Diseases of the genito-urinary organs and the kidney

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DISEASES

Genito-Urinary Organs

THE KIDNEY

BY

ROBERT HOLMES GREENE, A.M., M.D.

PROFESSOR OF GENITO-URINARY SURGERY, MEDICAL DEPARTMENT OP FORDHAM

UNIVERSITY ; GENITO-URINARY SURGEON TO THE CITY AND TO

THE FRENCH HOSPITAL, NEW YORK CITY

AND

HARLOW BROOKS, M.D.

ASSISTANT PROFESSOR OF CLINICAL MEDICINE, UNIVERSITY AND BELLEVUE HOSPITAL

MEDICAL SCHOOL; VISITING PHYSICIAN TO THE CITY

HOSPITAL, NEW YORK CITY

SECOND EDITION, REVISED AND ENLARGED

WITH 323 ILLUSTRATIONS

PHILADELPHIA AND LONDON

W. B. SAUNDERS COMPANY

1908

Set up, electrotyped, printed, and copyrighted September, 1907. Revised, reprinted,
and recopy righted September, 1908.

Copyright, 1908, by W. B. Saunders Company.

PRINTED IN AMERICA

PRESS OF

W. B. SAUNDERS COMPANY

PHILADELPHIA

This Book is Dedicated

TO

Ucmuel Bolton IBanoSt fiD.S),

as a tribute of respect for his researches in

Genito-Urinary Surgery and for the high

standard he has always maintained

as a member of the medical

Profession

PREFACE TO THE SECOND EDITION

In this second edition of our book we have introduced con-
siderable new material, discussing subjects not considered in our
first edition, and elaborating more fully certain portions of our
original text. Several new operative procedures are presented
and new methods which have appeared in the recent literature
and seem of definite value have been incorporated. Many
minor corrections and alterations have also been made, and the
writers trust that the book has been thereby improved.

While the surgical sections have been written by Dr. Greene,
and those essentially medical by Dr. Brooks, as in the previous
edition, the writers have worked conjointly in the hope that the
material may, therefore, be better adapted for the needs of the

general practitioner.

Robert Holmes Greene.
Harlow Brooks.

New York, September, 1908.

PREFACE

It. has been the purpose of the writers to present in this
volume a discussion of the more important disease conditions of
the uro-genital tract, taken from the standpoint of the general
practitioner and surgeon. In so far as possible they have at-
tempted to incorporate such methods as they personally have
found most practical and useful, all of which they believe may
be successfully employed in the hands of any well equipped prac-
titioner, familiar with modern medical and surgical technic.

The writers do not profess that the book is complete; this
would be impossible in a work of this size. They have attempted
to devote the greatest amount of space and the fullest descrip-
tions to those conditions and methods which have appeared to
them to be of the greatest importance, or to those which, being
of recent development, may be presumed to be less familiar to
the practitioner.

A larger amount of space has been devoted to the urinary
organs proper, and relatively less has been said of purely sexual
disorders.

The work is the conjoint product of a surgeon and a physician,
and it is intended that equal attention should be devoted to both
medical and surgical aspects of these diseases.

References to literature have not been exhaustively made.
So many suggestions of value have, however, been found in the
work of Berger and Hartmann and in that of Frisch and Zucker-
kandl that they require especial mention in this preface.

Robert Hoi^mes Greene.
Harlow Brooks.

New York, August, 1907.

CONTENTS

CHAPTER I Page

General Examination of Patients 1 7

The Instrumental Examination 31

Catheterization 41

CHAPTER II

Endoscopy. — Cystoscopy. — Catheterization of the Ureters 50

Endoscopy 50

Cystoscopy 54

Instrumental Examination of the Kidney 60

Catheterization of the Ureters 60

Methods of Separating the Urine from Each Kidney without

Catheterizing the Ureters 68

Tests Showing the Permeability of the Kidney 69

CHAPTER III

The Care of Urethral Instruments. — Preparation of Patient

and Surgeon for Operation 77

The Care of Urethral Instruments 77

Preparation of Patient for Operation 83

Preparation of Surgeon 87

CHAPTER IV

Examination of the Urine and Urethral Exudate 88

Examination of the Urine 88

Urinary Constituents 90

Microscopic Examination of the Urine 95

Organized Deposits 96

Crystalline Deposits lOi

Bacteria 103

Examination of the Urethral Exudate 104

Examination of the Seminal Secretion 115

Examination of Secretions and Exudates from the Female Geni-
tals 118

Examination for the Spirochaeta Pallida ' 1 20

CHAPTER V

The Kidney 123

Embryology 123

Anatomy 124

Physiology 1 30

Compensation in Renal Disease 134

CHAPTER VI

The Blood in Diseases of the Kidney 139

Blood-pressure in Renal Disease 144

13

14 CONTENTS

CHAPTER VII Page

The Ocular Manifestations of Renal Diseases 148

CHAPTER VIII

The Kidney in Acute Infectious Diseases. — Suppurative Nephritis 152

The Kidney in Acute Infectious Diseases 152

Suppurative Nephritis 157

CHAPTER IX

Bright's Disease 166

Pathology 166

Symptoms, Diagnosis, Course, and Prognosis 177

Treatment 181

CHAPTER X
Uremia 192

CHAPTER XI

Tuberculosis of the Kidney. — The Kidney in Syphilis 204

Tuberculosis of the Kidney 204

The Kidney in Syphilis 210

CHAPTER XII

Malformations and Displacements of the Kidney 213

Congenital Malformations 213

Movable and Floating Kidney 216

Hydronephrosis 219

CHAPTER XIII

Wounds and Injuries of the Kidney 227

Wounds 227

Injuries 229

CHAPTER XIV
Renal Calculus 234

CHAPTER XV

Tumors of the Kidney 243

Diagnosis 249

Treatment 251

CHAPTER XVI

The Surgery of the Kidney 252

Operations for the Exploration of the Kidney 254

Nephropexy 258

Nephrotomy 262

Nephrectomy 266

Ablation of the Kidney 275

Surgical Treatment of Bright's Disease 275

Lavage of the Pelvis of the Kidney 277

CHAPTER XVII
Anatomy, Physiology, and Pathologic Anatomy of the Ureters 278

CONTENTS 15

CHAPTER XVIII Page

Surgery of the Ureters axd for the Relief of Hydronephrosis. . 285

CHAPTER XIX
Anatomy, Physiology, and Pathology of the Bladder 298

CHAPTER XX

Diagnosis and Treatment of Diseases of the Bladder 310

Cystitis 3x1

Stone in the Bladder 318

Litholapaxy 322

Suprapubic Cystotomy 329

Cystotomy 337

Treatment of Bladder Tumors 340

Exstrophy of the Bladder 3^7

Injuries of the Bladder 35^

Rupture of the Bladder 355

Total Extirpation of Bladder 357

Hernia of the Bladder 358

Diverticula of Bladder 360

CHAPTER XXI
The Anatomy of the Penis and Male Urethra 362

CHAPTER XXII

Diseases of the Male Urethra 367

Urethritis 367

Symptoms 372

Diagnosis 374

Treatment of Non -Gonorrheal Urethritis 377

Abortive Treatment 378

Treatment of Acute Anterior Urethritis 380

Treatment of Chronic Anterior Urethritis 385

Treatment of Acute Posterior Urethritis 388

Treatment of Chronic Posterior Urethritis 388

Resume of the Treatment of Urethritis 390

Complications 391

Stricture of the Meatus in 403

Stricture of the Urethra in 404

Treatment for Retention of Urine and of Tight, Impassable

Stricture 409

Rupture of the Urethra 422

Abscess of Cowper's Glands 424

Resection of the Urethra 425

Operations for the Relief of Urethral Fistula 427

CHAPTER XXIII

The Female Urethra 435

Anatomy 435

Congenital Malformations 436

Examination of the Female Urethra 437

Stricture of the Female Urethra 438

Dilation of the Urethra 439

Urethral Fissure 440

Peri-urethral Abscess 440

Urethritis ' 440

Tumors 442

CHAPTER XXIV

The Penis 445

Injuries 445

Growths and Ulcerations 447

l6 CONTENTS

Page

Foreign Bodies and Calculi in the Urethra 449

Hypospadias 45°

Epispadias 455

Amputation of the Penis 457

Phimosis 462

Paraphimosis 403

Circumcision 404

CHAPTER XXV.

