina. The fistula can now be easily closed 
and the bladder so adjusted, if need be, that part of its peritoneal covering 
forms a part of the upper vagina, while the perittmeal opening is partly closed 
and drained for 6 or 8 days. This Imhl uietliod enaldes one to deal successfully 
with nil of this troublesome class of fistuhe. 

Rui'TURE OF THE SvMPiivsis. — We havc seen ^ ea.nes where the symphysis 
pubis has been punctured accidentally, with the formati<in of an exteDsivo 




434 



VESICAL, URETERAL, AND URETHRAL FISTULA. 



Sphinetsf sni " 



^ r^Muia 



_||r«|Wr»*Vtti.fiitMW 



\ 



vesicovaginal fistula. In 2 of the casc^ which caime under our care for opera- 
tion, wo succeeded withont ditfieultj in restoring tho symphvsia by cuttitig 
down upon it, denuding the bone on the opposite sides and joining the bonea 

totrether with a stout silvi^ 
wire. Union was not iiitcrfored 
with by the fact that in both 
cases sloughing bits of bone had 
to be cleared away first In 
such a case it is be«t to clean 
out all the spicules of bone and 
to close up the vaginal fistxtla 
first before uniting the bonea. 
In one of these caaea the 
bladder was torn almost into 2 
parts, the right and left halves 
being joined only by a bridge of 
tissue and the vortex, the right 
urethra going with the right 
half of the bladder, and the left 
urethra remaining in tlie left 
portion. We succeeded here in 
closing the enormoua rent in 
what was really a veeieo-vagino- 
vulvar fistula in one operation. 
We then removed the necrotic 
bone and wired the symphygia. , 
Tri spite of the fact that 
wpfe Tinable to cover np thi 
eilges of the wires completely, \ 
perfect union was seen 
throughout the entire opei 
tion. 

ToKX PERlXEtT?^!.— If th 

is a complete tear of the pe 
neum, it is a lietter plan 
close this completely, immediately after closing the vesical fistula, as neither 
the injuries is likely to heal if the other h left to coufaminate the wound. 

Recto-Vaginal Fistula (Figs. 535 and 5;^6).— This is a rare c^mpli 
tion of vesico-vaginal fistula, which is often beat treated in a similar manner 



FlO. 536. — UreTHHO- VAGINAL AND HeCTO-VAGINAL 

Fistula. In order to close tlie reetfi-vaginal 
fistula shown in the last figure, the perineum and 
the recto-vaginal septum were cut throuj^h all 
the way to fistula, a& shown in this picture* This 
incision gives a splendid exposure of the urethro- 
vaginal fistula, which is closed in the usual way. 
The reeto-v^^5inal fistula is by this incision trans* 
formed into a complete tear, which was closed in 
a mamier suitable to that condition. 



splitting through the coats of tht* vagiiiii in its Inng axis, Jissecting the rectiitii 
completely free from the vagina, and tlien inverting it a little on itself into the 
hi men of the howel by 2 or 3 layers of continiions fine eatgiit sntiire. It is not 
necesaarv to close the vagina over the nvtal woiin*!. After this is done the 
vesical fistula nuiy then be attended to. Unless bf>th fistuliP are closed at the 
same operation* the one left open is apt to interfere with the union of the other. 
Pyeloneimthitis. — When there is a pyelonephritis, this should be treated 
by splitting up the ureteral orifice into the bladder so as to give free exit to the 
urine and get the orifice out of the region of the field of operation^ treating the 
kidney, for some time before closing the fistula, by irrigations with boric acid 
Bohition or weak nitrate of silver solution (N, Bozeman). It 13 not safe to 
close a fistula in the presence of an existing renal infection* 



URETERAL FISTULA. 

An Injury to a ureter in the course of an operation may end in a fistula, due 
to the severance of a part or the whole of the ureter in its continuity. Such 
nn injury may also arise during cliildljirth, the rupture of the ureter in this case 
being associated with a deep tear extending up the lateral fornix from the 
cerv^ix. Ureteral injuries commonly befall the pelvic parts of the ureter and, 
as a rule, are found somewhere in the neighb(^rhiX)(I of the right or left brofid 
ligament base. A surgical injury inflicted upon the ureter is due either to the 
cutting of till* ureter inadvertently or to tying it» when after 8 or 9 days the 
ureter sloughs tlirungh and the upper end Ix^gins to discharge urine from the 
damageiJ kidney. Another eonuuon form of sxirgical injury is the more or less 
extensive sloughing of the ureter due to baring it and detacliing it from its 
source of blood supply, with more or leas injury of the vessels cnnirsing down 
on its external coat. Such an injury as this more comnaonly follows the re- 
moval of a cancerous utema. 

If the abdomen and the vaginal vault are closed, the discharge may take 
place in the peritoneal cavity and the patient may die with the injury unrecog- 
nized. If there is a drain out through the alKlominal wall or into the vagina 
the urine seeks this point fur escape, forming a perrtumeril fistula there. 

There is established in this way a contracting channel in the tissues between 
the divided end of the ureter and the extermd orifice. A tendency of this 
cliannel is to continue to contract and close, until it bec^omes a mere pore, 
causing a hydro-ureter and dilated renal pelvis on that side, which often ends in 
an infection of the ureter and the kidney. 



I 



436 



VESICAL, URETERAL, AND tTRETHRAL FIHTITL.^. 



A rarer fomi of in jury to the ureter is tliiit in which it is puiicturod, or toriij, 
or cut open on one side. There may then he a free escape of urine from that 
side for one or two weeks, when the wound closes and the patient recovers. 

Almost all Hurgical m'eterai iiijnrieH are of an avoidable nature. The ex- 
perience and skill of the surgeon are demonstrated by greater care in tying off 
the uterine vessels with the certainty that the ureter ia in no way involved. 

Extremr care shoukl lx» used in re- 
niuviug a cancerous uterus to a%^oid 
injuring the vessels of the ureter; we 
uiiiHt also sedulously avoid any ex- 
teiiHive denudation of the ureter, 
\Vht»rever possible, the ureter must 
be \vft attached to the underlying 
tissues and simply rolled over to- 
ward the pelvic wall without free- 
ing it. 

Before operating, the surgeon 
wants to deterndne three thiugB: 

(1) Is the fistula really ureteral 
or is it a vesical fistula ? 

(2) On whit'h side is the fistula 



Fig. 5;i7, — SAcirrAL \ iew of Knd uf Ure- 
ter, Bladder and Vagina in Case op 

Double UuETERo-VAfiiNAL Fistula. The gitnated; that is to say, which ureter 

two ontices of the ureters are shomi near , , \ ]? 

each other. Both ureters were cut off in ^^ evolved . 

an operation for eatieer of the cer\ix and f*3) What is the condition of the 

debuyrhed into the vault of the vag:itia. nriuary tract above the fistula ? Is 

c represents the strip clL-nuded across the ^i i • i ,i * a 

I -I - - • ii I I I ttie kidnev wortii savings 

vagma; a b the incisioa opeiiuig ttie blad- •; ^ ^ 

der. Uniting the vaj^inal deoudatlon e to Likewise, what is the condition 

the int-iiiiou b, the fistube of the right and of the opposite, presumahly sound, 

left ureters were sueceasfully turned into i ' i o 

*i- 11 jj kidney { 
the bladder. ■■ 

(1) Is the Fistula ITretcral or Is 

It Vesical? — Tf a colored fluid (milk or anilin sohition) is injeeled into the blad- 
der, when the fistula is vesical, the fluid escaping through it will be oolorrni, too, 
Tf, however, the fluid from the bladder is colored » while that escaping from the 
fistula continues «'lejn% then the listula nuLst be ureteral. 

(2) On Which Side Is the Fistula?— When the opening is vaginal, it 
usually lies on the a fleeted eide, but not always. Ofteu the diffienlties of the 
ri]ieration wnll suggest the side, but this is uol suflieient. To make sure, the 
l>atient must Ix* put in the kuet^breast posture and the ureteral orifice inspected 
ami eatheterized. If the catheter passes freely up one side and enters but 3 to 





5 em, of the other, thig determinrs the affoeted siile. On watching the orifices 
the affected side appears dead, while the other, es|ieeially when the kidney haB 
been Btimulated by an effervescent saline water, spurts intermittently in a 
normal manner. 

One of us (Kelly) had a case recently in which the surgeon was sure, on 
account of the diHicultics of the 
operation, that the fistula lay upon 
the ri^ht side. The vugina! open- 
in^ was in the right vault, hot on 
eatheterizin^ the ureter, it was 
found that the fistula was on the 
left, 

(3) The Condition of Both 
Urines, — This is demonstrated hy 
getting urine from llie bladder to 
represent the sound aide, and at 
the same time collecting urine 
from the fistulous side in a bed- 
pan or by means of a muslirooin 
catheter placed in the vagina. It 
is safer to resist the temptation to 
catheter ize the affected side. After 
such an act of catheter izing the 
patient is apt to have a chill and 
fever. 

If the fistulous side is badly infected, and it is important on account of 
some defect in the other kidney to save the fistulous side, then one should freely 
dilate the opening up into the ureter and utilize it as a means of irrigating 
the kidney daily with a nitrate of silver solution (say 1 to 1,000), at the same 
time giving 20 to 30 gr. of hexanjethylenctetramin. 

Operation. — One of two forms of operation may he chosen: either anastomo- 
sis of the ureter into itself or into the bladder, or removal of the kidney. If 
there is a bad infection of the urinary tract and the opposite kidney is sound, 
it is a safer plan tt* do a nejihrecloniy than to try to save a seriously crippled 
organ, incurring the great risk involved by an operation imder sucli conditions. 

Urktero-Ukktkrai. Anastomosis. — When the ureter is cut and the injury 
is recognized at the operation, as, for example, in one case where it was mis- 
taken for a large vein (in the authors' experienc*e), tlie lK?st plan of treat- 
ment is to graft the upiKT end at once into the lower. This can be done in the 



Fio. 538,— Completion of Ofbhation Seen in 
Last FmraE, The small piece of the va- 
gina, containing the end of ureter, is turned 
into the bladder by uniting the transverse 
incision in the bladder with the posterior 
dt'iiudcii vaginal surface (c to b). The su- 
turtss at a are simply to stop the bleeding. 




iSS 



VESICAL, URETERAL, AND URETHRAL FISTULA. 



V 



following simple manner: The lower end is slit a little on its upper side^ the 
mucosa is trimmed off from the edges so as to increase the raw surface, and 
stretched a little to enlarge its caliber. Then a suture is made to transfix the 
divided upper end, both ends of which are passed thrnuti^h tlie eye of a blunt 
needle. The needle thus anncd is now carried dcjwn the lumen of the lower end 
and brought out through its wall from 1 to 5 mm, distant from the orifice. By 
means of this traction suture the upper end of the ureter is now pulled well 
down into the lower end^ and held in siiit while the e<lges of tie lower end are 

sutured cMrefnlly on all sides with very 
fine silk or chromic gut to the upper 
end; then the ureter may be further 
fijced in its plaeo in the pelvis by a few 
delicate sutures passed with a fine 
neetJIe. A drain is always introduced 
afterwards, cither up into the abdomen 
or down into the vagina. It must never 
rest directly upon the sutured ureter, 
ITretero-Vesical Anastomosis,— 
It is hard to find and utilize the lower 
end of the ureter some weeks after the 
original operation when it has been cut 
low down on the pelvic floon The best 
plan is to draw the iipper end down 
and anastomose it into the bladder at 
the nearest point; if possible, into one 
of the vesical cornua. When the ureter 
IS a little too short, the bhidder can be 
h^ngthened 2 or 3 cm. by freeing it 
laterally and pulling it up. This opera- 
tion ought, when possible, to be done 
extraperitoneal ly through an incision 
alMiut six inches in length in the semi- 
lunar line directly over the pelvis. Working out toward the iliac fc 
and then pushing the peritoneum inward and continuing with a bli 
dissection down to the fl<x»r of the pelvis, the upper ureter is finally 
reached and gently fretMl ilown to its extreme lower end, where it is 
detached from the iiiitulous tract. It is important in liberating it not to 
sacrifice any of the length of the ureter. Dissecting a little more, extraperi- 
toneally^ a blunt instrument such as a closed forceps is introduced into the 



0. 539, — UafiTEiio-VAGiNAL Fistula. 
L Catheter inserted in fistula. The 
dotted line shows the location of the 
ififision for disset'ting out the lower 
end of the ureter and implanting it into 
the bladder. (t5ee following figure.) 



URETERAL FISTIXA. 



439 



bladder ttroiigh the urethra, and used to push the bladder up and back; some- 
times it is wcdl to make a transverse Fiu]irapiibie opening into the blailder, when 
a pair of forceps is introduced and the blatbk'r pushi'<i forward to the ureter at 
the point lying nearest to it By cutting carefully through the coats of the 
bhidder, the mueosa can bc^ pushed out beyond the inu.scular walk, and then 
incised, while the ureter, which has been slit up a little to enlarge its lumen, is 
grasped and drawn well into the bladder. The first step is to fix the vesical 
mucosa to the wall of the ureter by fine catgut sutures. The muscular walls of 




Fio. 540. — Urbtbho-vaoinal Fistula. II. The lander figure shows an openinK in the 
bladder through which the free end of the catheter 1ms bocii conducted antl tlien 
brought out through tlic urethra, by racAus of the open-air 8[)e€uluin. The lower end 
of the ureter is (iiasected free for a Uttlo distance. It is then drawn into the bladder 
by means of traction sutures plaetxl as shown in the smaller drawing. It is well to 
add another stitch or two to hold the ureter securely in place, 

the bladder are then sutured to the w^alla of the ureter by fine iiiterrupted ^ilk 
Hutures on all aides. After this the bladder is drawn up under the uretor, which 
lies in it as in a bed, and attaelied by several suture?^ The downward pull of 
the bladder may bo relieved by suturing it also to the pelvic wall. The wound 
is then carefully closed with a drain. 

¥retero- Vaginal Fistula, — A vaginal ureteral fistula may be turned into the 
bladder by lueaus of an operation devised by Maekenrodt, that is called en- 




440 



VESICAL, URETERAL, AND URETHRAL FISTUL.^. 



trnpionizing. A small opening ia mado into tlic blndder dose to tlic fishila, 
an incision is then made through the thickness of the viigiiial wail around the 
fistulous oiK?niiig, forming a colIarettCj which is freed enough to turn it into 
the adjacent bladder opening and held there by sutnres. 

In a case where there were two uretero-vaginal ti^stiila? at the vaginal vault, 
(Figs. 5^i7 and 538), one of us (Kelly) guceeeded in turning both into the 
bladder bj cutting into the bladder transversely across the vagina in its upper 



Fig, 54L — Uretero-vaginal Fistula. III. P'lQalstcp of the operation shown in the pre^ 
ecKling fij^urcM. Cldsure of the vaginal wall iivcr the frcetl ureter by iiitcmjpted sutures. 
The ureteral catht-'tyr may be left in place with advant-age for two or three days. 



portion, then connecting the ends of the incision by denuding a strip across 
the vagina posteriorly behind tho fistuke. Upon uniting tlie cut bladder wall 
t(* tho posterior vaginal wound^ both fistulie were turued into the bladder 
without touching theni^ niakiug a stirt of a colp<x;leisis of a liniited portion 
of the bladder. 

The entire procedure of finding, locating^ and treating a fistuhi of this kind 
is illustrated in Figures ri:j*J-54L 

If the ureter cani»ot be di83f*eted outj it umy be connected with an opening 
in the bladder as 8ho\\m in Figure 542. In all tlie.se casci^ where there is any 
infectioUj or where tlie excretion of urea is low, it is best not to waste time doing 




URETHRAL FISTULA, 



441 



URETHRAL FISTULA. 



) 



\ 



if/iaatomoais openitioiis, but to remove tlie kidiiey at once^ provided the other 
jtidney is normal or nearly bo. 

H "WTien the urethra opens into the vagina the fistula may be either simple or 
— aplieated. A simple fistula, lookinfr more or less liko a punched-out hole, is 
isily closed by putting a nie<liiini sized soft nib- 
?T catheter through the urethra into the bladder, 
^:rid with this as a guide freshening np the fiatnla*s 
^clgps and eloping it. The entheter prevents any 
^^ndency to constrict the urethral caliber. 

If there is plenty of tissue and the sides are 
easily brought together, a direct peripheral dc- 
iiiuintion may be made and the ti.ssne drawn to- 
^t'ther from side to side or, often better, in a fore 
Bmiid aft direction, leaving a line of union trans- 
verse to the axis of the vagina. If the neck of the 
bladder seems to be involved, great care must be 
t^ken to close with flaps from the vaginal mucosa 
and to sacrifice no tissue. 

Where there is complete loss of tissue across 
tkB urctlira, restoratiuu can be aecianplislied by 
splitting the edges of the npjier iiiid lower por- 

Kions; and tlien uniting them by sliding them to- 
other and suturing end to end. A semi-circle 
f Interrupted fine chromic catgut suture will do 
tlie work, if wounded surface is brought carefully 
tto wounded surface. X'^se a staphylorrlu^phy 
lueedle so as not to insult the ti^^snes, and pass 
mtermpted sutures not more than 5 mm. apart; 
ften a continuous suture is preferable. It is not 
ilways necessary in such a case to pass a catheter. 
be patient may get up and voitl ami, after a 
rief rest of a day or so, may go about her busi- 
avoiding, of course, any local insults. Tf 
Eire is tension at the wound, tending to pull the coapted surfaces tipnrt., it 
can be somewhat relieved by multiple small incisions in the vaginal tissues to 



Fio. 542.— Another Method 
OF Trratino Uretero- 
VAGiNAL Fistula. Whore 
not enough ureter can be 
freed to implaut it into 
bladder, a wide circular 
opening is made in the 
hla<ider, as shown at B. 
An oval-shaped denuda- 
tion of the vaginal wall is 
then made, to in elude l>oth 
the ureteral orifir*^ and the 
new op<Hiing into the blad- 
der. A little strip of va- 
ginal mucous membrane, 
shown between Ur and B, 
is left intact, and forms the 
lower end of tlie new ure- 
teral canaL A renal cath- 
eter, inserted into and 
limught out tlirougli the 
ojK*ning in the blaiider, is 
carried up through the ure- 
ter, as shown in the previ- 
ous figurtis. The sutures, 
placed as shoviTi, are tied. 