The Seminal Vesicles 47o

CHAPTER XXVI

Anatomy, Physiology, and Pathology of the Prostate Gland 480

Anatomy 480

Physiology 481

Congenital Defects 481

Injuries 482

Hyperemia 483

Prostatitis 483

Hypertrophy 485

CHAPTER XXVn

Diagnosis and Treatment of Diseases of the Prostate 494

Acute Prostatitis 494

Chronic Prostatitis 495

Abscess of the Prostate 505

Prostatic Calculi 507

Prostatic Hypertrophy 508

Removal of the Prostate through a Suprapubic Opening 520

Tumors of the Prostate 530

CHAPTER XXVni

Anatomy and Pathology of the Testicle and Epididymis 538

Anatomy 538

Pathology 541

Elephantiasis of the Scrotum 555

CHAPTER XXIX

The Treatment of Diseases of the Testicle and Epididymis 557

Therapeutic Measures '. 557

Surgery of the Testicle and Its Covering 561

Operation for Hydrocele 561

Epididymectomy 567

Castration 568

Treatment for Inguinal Retention of the Testicle 571

Treatment of Atrophy of the Testicle 574

Treatment of Injuries to the Testicle 574

The Treatment of Varicocele 575

The Treatment of Tumors of the Testicle 577

Irrigation and Drainage of the Seminal Duct and Vesicle through

the Vas Deferens 577

Treatment of Elephantiasis 579

CHAPTER XXX

Neuroses of the Sexual Organs 580

Index — 589

DISEASES OF THE

Genito-urinary Organs and Kidney

CHAPTER I

GENERAL EXAMINATION OF PATIENTS

The methods of examining patients who are beUeved to be suf-
fering from lesions of the urinary tract are so diverse that the in-
sertion of a chapter devoted to the discussion of these methods
has seemed desirable. Undoubtedly much that appears here is
already so well known as hardly to require mention. It is hoped,
nevertheless, that those to whom the treatment of urinary disease
is comparatively new work will find its perusal helpful. In our
experience, errors in diagnosis are most often due to neglect in
following a systematic method of examination.

The art of questioning the patients and of carefully interpreting
the answers plays so important a part in the formation of a correct
diagnosis in urinary diseases that it is well to cultivate a definite
method in this division of diagnostic work.

A good plan to follow, after eliciting the necessary information
regarding the family and personal history, is to question the pa-
tient concerning the symptoms complained of in the upper extrem-
ities, and so to continue on down the body to the soles of the feet.
Although in a few cases, as for instance, that of a young man
with a primary acute urethritis, it would be an unnecessary waste
of time to go into the usual questions concerning the family his-
tory, diseases of childhood, and habits of life, still, in the majority
of cases, a correct diagnosis can be made only after a thorough
examination — both objective and subjective.

General questions should bear upon the family history. The
cause of death of the various members of the patient's family
should be ascertained, and the important subject of hereditary
tendencies should receive full consideration. In this way a gouty
diathesis, a tendency toward nerve derangements and toward early
2 17

1 8 GENERAL EXAMINATION OF PATIENTS

arteriosclerosis, may be traced. Diseases of the nervous system
are increasing at an alarming rate, hence information concerning
hereditary tendencies toward the acquirement of nerve derange-
ments are particularly significant in this connection when we
remember how close a relationship exists between the condition
of the nervous system and that of the urinary tract. Diseases of
the former may give rise to functional diseased conditions of the
kidney, the urethra, the bladder, the prostate, and the sexual ap-
paratus. Certainly so far as the kidneys are concerned, and prob-
ably also to some extent with the other organs mentioned, nerve
derangement may even be the direct cause of organic changes in
them. Questions regarding a tendency toward early arterioscle-
rosis are of equal significance, certain American families displaying
an astonishing leaning in succeeding generations to suffer from
progressive changes in the arteries, such as cause apoplexy and
various forms of paralysis. This is particularly noticeable among
the wealthy, and seems to indicate that luxurious habits tend to
produce early changes in the arterial system, whereas excessive
nerve strain may give rise to some renal condition, such as inter-
stitial nephritis, and thereby shorten the life of the individual.

Personal questions can not be gone into too exhaustively, and
it is well to have some definite plan that will insure against any
important symptom being overlooked. The practitioner must be
prepared here to meet a certain amount of obtuseness, for even
individuals apparently well equipped mentally sometimes show an
inability to answer intelligently the simplest questions concerning
their past or present symptoms. In these cases, where the patient
is suffering from some obscure conditions, long and patient ques-
tioning may be necessary.

Interrogate first regarding the presence of headache in its va-
rious forms — frontal headache, for instance, if not due to a diseased
condition of the air-passages, is often associated with kidney
lesions. Next inquire into the condition of the hair, and the acute-
ness of sight, hearing, taste, and smell. Ascertain also the con-
dition of the throat, and inquire as to pain in the chest and shoul-
ders, pain in the back, shortness of breath, and palpitation of the
heart. Questions concerning the condition of the stomach and
the digestion in general may elicit valuable information. Con-

GENERAL EXAMINATION OF PATIENTS 1$

ceming pain in the abdomen or back, mere local pain, such as the
well-known kidney colic, the pain extending along the course of
the ureter, is generally due to calculus. In addition to this typical
renal colic, it should be remembered that other diseased conditions
of the kidney give rise to pain, which may start in the region of
that organ and follow the course of the ureter. Diseased con-
ditions of the kidney may give rise to pain in the lower extremities,
and very frequently in the lumbar region. The most common
type is the ordinary backache ; this latter, however, is not neces-
sarily diagnostic of diseased kidneys, and is very likely to be con-
fused with some diseased condition occurring in the sacro-iliac
synchondrosis. Zuckerkandl believes that a continuous pain in
the kidney which is increased by pressure and is accompanied
by endocarditis or myocarditis, associated with the passage of
bloody urine, would warrant the diagnosis of kidney infarct.
Pain in the kidney is generally believed to be relieved by rest
in a horizontal position, whereas standing or moving about is
said to increase it. This, however, is true not only of kidney
disorders, but is equally true of pain emanating from the kidney
region due to disturbance of other organs or to certain forms of
myalgia. Pain in the kidney is at times an indication of tubercu-
losis of the kidney, and when associated with blood in the urine is
quite suggestive of this affection.

The condition of the bowel should be definitely ascertained —
whether there is constipation, whether defecation is accompanied
by pain in the prostatic region, whether a discharge from the
urethra occurs during defecation, and whether there is pain in the
rectum.

Ascertain whether or not any present or past acute urethral dis-
charge has been observed; whether pus is discharging from the
urethra during the intervals of urination; whether a sUght dis-
charge appears with the first urine passed; whether there is a
discharge of a thin, milky character following urination or defe-
cation. A considerable amount of pus discharging between
intervals of urination is generally due to acute urethritis. It may
come from an abscess of the prostate or from an abscess of the
perineal tissues. The same is true of any considerable amount of
pus discharged at the beginning of urination. Discharges from

20 GENERAL EXAMINATION OF PATIENTS

the urethra following urination or defecation may be due to in-
creased secretion from the urethral glands or to spermatorrhea,
phosphaturia, or prostatorrhea. Shreds in the urine may be due
to a previous urethritis. Discharges from the urethra may also
be due to tuberculosis, and very rarely to a syphilitic involvement
of the urethra, such as chancre. During pneumonia, rheumatic
attacks, typhoid fever, or other infectious diseases pus may be
excreted from the urethra. As in the case of hematuria associated
with malaria, we are inclined to believe that this will appear only
in urethras that have been damaged, perhaps years before, by
some acute inflammatory condition, such as gonorrhea. Regard-
ing tuberculosis as a cause of purulent urethral discharge, we hold
a similar view as that expressed concerning malaria. It seems to
be well established that an antecedent gonorrhea predisposes to a
subsequent tubercular infection.

Next, all possible information concerning micturition should be
elicited. The force of the stream ; whether or not pain is present
during or after urination; whether the stream is interrupted or
suddenly checked, should all be inquired into, the answers to these
questions bearing upon a diseased prostatic condition or stone in
the bladder. Increased frequency of urination is a symptom
in a large variety of conditions; it may point to diabetes, to in-
creased ingestion of fluid, to polyuria (due to interstitial nephritis),
to various forms of gravel, to disease in the upper urinary passages,
to the influences of heat and cold, and to reflex irritation (in both
men and women) from diseases of the neighboring organs. In
young men it generally indicates some disease of the urethra; in
the elderly, as is well known, it points to diseases of the bladder or
prostate.

A diminished amount of urinary excretion or diminution in the
frequency of its elimination may be due to an unusually small in-
gestion of fluid or to excessive perspiration. The smallest amounts
that we have observed passed by healthy subjects have occurred
in cooks, stokers, and others whose occupation subjected them
to prolonged exposure to heat, and who did not counterbalance
the excessive perspiration by the ingestion of a proper amount
of fluid. Zuckerkandl considers stricture and enlarged prostate
as occasional causes of this condition; we believe that whereas

GENERAL EXAMINATION OF PATIENTS 21

they may occasionally be a cause of infrequent urination, the
converse is more often true. Tabes and other disturbances of
the spinal cord are also causes. The habit of many, particularly
of women employed in manufacturing establishments, of refrain-
ing, for as long a time as possible, from answering nature's demand
for the performance of this physiologic function is a common
cause of this condition. It is unfortunately too true that proper
accommodations are not always afforded to the employed, and
that a sense of delicacy often acts as a factor. Continued over-
distention of the bladder may later lead to the development of
cystitis, and this may explain the reason why women are more
often affected with cystitis than are men.

Whether there has been a change in the caliber of the stream
should be ascertained, although a correct conclusion can rarely
be reached in this way. Change in caliber from the normal is
ordinarily due to diseases of the urethra, such as stricture, which
may lead to the ejection of a crooked or a forked stream. Diseases
of the prostate, nervous system, or bladder-walls may give rise to
a mere dribbling of urine. Here it may be well to mention that
the careful anatomic investigations carried on by Ciechanowski
on the amount of muscular tissue in the bladder-walls in healthy
individuals show that in the aged there is a lessening in the
amount of normal bladder muscle tissue; that in old men,
as shown by accurate measurements, only about two-thirds of
the amount of muscular tissue present in healthy adults exists.
In children a long tight foreskin causes greater diminution in the
caliber of the stream; in adults, increase in size of the meatus
affects the caliber of the urinary stream. The force is also depen-
dent, to a great extent, upon the condition of the nerves and mus-
cles of the bladder and urethra, and upon the presence or absence
of urethral obstruction. When the stream is suddenly completely
checked, only to start again at full caliber, stone in the bladder
is generally indicated. If prostatic obstruction exists, the stop-
page is more gradual, ending in a sort of dribbling. Other bladder
lesions besides stone may probably give rise to sudden stoppage
of the flow. It has been observed in old men the trabeculae of
whose bladders were thickened and in whom repeated examina-
tions failed to elicit the presence of stone.

22 GENERAL EXAMINATION OF PATIENTS

The question as to whether or not pain accompanies urination
may not furnish much information, owing to the marked dif-
ferences regarding sensitiveness to pain that exists between various
individuals. Those suffering from neurasthenia or hyperesthesia
of the deep urethra may complain of painful micturition ; whereas
those suffering from marked organic disturbance in the urethral
canal may not. Some writers believe that pain occurring at
the beginning of urination indicates disease of the urethra and
prostate, and that pain at the end indicates disease of the bladder.
Pain in the bladder between the acts of urination may indi-
cate stone, tumors, or pus-formation in the prostate. Concen-
trated urine and the passage of gravel, as is well known, will give
rise to pain and disease of the bladder. Pain is most prolonged
and marked in the bladder region in acute cystitis, which may
be associated with tuberculosis or tumors, more especially those
of a malignant type. Tumors of the prostate, particularly cancer,
exhibit pain in the prostate as one of their most characteristic
symptoms, but this does not necessarily give rise to painful mic-
turition unless the disease has advanced beyond the prostatic
capsule. Pain in the glans penis is often caused by stone in the
bladder, and is less often associated with cystitis or gravel, which
gives rise to painful urination. Marked neurasthenics are oc-
casionally subject to spasmodic attacks of tenesmus, which occur
in the day-time, never at night, last for an hour or two, and pass
away. These attacks resemble those occurring from gravel. As
a general rule, gradual recovery follows. The origin of these
attacks is, at the present time, unknown.

An inquiry into urinary retention, partial or complete, may
elicit valuable information. Complete retention is in most in-
stances due either to strictui^e, more apt to occur in early life, or to
an enlarged prostate, the latter being usually the case in the aged.
Rupture of the urethra, coagulated blood in the bladder, and
various forms of apoplexy and paralysis may cause retention.
It also frequently follows a surgical operation for hemorrhoids,
gynecologic operations, or excessive tamponade. A condition of
chronic retention may be caused by overdistention of the bladder
and by hypertrophied prostate.

Incontinence may be due to acute urethritis and to prostatic

GENERAL EXAMINATION OF PATIENTS 23

disease; almost any injury of the muscles about the neck of the
bladder may act as a cause, and in children it is often seen as the
result of inefficient innervation. New-growths and diseases of the
spinal cord are also causes. Suprapubic, urethrorectal, or perineal
fistulas occurring after operations or as a result of tuberculosis
may give rise to this condition. It more frequently follows a
suprapubic or a urethrorectal than a perineal fistula.