442 VESICAL, URETERAL, AND URETHRAL FISTULJB. 

either side of the line of sutures, the principle so frequently employed after 
removing the breast for cancer. 

More extensive injuries of the urethra are of two sorts : splitting of the pos- 
terior wall — it may be in its whole extent ; total or almost total destruction. 

Every operation should aim to use to the utmost all the urethra which can 
be found. When the canal is merely split in its length, a good raw surface is 
secured on both sides by splitting the margins, which are then united, as we 
prefer, with fine chromic catgut suture, either interrupted or continuous. 

Any extensive destruction of the urethra is a serious matter. If it is gone 
in its entirety, and the neck of the bladder, also, there is no way of operating 
by which any uniformity in success can be expected. One of us (Kelly) suc- 
ceeded in one case by tunneling through the tissues under the symphysis, loosen- 
ing up a tongue of vaginal mucosa with its base at the hole in the bladder, and 
then, by inverting the flap, pulling it through the tunnel, and fixing it there. 
Little fistulas at the sides were closed; the canal, thus lined with mucosa, re- 
mained open, and, with a pessary, which was reinforced on its anterior bar so 
as to make a little pressure on the new urethra, permitted the patient to regain 
suflScient- control to hold urine for several hours. 

By utilizing the anterior vaginal wall, and the labia minora, a long, new 
spout-like urethra can be formed, terminating at the clitoris, but for the most 
part such urethras have but cosmetic value, and the leak goes on just as before. 
Many similar attempts have been made to relieve this difficulty, but they are 
without exception, we think, more curious and clever than helpful to the patient. 

We have succeeded in 2 other cases in restoring the urethra and urinary 
continence by taking flaps from the side of the vagina, denuding with ex- 
treme and minute care in the neighborhood of the nock of the bladder, and 
tlien sewing together the tissues from side to side* with extreme delicacy so 
as to reconstruct th(* urethra and to use at the same time any possible remains 
of the sphincter muscle which mifi:ht have Ix'en left behind, though it could not 
be seen. There is a hope of doing this when there is a little mucous furrow un- 
der the symphysis, which shows that, although the urethra have been injured 
extensively, the wall still persists. 

It should be kept in mind that the entire urethra external to the sphincter 
can be destroyed without any discomfort to the patient, and with perfect vesical 
control ; and, while sphincterless urethra? with good mechanical appliances can 
give comparative comfort, they do not conij)are with s])hincter restorations in 
functional results. Where it is possible to restore^ spliinc^ter union, the external 
canal may be neglected. Occasionally marked improvement of the sphincter 
after operation will follow electrical treatment. 



CHAPTER XXXIV. 
CYSTITIS. 

Cystitis is the common name for a variety of inflammatory diseases of the 
bladder, in their superficial forms aifecting the mucosa and the submucosa, and 
in more advanced stages invading the muscular coats, also. A cystitis may be 
localized in a particular area in the bladder, or it may be more or less general- 
ized, and in the most advanced cases may even involve the entire organ ; in the 
majority of instances it is patchy and restricted. 

ETIOLOGY. 

There must be at least two factors concerned in the causation of a cystitis : 
one, the infecting organisms ; the other, a trauma or a condition of lowered 
resistance which aifords them a nidus for development. Neither of these fac- 
tors alone is sufficient to set up an inflammation. It has been repeatedly and 
abundantly shown by experiment that the mere introduction of micro-organisms 
\rill not cause inflammation or even a passing reaction ; large quantities of bac- 
teria have been injected into the bladder by the urethra, but they have invari- 
ably been washed out again with the next act of urination without detriment to 
the organ. Again, it is a matter of daily note that in infections of the kidney 
enormous quantities of micro-organisms may be discharged down the ureter and 
lie in the bladder until they are passed out by the urethra without damaging 
the bladder at all. When an infection does take place in this way, it would 
aeem to occur oftenest by irritation of the area nearest the ureteral orifices by 
toxins, thus establishing a locus minoris resisteniice , which is then followed by 
the invasion of the bacteria. Furthermore, a traumatism, as at childbirth, or 
the lesions made by surgical instruments, will never alone evoke a cystitis. How- 
ever, if traumatism is repeated, sooner or later the micro-organisms from the 
neighboring bowel, or perhaps from the circulation, find a nidus, and an infec- 
tion is started which may continue indefinitely. 

Conditions predisposing to the localization of an infection in the bladder 
are : exposure to cold, exhaustion, irritating substances taken by the mouth, pro- 

443 



444 CYSTITIS. 

longed retention of the urine, as from stricture or the pressure of a tumor, the 
attrition of a calculus, tumor of the bladder with the accompanying strangurv 
and hyperdistention, inflammatory conditions in the cervix uteri or in the Fal- 
lopian tubes, or an inflamed and adherent bowel. It used to be common to 
see a cystitis spring up during convalescence after an abdominal hysterectomy 
for fibroid tumors. We once examinea one of these cases and found that the 
whole posterior surface of the bladder was thrown into ridges infiltrated with 
blood, due to the method of detaching the bladder from the cervix by rubbing 
it off with a piece of gauze. All that was then needed to produce a trouble- 
some inflammation was two or three catheterizations ! We now avoid touching 
the bladder at all and almost try not to see it 

The infecting organisms may enter the bladder from the kidney above- 
as in a descending tuberculosis, or in a typhoid case where the organisms are 
filtered out through the kidneys and lodge in the bladder — or the entrance may 
be effected through the blood. The latter method of entry is rare, seen perhaps 
in some cases of acute cystitis springing up in the course of infectious diseases 
and difficult to demonstrate. Again, the entrance is through the contiguous tis- 
sues from an infected ovarian or a dermoid cyst, or from an adherent bowel 
which perforates the bladder and pours in its irritating secretions, setting up a 
violent inflammation. Lastly, the urethra is the great portal of entry for all 
gonorrheal infections of the bladder, as well as for those lamentable cases which 
date from the introduction of a contaminated catheter. It is important in every 
record kept by specialists to state, when possible, the character of the invadimr 
organism or organisms. We do not mean to say that it is a sine qua non, for it 
cannot always be done, as a negative report often comes back from a first-class 
laboratory. We are further hindered by the fact that anaerobic organisms are 
sometimes present which are not readily recognized. The discovery of the germ 
does not necessarily influence treatment largely at the outset, especially in the 
hands of the general practitioner, but if the case defies his efforts to give n'lief, 
then it docs make a great difference if the germ can be named and followed up 
in the further management of the case. 

Those who have followed the history and the literature of cystitis for the 
past twenty-five years must have been appalled by the multiplying strange 
names of new biirteria cropping up, especially in French and Danish clinics, 
and more appalled still by the great diversity of opinion among the specialists 
exploiting this new field with such sportsmanlike zeal. It is satisfactory at least 
to be able to say that most of those weird organisms have taken off their masks 
and provc^n to b(^ various forms of our old enemy the colon bacillus, for with ihi:^ 
sinij)lifieation of classificati(m the difficulties have largely vanished. 



The organisms commonly found are the tiihercle bacillus, the gonococcus, 
the colon bncilhis, the typhoid bacillus, tlic staphylococcus, the streptococcuSj 
and the bacillus pyocyaneus. 

Jlixed infci'tinns are often grafted onto the tuhercdc haeillus, both in tlie 
kidnej^ and in tiie Idadder, giving rit^e to the most distressing forms of cystitis. 
Streptococci and staphylococci are apt to give way to a colon bacillus infection^ 
which is the commonest of all. 

One rule may be laid down in all cases for the guidance of the general 
practitioner: If an infection of the bladder does not clear uj) promptly, then 
the character of the organisms ought to be determined. This is, of course, a 
necessity, if vaccines are ti Ix^ used in the treatment. 

When a patient suffers from an acid cystitis with only a little fever and a 
little pus in the urine, the infection is apt to be tuberculous and the primary 
focus is in the kidney. Alkaline, animoniacal cystitis is only seen in women 
when there is a sloughing mucosa or a sloughing bladder tumor; it is far com- 
moner in men, and was probably much oftener seen by men of Gross's, Agnew's, 
and Ashhurst's generation than it is to-day. 

PATHOLOGY. 

Both the gross and microscopic anatomy of inflamed bladders vary im- 
mensely %vith the kind of infection, its stage, aiul its location, as well as with 
various coincident faett*rs such as retention and imperfcH^t trophic conditions. 

In acute cystitis there is comparatively little autopsy or surgical material 
at hand, with the result that studies have been infrequent. Motz and Denis 
(Ann, d. muL d, org, gemio-urin,, 1903, xxi, 898) have contributed some val- 
uable observations from a study of 14 specimens. They have noted the gross 
appearances of the mucosa so familiar to every cystoscopist ; that is, the uni- 
versal reddening, the dilated, arboreal-branching blood vessels, tho thickening, 
the ecchyraoses, and erosions. They further note that in acute cyatitia there is 
practically never involvement of the muscle and perivesical tissues. The lesions 
start in the epithelium, extend into the underlying mucosa, and then into the 
submucosa. In the beginning there is the dilatation of the Idooil vessels and 
infiltration with pdymorphonurlcar and plasma cells (Fig. 543). A little 
later a marked proliferation of the blood vessels occurs and often focal accumu- 
lations of leukocytes, making little abscesses. The mucosa is practically never 
adherent to the snbmucosa. Healing takes place first in the superficial layer, 
with the disappearance of indamniatorv products as well as of new-fc»rmed ves- 
sels. Contrary to the general description tJiere is little loss of epithelium. This 



I 





Fig, 543.^ — Section through Pakt op Bladder Wall, Shov, 

Cystitis. Th<* large spaces in the epithelial layer are fiOe<J , . lOi 

leukoc3't4?8. The uiiclerlying tissue shows a lesser despr^ of infiitraiion with teiiM 
The blowl-ves8i^ls arc greatly dilated. This is an early and mild stage of acute ( 
X 220 diameter, (Gyn. Sendee, J, H. H., Gyn, Path. No. 3849.) 

articles of Stoerk and Zuek<n*kaiidl (Ztsehn f. Urol, 1907, i, 3) and Hal 
Motz {Ann* d. mal. d. org, geniio-urifh, 1902, xx, 19, 129), 

WHiere retentions ot^eur, such as are typically present in enlargv^d pi 
and ill lack of trophic contrnl, a^ in taWs, the U adder is distentled^ then 
niarketl trabcculic, and ^rcat thickening of the muscular coats, in addil 
the changes incident to the chronic inilammatury process^ 





Fig, 544.— Schkmatic Representation of Down-dipping of Epithelium Simulatinq 
CJland Structure. (From Stoerk and ZuckerkaiKlL) 

nlcers» FrtH^ucntly piitebes of leukoplakia are ?€»eu. This latter condition is 
espcK'ially eomraon in patients of reduced general health. There is als*) the 
formation of cysts, the so-called cystitis cystica, a condition first described by 
A. S. fHnel (Arch, f, mikr, Anat., 181)0, xxxv, 389). 

The microscopic appearances are niont interesting. The iiirface epithelium 
is nearly always absent in part. The blood vessels of the mucosa and the sub- 
mueosa are dilated. There is a ijreat extravasation of imlyniorphonnclear leu- 
kocytes and hyj>ertrophy of plasma cells. This inflammatory tissue extends 
through the mui^cle coats and into the pe^ri vesical tissues. In very advanced 
caaes the muscle is largely replaced by fibrous tissue, and the i>erivesieal tissue 





Fio» 545. — Extensive Pbeudo-gland Foematiok !n a Case of Chbokic CVRfl^ 
Cystica. (From Stocrk and Zuckerkandl.) 

down into the submiicoaa, how it breaks in the center and forms cysta (FJ^ 
544), Hiifl how ill 8411110 cases rypicai glaTuls are fonned (Fig. 545), in ^^t^f 
way resembling the gkuds of the intestinal tract. These glands may Ije mul 
tiple branching afifairs. They are frequently the site of the development o/ 
carcinoma^ and afford a rational explanation for the adeno-carcinoma of ti« 



SYMPTOMS. 



449 



idder. The cysts to which they give rise vary In size from a pin-point to 
ctures as large as a pea, In the female alone the breaking down of these 



1 1 1> t <>r€tKr^ on ft c e 



'^« 



k 



Fig. 346,— Extensive Calc^areous Deposits in FiLADDEK ix Case of Chronic Cybtitis. 
Tlicileposit isinthefomiofaringaboutl cm. in width and extending all the way around 
tHe bladder as shown. Smaller deposits lie behind tlie ureteral orifices. The base of the 
bladder, as well as the doni?, is frc*e from all deposit. The small drawing above shows 
m epeculum view of the miernal urethral orifiee in the knee-chest posture. The cres- 
cesi below includes part of the calcareous ring; above is seen the normal bladder. 
CMre. G., June 16, 1906.) 



sts 18 frequently followed by uleeration and the deposition of caleium salts, 
living rise to the so-called incrustation or stalagmite bladder (Figs. 546 and 

SYMPTOMS. 

The characteristic symptoms of a cystitis are pain and dysuria; added to 
hege there is a desire to urinate frequently, with more or less local tenderness^ 
and a sense of pressure or bearing dtnvn in the lower abdomen. One occasion- 

Illy sees cases where the frequent urination (pollakinrin) is absent and the 
atient urinates with only average frequeney but suffers in the act. The 



450 



CYSTITIS. 



urinary distress is marked in the bc^iiuiing, but there is only a slightly inci^aied 
frequency, which gradually grows wor^u until, in the course of a few raoutb.the 
case may become one of incessant strangury. Again, the ayniptoma may npr^ 
sent the subsidence of an acute attack which lapses into a chronic one, with bi- 

cned^ hut still marked frequency The 
stress of the pain falls often in the night, 
when the poor sufferer becomes worn ml 
with her vigils and the necessity of jH^cttinij 
up to urinate. The worn, emaciated facipa 
uf the bad chronic cystitis patient is ch»r 
actcristic. We have known some who aim* 
ply spent most of their time siuing on a 
fhair with a hole in the seat over a pt. 
Again, a constant spasmodic condition ivf 
the bladder causes a dribbling indigtinsniishahle at first from the simpler fomu 
of incontinence. There is always some pus in the urine, so small in amount at 
first that it may be found only after collecting a considerable quantity forer 
amination. With the continuance of the disease the pus increases, until the 
urine is murky and throws down a heavy sediment of pus, mucus, and epithelinl 
debris. 



Fig. 547, — C^alcakeous Deposits os 
Bi..\DDER Wall. Two cystoscopic 
views of contiguous portions of 
bladder. (H., Feb. 24, 1900.) 



DUGNOSIS, 



I 



The diagnosis of a cystitis is conuiionly made when a patient sufferini; fmin 
frequent and painful urination is found to pass urine containing pus, hut. ihii 
is nut sufficient. The diagnosis reaches complete certainty when the iiwpec^ 
tion of the inferior of the bladder reveals the inflamed condition to the cycv 
A symptomatic diagnosis can only infnrm us in a gc^neric way that tie patient 
has a cystitis^ but it tells us nothing specific as to the extent or the grade of the 
disease. If the urine is loaded with pus, we infer that the disease is extcnaiTe^ 
but this inference ia not so certain, as the pus may come down from a UJ 
kidney. 

The method of direct examination consists in inspection and palpation; by 
palpation we recognize vesical tenderness and» in advanced c^ses, an infiltration 
of the bladder walls. Palpation is l>est made bimanually with a finger in tie 
vagina and a hand on the lower abdomen; or, in a man, with the finger in the 
rectum. The bladder .shutitd be examined when empty and again when iin»J- 
erately full. Particular attention must also be paid to any perivesicat foci of 




iuflainniatlon, nml above all to the condi- 
tion of the ureters in their terniiiial por- 
tions. Any cord-like thickening here 
should at once arouse suspicion as to the 
integrity of the kidney above it. 

The capacity of the bladder ought to be 
measnred in every case. This determines 
not 80 much the degree of erjntraction as 
the question of its intuleranec, A normal 
blad<]er ought to hold 300 to 500 c. c. A 
really contracted, non-distondable bladder 
is rarely seen in women. 

Only by cystoscopy can we determine 
and chart out the exact site of the lesiona* 
their extent, and the degree of intlannna- 
tion present (Fig- 548). The urine must 
be examined for pus, bhidder epithelium, 
crystals of salts, bacteria, and albuniin. 
In cystitis the albumin usually forms a 
small, delicate ring with the nitric acid 
test. If there is a well-detined ring, a kid- 
ncy is probably involved and ought to be 
investigated (T* R Brown). We wish to 
emphasize for the generai practitioner the 
extreme importance of a direct inspection 
of the bladder in all cases of cystitis which 
do not clear up promptly after a brief 
period of treatment; this is the more ur- 
gent because all eases of cystitis are readily 
controllable in their earlier stages. It is 
also the habit of not a few physicians, we 
fear, to lalxd a case cystitis simply because 
the patient complains that she has to 
urinate frequently (pollakiuriaV If, on 
top of this diagnosis, there follows a 
regimen of catheterizations and irriga- 
tions, a harmless affei'tion, without any 
underlying basis of inflammation^ may be 
even of a severe grade. 