Questions should be asked concerning the character of the urine
passed, whether its color is normal, dark, light, bloody, black, or
milky. In diabetes and chronic diseases of the upper urinary
tract straw-colored urine is the rule. Black urine, or that which
becomes black after standing a short time, is generally due to the
ingestion of carbolic acid or other hemolytic substances, and occa-
sionally it is due to the formation of a substance called melanin;
this last renders the urine cloudy, with the deposition of black,
sooty particles. When the urine is bloody, it may be of a dark
hue, and is then probably due to hemorrhage in the upper urinary
passages. The clot formations in the ureter, passed out in the
urine, and resembling earth-worms, are diagnostic of renal hemor-
rhage. Bloody urine is often, of course, due to disease of the blad-
der or ureter; fresh colored blood in the urine is usually the re-
sult of disease of the urethra. Blood is seen in the urine after
certain forms of trauma, stone, after the ingestion of various
drugs, such as cantharides, and as an accompaniment of infectious
diseases, such as typhoid fever and malaria. Malarial fever may
not infrequently give rise to hematuria, but hematuria associated
with malaria very rarely occurs in a previously undamaged urethra.
Blood in the urine may be the first symptom of tuberculosis of the
urinary tract, especially of the kidney. Milky colored urine may
be due to the admixture of pus or to phosphaturia or chyluria ; and
thick, brownish-colored urine to the presence of urates. Filaria
and various forms of parasites may give rise either to bloody or to
milky urine.

The history of previous diseases should be thoroughly inquired
into, since such diseases as scarlatina, syphilis, or even previous
attacks of urethritis cause changes in the kidneys. A knowledge
of the habits of the patient's life, his occupation, and the climate
to which he has been accustomed will also be of assistance not

24 GENERAL EXAMINATION OF PATIENTS

only in the making of a correct diagnosis, but also in indicating
the prognosis and formulating the treatment. All observers are
agreed as to the difficulty in effecting a cure in so common a con-
dition as urethritis in persons subject to much vibration, such as
railroad employees or automobilists experience.

Information can also be obtained by inquiring into the sexual
life of the patient.

These manifold questions demand painstaking effort on the
part of the examiner; but if by so doing he is able to encourage
the confidence of his patient and if his judgment is sufficiently keen
and his faculties in general are sufficiently discriminative to enable
him to ascribe the proper clinical import to the facts elicited, the
diagnosis, which often can be reached in no other way, will be
sufficiently accurate to reward his efforts.

General inspection of the patient may follow the questioning.
His actions and the manner in which he replies having previously
been noticed, his body should now be carefully examined. In
some diseases of the kidney, bladder, and prostate the hair pre-
sents a dry and brittle appearance that, once seen, is easily recog-
nized. In secondary syphilis, round patches of alopecia are fre-
quently seen. Any eruption on the face, neck, or trunk, old scars,
and growths may all tell their tale. Disturbances of the pupil
may be indicative of locomotor ataxia, which is often mistaken for
some disease of the urinary apparatus, an error that should be
guarded against. The condition and shape of the teeth may show
the result of hereditary syphilis. Important aid may be obtained
from studying the color of the lips, a bluish hue indicating possible
venous stasis. The position of the apex-beat of the heart, espe-
cially if it occurs below or to the left of the normal point, is
well worth ascertaining. The cremasteric, knee-jerk, and ankle-
clonus reflexes should be tested. The power of coordination
should be investigated by the simpler tests, such as having the
patient stand with his eyes closed and his heels and toes together
and bringing the index-fingers in apposition. Cases of disturbed
urinary function difficult of diagnosis have been brought under
our observation in which the increased knee-jerk reflex seemed
to eliminate locomotor ataxia and in which the patients were
not neurasthenic, the increased reflexes afterward proving to

GENERAL EXAMINATION OF PATIENTS 2$

be due to a myelitis that preceded the onset of locomotor ataxia.
Undoubtedly many somewhat similar cases are confounded
with organic disease of the urinary tract, the practitioner fail-
ing to grasp the significance and seriousness of the existing ner-
vous symptoms. Involuntary muscular contractions should be
inquired into. A tendency to lift one leg is often indicative of
abscess formation on that side, and is associated frequently with
pyelonephritis.

A physical examination by means of percussion and palpation,
and an examination of the secretions should now be made before
proceeding to instrumental examination. It is very often pos-
sible, as the result of questioning alone and through a process
of exclusion, to arrive at a fairly accurate diagnosis. The physical
examination of the kidneys is elsewhere exhaustively considered,
but will be merely alluded to here. Casper states that by percus-
sion it may be possible to diagnose a kidney tumor from an intes-
tinal tumor, as the latter gives rise to a tympanitic sound; person-
ally, we have not been able to obtain much information from
percussion. The statement, so widely believed, that a kidney
tumor will fall backward when the patient is lying on his back,
with pelvis and legs lifted, is a method of differentiation that we
have also found of no use. Clinically, we have found that tumors
of the kidney can be accurately differentiated from those involving
neighboring organs only by performing an exploratory operation.
However, palpation with percussion will often be the means of
determining the presence or absence of tumors of the kidney or
neighboring organs. In order to obtain the best results from pal-
pation of the kidney the patient should be on his back, with knees
flexed, but avoiding 'all tension of the abdominal muscles; the
examiner should place one hand beneath the back and press up-
ward between the crest of the ilium and the last rib; the other
hand should be placed directly over this, and press downward on
the abdominal wall. A similar procedure may be carried out
with the patient lying on one side or standing and bending over a
chair.

As mentioned in the chapter on the Kidney, it is well to mas-
sage and manipulate the abdomen, following the course of the
ureter in the case of suspected pyelonephritis; as a result of this

26 GENERAL EXAMINATION OF PATIENTS

manipulation pus or an increased amount of it will be noticed
in the urine. Pyelonephritic kidneys are usually tender on
pressure, although it is sometimes difficult to determine whether
the tenderness is due to a diseased kidney or to some other
condition, such as the result of injury to the sacro-iliac synchon-
drosis.

Percussion and palpation of the bladder region are occasionally
of value. It should be remembered that patients suffering from
prostatic hypertrophy may have thickened bladder-walls, or, as a
result of retention, the bladder may be much distended. This
latter condition, together with a thickened bladder-wall, we
have known mistaken for an abdominal tumor. In any one, male
or female, even if no history of retention has been given, in whom
the presence of an abdominal tumor is suspected, unless its nature
can be very clearly determined by other means, it is well to
catheterize the bladder and study the results. The groins should
be palpated to ascertain the presence or absence of hernia. Re-
tained testicle should be looked for, and the general appearance
of the genital organs observed. The condition of the foreskin
should be learned, and disease or ulceration of the testicle looked
for. The nature of the scrotal contents should be ascertained,
for it should be remembered that tuberculosis is prone to cause
early invasion of the testicle or epididymis.

An examination of the heart will reveal an^'^ tendency toward
enlargement, either from the dilatation or the hypertrophy so
closely associated with kidney disease. The pulse, either with
or without sphygmographic tracings, will give some conception of
the amount of arterial pressure. The temperature will indicate
the presence or absence of fever, which may have its origin in the
urethral canal.

Urinary fevers may be divided roughly into three classes :

I. There is a continuous form that comes on a few hours after
catheterization, rupture of the urethra, or some form of trauma;'
it is generally inaugurated by a chill, followed by high temperature,
which subsides in a day or two at the most, when convalescence
ensues. Occasionally this fever is of a fulminating character, the
temperature remaining very high, death sometimes occurring in
a comparatively short time.

GENERAL EXAMINATION OF PATIENTS 27

2. The second form of urinary fever is intermittent in charac-
ter, with only a slight rise in temperature, followed by a return
to the normal, and then another rise; clinically this resembles
mild malarial fever. It may be due to injury caused by improper
instrumentation, or it may be associated with the presence of pus
in the prostate, kidney, bladder, or elsewhere.

3. The third class is of a remittent type, the temperature,
while not high, never reaching the normal until convalescence.
Just as in gangrene of the appendix or other organs, it occasionally
happens that an abscess in the urinary tract may cause such pro-
found sepsis as to result fatally without exhibiting a rise in tem-
perature. We have met such a case due to a large abscess in the
prostate.

In most fatal cases of urinary sepsis attended with fever post-
mortem examination reveals multiple abscesses of the kidney.
When death has resulted directly or indirectly from stricture or
from prolonged retention, the postmortem shows that dilatation
of the ureters takes place, that the pelvis of the kidney has become
infected, and that multiple abscesses have formed in the kidneys
as the terminal process in the disease.

The treatment of urinary fever should be that of the treatment
of sepsis following disease in other portions of the body. Prophy-
laxis through surgical cleanliness, gentleness in instrumentation,
proper drainage, prompt surgical interference, stimulants when
required, salt-water enemas, warmth, rest in bed, and measures
to support the heart are indicated. Proper prophylactic meas-
ures may consist in the internal administration of urinary antisep-
tics or of quinin, either for some time before or immediately fol-
lowing any instrumentation or operation on the urinary tract.

The examination of the prostate may profitably be postponed
until after instruments have been passed into the urethra, should
the diagnosis necessitate the latter measure. By observing this
rule the danger of urethral infection is somewhat lessened. But
when instrumentation is not to be resorted to, the examination
of the prostate may terminate the general physical examination.
A thorough examination of this gland can best be made with the
finger in the rectum after an instrument has been placed into the
bladder and allowed to remain there; this affords a means of

38

GENERAL EXAMINATION OF PATIENTS

estimating the distance between the finger and the instrument.
The ordinary procedure for prostatic examination through the
rectum is to have the patient bend over a chair or a table; the
examiner introduces the forefinger of the right hand, covered
with a well-lubricated finger-tip, into the rectum, and searches
for any enlargement of the prostate or of the seminal vesicles.

Fig. I. — Examination of the prostate by the rectum only. Also position for massage of the

prostate.

Any difference between the two lobes can be ascertained at the
same time, also any points of softening that might be indicative
of a prostatic abscess. When the latter condition exists, a sort
of dimple will probably be present in the prostate. When the
abscess is extensive, slight massage of the side of this dimple may
cause pus to exude from the meatus. Should the patient urinate
after the massage, if abscess of the prostate is present, the urine

GENERAL EXAMINATION OF PATIENTS 29

will usually contain large quantities of pus. When the seminal
vesicles are enlarged, they will ordinarily be found to run off like
cords, at an angle with the apex of the prostate, forming with it a
triangle whose base is the base of the bladder and whose apex is the
prostate. Massage may also be applied to the seminal vesicles and
to the prostate for the purpose of obtaining their contents for
microscopic examination and for the purpose of locating painful
areas.

In women a vaginal examination may give considerable infor-
mation as to the condition at the base of the bladder, and when
made bimanually, as to the condition of the ureters. With thin
male subjects it is well, besides examining the prostate through
the rectum by the method previously suggested, to place th2
patient on his back, and to introduce the forefinger of the one hand
into the rectum and, with the other hand on the abdomen, to
press down over the suprapubic region. Considerable experience
is necessary to correctly diagnose diseased conditions of the pros-
tate or seminal vesicles by means of rectal examination alone, no
instrument at the time being present in the bladder, and we find
that even intelligent members of house staffs in hospitals are
repeatedly making mistakes as to the findings derived from that
procedure and drawing false conclusions from it. The mistake
most frequently made is that of supposing an enlargement of the
prostate or seminal vesicles to exist when none is present. In-
formation concerning a stone in the bladder can rarely be ascer-
tained by rectal examination, and still more rarely is it possible to
learn the condition of the ureters in the male by this method.

An examination of the secretions is the next step in order, and it
is best that this be made, in part at least, at the patient's first
visit. When tuberculosis is suspected, prolonged examination is
necessary to detect the presence of the tubercle bacillus with abso-
lute certainty, and some time must elapse before the diagnosis
can be arrived at. Other conditions, however, may be more sum-
marily dealt with. In cases of acute urethritis the discharge may
be washed out from the urethra as far as the bulb, and the urine
may then be passed and collected for examination. After this
process the bladder may be washed out, emptied, and, if thought
advisable, the prostate massaged, and an attempt at urination
made. A few drops of this urine should be preserved for a future

30 GENERAL EXAMINATION OF PATIENTS

examination, in order to ascertain the condition of the prostate
and seminal vesicles. In those individuals in whom no acute dis-
charge is present, washing out of the anterior urethra will be un-
necessary; the patient should, however, be requested to urinate,
and the urine be set aside for examination or a simple examination
immediately made.

We have found some of the glass tests advocated for the purpose
of locating the seat of urethritis to be misleading. One of these
fallacious tests is to have the patient pass half the urine into one
glass and half into another. If the urine in the second glass is
clear, whereas cloudiness or shreds are present in the other, this has
often been thought to prove conclusively that the inflammation is
confined to the anterior urethra. This test has been proved to be
unreliable, since if but a slight amount of discharge were present,
it could be washed out with the first half of the urine passed, even
when the inflammation extended, as it usually does, throughout
the entire urethral tract. The test may, however, have a relative
value if made when a large amount of urine is in the bladder, as on
the first urination after rising. If both glasses are then found to be
cloudy, and the patient is asked to urinate in the same manner
later in the day, when the bladder contains but a small amount, and
all the cloudiness is found to be confined to the first glass, this
would indicate the existence of a posterior urethritis ; if, however,
then neither glass is clear and the cloudiness is seen microscopically
to be due to pus, or the shreds to be made up of pus-corpuscles, a
cystitis or kidney involvement would be demonstrated. If the
early morning urine is collected in three glasses and all are found
to be cloudy and to contain pus or numerous shreds, it indicates,
generally, that the inflammation is beyond the posterior urethra.
These various glass tests will be referred to again under the
Diagnosis of Urethritis (p. 375).

The chemic examination of the urine is dealt with in more detail
elsewhere (p. 88), but there are several valuable simple tests
for learning some of its possible constituents that may be made
expeditiously at the time the patient is being examined. Cloudy
urine is ordinarily due to the presence of mucus, pus, bacteria,
urates, phosphates, carbonates, or albumin; a simple test for
determining to which of these agents the cloudiness is due has
been outlined by Ultzmann, of Vienna. A portion of the urine

THE INSTRUMENTAL EXAMINATION 3 1

is placed in a test-tube and the upper portion boiled. If it imme-
diately becomes clear, the cloudiness is due to the presence of
urates; if it becomes more cloudy, to phosphates, carbonates, or
albumin; and if it remains unchanged, to pus or mucus. If, then,
by, adding a drop of dilute acetic acid to the urine it is immediately
clarified, the cloudiness was due to an excess of phosphates ; and if,
in addition, it effervesces in clearing up, it was due to carbonates.
If it becomes still more cloudy, albumin is present, and if it remains
unchanged, pus, mucus, or bacteria may be said to be present.

A very popular test for mucus or pus is to add an equal amount
of liquor potassae to the urine in the tube ; shake the tube well,
and if the mixture shows considerable cloudiness, particularly
if of a stringy character, the presence of pus or mucus may be
said to be established.