Fig, 54S.^Inspecting and Plottino 

Out a Focus of Dl^^t:ASE in Blad- 
der WITH Open-air Cystoscope. 
The cystosco|)e is introduced so 
that it ahuost touches the part of 
the bladder wall under inspection. 
By moving the s|)ecuhmi across the 
field a series of views is secured 
which, taken together, covers mul 
nicaiiures accurately the lioHirt'd 
area. In the ijpf>or fi|;^rc an irre^- 
ular pati'h of uleeratiun under in- 
spef'tinii lias tlius been plotted out 
and recoQiitruet^xl on paper liy jot- 
ting down l\w individual views, as 
shown. By this means not only the 
outline, but the sise can be accu- 
rately determined and recordeti* 

eon verted into an actual infection 




452 CYSTITIS. 

The Examination by Cystoscope. — This may be made with or without anes- 
thesia. Where the urethra is more or less dilated from repeated catheteriza- 
tions, when the patient is self-controlled and tolerates an examination well, it 
may be made with entire satisfaction without any anesthetic, that is to say, in 
nine cases out of ten. A bad cystitis, howevei;, with extreme sensitiveness and 
much strangury, is best investigated under profound anesthesia; at any rate 
the first searching examination is best made in that way. We prefer to use 
the open-air cystoscope, as the bladder, even under the deepest anesthesia, 
may be utterly intolerant of any forced distention. After the patient is com- 
pletely anesthetized, she is placed in the knee-breast posture and held there by 
an assistant sitting on each side with an arm thrown over the back and around 
the waist, and one hand gripping the knee in the popliteal space, in this manner 
holding the thighs vertical. The back must bo well curved in, the head low, 
and the face turned to one side. The examiner now lets air into the vagina to 
drop the base of the bladder to the plane of vision ; he next cleanses the external 
urethral orifice and introduces the conical calibrator, and, giving it a slightly 
boring motion, uses it to enlarge the external urethral orifice up to 10 mm. 
in diameter. The Ifo. 10 cystoscope is then introduced, and the obturator 
withdrawn; the air at once rushes into the bladder and distends it. This 
degree of dilatation is a good preliminary to any subsequent treatment. In 
some cases it may even bo well to dilate up to 12 mm. in diameter. The 
examiner now reflects the electric light held just over the sacrum and proceeds 
to inspect the walls of the bladder in an orderly manner. If the little urine 
left in the bladder interferes with the view, it is readily sucked out with the 
evacuator. The first observation taken relates to the degree of expansion of 
the bladder. In an average case the posterior wall drops away from the an- 
terior until it is distant about 0-7 cm. from the internal urethral orifice, easily 
measured on the speculum. When there is much inflammation, with an intol- 
erant bladder, thc^ distance may not Ixj over 2 em. The first point examined is 
naturally the area first visible, the posterior wall. An inflammation here is 
apt to extend to the right and to the left and out onto the base. The inflamma- 
tion seems to lodge by predilection along the fold stretching from the right to 
the left cornu. 

The middle or sagittal line of the bladder is an equator easily known and 
affords the most convenient point of description for lesions located on it or to 
the right or the left. The end of a speculum of known size can be applied to 
the lesions, and exact measuroinents made of thcMr extent and irregularities 
(see Fig. 548). After descril)ing any lesions on the posterior wall, the exam- 
iner then turns naturally to the right and the left lateral walls, and next to 




the vertex of tlie bliulder. Tlini, 
dropping the handle of the cystoseopcj 
he looks lip to the base of tlie bladd^'r 
with its trigonum and the ureteral 
orifircs luid the area about the in- 
ternal oriHee of tlie urethra. This 
region needs espeeially eareful ex- 
aniiiiation, particularly in determin- 
iug the exaet lo<'atinn of any ureai* 
near to the urethral oriiices. An ab- 
normal ureteral orifice is more red- 
dened than usual, anc] may Ite di- 
lated, the sito of ulceration, or de- 
pressed in a poeket, and always needs 

further careful study, for it is the ^^^'' 549.— Ulcers on Trigonum. Note re- 
lations to ureteral ori ticca and urethra. 



(From John Ncff.) 



sign manual of disease higher up. 

Alter completing the examination of 

the base and of the trigonum, the speculum is then elevated to an extreme posi* 

tion and the retrosymphyseal area is exaiuineth In our experience inllanuna- 

iiu-y lesions are not so often 
found here. 

The lesions of cystitis 
tlnis fiumd are not often 
univer.sah as we used to 
inuigine them a long gen- 
eration ago, bc»fore the day 
of <'ystoseopie examina- 
tions. The picture of cys- 
titis then iu the mind of 
the i+nrgt^m was one of a 
uniform reddening of the 
whole of tlje lining of the 
bladder. Nowadays, even 
when one tloes find such an 
extt'U.Hive reddening of the^ 
mucosa, ihero is also some 
intense localized focus or 

ulcer, wliich is the original S4»at of the disease (Figs, 5 H> and 550). 

In general the characteristic lesions of the cystitis are a reddening of the 



m 



Fig* 550. — Calcvreocs Deposits SrRRoi7Ni>ED by 
Markjcd Injection of Bi^dder. Immediately in 
front of the largest patch is a veaico-vagin&l fistula. 
(Miss M,, Feb. 28. 1900.) 



I 





464 



CYSTITIS. 



inucosa^ a disappearaiire of the finer vessels and then of the larger vesads^ botb 
seen so conspiniuiisly in th«> nornml bladder tiividiiig it up like a landiHiiape 
well watered with streams. When the vessels disappear they leave behind orijj 
an irritatc'd, aii|n\y, reddened surface. Ilere and there may he spots of iilci^rs^ 
tion with acciMtiulnted ]uis aJid little heniorrhii^ic areas. The disease is mom 

or less patchy in extewl; tlw> 
patches lire irregular, nmni 
ed, and erc*natef and moh' or 
less euurtiient. Again, the 
infection is petechial, and 
there are little iilcfTaled 
spots, centers of an iiitcn^. 
infljuiiniatorv zone, likt- m 
many little volcanoes beH- 
ing (»ut fire. 

When the ulcerated aaa 
heals, it contracts aa<i as- 
sumes a linear or Unear 
radiating form (Fig. iuA)] 
and ill time the line ui \h 
old ulcer stands out a sharp 
falcifoTOi ridge* dividiiii: the 
hi udder into conspiououa 
deep locnli, seriously inter 
fering with its expansion. 
Fleernhons along thm 
sickle-shaped ridges are peculiarly slow in liealing and sometime® give riic to 
most trouljlcsoiiie hlecding. When they heal tiiey look so avascular tbt it 
is a temptation to cut tliem on sight 

Catheterization. — ^The important query f>ften arises whether it is navisjiit 
to eatheterize one or Wh ureters in tlie |>resenee of a cystitis. We have catk- 
terized literally thousands of times under snrh conditions and have never yet 
seen any regrettable accident. We do not, however, mean that the catheter b 
to be passed nj> in any case withont nnnsnal precautions. 

First of all, if one ureter is manifestly diseased, we eatheterize that hj 
preference. If it is necessary to catheterize a sound ureter, clean out the luowni 
of the speculum with a silver nitrate solntifm (2 per cent.), and apply the 
solution around the orifice of the ureter before slipping iu the catheter, ^^v 
do not leave the catheter in any longer than necessary. 



FiG, 5.5 L— Linear Healing Ulcer on Posterior 
Bladder Wall, as Seen through Cvstoscope, 
Tfie surface of ulcer is yellowish white; surrounding 
this is iin intensely red zone about 3 mm. wide. 
Beyond this zone are large injeclcd blood vessels, all 
apparently radiating from the ulcer. The positions 
of tlie uretenil orifices are sho\^ii by the crosses 
aboA'e. The smaller drawing to the right shows two 
small round uleei-s in the SiUnc bladder, (From P. 
Unrrh, Jim, 19, 1897/) 



DIAGNOSIS. 

A satisfactory analysis of urine from the iincathotorizfd ride can bo made 
from urine collected from a ciitheter inserted into the bladder. The delay in 
the bladder is so short that the contamination is minimal. 

Differential Diagnosia. — A ilitTerentiaJ diagnosis must be made between cya- 
titis and an irritable bladder or a 
hyperemia of tlie tri^onmn. In an 
**irritable bladder" there is no in- 
flammation and there is no pus in the 
urine, and iiu inilainnuittirv area is 
seen. In hvperemin the tri«j^onnm id 
mure or less extensively reddened and 
painful to touch, and the patient 
passes water frequeDtly, but either 
no pus is found or, at most, a few 
leukocytes are discuvered in a -'t- 
hours' sj)rcinien. Such cases bear nn 
relationship whatever to true cystitis 
until they are maltreated; if^ how- 
ever, they are subjected to active lo- 
cal treatment an obstinate, severe 
cystitis nuiy be grafted onto the 
milder malady. A baeteriuna is 
distinpiishcd from cystitis by the ah- 
sence nf local lesions. We must also 
distiTiiinisli cystitis from a p4'inaki- 
uria due to pregrnancy or the pressure 
of a tuuior on tlie bladder. Ajerain, 
the absence of changes in the urine and local changes in the bladder are the 
dia^rnostic marks. 

We call attention to these obvious matters because some of our muIti-speciiJ- 
ist pbyHieiaus are inclined to overlook the microscopic examination of the urine 
and the demonstration of pus as essential in the diagnosis. 

In making a diagnosis of cystitis it is always best to try to distinguish at 
once between those which may be calk*d inllaniination pure and simple and 
those which are dependent upon some c»bvionsly provoi^ativo factor, such as a 
stone, a tumor, or a pmria from the kidney* or a fistula from a neighboring 
organ. 

There is also a dcr^quamative affection, marked by the presence of many 
minute clumps of epilhelinm floating in the urine^ which may persist long 




■ 



Fig* 552.--ENoRMOtm Hyperthopht wrrn 
Edema of Anterior Vaoinal Wall Suiu- 
LATiNo Cystocele. This rondition is 
due to a cystitis. (Miss F,, Nov, 27, 1895.) 




456 CYSTITIS. 

after the inflammation and the organisms have disappeared; here, too, the 
microscope and inspection allay all doubt. 

In order to distinguish the organism which is the underlying cause of the 
persistence of the inflanmiation, one must, first of all, recall the fact that a 
persistent acid pyuria, with a rather small quantity of pus and some little 
fever, is apt to be a tuberculous affection. 

The organisms should be taken for cultural purposes either by a sterile 
catheter, after cleansing the urethral orifice, or directly from the bladder 
through a cystoscope. 

An interesting change sometimes observed with a cystitis is shown in 
Figure 552. Such an appearance on ordinary vaginal inspection suggests a 
simple cystocele or a urethrocele, but on passing a catheter the tissues are 
found edematous and hypertrophied. 



TREATMENT. 
GENERAL PRINCIPLES. 

It is important in treating cystitis to distinguish in the first place between 
the acute and the chronic forms and to isolate, when possible, the bacteria caus- 
ing inflammation. One ought, in every case, to start out with a well defined 
progressive plan of treatment. It is a common and grave error to adopt some 
one course and to stick to that for months or even for years, irrespective of the 
results. We have in mind here more particularly those physicians who use 
irrigations of the bladder to the exclusion of all other methods. In a puzzling 
case it may be stated as an important principle to proceed tentatively from 
the milder to the more drastic measures. 

Combinations of several methods are often necessary, as, for example, sim- 
ple hygiene and medication by mouth, combined with local treatments. An- 
other valuable dictum is that a large percentage of cystitides owe their origin 
and their maintenance to an infected kidney, and the bladder cannot be cured 
until the diseased organ above is cured. 

In all forms of treatment, as far as possible, the patient should be spared 
unnecessary suffering ; any line of treatment which is excessively painful must, 
as a rule, bo abandoned for something less drastic and distressing. As a rule, 
more harm than good is done by very painful treatments. The length of time 
necessary to cflFeet a cure depends entirely upon the cause and the extent of the 
disease. A patient with a calculous cystitis is relieved of her suffering and 



TREATMENT. 457 

quickly cured by the simple removal of the stone. Chronic cases which have 
already been under treatment for years may require several months or longer 
to secure relief. In some of our earlier chronic cases we even spent several 
years in eradicating the disease; we did not then always know what were the 
best stops to take at first, nor did we always know so well when it was wisest 
to abandon one form of treatment and to adopt another more radical one. 

ACUTE CYSTITIS. 

In acute cystitis we are more limited in our methods of attack than in the 
chronic forms. Here, however, simpler measures are effective, and with proper 
treatment the affection tends to run a self-limited course. The methods of 
treatment employed may bo grouped as: 

Sedative 
Medicinal - 
Hygienic 
Irrigations 
Instillations 

Drainage (as a last resort; by the vagina in women — supra- 
pubically in men). 

The patient ought to go to bed and stay there until the acute part of the 
attack is over. Small doses of morphia may be necessary to relieve pain. 
Abundance of water, preferably one of the alkaline waters, should be given, 
as it has a distinct sedative effect. Copaiba capsules should be given in gonor- 
rheal cases. Urotropin (hexamethylenetetramin, U. S. P., cheaper) is particu- 
larly valuable in colon bacillus and typhoid infections, not infrequently serving 
to cut the disease short. If the bladder is not too tender, it should be irrigated 
once or twice a day with a warm boric acid solution, distending it as much as 
the patient can stand without marked discomfort. At the end of the irriga- 
tion a teaspoonful of 50 per cent solution of arg\Tol may bo thrown into the 
bladder and left there (instillation). Protargol is valuable when used in in- 
stillation, of a strength varying from 1 to 10 per cent., or stronger, accord- 
ing to the tolerance. If the trouble inclines to linger aft^r using these ordi- 
nary measures, a vaccine may be made by culture from the organism and in- 
jected. If the case tends to run a more protracted course, it will be well to 
put the patient under a gas anesthetic, to examine thoroughly with the cysto- 
scope, and then to drain the bladder for several weeks by making a vaginal 
incision. 



468 CYSTITIS. 



THE TREATMENT OP CYSTITIS BASED ON THE FORM OP THE INFECTION 

A point often of value is the treatment of the cystitis from the standpoir 
of the character of the infecting organism, by using some bactericidal agei 
known to be inimical to the particular form of infection. The general pract 
tioner, living at a convenient distance, may take a fresh catheterized spocimc. 
of the urine to a pathologist to examine. A doctor living in the country wS 
do best to boil a bottle and its cork and then, after washing the urethral orifir- 
to draw the urine directly into the bottle through a sterile catheter, to cork 
and send it off to the nearest competent pathologist. 

The organisms which it is valuable to know in this connection are these: 

Tubercle bacillus 

Gronococcus 

Colon bacillus 

Typhoid bacillus 

Proteus 

Staphylococcus 

Streptococcus. 

We are able here to distinguish five different forms of treatment, according 
as they are applied to one or other of these groups of infecting organisms; for 
example, when tubercle bacilli are found, the general practitioner may safely 
conclude at once that the trouble is quite certainly renal in its origin and 
surgical in its treatment. Gonococcal cystitis will disappear under the use of 
oil of copaiba, or the oil of sandalwood. The colon bacillus and the typhoid 
bacillus are more affected by urotropin taken in doses of 3 to 15 or 20 grains 4 
times a day, according to the toleration — big doses, if they do not irritate the 
bladder, are, as a rule, most efficient. The diphtheria bacillus (rarely fuiind^ 
calls for the administration of antitoxin. If the proteus is found and the urine 
is alkaline, give benzoic acid in doses of 10 to 15 grains to make it acid, and 
then follow this with urotropin. Staphylococci and streptococci also call fo 
the use of urotropin. 

TREATMENT OF CHRONIC CYSTITIS. 

Chronic forms of cystitis are among the most distressing ailments the phv 
sician is ever called upon to treat. The pain is peculiarly wearinir, as there i 
no let-up night or day. Judgment here is often difficult, for the vari<»us form: 
of treatment call for considerable practical skill in applying them to an indi 



TREATMENT. 459 

ridual case. It may, however, be said that almost all cases, no matter how 
inveterate, can be cured in time, excepting those of advanced tuberculosis. 
Categorically stated, the methods of cure in chronic cystitis are: 

1. Elimination of a renal source of infection. 

2. Hygiene. 

3. Medication. 

4. Irrigations. 

5. Insiillations. 

6. Distentions. 

7. Topical treatments through the open-air cystoscope. 

8. Curettage. 

9. Drainage of the bladder by the urethra. 

10. Drainage by a vesico-vaginal incision. 

11. Tub treatment. 

12. Excision of the diseased area. 

In every case several of these methods are used simultaneously^ and in each 
instance the physician must be ready to adopt another plan of treatment pro- 
vided one plan fails after due trial. 

1. Elimination of Benal Infection. — Before beginning the treatment of 
chronic cystitis, the question of the renal source of the infection should be 
decided by a preliminary cystoscopic examination. Not infrequently the 
fountain of the trouble lies above ; this observation is common when the kidney 
is tuberculous, or when it contains a stone, or again when there is a chronic 
pyelitis. Under such conditions, all that the treatment of the bladder alone can 
effect is some illusory temporary amelioration of the symptoms. On the other 
hand, if we find that the trouble is due, say, to a light pyelitis, and proceed to 
treat the kidney by irrigations or even by drainage at the same time that the 
bladder is under treatment, the improvement is rapid and permanent Some- 
times a cystitis develops upon a bladder irritated by toxins poured down the 
ureter. Again let us say: In every case of cystitis have the kid- 
neys in mind until it is proven that they are not at fault. 