It is hardly necessary to state that when the presence of any
of the above-mentioned substances has been detected, these tests
must be further confirmed by means of more accurate methods.

THE INSTRUMENTAL EXAMINATION
The verbal and physical examination of the patient having
been completed and the urinary and other secretions of the body
having also been examined, it is often necessary, in addition, as
previously mentioned, to complete the examination by the intro-
duction of some instruments, such as a catheter, bougie, sound,
searcher, or possibly endoscope or cystoscope, into the urethra or
bladder. A detailed description of all these instruments is unneces-
sary; the following are those that have given the most satisfac-
tion in the writer's hands. For ordinary purposes of catheter-
ization, the soft-rubber, velvet-eyed catheter is probably the form
most generally used. The smaller catheters are to be preferred
to the larger. No catheter should be used ordinarily that has
any hole besides the eye, and care should be taken that there
are no rough places on the instrument that might scratch the
urethra — -particularly, that there is no joughness about the eye.
Often, after very little use, the edges of the eye of the catheter
become roughened. This should be particularly guarded against
where the services of a physician or of a trained attendant cannot
be procured, and where the patient must be taught to use the

32 GENERAL EXAMINATION OF PATIENTS

instrument himself. The shafts of these catheters, as ordinarily
made, are round. Soft-rubber catheters, somewhat flattened at
the lower end, have recently been put on the market. They are
said to be useful in cases of enlarged prostate ; the urethra being
stretched by the prostatic enlargement, is necessarily generally
narrowed from side to side, and a catheter somewhat flattened on
the side will thus more easily conform to the shape of the canal.
They are also made flattened at the top and the bottom. Soft-
rubber catheters have very little penetrating force, their intro-
duction being easily hindered by stricture of the urethra ; in cases
of enlarged prostate, moreover, where the prostate alters the
natural curve of the urethra, they are particularly likely to curl
up at the bulbomembranous junction. They are also introduced
with difficulty if a spasm of the urethral muscle — a so-called
spasmodic stricture — exists.

Catheters of gummed linen or silk with flexible olive ends pre-
ceding the entrance of the eye are extremely useful, when pro-
perly constructed. They are of value not only for the ordinary
purpose of a catheter to empty the bladder, but are useful for
examining the urethra in both its anterior and its posterior por-
tions, as the flexible bulbous point very easily detects any irregu-
larity in the canal. Then, too, they are useful as a means of mak-
ing applications to the posterior urethra and bladder. In choos-
ing catheters of this description great care should be exercised.
As ordinarily made in this country, the olive-pointed ends are too
inflexible, and the catheters partake too much of the nature of an
Indian arrow. Such instruments are likely to do more harm than
good. When the ends are extremely flexible, however, they are
useful in overcoming urethral obstacles, such as strictures of not
too small caliber; they are more useful than soft catheters in
overcoming spasms at the neck of the bladder, and if flexible enough
and not too large, will not irritate the urethra. Ordinarily they
can be introduced into the bladder with less pain to the patient
than any other form of catheter. For emptying the bladder,
where this must be done rapidly, they are not, as a rule, so service-
able as some others, and in old prostatics, with large quantities
of residual urine, or in cases where a large amount of fluid is to
be evacuated from the bladder, they may not be found so prac-

THE INSTRUMENTAL EXAMINATION 33

tical as the soft-rubber catheters or those of some other shape or
material, on account of their comparatively small lumen. Ordi-
narily, they may be procured in two forms — those whose upper
extremity is of the same circumference as the shaft, and those in
which the upper extremity is funneled, in order that the fluid may
be more easily injected through them by means of the nozzle of a
syringe. For this same purpose a small piece of rubber tubing may
be attached to the upper extremity and the nozzle of the syringe
introduced into this. These have been found more useful than
any other instrument for the purpose of irrigating the deep
urethra and the bladder. The best of these instruments are those
made in France. The most practical for use are Nos. 10 and 12
French.

Being unirritating, they are useful for purposes of irrigation
where it is desired to introduce quite a large quantity of fluid
along the floor of the posterior urethra and into the bladder. They
are also very useful for purposes of instillation — that is, the pro-
cess by which a few drops of fluid, generally some strong solution,
are applied to the neck of the bladder.

The uselessness of a multiplicity of instruments has often been
proved. Clinical experience has demonstrated that these simple
bulb-pointed flexible tipped catheters are useful for purposes for
which many different forms of instruments are advocated. Silk
gum catheters with stylets — the stylet being introduced for the pur-
pose of making them unyielding and permitting them to be bent
into any desirable shape — have often been used in the past and
are still recommended by some as the best form of catheter for use
by old men who are obliged to use one constantly. Their value
has probably been very much overrated. An ordinary soft-rubber
catheter is the safest one for the individual to use on himself.
When, because of malformation of the prostate, the soft catheter
cannot be made to penetrate, one of the larger sizes of the French
olive-tipped flexible catheters, just described, should be tried.
That failing, one of the particular shape best adapted to overcome
the particular form of prostatic obstruction present should be used.

There are three forms of these catheters: the "Mercier
coudd," "bicoude," and the large prostatic curve (see figs.
2, 3, 4, 5). The instruments with the large curves are ordi-
3

34

GENERAL EXAMINATION OF PATIENTS

narily made of metal, and the smaller are made of either metal
or silk. The simpler curves, such as the "Mercier coud^,"

Fig. 2. — German silver metal catheter, with ordinary urethral curve.

should first be tried in an endeavor to pass through an obstructed
prostatic urethra; if these fail to pass, the "bicoud^," or the cath-

Fig. 3.— Mercier's coudfi catheter.

eter with the large prostatic curve, may be tried. Often a metal
catheter with the ordinary normal urethral curve will be found

"!Sr

Fig. 4.— Mercier's bicoud6 metal catheter.

useful. It is advisable to keep on hand a series of metal catheters
of the following four types : "Normal curve," "Mercier," "coud6,"

J^

-or

^nQ

Fig. 5i — Metal catheter with prostatic curve.

"bicoud^," and large "prostatic" curve. The use of retention
catheters is coming into increased favor. They usually consist

THE INSTRUMENTAL, EXAMINATION 35

of an instrument with a collar, the Pezzer retention catheter
(fig. 6), or a catheter with a wing on each side, the Malecot
retention catheter (fig. 7) ; the catheter being introduced into
the bladder, the collar or wing prevents its escape unless some
little traction is used by the attending surgeon. An ordinary
catheter may be held in place in the bladder by fastening linen
threads around the glans, or by the use of adhesive plaster.
These retention catheters sometimes remain in place for a period
of two weeks without necessitating removal or causing much irrita-

Fig. 6.— Pezzer retention catheter.

tion. It not infrequently happens that in those cases in which it is
most desirable that a catheter be retained, as after operations on
tubercular subjects, this will not be found feasible. A retention
catheter must generally be eventually removed because of the
local irritation it produces inside the bladder at its neck ; its pres-
sure sometimes sets up a general urethritis.

Zuckerkandl^ considers that a retention catheter can be retained
longer without causing irritation, the urethra being better pro-
tected from infection from the outside if a spica bandage, com-

Fig. 7.— Malficot retention catheter.

mencing at the base of the shaft of the penis, is wound around it
to the glans, over the glans, and for an inch or two on the shaft of
the catheter, the other end of the catheter being run through
sterilized cotton in the neck of the bottle or other receptacle that
is to receive the urine.