2. Hygiene. — Every cystitis patient needs rest, and does better for spend- 
ing either all the time, or a considerable portion of it, on her back in bed. Food 
should be light and nourishing. Baths and massage keep the skin active and 
are most valuable adjuncts. The lower intestinal tract should be kept open. 
Patients who have the means at conunand, do well, as they improve, to drive 
out in the fresh air and to sleep out-of-doors. 

3. Medication. — The object of internal medication is two-fold: first, to 
relieve the burning and pain and other symptoms; second, to destroy the in- 



400 



CYSTITIS. 



fecting organiBiii. The older remedies, sncli as bucliu, copaiba, and triticnm^ 
apparently gave some help, but are but little used now. In acute cystitis it is 
jiistitiable to employ the sedatives morphin and codein. They shonld never be 
used in chronic cases. A simple hut sometimes very soothing preparation is 
that containing 20 gr* of potassium citrate and ten drops of a tincture of 









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Fig. 553. — Irrigation of Bladder through Two-way Catheter. The uilet flow should 
be larger than the outlet. By varying the height of the funnel^ the irrigation can be 
carried on rapidly or slowly and with any degree of bladder distent ioQ desired. Gmxm_ 
should be taken to avoid over distention. 



hyoscyamus to the dose. This can be repeated every two or three hours, and 
should be taken with much water. The value of the urinary antiseptics depen- 
dent upon the liberation of fomuilin is fully discussed in Chapter XXIIT. 

Personally, in the great niuUitude of new preparations, we have seen 
nothing superior to the old hexamethylenamiii. There are at least 50 combina- 
tions of this substance with other eonipounds, antl new ones are coming out 
every year. They are all of marked value in the treatment of both acute and 
chronic cystitis. 






Fio, 554. — One Method of Irriqating Bladdck by Means of Two-wat Catheter. 



urine of a cystitis patient, especially when animoniacali are often capable in 
themselves of perpetuating and aggravating the disease. It is, therefore, some- 
times enough to wash the bladder out thoroughly once or twice a day to effeot 
a cure. If the urine is acid, the bladder may Ikj washed out with a b^irax solu- 
tion, a tenspminfiil to a pint of warm w^ater; if it is alkaline, use a boric acid 
solution of half that strength, A pale pink solution of permanganate of potash 





462 



CYSTITIS. 



is sometimes serviceable ; again, a weak solution of bichlorid of mercury, say 
to 10,000 or 20,000, or a weak solution of carbolic acid, say 1 to 500, is servic:^ 
able. 

A good way to irrigate is to take a funnel attached to a catheter by a rub^>^ 
tube 2 feet long; fill the funnel and the tubing with the solution, and in'^ 
duce the catheter into the bladder (Figs. 653 and 554), taking care not ta j^ 

any air get into the bladder ^ 
cause distress. The solution 
should be allowed to run in 
slowly and then to run oat 
through the lowered inverted 
funnel. Repeat this several 
times until the fluid is clear. 
By raising and dropping the 
funnel rapidly, strong currents 
are created in the bladder which 
make the washing out more effi- 
cacious. After the first rinsing 
the same water may be mn in 
and out two or three times. We 
believe that the efficacy of the 
irrigation, as of all intravesical 
treatments with large quantities 
of fluid, is much enhano^l bv 
using the solution as hot as the 
patient can bear it, say in the 
neighborhood of 105^ F. The 
bladder may be irrigaU^d in this 
way once or twice daily. 

If the first treatments are 
painful it is well to give the last irrigation earlier in the afternoon to pve the 
bladder a chance to quiet down before sleeping time. A good irrigating fluid 
is a simple, hot saline solution (a teaspoonful of salt to the pint). 

5. Instillations. — An instillation is the injection of a medicated solution 
into the bladder with the intention of leaving it there for a longer or shorter 
time, with the object of sterilizing the urine or of acting up<^n the inllumed 
walls of the bladder. An instillation is not often used alone, but is more 
effective following irrigation, or irrigation with distention. The In^t solu- 
tions for instillations are nitrate of silver, from 1 to 1,500 down to 1 to 100; 




Fig. 555. — Dickinson's Two-way Catheter. After 
introducing the catheter into the bladder, the 
clamp is removed from the rubber tube, which 
permits the urine to escape. The clamp is then 
reapplied and the medicament in the bulb 
squeezed into the bladder. 



TREATMENT. 



4C3 



argvrolj one or two teaspoonsful of a mO to a 50 per cent solution; and 
protar^l in a strength of 2 to 10 per cent. I>iekins<in*8 syringe (Fig. 555) 
is a convenient instrument for emptying the bladder and injecting the raedi- 
cated Boliition, It consists of a double glass oathelor. The lower one empties 
the urine from the bladder ; this is then stopped otT, while the hulb is squeezed 
and the medicated solution contained in it is thrown into the Madder. 

6. Distentions. — ProgreBsive distention is perhaps the most important 
single funii of treatment for the relief of bad cases of cystitis* The object of 
the distention is to eliminate the disease by stretching the bladder to the limit 
of its capacity, exercising its walls, and evacuating the fluid and cleansing it* 
Most chronically iiiflann^d hhulders cannot hold over .'10 or 50 c. c, of urine- 
Cases of this kind call either fur distention or, if that is intolerable, for an 
incision in the base of the bladder, draining and setting it at rest. We have 
cured many of these eases by a combination of irrigation, distention, and in- 
stillation treatments, and it is surprising w^hat can he done with the conperation 
of the patient in the hands of a nurse of eiidli?ss persevminct^ whu knows what 
is to be accomplished and persists from day to day, stretching the bladder little 
by little, until it advances by degrees to 100, 200, and even 500 c. c. or more, 
when the euro is atttiiiUHl. In just thc^ae cases we always give nuire credit to the 
faithful nurse than to the doctor. At first cleanse the bladder by irrigating and 
distend it to a maximum several times; then, after emptying, iujer*t 5 or 10 
c. c. of argyrol or protargol solution. In onler to assist the tolerance of the 
bladder we sometimes inject a 1 per cent, sohition of ccK^ain, leaving it 
there for 5 minutes, and then we begin the distention treatments. The 
fluid used in distention is either a one-half 8aturat«?d hot boric acid solu- 
tion, or a noruuil saHno solution, or lysol, \/i to ^M per cent., or carbolic acid, 
y^ per cent. 

The apparatus used is a simple funnel connected w^ith a glass catheter by a 
rubber tube about 4 feet long; there is a glass joint in the ntiddle to show 
whether the fluid is running or not, and to reveal the presence of air. The 
first days or weeks of treatment arc often discouraging to doctor, patient^ and 
nurse. We have found it a help to make a chart like tliat shown (Fig, 556), 
graded from zero uji to 500, and extending over a period of from G to 8 
weeks. The tested capacity of the bladder is put down as the starting point 
in the first eolunui, and then day by day, as the distentions are made, a 
mark is set on the chart opposite the corresponding figure. The patient in this 
way sees just what is wanted, she is encouraged l»y any little gains, and, alx»ve 
all, is inclined to permit the distentions to be carried a little further each time 
m order to make a gain* 




464 



CYSTITIS. 



These progressive treatments are of the utmost value in curing those ca^^ 
which are commonly called "contracted bladders," which we will describe m^^ 
fully later. Only a well trained nurse should be entrusted with this delic^ 



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Fig. 556. — Chart Showing Progress under Distention Treatments. The chart is 
hung upon the wall in the patient's room to show the progress made from week to week 
under distention treatments in a case of severe cystitis with "contraction" of the blad- 
der. It is best, as a rule, to take the chart down and to discontinue treatments over the 
menstrual period, aa there is usually more or less falling back then. 

treatment, calling for so much tact and judgment The fluid should be intro- 
duced slowly into the bladder through the catheter, proceeding more and more 
slowly as the maximum is approached. It is well to distend the bladder in this 
way three or four times at each sitting. The chart here shown is from an 
actual case. 



TREATMENT. 



465 



After expancJiiig the bladiler witli a bland fluid and eiiiptyiiig it, it is often 
well to run in a weak silver snlutioii, my 1 to 1,000, or 1 to 500, or stronger if 
the patient ran stand it, and to leave thif4 in for a few niinntes or nntil tho 
urine is passed; or agaiiij after emptying the bladder, one may inject a few 
c. c, of an argyrol or protargol solnlion, 

7» Topical Treatments Through the Open Air Cystoscope. — A topical treat- 
ment is the direct applieation of a medicated solution to the dist^agod area in the 
blatlder withont touehing the somid tissues; this is done in tbi knee^breast pos- 
ture through the oiM*n-air eystosoope. Such treatmentij are not aenncoable 
in all cases of cystitiB, but are best used where the cystitis is localized and 
there is no diffuse surrounding inflammation or thickening, and in the ab- 
sence of excessive tenderness. Snndl areas of ideeration above the trigonum 
or on tho posterior wall of the blatlder are treated with advantage in this 
way. The best solution lo use is nitrate of silver, making, for example, a few 
applications of a 5 per cent, solution, and repeating this at intervals of alMuit 
5 days with a 3 per c€*nt. solution. The apfdication is made by putting 
the patient in the knee-breast posture, intmdiu'iug the No. 10 speculum, empty- 
ing the bladder of its urine if it interferes wilh the applieation, r nd then, with 
an aj»plieator armed with a pledget of cotton saturated with the solution, or with 
the cotton pledget held in the grasp of an alligator forceps, making the apfdiea- 
tion directly to the uleerated surface, placing the cotton fiir a few seconds or 
longer against it. In this way the surface is whitened arid the area sterilized 
for a time. Be careful not to have too much solution to run down over the 
sound tissueSp It is an excellent plan, in treating larger areas in this way, to 
use what we call sequestration treatments. In doing this we apply the end of 
the speculum to the ulcer, or a ])art of it, so as to shut it off completely from 
the rest of the bladder. In this way a strong applieation of 10, 20, or 40 per 
cent, can lie made, the end of the speculum thtni being applied to the area imme- 
diately adjacent and a similar treatment given. By continuing to apply the 
end of the speculum to the contiguous parts of the affectcnl area an extensive 
surface can bo covered with the treatments without involving the rest of the 
bladder. 

8. Curettage.— Cu ret tage of the diseased bladder is ftometimes serviceable, 
A few years ago we made frequent use of the sharp curette in removing diseases! 
surfaces, endeavoring to stimulate the tissues to throw off the infection* We 
believe that a fenestrated sharp curette is oc*casionally usefid in treating small 
areas of inflammation. The sf>ot to \k\ curetted should Ix? carefully located 
through a larger cystijscope. No. 12, and then the curette should be used under 
the direct control of the eye. The ureteral orifice© must be spared, as au injury 




466 CYSTITIS. 

at this point favors an ascending infection (J. Sampson). Another way of 
curetting the bladder is to wipe it out thoroughly with gauze. After a supra- 
pubic or a vaginal incision has been made it can be wiped out with a piece of 
gauze stretched over the finger and used to rub off the surfaces as though one 
were attempting to scrub out the infection. Such a treatment is a good prelim- 
inary to the faithful use of irrigations to keep the bladder clean and free from 
any accumulating debris. We have tried packing the bladder with a long strip 
of narrow gauze, medicated or plain, left hanging out of the urethra as a drain, 
to act as a cleansing medium. We believe this procedure may have a small 
field of usefulness in the future. 

9. Drainage of the Bladder by the Urethra. — In some cases the bladder may 
be continuously drained by means of a small mushroom catheter introduced 
through the urethra. This may be left in for a week or longer, by its continu- 
ous drainage preventing distention of the bladder, and keeping the organ at 
rest ; few patients, however, will tolerate the presence of the catheter in the 
urethra for days together. The catheters so introduced should be kept clean by 
irrigating the bladder thoroughly at least once or twice every day. One of U3 
(Bumam) has used constant irrigation in this way with good results, ke<»ping 
two small catheters cemented side by side in the urethra. 

10. Drainage by a Yesico-vaginal Incision. — One of the most valuable meth- 
ods of treatment at our disposal is drainage through the vesico- vaginal septum, 
effected by cutting through the anterior vaginal wall and establishing a fistula 
there. This is the classic procedure for bad cases, much used by the distin- 
guished T. A. Emmett. The cases in which it is proper to use this form of 
treatment must be carefully distinguished, as it is distressing to a patient to 
live for several weeks or months with constant escape of urine and with the 
expectation of an operation for a fistula at the end of the period. It is best 
adapted to those cases which are of long standing, painful, and utterly in- 
tolerant of any distentions or any local forms of treatment. As a rule, with 
extreme patience even the worst and most intolerant cases of cystitis can b^ 
distended by devoting weeks to securing the first substantial improvement. It 
is in just this class of case, however, that the drainage plan of treatment does 
its best work, by cutting off this period of delay and saving several months in 
the recovery. The effect of the drainage is to put the bladder completely at 
rest and to keep it clean. To do this the opening should be large enough for 
the urine to escape freely; the vaginal opening must also be sufficiently large 
to prevent any retention of urine in the vagina. In some of the bad ca>o:= of 
ulcerated cystitis, after making a thorough preliminary examination iiwr 
anesthesia, it is well to proceed at once to make the vesico-vaijinal opening. 



TREATMENT. 



467 



This is done in the dorsal position by tlistendin^ tho bhnldor witli water, 
introducing a pair of cnrved artorv foreepa tliruii«h the urethra, ami pushing 
d<iwn the anterior vaginal wall just beyond 
the internal urethral oritiee, while the pos- 
terior wall is retracted by a Sinia speculum. 
(E. i\ IhKliey, *^Tho Frincijdes and Prac- 
tice of Gynecology,*' 1904, 3;J1.) The in- 
cision is now made backward in the median 
line, either with a sharp, pointed scisi^ors, 
or a knife, cuttinf^ through all the layers 
between the bhuhlcr and the vagina. This 
ojiening sliould bo about ^')4 5neb in length. 
If the patient baa been exannncd in the 
knee-breast posture arid the bladder ia full 
of air^ a quick way of making the opening 
in the bladder is to plunge a curved knife 
tbrougli the septum, while retracting the 
posterior vaginal wall by a speculum. An 
ample opening can be made in this way in 
less tiuie than it takes to describe it (Fig. 
557). 

The next step is to suture the mucous 
membrane of the bladder to the vaginal 
nmci>sa to prevent t<x> rapid clos^ure. If 
the opening is easily accesisihle thn two 
mucosa* may be xmited with a eontinuoiiii 
line catgut suture (Fig. 558). As a rule, 
bowcver, the surgeon will find that it ia 
easier to unite them with from 4 to C inter- 
rupted sutures. In a nullipara it will be 
necessary to break doT;^Ti the vagituil open- 
ing by incising the perineum posteriorly, 
and then drawing out and sewing the 
vaginal mucosa to the skin, so as to leave a 
good opimi ug for the immediate escape? of 
urine. Unless this is done, a tight vaginal orifice is left, and, w^hen the patient 
lies down, the nrine accumulates in the vagina, backs up into the bladder, arid 
causes all the dii^tress it did before the bladder was opcmetl. A patient with a 
fistula of this kind ought not to expect to have it closed in lees than G weekH to 



Fiti. 557. — Operative Formation of 

VE6I CO -VAGINAL F ISTU LA, A 

clamp i.s intnxluced ilirough the 
urethra and shghtly opened. This 
serves as a guide in making a mid- 
line incision with the knife, as 
shown. The opening should bisect 
the triRonum, but not cut the 
sphincter of the neek of bladder. 
It should, however, be sufficiently 
long to prevent premature cloaure. 
(Mre, A., 1910.) 




4as 



CYSTITIS. 



^ 



6 montJis, Then if, on exaniiiiatioii, tlie bladder walk are found entirely healed, 
the opening may bo cloaed by splitting the mucosa^ and sewing tbe tissues to- 
gether without loss of substance (see operations for vesico-vaginal fistula). Lin- 
gering infections nnist be treated bv irrigations or distentions. Sometimes one 
sneeeeds by draining^ which clears up the disease down to its reaidual point; 
that is to say, there may remain after drainage, as after distention treatments, 
au obstinate area of inflammation which refuses to get well, a SL»rt of irreducible 

minimum inflammation. This the oper- 
ator proceeds to treat more aggressively 
by excision (q.v.). 

A patient with a fistula needs con- 
stant care and supervision, and does blot- 
ter if she can remain in the hospital. A 
protracted case, however, usually prefers 
to go home and trust to time and the con- 
, \vs. y^f tinnons drainage to relievo the intlamina* 

■MA|MjM |[^\^i^fdi' ^^^^' returning after a stated interval to 

^Bj^Hj^H BEJKjJ^P tbe hospital for inspection and closure of 

^ ' the opening. 

11. Tub Treatment.^In several in- 
stances of extremely obstinate cystitis we 
have succeeded in securing entire relief 
and recovery by keeping the patient in 
a warm water bath, after G. L. Hun- 
ner's plan (J. Am. MecL Ass., 1907^ 
xlix, 20G6), the purpose of whieli is to keep up a eontinua! drainage and cleans* 
ing of the wound. To make t!iis effective there nim^t be a venico- vaginal or a 
snprapnbic opening, or both, and the vaginal orifice must be sufficiently dilated 
to allow the water free entrance and exit. Sometimes a catheter introduced 
into the urethra or through a suprapubic opening serves well to keep up a con- 
tinuous flow when connected with a reservoir above (Fig. r*50). The patient 
is immersed in the bath as far as the lower ab<lomen, and as she lies comfort- 
ably in the warm w^ator she is able to annise herself with reading, sewing, or 
other occupations. The water enters and runs out of the tub continuously, and 
is kept at a temperature of al)out lOO'^ F. by means of a thermostat, which 
regulates the gas so that there is a continual delivery of warm water from the 
cold water spigot, if need 1ji*, into the warm tub. The patient is kept in the 
tub as long as i^he can stand it with comfort. Jlost patients do not tolerate the 
treatment well at first, and can only remain in the water for from half an hour 



Fig. 558.— Completion op Operation 
Shown in Last Figure. The su- 
turing of the vesical to the vaginal 
mucous membrane h easily carried out 
with calgui sutures and msures against 
six»utaneoujs closure, which otherwise 
occurs. 