Bougies are instruments made of gummed silk or linen, and are
used for the purpose of examining the urethral canal or for dilat-

* " Die Asepsis in der Urologie," Friesch und Zuckerkandl, " Handbuch
der Urologie," Vienna, 1904.

36 GENERAL EXAMINATION OF PATIENTS

ing strictures. Filiform bougies, so called from their minute size,
are ordinarily used as guides to effect an entrance into the bladder
in cases of retention from stricture of the urethra. Ordinarily
they are made of whalebone, although the very small ones recently
introduced are made of catgut. These catgut bougies are useful
little instruments, for by their means the bladder may be entered
when all other forms of bougies have failed. They are not, how-
ever, ordinarily required, and are very easily so damaged as to
unfit them for use. The filiform bougies made of whalebone are
generally put up in different lengths, the longest being twice that
of the short ones. Where it is impossible to obtain the assorted
lengths, the long ones should preferably be kept on hand. In
cases of stricture in a long urethra, after introducing a short bougie
into the bladder it occasionally happens, if an attempt is made
to run a tunneled sound over it, that the upper end of the bougie,
if a short one is used, will be carried into the urethra, beyond the

meatus. Whalebone bou-

_g ■:^>^'^ff :• gies have small flexible

— "t^^^^^^^ rounded points on their

Fig. 8. -Olivary gum bougie. cuds ; othcrs end with

straight points, and still
others are twisted. The choice of these for general use is depen-
dent on the surgeon's preference; ordinarily, when it is possible
to pass them, the round-tipped ones are to be preferred. A
filiform bougie, made of whalebone, of the ordinary circumference
of the fiUform at the lower extremity, but with a long shaft grad-
ually increasing in circumference, has been on the market for
several years under the name of the Banks filiform, or whip bougie.
Experience with this instrument has demonstrated that, being
made of whalebone, it is not flexible enough to possess much ad-
vantage over the ordinary filiforms. To overcome this, Tiemann
& Co., of New York, have, at our suggestion, had instruments made
in Paris of the same shape as the Banks bougie, gummed silk taking
the place of whalebone. These instruments are found to be much
more flexible and useful, and are recommended as a useful addition
to the surgical outfit of the general practitioner. In cases of stric-
ture, the flexible point having passed the strictured portion, it is
only necessary to keep pushing the instrument down through the

THE INSTRUMENTAL EXAMINATION 37

urethra — the lower end of it will double up in the bladder until
the largest part of the circumference has passed the strictured
portion, thus dilating the stricture. Following the removal of
this instrument a silk, oHve-pointed bougie of small caliber can
ordinarily be passed. These olive-pointed silk bougies may be
obtained in the various sizes up to No. 20 French or larger. They
are useful for dilating strictures of small caliber, but should not,
ordinarily, be used of a circumference larger than the No. 20
French; when it is desired to dilate through a larger opening,
metal instruments should be substituted. In choosing these
bougies it is always well, as previously stated, to obtain those
with the most flexible neck, thus lessening the danger of inflicting
injury on the urethra.

Bougies a boule are used for examining the urethral canal.
They may be had in varying sizes. They are made of either rubber
or metal, the former being preferable, and are useful for locating

Fig. 9. — Otis' metallic bougie sl boule.

any foreign masses or other constricting lesions that may exist
in the anterior urethra ; they are also useful for diagnosing the
various forms of stricture that may occur there. An obstacle
having been met, the largest bougie h boule that will pass the
obstacle can be introduced through the urethra; if the next size
larger will not penetrate, a correct idea may be had as to the cir-
cumference of the urethra at the strictured portion. These in-
struments are not to be recommended in the treatment of disease,
and it is not advisable, ordinarily, to use them for diagnostic pur-
poses or for detecting or treating lesions beyond the bulboraem-
branous junction. For ordinary diagnostic purposes the flexible
olive-pointed gum bougie previously described is preferable.

Various ingenious contrivances have been devised for accurately
measuring the circumference of the anterior urethra. These
instruments, with the exception of the bougies k boule previously
mentioned, are known as urethrometers. The only one that will be

38

GENERAL EXAMINATION OF PATIENTS

described here is the Otis urethrometer, which was designed by
the late Dr. Fessenden D. Otis, of New York. It fulfils the pur-
pose for which it was designed so well that any description
of the various other instruments, mostly of foreign make,

invented for this purpose is needless.
The instrument, with the end of
the shaft closed, is passed through
the strictured portion of the urethra
and distended until it cannot be with-
drawn because of the obstacle in front
of it. The index on the dial plate
will show the circumference of the ure-
thra at the strictured portion. The
end can then be contracted enough to
allow the strictured portion to be
passed, and later again, as the instru-
ment is withdrawn, distended to show
the presence and size of any other stric-
tured portion that may be met.

Sounds are steel instruments varying
from Nos. lo to 40 French scale, and
ordinarily used for distending the ure-
thra in the treatment of stricture ; they
are also introduced for their general
effect in relieving hyperemic or chron-
ically congested conditions of the mu-
cous membrane of the urethra: this is
accomplished as the result of pressure.
The numbers most ordinarily used are
from No. 15 to No. 35 French. These
sounds are obtained with curves vary-
ing as regards either their form or
length. The several different forms of
curve ordinarily on the market have about the same degree
of usefulness. Every surgeon's outfit should contain a few
sounds with the so-called Benique curve, which are partic-
ularly useful in cases of enlarged prostate. Sounds having the
Guyon curve are, for ordinary purposes, probably as good as any

Fig. 10. — Otis' latest urethrometer.

THE INSTRUMENTAL EXAMINATION

39

that can be procured. The blunt-pointed sounds now on the
market are undesirable, there being very little difference in their
size from their extreme end to their full circumference. Ex-
perience has proved that such sounds are much more difficult to
introduce into the bladder than those of tapering form. It must
be remembered that a sound
must answer the purposes
of a wedge to a considerable
extent, and it should, there-
fore, be shaped accordingly.

Straight sounds may also
be had, and are used at
times for distention of stric-
tures of the anterior urethra.

Searchers are instruments
used for detecting the pres-
ence of stone and tumors
in the bladder, and for ob-
taining a general idea of
the topography of the blad-
der, prostate, and urethra.

They are made in various shapes and forms, but the Thompson
searcher is the one most generally used. Hollow searchers answer
the purpose of metal catheters. Their use is described in detail
in another portion of the book. In purchasing searchers care
should be taken to see that the plug at the upper end is well
fitted in and is secured to the end of the searcher by a chain.

Fig. II. — Showing proper (A) and improper (B)
conicity of sound.

V

' «^' ' ■ " n

S^^^SffiXjlJ

Fig. 12. — Thompson's searcher.

Short straight sounds of large diameter are useful for keeping
the meatus distended after meatotomy has been performed. In-
struments, such as the cystoscope and the endoscope, which are
useful for examining the urethra, under direct or artificial light,
are described in detail elsewhere.

40

GENERAL EXAMINATION OF PATIENTS

Glass syringes may be had in several different forms, having
ordinarily a capacity of from four to six ounces; the advantage
of these is that their contents are visible. For general urethral

Fig- 13— Janet syringe.

purposes, however, metal syringes, some of which are so made
that they can be easily taken apart and sterilized, are the most
useful.

Fig. 14.— Janet syringe.

For the patient's own use, blunt-pointed glass syringes with or
without rubber ends are useful.