TREATMENT, 



469 



to an hour once or twice a day. Later a patieTit stays in with etitire comfort 
for three or four hours or eveu longer. Treatment can be kept up for several 
iroeka and stopped when the disease has almost disappeared. Remember that 
a bappj alternative to these tub treatments is the introdnction, throngh the 
urethra, of 2 small eathetcra cenienteil together and held in place by a piece 



f_-^ 



**^G. 659. — Hunnkr's Plan of Continuous Irhhiation of Bladder with Patient in a 
Tub. The catheter enters the bladder ttirough the urethra and the outflow takes place 
through an artificial vesico-vai^nal fistula. The pliotograph is one of a rclel)rated case 

■ in the annals of the hospital as the patient h?id had her difcjtressing disease for many 
years and suffered many things of many physicians in vain* 

jpf rubber sheeting farming a perineal pad. In tbi^ way the irrigations can be 
^Bept up night and day. By raising the irrigating bottle the degree of distention 
^fcf the bladder is regulated and can be varied from time to time. The use of 
^ bed pan, as shown in Figure 560, may also be found of great value, 
1 give here a few typical cases with the results : 



Mrs. J. A. W., age 37, admitted to hospital March 8 1910* The complaint 

^iraf* pain and frequency of voiding, which at(^adily grew worse, the patient 

ting forced to void from to S times at night and from 15 to 20 times 



470 



CYSTITIS. 



duriiii? the day. The trouble came cm withoitt any warning whatsoerer. 
The piitieiit had bi'cn married for 8 years and had no children. On exam- 
inatian the urine was found to contain pus, some albumin, a few red blood cells, 
and colon bacilli in abiaidatice. The* l>laddGr showed the entire left half deeply 

iiitianied and infectycd. The 
b 1 a d d e r measurements 
were; 5 cm, posterior wall, 
J] cm. vertex, 3.5 era, left 
coriiu, cni. right cornu ; 
ita capacity was only 60 
c. c. The patient had a 
series of treatments consist- 
ing of daily irrigations and 
distentions with Y^ cartHdie 
acid solution and applica- 
tirms of silver nitrate, 1 to 
1,400, starting on ilarch 
12th anrl ending on May 
14th, which entirely cleared 
up the indammation, and 
the bladder developed a ca- 
pacity of 440 c, c. in com- 
parison to the capacity t on cntrimce, of only *iO c, c. The kidneys in this case 
were carefully examined and found to be quite normal. 

Miss E. A., age 20, admitted April 8, 1910. This patient suffered with 
tuberculosis of the right kiilncy and of the bladder* llcr trouble began 2 
years previously with frequency of urination, until she had to void every 15 
minutes, day and night. This had grown worse by nervousness and the bladder 
irrigations which she had been having. On examination the urine was found 
to contain an abundant amount of pus and tubercle bacilli. Cystoscopic exam- 
ination showed the main trouble around the ureteral orifice. There was also 
extensive disease of the right side of the bladder, the left side working with 
:>mparative ease. As the catheterization of the ureter showed that the right 
fcide was tiil>erculous and the left side normal, right nephrectomy was carried 
out on April 22, 1010. 

When the patient came in the bladder mf>asurcments were: posterior wall 
2.5 cm,; vertex, 2 cm,; left cornu, H cm,; right cornu, 2,5 cm. 

After removal of the kidney and ureter by operation, and distentiona of 



Fig. 560, — Continuois Ikkigation of thr Bladder 
wriH Patient in Bed on Bed-pan. 




TREATMENT. 



471 



tho bladder which incrtiisod its capacity from fiO to 300 c. c, evs^toflonpic ex- 
aramrttion showed that the bladder and ui'iue had become perftictly normaL 

12, Excision of the Kaeaaed Area. — One of the most vahiahle and con- 
venient of all fnniis of tre^atmout at our disposal is that of exeision of the dis- 
eased area. It is never a method of first resort. When, however, treatment 
bv irrigation^ distention, and drainage, in j^pite of the fact that the disease 
has cleared up in almost all parts of the bladder, leaves a residual area of 



Fig. 561. — Lakge Solitary Ulceb or Bladder, as Seek through ScpRAPnBic Opening. 

{A., Aug. 10, 1900.) 

ulceration or grannlation» particularly when there is a tendency toward hem- 
orrhage, then this af2:|]:ressive piece of surji^ry may be used as a last resort. 
It often gives prompt and radical relief. Preliminary to excision the diseased 
area should have been carefully studied, measured, and mapped out (Fig. 
548). 

The method of performing an excision is to insert a mnahrormi catheter 
into the bliidder aud after washing it out well, to leave it there, llien put tho 
patient in the Trendidenhurg position, making a transverse suprapubic inei^on 
about an inch above the s^nnphysis pubis, taking care at every step not to open 
the peritoneum. .Vs soon as the deep fascia is divided and df^taehed from the 
recti in a direction up as well as down, the lax muscles j»n widely retracted. 




472 



CYSTITIS. 



Kext take a Politzcr bag or a Davidson*8 syringe and force air into the bladder 
until it is felt rising up like a hard lump behind the symphysisj being careful 
not to burst it* The top of the tense bladder is easily handled and freed from 
the investing fat Throughout the whole prorednre of opening the bladder do 
not detach the investing loose faBeia, but mark it and, if necessary , put a 
Btitch through it so that it can be picked up readily at the closure of the wound. 



Fio. 562,— Suprapubic Excision of Ulgek of Bladder. The bladder is opened through 
a niid-lme incision and the ulcer on the upper posterior wall is exposed. The dotted 
line maps the part of the bladder to be excised. (A., Feb, 21, 1910.) 

As soon as the vertex comes into view, It is caught on either aide with a silk 
traction suture, and then incised in the median line. Throngh this opening, 
with a head mirror and a cyliiulrical metal speeulum (Kelly's), the bladder 
is exaniineJ in all its parts, determining exactly the location and extent of 
the disease. If the excision is to extend from the vertex down toward the 
base, the median vesical incision is best^ but if the area to be excised lies 
wholly below the plane of the incision, then it is better to open the bladder 
transversely to get a freer access to the interior. An affected area near the 
vertex or on the posterior wall is now excised, using blunt scissors and carrying 
the dissection through the mucosa and musmilaris in the sound tissues around 
the diseased area. Any actively bleeding vessels must be caught with pointed 





FiQ. 663. — SscoKD Step in Operation Shown in Last Figure. The drawing to the right 
shows dissection of the ptTitoneiiJii from jmrt of the bhwlder, the ae^it of ulcer. The 
diagram to the left shows the direct ion and extent of separation, as indicated by arrows. 

tiiiuoiis interlocking fine silk suture may thr-n be used on the outside of the 
bhidder to reinforce the inside sewing, while an additional fine silk or fine linen 
suture draws the investing fibrous fascia over the bladder wound and protects 
it completely. The fascia is then united from side to side, and, finally^ the 
skin, closing the abdominal wound in all but its median part, where a small 
drain is inserted and irft for three or four days. A niushr<Hira catheter is then 
left in the bladder, through »he urethra, and the bladder kept empty and gently 
washed out twice daily for a week. The entire procedure ia well shown in 
Figures 501-5G5. 




474 



CY8TIT1S. 



».^-? 



"s^^?^^/ 



Fig. 564.— Third Step in Excision of 
Ulcer from Bl.ujder. The ulcer 
is excised and the bladder is being 
sewn together with figuro-of-oight 
fine catgut sutures, as shown. 



If the disease is more extenfiive, as in 
tuberculosis, and it is uecessary, in order 
to attack it eflfeotuallj, to get a better ex- 
posure and to cnt thron^h the peritoneum, 
we do not hesitate to do this, making a 
free incision and packing oil the rest of 
tlie peritoneal cavity on all sides so as to 
isolate the fjelvic peritoneum. 

In a woman the uterus can be caught 
and lifted up and the bladder detach€*d 
from the cervix when the disease extends 
below this point. A w^edge of the blad- 
der, iiiclnding its peritoneal covering, is 
then freely excised, and the organ closed 
up with one or two layers of sutures unit- 
iiijl the peritoneal surfaces over tiio wound. 
Sequestration. — The round ligaments and the uterus can then be 

sutured to the abilominal wall from side to side above the pelvic brim in order to 

seqiicBtrate ciunpletely this portion of tlic peritoneal cavity and thus eliminate 

nil danger of infwtion (Figs. 5<i()-r»<l8}, The little artifiiual peritoneal pouch 

shut off in this way can be drained 

freely through the lower angle of 

the incision. In a case of liemorrha- 

gic cystitis in which we did this we 

had occasion to open the abdomen 

several years later for aiuither cause 

antl found no trace of the se<piestra- 

tion operation; the adhesions had 

been abaorbe<l and the parts had 

gone back to their normal condition. 
The amount of tissue excised 

from the bladder may vary from 

a wedge not more til jin '3 or 4 cm. in Fio. 565. — The Last Step in Excision or U; 

length, bv 2 or *i ctn. in width, to 





onc-third or even one-half the size 
of the bladder. The larger exci- 
siims are especially made in tuber- 
culons cases whei*e kidney, ureter, 
and bladder are seriously diseaijed. 



OF Bladder. The bladder is closed down ' 
the bst stitch, which is not yet tied. Tlie 
perivesieal fibrous tissue, which we have 
tlirougliout avoided stripping off or injurin|t, 
is now brought together with a contini 
half-hitehiiig stitch, b^ shown. This cove _ 
the suturo.s in the bladder and adds greallir 
to the security of the closure. 




Cicatrices in the Bladder* — ^Thoso 
wliu reetivc^r fruin }t at^'ere cystitis 
often find that the capacity of the 
hladHer is greatly lessened, and 
nuiy hiiagine that the neeesaitj for 
urinating frequently shows that 
the inflammatory disease atill per- 
sists. Examination reveals a blad- 
der divided into one or more loeiili 
by prominent, sharp, falcifonn, non- 
vascular ridges. Ilerejics the dif- 
ficulty ^ and the tiuestioii is what 
can we do to relieve it. Ordinary 
irrigation and distention treatments 
arc of no avail, hut w*e have sev- 
eral times sncceasfnlly carried out 
the following plan : We first mea* 
sure and establish carefully the 



Fig, 566, — Sequestr.\tion or Blabder to 
Insure AGAm»T Peritomtis AtTKa a 8i;- 
PRAPUBic Operation. Thr rliagram shows 
a sa^ttal \iew of the binly. Note tlie de- 
tachment of the peril oneyni, whit-h m 
sutured to the top of the fundus uteri and 
to the round Ugaments. Note also the 
line of sutures in the bladder walL 



eapaeity of the bladder. We will 
say it holds 100 to 150 c. c. We put the patient under profound anes- 
thesia and fill tlie bladder; then slowly, with a pistcm syringe, force in 



^cK^sJ}p^^ 





% 



Fio. 567* — SEQtJESTRATniN OF Bladder, as Seen from Front. The decree of detachment 
of the peritoueutii from the anterior abdominal wall will depend upon the length of 

the incision made iu the bladder. 




476 



CYSTITIS. 



about 100 c. c, more; there may bo a little bleeding afterwards. The pat4.<^ 
is kept quiet for a few ilaj8 until this is over; she returiia after 3 or 4 ^^iQ^J 
for another distention treatment np to 300 or 380 c. c. The effect of thii ^^^ 
rupture the septa slightly, leaving a superficial healing area, ^^^le^e tJie ^^ 

turn is dharp and st^^^ 
out prominently, one ^] 
put the patient in the l^^-^ 
breast position ^j\ 
through the open Qygf^ 
scope cut it carefiiKv j^ 
several points with &Xivn]. 
ligator bladder ftcis^orH 
(Fig. 560). Both ofthe^e 
proceflures, that of over- 
distent ion and the umm 
of the septum, need to be 
carefully perforuie^l If 
carelessly done there will 
undoubtedly be soniecaaea 
of rupture of the biaddiT 
followed by j)erit<mitu 
or urinary infiltnitkm. 
liMiere this treatment liiu 
not been sTiecessful or \h 
tendency to bleeJ ia 
marked, we prefer opening the bladder supra puhically and completely eicisinc 
the scar area. 

Summary,— To sum up what has been said previously regarding the treat- 
ment of cystitis, it is a matter of first iraixjrtance that the physician should seek 
every opportunity to familiarize himself with the disease, Ouly with a famil- 
iarity gained by constant obscrvatitm and careful attention to results of differ 
ent methods of treatment can he undertake any given case with preciflion aiiJ 
assurance as to the final outcome. Only, too, with a familiarity gain^l by 
experience will he be enabled to decide just what forms of treatment an* mo^t 
likely to prove elTeetive in a given case, and to avoid the wnretched dilafrtrv 
process of adhering indefinitely to one plan of treatment We would emplifti 
again the fact that the treatment in almost everv" ease Is of a progressive 
acter and that, if a milder form of treatment does not promptly yield 
results, the next most aggressive form should be tried. In the worst cuses it ia 



Fte* M8te — Skquestratioi* of Blabder in Male by Su- 
turing Omentum to Its Posterior Surface. A 
drain is introilucod through the abdominal incision 
into tbe iiew-formed retrovesical space. The condi* 
tions pictured arc those after completion of an opera- 
tion. 





CONTRACTED BLADDER. 477 

sometimes the best policy to proceed at once to make a fistulous opening to rest 
the shattered nerves and the inflamed bladder. Again, when the disease has 
lx»en brought to what we call the irreducible minimum, that is to say to an infil- 
trated, ulcerated, bleeding area which, like an old devitalized scar, simply can- 




FiG. 569. — Alugator Scissors. These scissors work on the same principle as the alliga- 
tor forceps and are very useful when it is necessary to use scissors inside the bladder 
through an open-air speculum introduced into urethra. (H natural size.) 

not form an epithelial covering, then time is wasted in attempting to do any- 
thing short of an excision. In the hemorrhagic cases we proceed more promptly 
to the excision treatment than in others. 



CONTRACTED BLADDER. 

A contracted bladder is one which remains permanently contracted and 
refuses to hold any more than a few c. c. of urine. In extreme cases the urine 
may dribble away continuously as fast as it flows in through the ureters. In 
others, as soon as a few teaspoonsful of urine have accumulated, the patient has 
to void and expel its contents. The term "contracted bladder," as thus defined. 



478 CYSTITIS. 

is symptomatic rather than anatomical, and is commonly used to designate 
organ which refuses to exercise its function as a reservoir for the accumula%- 
and discharge of urine at normal intervals, and which is incapable of so act:;;^ 
A variety of affections with this common symptom are wrongly grouped u^^ 
this caption. 

A true contracted bladder is an affection, fortunately rare, in whict^ .. 
walls of the bladder are extensively infiltrated, or in which the muscular ^ 
have been more or less completely destroyed by chronic inflammation. The qU 
tuberculous infiltrated bladders are to be regarded as the end-products of ^ 
vesical tuberculosis which has already run a protracted course in one of tie 
kidneys. We restrict the name "contracted bladder" to this final stage of a 
chronically inflamed bladder, with the destruction of its muscular coats. We 
think we are safe in saying that 19 out of every 20 patients sent to the spe- 
cialist and labeled "contracted bladder^' are simply old cases of inflamed 
bladders intolerant of any urine, but still capable, under faithful treatment, 
of being distended to hold several hundred c. c. In 20 years we have had 
many cases referred to us as contracted bladder, some of them urinating con- 
stantly and almost spending their lives over a urinal or wearing absorbent 
pads, expelling little quantities of bloody, foul urine, but not one of them 
pxcept the tuberculous cases has proved to be a true contracted bladder. 

If the muscular coats have been destroyed by inflammation, the injurv is 
irreparable, and the last result is an ascending renal infection. In making a 
diagnosis of a contracted bladder one must give due regard to the history of a 
protracted, severe cystitis, and then, putting the patient under an anesthetic, 
examine the bladder carefully bimanually, when the contracted organ appears 
as an ovoid, hard tumor lodged behind the symphysis. If the attempt is made 
to force fluid into the bladder under gentle pressure to estimate its capacity, 
it will be found capable of holding only a few c. c, but it should be borne in 
mind that in an ordinary severe cystitis it takes a profound anesthesia to do 
away with the vesical reflex spasmodic resistance. 

Treatment. — In all grades of cystic inflammation approaching the extreme 
forms, say down to a cubic capacity of 50 or even as low as 30 c. c, there is a 
hope of effecting a cure by drainage of the organ through its base, giving entire 
rest, followed by subsequent distentions. The difficult phase of the treatment 
is often the earliest step of inducing a toleration of the first 30 or 50 c.c. 
After this initial step is taken, often with infinite patience, the distention 
sometimes runs up rapidly until 200 or 300 c. c. flow in, when it may once 
ai^ain become difficult. 

In the extreme form of contracted bladder, where the anatomical elements 



have been destroyed, there can l»e but one* hoists namely that of enlarging ita 
capacity at the expense of some other organ. 

W. Kansoh (Arch, /, kiln. Chir., 1007, Ixxxiii, 77) deserilics a case of a 
true contracted bladder in a young man snffering from a constant dribhiing of 
the urine, whicli was treated by detaching a loop of the ileum and re-anastomos- 
ing the bowel, at the same time sewing up the ends of the detached loop and 
bringing it down in close relation with the dorsum of the bladder, with which 
it \va8 ultiniately connected l>y a neries ijf ojK'rutions. By this means the 
capacity of the bladder was enlarged to 2*K) t\i\, and the patient was able to 
hold the urine from one to two hours. lie dieil (S months nf ter llic operation, 
it wad thought of tubereidosis* 



ULCER OF THE BLADDER 

Ulcer of the bladder i.s a not infrequent complication f»f chronic cystitis, 
and is present in most tuberculous bladders. •Indei>cndent of infection, there 
is a most interesting type of ulcer first noted by Lawson Tait in 187t), and givcm 
definite importance by Le Fur in *"l>es ulcerations vosicales et en particulier 
de Tulcere simple de la vessie/' Paris, 1901, a volume of over 800 pages. From 
time to time since Le Fur's report others, mostly case repi^rts, have followed. 
Leo Buerger (J, Am, Med, Ass., IDl'l, be, 41tJ) records two intcrestiu!:; cas<?8. 
I'nder TulH?rcu]osis and Cystitis the question of the infectious ulcers has 
already been fully considered. Here we will confine ourselves solely to the 
other fonn. T.e Fur divides this class of ulcers into three sub-classes: first 
simjjle ulcer, situated near the neck of the bladder or on the trigouum, which 
is usually single, with its edges rounded, its base indurated, and the vessels 
dilated about it, in sixe varying from a pea to several cm. Second, acute per- 
forating ulcer, seated in the vertex an<l particularly in the postc^rior wall: about 
these ulcers, which are usually punched out, the blood vessels are injected and 
there are frequently ecchymosea. Third, trophic ulcers, due to lesions of the 
central nervous system, or to injuries during operations about the bladder; 
these ulcers look like the others. The etiology is complex; in some cases it 
is clenrly trophic. In most cases infection, which disappears, has been the 
cause. Le Fur has demonstrated eJtperimentally that injuries, such as tying 
the urethra and adding infection, are potent causative factors. 

In simple ulcer the solitary symptom is hematuria, intermittent in 
character. It closely simulates the hemorrhage due to neoplasm of the bladder. 
In the perforating ulcer infection and peritonitis are added to the hematuria. 



I 




480 CYSTITIS. 

The diagnosis rests upon a thorough and careful cystoscopic examina- 
tion. The treatment for simple ulcer is topical application through the 
cystoscope. Buerger has noted marked improvement by light fulgiiration. 
When these measures fail the ulcer should be excised through a suprapubic 
opening, the technique of which is fully given on page 471. In perforating 
ulcer the suprapubic operation is indicated from the very beginning. 



CYSTITIS EST CHILDREN. 

Cystitis in infancy and childhood is not infrequent. It is commoner in the 
female than in the male, and is often associated with pyelitis. It may arise 
during any of the acute infectious diseases, and is especially common in dis- 
eases of the intestinal tract, to such an extent that regulation of the bowels is t 
more important therapeutic measure than the usual local measures for the 
urinary tract Dr. George Waugh, of the Great Ormond Street Hospital of 
London, has observed the permanent cure of several cases of bacteriuria, which 
have resisted all treatment by appendectomy, relieving a chronic constipation. 
As a rule, frequency of voiding, with pain, fretfulness and crying at everv 
emptying of the bladder should attract attention to the condition. In the 
severer cases there is often fever. 

The principal literature has already been outlined in Chapter XXIII on 
Pyelitis. The treatment is also fully discussed there. 



EXFOLIATIVE CYSTITIS. 

An exfoliative cystitis is a peculiar inflammatory disease in which the 
mucous membrane of the bladder becomes necrotic and is thrown oflF entire or 
in shreds and expelled by the urethra. It is oftenest seen associated with a 
retroflexed pregnant uterus in the fourth or fifth month, or with a large tumor 
choking the pelvis and pressing upon the neck of the bladder and producing 
overdistention and ischemia. The membrane has been erroneously called diph- 
theritic and croupous. The tissue thrown off is the necrotic lining of the blad- 
der, including its mucosa and submucosa, with more or less superficial layers 
of muscle, rarely extending into the deeper muscularis or to the peritoneum. 

Boldt (Am. J. Obst., 1888, xxi, 350) gives the appropriate name of cys- 
titis suppurativa exfoliata to this disease. We owe the first care 
ful examination of the membrane to the anatomist Luschka. 



EXFOLIATIVE CY8TITIS. 



4fil 



The oiTtcomc of snvh a clt'sqaamation is either a i^!ow, complete recovery, or 
a recovery with incontinence and a contracted bladder. Death takes place from 
sepsis and double pyelitis. Patientj^ die when the teioperature risea above 105^ 
F, (Boldt), Ttei^enenition of the iimcosa must take place from i^landular 
spaces left btdiind and from the nretiral and internal urethral orifices. 

Important articles on this subject are by: Boldt (Am. J, OhsL, 1888, xxi, 
350) ; Krtikenberg {Arch, /, Gyru, 1882, xix, 261) ; Stoeckel (Monatsben /, 
Urol,, 1002, vii, iiOl). 

Symptoms, — The first symptom of exfoliative cystitis is retention of urine 
followed by dribbling. Hemorrhage may be marked^ and vesi(»al over- 
distention and colicky pains are proniinent features, A vaginal examination 
may show that the tissues are edematous. The pulse creeps up and there is an 
anxiouSj pinched exjiression of the face, as the patient lies in a dtirsul position 
with the legs drawn up. Later the foul, ammoniacal urine is loaded with pus 
and .shreds of connect ive tissue, ami epithelium and urinary salts pansed under 
marked straining. The most characteristic appearance is the protrusion of 
shreds of membrane or even of a complete membranous sac, which looks like a 
bladder in process of complete inversion. This extraordinary sight is rendered 
the more retnarkable when the sac is heavily coated with the salts of the urine- 
Under violent straining this bag may be dischargt^d from the urethra. 

Etiology,— While pregnancy in the fourth or fifth months and the pressure 
of a tumor are the common causes, exfoliation has been noted even in the second 
month of pregnancy. It may follow a surgical operation, such as extirpation 
of a cancerous uterus by the vagina (Thaler, CiitrlhL /, Giftu, KUl, xxxv, 
550). Again, it may follow an abdominal surgical operation, such as the re- 
moval of subserous myoma (Lftehlein, Zhchr^ /. ilehurtsh. u, ff//n.. l.**8S, xiv, 
584), It has also been seen after injecting a caustic or a strong chemical solu- 
tion, such as a hot salt solution, into the bladder (J. Mock, Ann, d, mah rf. 
org, geniio-nrin,, 1011, xxix, 1633). 

J, 0. Warren (Bofifon Med, and Surg, J., 1S06, cxxxiv, 641) reports a case 
from the practice of W. L. Kichardson. The patient, who was not pregnant, 
was treated for a vaginismus by dilating the introitus. During convalescence 
she had a vesical irritation, which grew worse until a mass was seen protruding 
from the urethra about the size of the last tw^o joints of the little finger. This 
was extracted in one continuous sheet. The patient suffered from incontinence 
and wore a rubber urinal ; later she had to urinate every two or two and a half 
hours. An examination showml considerable residual urine in the bladder. 
She slowly improved and, after 2 years, seemed normal. 

Hurry Fenwuck exhibited a specimen of the mucous membrane of the blad- 



482 CYSTITIS. 

der of a man removed through a perineal section done for the relief of a long. 
standing purulent cystitis. 

As Warren states, an intense bacterial inflammation of the bladder mucosa 
may cause exfoliation. 

Haultain (cited by Fenwick, Lancet, 1894, i, 209) collected 33 cases asso- 
ciated with pregnancy, 20 of which were due to septic infection, etc. 

Diagnosis. — At first the symptoms may be those of ordinary cystitis. Ex- 
amination shows the retroflexed pregnant uterus choking the pelvis. If then 
there is a cystitis and blood is passed, there is imminent danger of exfoliation. 
When a membrane covered with urinary salts begins to protrude from the 
urethra in a case of pelvic obstruction, the diagnosis is obvious. The mem- 
brane, whole or in shreds, is the distinguishing feature. 

Treatment. — The treatment first and foremost must be prophylactic. Any 
retroflexed gravid uterus or tumor choking the pelvis must be watched with 
anxious solicitude. Any interference with the bladder function is an unmis- 
takable warning to begin putting up the prophylactic fences by taking steps 
looking toward the relief of the pressure as speedily as possible. Belief may 
sometimes be given even when the necrotic process is already under way, as 
shown by an instructive case treated by F. Ahlfeld (CntrlbL f. Gyru, 1898, 
xxii, 1017), whose patient recovered and went to term. The details in brief 
were these : The obstructed bladder reached the navel and contained purulent, 
turbid urine, with shreds of its lining membrane. Ahlfeld pushed the uterus 
up a little and inserted a large Meyer's ring pessary into the vagina ; at the 
same time the bladder was treated with repeated cleansing irrigations. A little 
later the patient was put in the knee-elbow posture to assist in the reposition. 
Under this simple, sensible treatment the bladder improved, the uterus righted 
itself, and the pregnancy went to term. The lesson to be learned from this is 
that although we cannot often expect such a fortunate outcome, we should at 
least make the effort to attain it in a case not too far advanced. If the uterus 
cannot readily be brought into position with the resultant relief of the pres- 
sure, then it must bo evacuated by dilating the cervix and packing it with iod<>- 
form gauze until the ovum is cast off. Extreme care must be taken not to 
introduce any of the discharges from the bladder into the vagina. 

When a tumor or a cyst chokes the pelvis, one may try to push it up into 
the abdomen, but unfortunately it is not likely to stay there. Here one will do 
well to consider an immediate operation to remove the pressure, if the patient's 
condition permits. If a necrosis starts in with an incarcerated pelvic tumor, 
wo believe the best jilan would be to take the tumor away by an abdominal 
operation and to drain the bladder by making a long incision in the median 



SYPHILIS OF THE 

line ahtjost from cervix to urethra, witli*>iit atwin^ the two nmcostp tofjether. 
This latter plan of eoutirmoiie driiinagf, to whirb irri^i^atiotis ean he atkled with 
BO niurh advantage, ia well worth trying in any case not associated with preg- 
natjcy. 

In the ease of an adherent retroflexed uterus the safer j>Ian is to empty the 
nterus by the vagina and to treat the bladder. If seen early, an abdominal 
o]ieration freeing the nterus and bringing it itito autepositioii may aolve tbe 
problem happily. 

The trc^atment of the local condition of the bladder must be dircjcted ( 1 ) 
to obviate any obstruction of the urothra by membranes in process of separa- 
tion, preventini; n^tention of the nrine; (2) to rid the bladder of the rapidly 
aceimnniutini^ debris of niend>rane8, pns, and bkfrrid, and to hi^al it. 

If the protruding membrane is miidc up of tbe mner>sa inerusted with salts, 
it may be carefully draw^n out a little and snipi>ed oflF or pc»rforated. The 
bladder should be irrigated two or three tinu^s a day, using a weak, warm per- 
manganate solution, injeeting at the end of the washing 50 e. e. of a stdution of 
nitrate of silver, 1 to 1,000. A continuous irrigation is secured by a fine double 
catheter introduced through the urethra, passing through a small perineal pud 
of rubber, which serves to hold it in place. These cleansing local treatments 
are sedative in their action, but in severe eases one must use ojuum to prevent 
straining an<l the* t* rrific expiUsive efforts which can even rupture the weak- 
ened, paretic bladder w*all* 



SYPHILIS OF THE BLADDER. 

Syphilis of the urinary organs is comparatively rare» rarer in the bladder 
than in the kidney. Nit;5e was able to say, in 1907, that m far, ho had not 
recognised syphilis in the bladder. Casper repeats this assertion as to the liv- 
iTig subject. M, Morris (iT^dtana Med. J,, 1897, x\i, 5) describes gumma of 
the bl ad tier. 

For further study consult P, Asch (Zischr. f, Uroh, 1911, v, 504); Mar- 
gnlies {Ann, d. miiL d. org, (fenito'tirin,, 1U02, xx, 385), and Le Fur (Ann, 
d, mnL d. org, genifo-urin,, 1902, xx, 1519). 

Sypliilitic disease of the bladder, when found, generally belongs to the ter- 
tiary period* The gummata are apt to have a small, papillomatous appearance, 
or again there is a frank, uleerated condition of the vesical mucosa, which has 
nothing in its api>earanoe to suggest its origin. The ulcjpr^ sejitetl at the Iwise 
of the bladder, somewhere near one of the ureteral orificca of the trigonum, 



I 




484 CYSTITIS. 

presents an undermined, irregular margin coming out rather prominently from 
the interior of the bladder, surrounded by a red area, while the central part 
shows the detritus and grayish slough of an ulcer. In one case of evi<lont cvi- 
titis the history of hemorrhage was prominent. Sometimes the disease mani- 
fests itself in a thickening of the bladder walls at its anterior j)ortion, extend- 
ing down the urethra, where there is a gummatous, edematous infiltration of 
urethra and bladder associated with dysuria and incontinence. 

Diagnosis. — The diagnosis is best made by giving close attention, in any 
obscure and obstinate case of cystitis, to the history of syphilis, often insuit 
ciently treated, which may have antedated the present affection by 10 or even 
20 years. Syphilis should be considered where there is an obstinate catarrhal 
affection, demonstrably not tuberculous, which resists all the customary 
methods of treatment. No other affection of the bladder will clear up under 
anti-syphilitic treatment. In one case on record there was a giunmatous 
tumor projecting into the bladder, which was mistaken for malignant disease, 
and an operation urged. The long duration of the complaint, however, tends to 
preclude this diagnosis. Doubt once raised, a positive Wassermann reaction 
will, of course, clear up the matter. A scraping of the lesion should be made 
and the spirochete looked for. In a case of G. von Engelmann (Folia Urolog- 
ica, 1911, V, 472), a woman sixty years old had for half a year suffered from 
hemorrhages of the bladder. Cystoscopic examination showed, in the nei^- 
borhood of the right ureter, a tumor 3 cm. long, ulcerated, covered with pu«, 
and incrusted, which the surgeon suspected was a carcinoma. However, on 
learning that she had had syphilis 20 years before, he ordered the mercurial 
cure, when the ulceration rapidly disappeared and the tumor left no trace 
behind. 

Treatment. — The treatment of syphilis of the bladder is specific, by sal- 
varsan, mercury, and the iodids; under this plan brilliant cures have been 
made, and without it nothing avails. Surgery is out of place here. 

Asch dwells further upon the association of bladder symptoms with certain 
"parasyphilitic" affections, and points out, aside from the well-known paralyses 
of the bladder associated with tabes, that a trabecular bladder is itself one of i 
the early symptoms of tabes which may appear before any other sign. lie cites i 
a case where the difficulties with urination and the traboculie appt^ared 10 | 
years before the disappearance of patellar and pupillary reflexes. Later the 
bladder pains take the form of crises. Therefore, in the absence of any mani- 
fest cause for a trabecular bladder one must consider tabes. He cites a case 
under his care for occasional retention of urine where nothing could bo f<>iiii«l 
in the urinary organs to account for the retention except a slightly nMlJentil 



MALAKOPLAKIA. 



485 



and swollen lilmlder muoosa. Curcfni cxaiiiinatidii ahowcd a sliip^gish pupillary 
rcaotutii and patellar reflex, but no other tabetic si^^^iis. Another paticut simply 
had ditKciilty in urinatiug, with a little reddening of the mucosa; 2 years later 
a tabes rapidly ran it8 course. A/ijain another patient complained of the terrific 
straining which he must make in onler to urinate; this was so violent that 
defecation was associated w^ith the act. There was nothing in the urinary pas- 
sages to account for this. The pupils were somewhat sluggish and the patellar 
reflexes were weak, Romberg's phennmenon was only snggested, and the Was- 
sorniann reaction was weakly positive. These cases are not so hopeless as they 
seem to be at first sight, since a very active anti-luetic treatment and, above all, 
the intraspinal treatments wdth salvarsan have come to bring relief to these 
sufferers. 

MALAKOPLAKIiL 

This extremely interesting hut rare condition of the bladder was first de- 
scribed and named by von llansemaitn {Arch. /. path, AnaL u, PhysioL, Vir- 
chow, 11*0:], clxxiii, 302). ilont uf tho casea recorded have been found at 
antopsy, although the condition has Itren observed during life. It may be in 
association with colon-cystitis, or a tnlxTculons cystitis, ur alone. The cluirac- 
teristic lesion is a small yellow plaque sharply defined from the bladder mucosa. 
These plaques vary in size from that of a pea t-o a quarter of a dollar, are in- 
variably multiple, and freqnenrly confluent. There is usually a pitting in the 
center, and in the larger plaques an ulceration. They extend into the sub- 
mucosa. On microst^opic section the plaque is f<uind t<* l>e made up 
of large, flat cells with small eceentrieally phiced nuclei. Tljese cells 
arc packed closely together, with only a fine connwtivo tissue stroma l>e- 
tween them. In adclitiou to thesi? characteristic cells, there are colorless lx>ilies 
which are very brittle and which vary in shape, most of theui being roughly 
glolnilar and on the average 5 or *» microns in tlnckness. These He cither bo- 
twt»en the cells or in them, and are influenced by neither aciils nor alkalis, 
as shown by stains containing iron. It is believed that they may be derived 
from the hemoglobin. 

The histogenetie origin of these plaques is not known. Many authors have 
insisted that they are tulHTculous. This seems questionable. No well- 
defined symptomatology has Ixxni worked out; the diagnosis in life should be 
made by cystoscopic examination and the ri'inoval of the tissue for Tnicros(*o|nc 
examinations. One of (he most recent and lx»st considerations of this subject 
occurs in the article of Max Walds^dunidt {Zlsrkr. /* UroL, 11)12, vi, 541). 



1 




CHAPTER XXXV. 
INJURIES OF THE BLADDER AND URETHRA. 

We will consider under this caption injuries to the bladder outside of labor 
or the use of obstetric forceps, symphysiotomy, pubiotomy, lithotomy, herni- 
otomy, and other accidental surgical injuries. In other words, our caption 
covers only injuries which are due to violence or to accident. It is evident that 
injuries of this character naturally affect men for the most part, as they are 
more exposed to harm from travel, from dangerous occupation, from brawling 
when in liquor, etc. 

Xitzo and Sonnenburg, as well as Tuffier, reckon the proportion as 90 per 
cent, men to 10 per cent women. Women are also less liable to injury because 
of the transverse position of the bladder in them, as well as because it lies on an 
elastic cushion protected by the uterus behind. Occasional cases of rupture in 
children are found scattered through surgical literature. 

The successful treatment of these injuries is one of the greatest triumphs 
of modern surgery, for they were ever the despair of all the older physicians 
and surgeons, and the undisputed aphorism comes down to us from Grt'ek 
antiquity that "no case of injury of the bladder ever recovers." It has re- 
mained for the last thirty years to bring this lesion within the reach of surgery 
and to transform defeat into victory by healing a large percentage of the cases. 
From the year 1878 on, surgical literature teems with references to this im- 
portant subject. 

One of the first writers to collect, study, and summarize a considerable 
group of cases was Stephen Smith, of Xew York, Assistant Surgi»on to Bellevue 
Hospital (X. Y. J, Med., 1851, vi, n. s., 338). 

To the credit of American surgery, the first successful operation was done 
by Dr. A. G. Walter, of Pittsburgh, Pennsylvania, in the year 1859 (Med. and 
Surg. Reporter, 1861, vii, 153). 

The patient was a blacksmith, 22 years old, who was kicked in the abdomen 
in a fight ; following this he had strangury, with intense abdominal pain and 
inability to urinate. Dr. Walter says that, as he could got no backing frnm his 
consultants, he opened the abdomen on his own responsibility 10 hours after 

486 



HISTORY. 



487 



the iiijiirj, inakinir a median incision oxtenilin^ almost from iimbilirus to 
pubis. The acciinnihited urine was earcfnlly spoiiire*! ont of the cavity, when 
a rent two inches in extent was found in th(> funtlns of the bladder. *'The 
cavity of the abJonien being cleansed of the noxious agt^nt, the wound of the 
bladder was left to itself, as no nrine was seen to escape from it/* Tlie 
abdomen was closed with silver wire sntnres. The patient made a good re- 
covery, with a retention catheter kept in between two and three weeks. Wal- 
ter then nrgea this as the only proper plan of treatment, and further says: 
''To preserve a patient's life nnder these circniaHtances, it must be resorted 
to at once, as withont it the efforts of nature and the resources of scieuoe are 
puwerlens/' 

The following articles may l>e read with advantage: 

'^Die Traunien dcr Harnblase" by llox Bartels {Arch. /. Hin. Chir,, 1878, 
xxii, 519), Bartela was the first to go fully and cxhanstivcly into the history 
of the subject in a monograph of lf>0 pagers; his elaborate paper includes a 
study of 504 eases of injury of the bladder. 

There is a brief but valuable paper with statistics, by James Kerr, in the 
Annals of Stfrgeiy, 181)3, xviii, 047, 

Samuel Alexander has a careful paper on intraperitoneal rupture of the 
bbiddcr treated by laparotomy and suture (Ann. Surrj,, 11K)1, xxxiv, 2(rj). 

Daniel Fiske Jones (Ann, Surg., liWA, xxxvii, 215) writes on intraperi- 
toneal rtipture of the bladder. 

Aslihurst [Am, J, MecL ScL, llHHi, m s., cxxxii, 17) has a ihornugh-going 
study of the subject with full citation of all the important literature. 

F. A. Besley {Surg., Oyn. and ObsL, 19D7j iv, 514) goes carefully into 
the mechanism of the injury and cites a number of cxperiTtients, with d^nirnuns. 

E. J. Senn (J. Am. Med. Ass,, VM)7^ xlviii, 1021) nc^tes that in 170 cases 
of ruptured bladder there were 109 eases of fractured pelvis, 

Edward Quick (Ann* Surg., 1S)07, xlv, 94) reports a case operated upon 
successfully 254 hours after accident. 

Watson and Cunningham give rupture of the bladder careful consideration 
in their *'GeniU>Urinary Diseases," 1908, i, 447, and present valuable sta- 
tistics. 

I. E. Tikanadze (Ztschr. /. Urol., 11)09, iii, 841 > has a paper on the ques- 
tion of surgical intervention in shot w^ounds of the bladder. 

P. Wolfer contributes an important paper on the traumatic injury of the 
bladder from Krnnlcin's f'linic, Zurich, in the Beiirtige snir klinischen Chir- 
urgie, 1910, Ixvi, 2S0, 

Moritjc Cohn {DlscK Zlschr. /, Chir., 1911, cix, 509) writes upon in* 



488 INJURIES OF THE BLADDER AND URETHRA. 

complete rupture of the bladder, and A. Galaktionow (Dtsch. ^Ztschr. /. Chir., 
1911, ex, 449) upon intraperitoneal rupture of the bladder. 



ETIOLOGY. 

The causes of a rupture are two: first, a full bladder; and, second, an 
injury in the region of the lower abdomen. The empty bladder is almost 
never injured unless it be from a stab wound or a gunshot wound. If the 
bladder is full, a rupture may then be brought about either by a blow upon the 
abdomen, a fall on the buttocks, or a crushing force applied to the pelvis. 

Richard Douglas ("Surgical Diseases of the Abdomen," 1903, 659) states: 
"Since 1897, we are able to tabulate 9 cases of intraperitoneal rupture of 
the bladder out of 113 contusions of the abdomen, a relative frequency of 8 
per cent, as compared with the total number of traumatisms." 

Eailroad injuries, falls from a wagon, being ridden over by a wagon, a fall 
from a height, a kick, a shot wound or stab wound of the bladder are common 
causes. 

Bartels (loc. ciL) subdivides his 504 cases of vesical rupture as follows: 

Stab wounds, 50. 

Shot wounds, 285. 

Simple lacerations, 169. 

Also, of his 504 cases, 74 had an injury of the rectum, 196 had bone in- 
juries. 

It is a serious question whether a violent muscular contraction of the ab- 
dominal walls can rupture a full normal bladder; a few cases seem to show 
that such an accident can occur. A diseased bladder may be ruptured in this 
way. 

Rare instances of rupture in women have been observed in the third and 
fourth months of pregnancy with retroversion; in one the rupture occurred 
from sneezing, without any gangrene of the mucosa or evident weakening of the 
vesical wall. As noticed by numerous writers, for more than half a century, 
drinkers are pre(lisj)osed to rupture of the bladder, for all the predisposing 
factors are there. The bladder is constantly filled to overdistention, the sensi- 
bility of the patient to a normal desire to evacuate being benumbed, his abdom- 
inal muscles are relaxed and not on their guard, and he is quarrelsome — then 
there is a fight or a fall and a rupture. 

Rivington states that, in 41 out of 108 cases of simple intraperitoneal rup- 
ture of the bladder, it is distinctly specified or else implied that the patient had 



F 



SEQUELS. 489 

been drinking alcoholic liquors, or was actually drunk at the time of the acci- 
dent. 

Ashhurst dwells particularly on this factor, and further notes that, in cases 
jii which the patient was intoxicated at the time of accident, the mortality was 
over 43 per cent., while among the sober it was less than 28 per cent. 



CLASSmCATION. 

The character of injury thus produced varies from a small point of rupture 
oil the peritoneal surface to a rupture extending fore and aft over the whole 
extent of the bladder. 

The laceration is either extraperitoneal or intraperitoneal ; it may also be 
subperitoneal, not involving all the coats of the bladder; this is called "incom- 
plete rupture." 

A further exceedingly important classification is that of ruptures with and 
without any external wound, the external wound naturally predisposing to 
infection. 

Injuries of the bladder are also subdivided according as they are compli- 
cated by other injuries, such as fracture of the pelvis and rupture of the rectum 
(by impaling). Shot wounds constitute a special class, in that the bladder is 
liable to be injured in more than one place, and large vessels in the neighbor- 
hood may be injured coincidently. Gunshot wounds are naturally commoner 
in war times. It is evident, therefore, that statistics taken then will vary 
greatly from those taken in times of peace. 

The frequency of the intraperitoneal to the frequency of the extraperi- 
toneal ruptures is as 80 to 20. Bartels estimates 60 per cent., however, as intra- 
peritoneal. 

SEQUELS. 

The results of rupture of the bladder are extravasation of urine and blood 
into the surroimding tissues, followed later by infection, suppuration, and sep- 
tic absorption. In intraperitoneal rupture a mild irritative peritonitis may 
result, which, in a few days, becomes septic, and is followed by death. Death 
occurs from shock, from the coincident injury, from hemorrhage, from perito- 
riitis, septicemia, or pneumonia. In the extraperitoneal cases the septicemia 
niay arise from septic thrombi at the neck of the bladder. Peritonitis, one of 
the most serious sequelae, arises from an infection transmitted from the bowel 



490 INJURIES OF THE BLADDER AND URETHRA. 

or from a coincident injury of the bowel, or from infection extending in from 
the external wound, or, again, from a preexisting cystitis. 



DIAGNOSIS. 

The cardinal diagnostic points are an injury, followed by desire to urinate, 
often with distressing inability to pass more than a little bloody urine but with 
unabated desire, and a swelling in the lower abdomen. 

If the extravasation is intraperitoneal, there are the symptoms of a mild 
peritonitis, which, after a few days, grow worse, with increasing distention of 
the abdomen, elevation of the temperature and pulse, and evident accumulation 
of fluid in the abdomen. A catheter brings away only a few drops of bloody 
urine. Fever, until there is an infection, is slight or entirely absent. The 
diagnosis may be easy or diflScult. It may be completely masked when there 
has been an injury, a fall, or a crushing accident with profound shock. The 
accumulation of urine in the abdomen reached as much as six quarts in Judd's 
case. 

When there are other coincident severe injuries, the surgeon is most liable 
to attribute the anuria to the profound shock. 

The cardinal points in the diagnosis, then, are, in resume : strangury and 
"bloody anuria," with pain above the symphysis. In his case of intraperitoneal 
rupture Quick puts the diagnostic points as follows : 

"The sudden development of ascites following trauma, the strangury, blood 
from urethra, and the practical anuria for eleven days made the diagnosis of 
intraperitoneal rupture of the urinary tract the most probable." 

Up to the first 20 hours the symptoms are strangury and the inability to 
urinate. After that there is liable to be the added element of infection, accom- 
panied by fever, and, in intraperitoneal rupture, tumor and peritoneal symj)- 
toms. 

The urgent symptoms of the rupture, so evident in the first few hours, fade 
away in a few days, while those of peritonitis become more prominent. For 
this reason it is important to secure a careful history. 

There is a natural desire on the part of the physician in attendance to 
explore the bladder at once with a catheter, in which case he may push the })oint 
of the catheter up against the abdominal wall, where it may be felt just luider 
th(^ skin, if it has passed through the rupture into the abdominal cavity. The 
rule in Zeidler's clinic is that the catheter is not essential to diagnosis, which 
must be made from the symptom-complex, and further that the catheter may 



f 



DIAGNOSIS. 491 



he used but once, and that just before the operation exposing the wound in the 

Madder. This avoids the risk of ingrafting an infectious peritonitis by the 

in<lul^ence of the natural desire to try to relieve by the catheter. We believe 

tkM, at catheterization is not so dangerous if done with extreme care, but it ought 

xiCDt to be done often. 

It is further improper to inject fluids or gas into the bladder to see whether 
i-t: returns in full amount. 

Occasionally, in a doubtful case, with an X-ray apparatus at hand, a diag- 

:H:3.osi3 can be made by injecting about 100 c. c. of a one per cent, emulsion 

<:^:f silver iodid into the bladder and then taking a radiogram. The diffuse 

c^liaracter of the picture, without the lines of delimitation of the normal blad- 

ci^r, will at once graphically demonstrate the existence of a rupture. If 

^.liere is an external wound the radiogram will also show its location and 

i^:xtent. 

Xot infrequently a differential diagnosis must be made between a ruptured 
Xdidney and a ruptured bladder. In both conditions we find profound shock 
-«^ith anuria or the occasional passage of a little bloody urine, and it is not 
always possible to determine whether the kidney or the bladder is hurt The 
gturgeon has often found himself obliged to make an incision into the loin 
-to expose the kidney down to the bladder before he could discover just 
^vhere the mischief lay. Any mark of a bruise in one region or the other 
is, of course, a valuable guide in determining where to cut. In such a 
<:loubtful case one is justified in testing the ability of the bladder to hold and 
^0 return a pint of fluid injected by catheter just before operation. Here, 
^00, the emulsion of silver iodid and the X-ray will be of service. The same 
emulsion can be used in the renal pelvis, injected through a renal catheter, 
"but the difficulty is that the patient is apt to be so extremely ill he cannot 
be much handled. The X-ray picture of a crushed kidney will also fail to 
show the customary outline of the normal organ for which every good radio- 
grapher looks. 

In all cases in which a patient who has had an injury complains of a tenes- 
mus in the bladder and inability to urinate, and is nauseated and tympanitic, 
we must consider carefully the possibility of a rupture of the bladder. In 
incomplete rupture of the bladder there is a desire to urinate, sometimes with 
inability to do so, but the abdominal svTiiptoms are lacking. The tenesmus dis- 
appears when the bladder is emptied of its bloody urine. If an incomplete 
rapture is neglected there is often a gradual infiltration of the vesical walls, 
lifting up the coverings of the bladder and ending in an infection which may 
even terminate in a peritonitis. 



492 INJURIES OF THE BLADDER AND URETHRA. 



TREATMENT. 

There is no condition in surgery for which the treatment has shown a more 
satisfactory improvement than rupture of the bladder, the universal rule of 
death having been reversed, so that the patient may have a far greater chance 
of living than dying if he is properly cared for, complications being absent 
Ullman, for example, found that in 237 cases of rupture not operated upon, 
there were only 22 recoveries; of 143 of these in which the rupture was intra- 
peritoneal, only 2 recovered, while in 04 of extraperitoneal rupture there were 
20 recoveries. The prognosis, of course, becomes worse according to the char- 
acter of the associated injuries, especially in cases of fracture of the pelvis. 
The mortality is lessened greatly by prompt operative interference, and almost 
doubled after the first 12 hours. 

Sieur (Arch, gen, de med., 1894, i, 282) gives the following significant 
figures from a small group of 34 cases : 

Operated upon. No. 

In the first 12 hours 13 

Between 12 and 24 hours 10 

Two or three days after .injury 11 

Watson and Cunningham show that the mortality is 88.7 per cent ir:^^ 
cases treated expectantly, while it is 42.2 per cent, in cases treated b^^-^, 
operation. Sehlanger estimates a 50 per cent, mortality, and Alexander 41 ^^1 
per cent. 

These figures discourage delay, but they are not calculated to make tb^:::;:^^ 
surgeon despair in the late cases, for recovery from an intraperitoneal iiijui — :^cj.y 
which has lasted for some days is possible. For example, Blumer had a car ^^^. 
operated upon on the sixth day with recovery, and E. Quick {Ann, Surg,, 190" ^)7^ 
xlv, 94) operated successfully 254 hours after the injury. lie first cathetx^riz^ jirrel 
and drew off 5,800 c. c. of bloody urine by the catheter, causing a disappearan* .^noo 

of the abdominal distention, after which the operation was done and the putii** ^.ut 

recovered. 

James R. Judd (J. Am, Med, Asso., 1910, liv, 1207) operated after 77 

hours, and let out alxnit G quarts of urine from the abdominal cavity; i^ fjj^. 
peritoneum was everywhere injected, but there were no other evidences of pe^^ri- 
tonitis. The torn edges of the bladder were freshened and sutured, the abiloi^^^ieTi 
was closed, and the patient made a good recovery. 



Cures. 


Deaths. 


8 


5 


3 


7 


3 


8 



Walter, as quoted, was the first to succeed by opening the abdomen and 
evaciiatifi^ the urine. 

IL 11. tinnit, of Loiiiavillej Ky. (/, Am, Med, Asso., 1888, xi, 118), has 
the high honor of l)eii)g the firs( surgeon to o[)eii the ubdonitni and suture the 
rent iu the blatlder succest<ful!y. Grant did this, with the concurrence and 
assiBtatico of Dr» A, M. Carteledge, on a ]>atient It* years of age, who, 5 honrs 
before, had been rnn over by a wagon, which passed across his pelvis. An in- 
cision w^as made up to the umbilicus and a half gallon of bloody urine removed; 
the rent iu the fundus of the bhidder was foiuid to Ije i^V'j incites in a trans- 
verse direction. It was elost^d with 11 sutures of carlndizcd silk, A soft 
rnhl>er draiuage tube was then inserted behind the hbidder, and the rest ot 
the incision was closedi The patient w^as eatheterized every 2 h*>urs after- 
ward and made an excellent recovery. The cafheter is oidy a valuable adjuvant 
and not a curative agent, whether used temporarily or permanently, nor ought 
one to use the catheter to nuike |ieritniu*ul lavages, (Thorp.) 

Fuueturo by the rectum or suprapubicalty is also a pnxiedure to be re- 
jected. 

These methods, which would he extremely valuable iu the absence of sur- 
gery, must never be allowed to take the place, as tem|xirary procedures, of the 
exposure and dire<^t treatment of the wound in the bladder. 

Surgical treatment to-day is undoubtedly the one safe way of handling rup- 
ture of the bladder. The object of the surgeon is to obviate the two most seri- 
ous risks, namely: (a) peritonitis in the intraperitoneal, and (b) urinary 
iiiflltratiou in the extraperitoneal eases. These ends are attained by a free 
8U[)rapubic incision exposing the tear, by suture of the tear, and by drainage of 
the wound and of the bladder. The ojieration ought to l)e done as soon as the 
diagnosis is made, nidess profound shock calls ftu* a temporary delay. 

In bad cases spinal anesthesia or a local anesthetic, such as novocain, w*ill 
he better than ether or gas. In event of a general anesthetic the responsibility 
of the anesthetist is great. Relaxation is absolutely necessary, but the amount 
of the anesthetic must Im^ limited to the absolute necessities of the case. 

The abdomen must be thoroughly dried out in a position of moderate eleva- 
tion. The best suture nuiterial is chromic catgtit or fine silk. One may, like 
Alharran, sew up with a eontlnnoua catgut suture and then over this pass a 
continuous sero-serous suture of silk through all the layers of the bladder, in- 
chiding the mucosa. A continuous suture saves much time, but it must be 
snugly adjusted and each point of the suture passed alxint 3 ram, from the last 
one. If it is difficult to reach the iwDsterior part of the wound, it may be drawn 
up into view by first sewing the part nearest to the operator^ and then^ ad- 




494 INJURIES OF THE BLADDER AND URETHRA. 

vancing step by step, if interrupted sutures are used, pulling on them and go 
drawing the posterior part into view. (Jones.) 

The patient is then let down from his elevated position and the abdominal 
wound closed with a drainage tube surrounded by gauze and inserted in the 
lower angle, where it can be left for two or three days. A self-retaining cathe- 
ter is then passed by the urethra into the bladder, and the bladder kept drained 
also for several days. If the patient is in an extremely bad condition, the most 
the operator is able to do may be to open and drain the peritoneal cavity or to 
drain the prevesical space and insert a catheter into the bladder. 

In intraperitoneal rupture, where the wound is more irregular, the operator 
may be obliged to content himself by sewing up as much of the rupture as he 
can and then draining the prevesical space, trusting to the drain, and to the 
urethral catheter draining the bladder, to put the parts at rest and facilitate tho 
cure and the rapid closure of the opening. In some extraperitoneal ruptures 
the location of the swelling will clearly indicate a deep j)erineal incision and 
drainage or a suprapubic or an inguinal opening, or, better still, two of these 
incisions combined. 

Hildebrandt (Berl. klin. Wchnschr., 1907, xliv, 137), in intraperitoneal 
rupture, recommends extraperitoneal izing the bladder by sewing the peritoneum 
of the abdominal wall back of the wound in the bladder, after the latter has 
been sutured. It is readily done when the rupture is at the vertex of the blad- 
der. In women, if the tear is bad and the suturing uncertain, we would recom- 
mend extraperitonealizing the bladder by sewing the round ligaments and the 
fundus of the uterus to the abdominal wall from side to side, thus putting the 
bladder into a little peritoneal pouch detached from the rest of the abdomen 
This separation will last a few weeks and will later disappear entirely. 

P. Wolfer, in behalf of Kronlein's clinic (Beitr. z. klin. Chir., 1910, Ixvi, 
280), tabulates G7 cases of stab or impaling injuries (Stichverletzung). 

The sharp or blunt instrument may enter the pubic region above th-^ 
symphysis, or pass up through the perineal region, or, rarely, it enters tlirout;^ 
the obturator foramen, or through the vagina, or the gluteal regions. 

When the peritoneum is injured the earliest possible operation should l^ 
done to expose the wound, to close it, and to drain the peritoneal cavity. Wbei^ 
the peritoneum is not involved, the surgeon then has to take care of the coutusKHi 
rupture as well as of the wound in the bladder. If the rectum is injureil, this 
must be drained by inserting a large tube surrounded by gauze. In some cases 
it is .sufficient to put a permanent catheter in the bladder to keep it empty, thu: 
preventing the urine from being poured out through the wound and eontanii 
nating it. Where the injury to the bladder has been but slight, eases have beei 



treated successfiillv bj oathetf-rizing at ylic»rt iutt^rvak. If the rxteriml wound 
18 large, it luav ]w suture<l in part and lire rcniaiiidcT drained. 

In tbo large and imi>ortaiit grotip of shot wounds in t Ij r bladder, 
Tikanadze, in v. l*Vd.Tiiff'H C^linio (DfsrL Zfsrhr. f, i'roL, VMVJ, iii, S41 ), 
recoiiiint'nds operation at tho earliest pnssiblu moment. A sujirainibie extra- 
peritoneal ineiwion is made. If neeessary, the peritoneum is opened, arid then, 
if the Iwation of the wonn<l in the bladder is not fonnd readily, the bladder 
ought to Im? opened, the nmeosa exnntiiietl earefnlly, and the wonnd tli^eovered 
from wirhin, when the openings may also be i^ewed from within, using plain 
{■atgnt sntnrf^s whieh will be alworbeil in part and discdiarged in ]>art. In sneb 
injuries we nnist always look fur a second woumb SonietinieH the ball is found 
within the bladder, where it mny form the nueleu:? nf a ealenlus, 

i\ II. Anderson (J. Am. M, Ass., 11)00, xjtxiv, 1505) wishes to dwell upon 
the value of hot saline infnsiitn in a ba^lly shocked ease, and gives a clear ac*- 
eitunt nf a gunshot Avuund einisid by a bar*r<K)m rnw. The bullet, o8 ealiber. 
enlered the right bnttnek behind the feunir and lodged in the bhnlden The 
patient, seen tl honra later, was in profound slux'k and nneongtcions, the breath 
iiig was fiujH'rfieial, and the extremities cold and flabby. The surgeon waited 
20 hours for hitn to improve, in the meantime giving two injeetions of a quart 
of salt rtohition at a tempiTntnre of ahont 135^ F. The writer was greatly 
impreHsi^d by tin^ evident improvement whieh followed the several iujV^ction^ 
of snline solution into the rt^etnm. A suprnpubie evHtotomy was <lone and 
the bullet fonml lt>ose in tht* bottom of the bhulder, whieh hiid a little bole in its 
posterior w^alL The bUuider was then drained by the urethra without suturing 
the hole, hut the peritcmenm w^as not openetl. About 5 bt)urs biter the p!ilae 
eould not be eounted at tlie wri-^t, so the alxltiminal eavity was op^ied at onee 
mid a quantity of grayish, foul-smelling fluid evaeuated. After almndant wash- 
ings of the ahthuuen, it was closed, with a drainage tube reaching to tlir iMtttovn 
*if the eavity l>ehind the bladder* The patient left the hospital w^el! on the 21*th 
day. 

In in e o m p 1 e t e rupture of the b 1 a d d e r, uidess the synuptoms 
are slight, we ought in oj^erate, o]xnung the bladder, and tliseovering arid treat- 
ing the injury <lireetly. lender ibis head see an article by M. <'<ihn in Ptsrh. 
Xischr. f* (/hir., 1011, eix, 500, It is l>est not to wait for threatening symp- 
toms, but to f«»restall the urinary inflhrafititi and detachment of the mucosa 
with the subseiiuent infection, whii^li lias destmyed some cases treated expec- 
tantly. If, afO^r exposing the bladdfT, no injury is seen on the external siirfiice, 
then it msiy 1m* o|H*ned and tbe mntujsa earefully exaniiuHb If a rent is found 
in tin* mucosa, it umy W' s^^wed up from tbe itiside, then the anterior wound 




496 INJURIES OF THE BLADDER AND URETHRA. 

made for inspection should be closed, and the suprapubic incision also closed 
with a small drain. It is well, sometimes, to draw the peritoneal surfaces 
together with a row of sutures, further inverting the wound area and oi>posing 
a buttress to the invasion of infection. If the wound cannot be sewed up inside, 
we may then make a complete rupture of it, enlarging it as necessary, and sew- 
ing it up wholly from the abdominal side in two layers. 




CHAPTER XXXVI, 



DISEASES OF THE PREVESICAL SPACE. 

Definition. — The prevesical or prei>eritonefll space, or, as it is sometimes 
calleil, tbe space of Retziusj is an aiiotomica] area desi^ied to accommcHlate the 
exparuling and contract iiig bladtlor, and to allow it the ntmost freedom of motion 
without interference by the abdominal pressure of the surrounding organs. 

This space, firist described by Kctzins, the Swcnlish anjitoinist, is compared 
by him to the capsule of Tenon, in which tlie eyeball so freely plays. 

The limits of this vesical pocket are; 

In f r o n t, the posterior surfaces of the synipliysis pubis, and of the lower 
portion of the recti muscles, extending above as far as the falciform semilnnar 
line of Dongla^; posteriorly, the peritoneum ; laterally, the external 
liorder of the recti muscles; below, the perivesical cellular tissue continuous 
with that of the true pelvis, the fascia propria of the pelvis. 

The relations of the prevesicid space to the surface of the body are describe*d 
by Bouilly in the foUuwing manner; 

(1) A transverse line is drawn across the linea alba about 8 or 9 cm. 
lxdo%v the umbilicus , 

(2) Two vertical lines are drawn along the external border of the recti 
muscles extending from this transverse line down to the pubis. In this way a 
rectangular space is marked out, behind which the bladder enlarges as it ascends 
from the pelvic cavity in a state of mwlerate distention. This quadrangular 
area is a relatively weak space in the alxlominal wall, which is here easily 
pushed forward by the distention of the bladder or by any other fluid collection 
In^hinrl the recti muscles. 

Introductory. — ^A study of the anatomical facts just given shows that the 
bladder^ no less than the uterus and tbe lower part of the rectum, is supplied 
with a si>ecial anatomical arrangement, consisting of loose cellular tissue, to 
provide for marked variations in its form. While the rectum is limited! by its 
position in its Ijouy pelvis, and only the l«>wer ]iart of the uterus is extensively 
surrounded by loose areolar tissue, the bladiler, on the other hand, is much more 
richly supplied to provide for more fre<|uent and extreme variations in size; 



^ 



498 



DISEASES OF THE PREVESICAL SPACE. 



the aiialr>g>", thereforej of the bladder to the other pelvic organs is closer than 
has been siispc?cted, and, indeed^ the bladtler iiiav well be liiken as the type of 
expansive organs in tho body. 

Two foriiiH of iliseasfi in general are funitd involving the prevesical space, 
inManinnitory affections and tmoora of several kinds, as cysts, lil»rf)i<! fmiHtrs, 
and exostoscH. 

Anothpr important classification of these diseases separates those affections 
which start in the prevesicul area from those which start elsewhere and only 
invtilve it iiecondarilv; this ehtssitiention is particuhirly inipirtaiit in considef- 
ing the group of inflammatory affections where it is a mutter of prime neceasity 
to discover the original focus of the disease and to remove it, as well as its 
secpielix*. 

There is nothing whatever peculiar al>out Hie prevesical area rendering it 
speciallv liable to any particular ff>rm uf diBfase; its affections are among the 
rarest known to stirgcry. The diseases ninst frequently encountered here are 
indammatory affections transmitted from the bladder, nrinarv infiltration and 
inflammation from ruptured bladder, and exostoses and inflammation from 
necrosis of the symphj^sis. 

We have been niucli impresseti, while scanning the literature of this subject, 
with the unsatisfactory nature of the case diagnoses. The mere presence of an 
abscess pointing above the symphysis is by no means sufficient to make the 
diagnosis certain. Intra pel vie tumors sometimes adhere to the lower abdominal 
wall and present many of the characteristics of an enlargement in front of the 
peritonenra ; pelvic abscesses and the abscess assoi'ialed with an appendicitis 
may also bnrrow and cause the formation of a phlegmon at this point 

Hiitory.— TIic history of prevesical affections is brief hut interesting. Bep- 
nntz (Arrkives gen. df juecL, 1850, Ixxxiii, 1:^9) pul>lishe<l a memoir in 1850 
on ^'Phlegmons de la parol anterieure de Tabdomen/' in which he discusses the 
intiammatory affections of the prevesical space under the title *^Phlegraon of 
the Fascia Propria." 

Ketzius publiKhed the first elalwrate anatomical description of the area in 
1856 at the Academy of Stockholm, and this work of Retziua was conimuni- 
cated by the distinguished anatomist Ilyrtl, in 1858, to the Academy at Vienna, 
The most complete works which have appcarcil since ihat time are found in 
several French theses which have in great measure been inspired by the work of 
Gnyon, Among the most important of these are those of Poisson, Gerardiii, 
Bouilly, and Villiers. 

Trecourt (''ilemoires ct observations *le chirurgie/' Paris, 1769^ Obaer. 15, 
152) furnishes us with the first published case, in a girl from 22 to 23 years 




CLINICAL IIIRTORY. ^^^flP 490 

of age, who had an aKsceas m lurgts as a turkey's o^g ahovo the sNTiiphysis, 
which he opened with a bii^itoury, two fingers' width to the right of the linea 
alba. On carrying the finger to the bottom of the abscess it entered a hirge 
eavity and pasi*ed easily fo the left of the Hnea alha and heni^atti it, Tlie 
woTiud oloaed slowly under treatment, and the patient recovered. The eoniplete 
deiicriptioTi leaves little to be desire*! from a eliniral standpoint, 

A ease of de ta Motte (**Traite eomplet de ehirnrgie/' edit, par M, Sabatier, 
I, Obs. 50, 201)) serves well to show the ditfieulties of diagnoHis, While this 
ease has been cited in the literature of prevesical inflammations^ we believe it 
was rather one of appendicitis with a localized peritonitis which that surgeon 
opened and drained with a good result. 

GHnical History,— Inflammatory tumors of the prevesical space either orig- 
inate in this area, when they may he called iciiopathie, or they are se^jUidte of 
disease elsewhere, and shouhl Ije styleil symptomatic, Bonilly, in a collection 
of 43 cases, found 27 idiopathic and IG syitiptomalie ; without doubt the clijser 
sifting which this subject is destined to receive in the near future will more 
(ban reverse these figures. 

In the first group of 27 eases of idiopathie aflfectiona the patients varied in 
age from S to ^1 years, and there were but 4 females. (^lie of these eases is 
cited by Boyer (**Traite des maladies ehirurgieales/' etc., 1S24, ix, oO) ; a 
woman y 26 years of age, fell feet, in the second month of her pregnancy, and 6 
weeks later felt the firat violent pains in the lower abdomen. Au abscess 
formed and opened in two places, at the nmbilicus and just alKive the pubis. 
Roth openings remained patulous, and the urine eseajied by them, as well as by 
the urethra, until she passeil through a natural confinement, when the fistulae 
closed of tliemsclves. 

In the group of symptomatic inflammatory affections Bouilly finds that 
9 out of 20 eases were in w^omrn. While in men the primary focus of the 
disease was almost always in the bladder, in women the original seat of the 
trouble was ulerine or j>eriuterine. lie states that '*in woman the inflamma- 
tury eiihirgemcnt of the spui-c tti Kctzins is oftentimes nothing else but the ex- 
tension of a pblegiijon of the broad ligament, or of the cellular tissue of the 
iliae fossa, developing under the same conditions, that is to say, after a confine- 
ment.'' 

One of the most important causes of suppurative inflammation is found in 
the injuries to the symphysis sustained during lalnir, sii* h as rupture of the 
joints, or symphysiotomy. A case of this kind came under our observation in 
the service of J. W. Williams, uf the Obstetrical Department of the Johns 
Hopkins Hospital. 



500 DISEASES OF THE PREVESICAL SPACE. 

A case of suppurative inflammation of the symphysis pubis associated with 
the formation of a large abscess of the prevesical space is given by Dr. J. A. 
Gordon (Boston Med. and Surg. Jour., 1876, xcv, 734). "The patient, twenty- 
four years of age, had symptoms during her third pregnancy indicating relaxa- 
tion of the symphysis. Aching and sharp pains in the pelvis and thighs began 
on the fifth day after delivery, and increased in severity during several days 
following. Slight chills occurred on the ninth day, with increase of tempera- 
ture. On the fifteenth day the temperature was 103° F. ; there was prostra- 
tion, nausea, and vomiting, with coated, dry tongue. The slightest motion 
induced extreme pain. Decubitus was dorsal only, with feet widely extended. 
Pressure near the pubic symphysis caused intense suflFering. Catheterization 
was necessary twice daily. On the eighteenth day a severe chill occurred ; the 
temperature reached 105^/4°, and the pulse 120. Constitutional symptoms 
abated the following day, and eleven days later (the thirtieth day after con- 
finement) Dr. Gordon, by means of the pneumatic aspirator, evacuated ten 
ounces of pus from the mens veneris. The fluctuating tumor at this point, pre- 
vious to the removal of the pus, was of the size and shape of half a cocoanut 
There was a free, bright-red discharge from the vagina. A fluctuating tumor 
pressed the uterus backward and occupied the front of the pelvic cavity, dis- 
placing the urethra and extending downward into the left labium. Three days 
later, about the same quantity of pus was withdrawn from the left labium. 
Two or three days after this the abscess pointed on the inside of the left thigh. 
Incision was made with a bistoury, and about half a pint of pus was removed. 
Complete relief of all the symptoms ensued. The patient walked about in 
three weeks, but wore a hip-binder for several months. Recovery was com- 
plete." 

The symptoms of the disease may be divided into two stages: 

(1) A period of general disturbance and local disturbances with intestinal 
or vesical symptoms; 

(2) A period of the formation of the tumor above the symphysis. 

The urinary troubles are not constant, and, with the intestinal disturbances, 
would rather seem, as Bouilly says, to point to the r