For bladder irrigation the syringe with a large rubber bulb

Fig. T5.— Hayden-Janet syringe.

and stop-cock, as illustrated in Fig 16, is the one that will be
found most convenient for the patient's own use, where an en-
larged prostate gives rise to the necessity for catheter life.

CATHETERIZATION

41

In addition, there are various forms of instruments, some of
which are to be attached to the syringe especially designed
for making applications to the deep urethra. The two best

Fig. 16.— Rubber bag and stopcock for injecting.

known of these are the Ultzmann syringe, for instillation,
and the Ultzmann metal catheter for irrigating purposes.

Instruments to be used for similar purposes have been devised
by Guyon and many others. Experience has proved that, either
for instillation or for irrigation, as good results can be obtained

Fig. 17. — Ultzmann's syringe for instillation.

from the use of the ordinary flexible, olive-pointed silk catheter of
small caliber.

CATHETERIZATION

In the chapter on the Sterilization of Instruments and the

Fig. 18. — Ultzmann's irrigator for deep urethra.

Preparation of Patients for Operation the question of sterility as
regards instruments and the field of operation in catheterization
is considered more in detail (p. 77), for, after all, it is well, as has

42 GENERAL EXAMINATION OF PATIENTS

been stated by other writers on the subject, to regard catheteriza-
tion as an operative measure. It should be constantly borne in
mind that as the urethra is the natural habitat of organisms
capable of setting up inflammation when an opening offers from
any traumatism that may occur there infection is liable to arise,
hence the necessity of observing all possible precautions to render
the field and the instruments sterile. More with the view of
refreshing the reader's memory than from a desire to improve
upon the directions given in many text-books on surgery as to the
manner in which a urethral instrument should be passed, the
following description is given:

In order to properly enter the bladder, the catheter, bougie, or
sound must, after the instrument passes the bulbomembranous
junction, correspond in shape to this curve. The steel and some
of the silk instruments already mentioned are curved before using,
following either the normal curve, or being made to correspond
to any deviation from the normal curve of the urethra, such as
might be caused by an enlargement of the prostate. The straight
instruments, being flexible, are made to assume the proper curve
by the pressure from the urethra in its curved portion. The
pendulous urethra, being straight from the meatus to the bulbo-
membranous junction, a straight instrument, if flexible, will
penetrate as far as the bulbomembranous junction, but after
this point is passed, and we get beyond into the remaining por-
tion of the urethra to the bladder, a fixed canal is encountered.
This being the case, it should be borne in mind that both the
flexible and the fixed urethra must be so dealt with as to cause
the least possible irritation, and also that the beak of the instru-
ment, having entered the bladder, is not to be pushed so far back
into the bladder as to cause injury to the posterior bladder-wall.

In passing a straight flexible instrument, the field having been
properly cleansed and the instrument lubricated, it may be
introduced with the patient either lying down or standing, the
operator standing on either side of the patient, as may seem most
convenient. The instrument is passed easily in as far as the
bulbomembranous junction, at which point, ordinarily, some
slight resistance is met. Individuals of the neurotic type are
extremely likely to exhibit sensitive points in the anterior ure-

CATHETERIZATION 43

thra, even if little or no organic disturbance exists there. Under
such circumstances pain will be considerably lessened by using
a generous amount of lubricant, and passing the instrument very
slowly; by grasping the glans penis and extending the urethra,
and at the same time pressing on the bulbomembranous junction
with the finger over it on the perineum, the angle will become a
little less acute where the pendulous urethra joins the beginning
of the fixed curved portion of the urethra, and the instrument
will slip more easily into this curved portion.

The resistance which the straight instrument meets when
passed as far as the bulbomembranous junction, if no stricture
exists, may be owing to the contraction of the sphincter urethrae
muscle. This is generally more pronounced in neurotic persons
and in those on whom the catheter is passed for the first time,
and is again referred to under spasmodic stricture. In passing a
straight instrument, by elongating and depressing the penis, there-
by putting the urethra on the stretch, and by making slight gentle
perineal pressure, this obstruction, if present, is generally overcome.
Care should be observed not to exert too much pressure, and that
it may be directed properly.

In passing instruments, whether straight or curved, the portion
of the urethral canal most likely to be injured is the floor of the
urethra at the bulbomembranous junction.

It is a safe plan, in using either a straight or a curved instru-
ment, to keep closely to the roof of the urethra until the instru-
ment has entered the curved portion, pushing it forward with a
slow and gliding movement; it should be borne in mind in every
case, whether the instrument is passed by the operator or by the
patient himself, that the object sought is to make the end of the
catheter find the anterior opening of the fixed portion of the
urethra. If the operator loses sight of this aim, he may fail to
find the opening.

Ordinarily, when a catheter, either straight or curved, enters
the bladder, this is evidenced by the relaxation of the contracted
muscle or by the escape of a small quantity of urine from the end
of the catheter. In thin subjects this fact may also be easily
determined by placing the palm of the hand on the abdomen
above the pubes, when the beak of the instrument can be felt

44

GENERAL EXAMINATION OF PATIENTS

against the hand if a curved metal sound or catheter has been
used. If doubt exists, three or four ounces of fluid may be injected
through the catheter by means of a syringe. If the fluid runs into
the bladder, ordinarily it will return through the catheter when the
latter is depressed. If it does not run out again through the cathe-
ter on depressing the penis, it demonstrates that while the curved
portion of the urethra may have been reached, the instrument has
not as yet pushed far enough along the urethra to meet the bladder.
If the fluid injected is not returned through the end of the catheter

Fig. 19.— Illustrating first position in passing sound or other steel instrument into bladder.

when depressed and does not remain in the bladder, but runs out
of the meatus along the side of the catheter, it is evidence that the
curved portion of the urethra has not been passed, and that the
compressor urethrae muscle has not yet relaxed.

In passing a curved instrument the operator stands at the side
of the patient that is most convenient to him. The penis is grasped
in the left hand, the instrument being held in the right. The organ
is put well on the stretch, and held at an angle of about 45 degrees
to the body. The operator should have in mind that, until the
bulbomembranous junction is reached, the straight portion of the

CATHETERIZATION

45

curved instrument should be kept as nearly parallel with the body
as possible. The instrument may, if it is more convenient, be in-
troduced with the upper portion pointing toward the feet of the pa-
tient, being rotated down into the urethra until it is parallel with
the groin, and then revolved again until its upper extremity is paral-
lel with the abdomen, the upper portion being just below the umbili-
cus; or, in passing the instrument, it may first be introduced parallel
to the groin, and then be brought around on a plane parallel to
the abdomen. In either case this last should be the final position
before the attempt is made to pass the instrument into the blad-

Fig. 20. — Illustrating second position in passing sound.

der. Figs. 19 and 20 illustrate these positions. During this pro-
cedure no forcible attempt should be made to push the instrument
into the urethra; the urethra should, rather, be pulled up on the
instrument, put and kept on the stretch by the fingers of the left
hand, the thumb and forefinger of the right hand holding the in-
strument— not firmly, but as if they were balancing it. While the
catheter is still so balanced its curve will disappear into the urethra
for four or five inches, the urethra having, as previously directed,
been brought well up on the instrument by the left hand. The
shaft of the instrument should, as was mentioned before, be kept

46

GENERAL EXAMINATION OF PATIENTS

parallel to the abdomen, the left hand keeping the urethra on
the stretch. Then raise the urethra, containing the instrument,
to a position at a right angle with the patient's body. Next, the
penis, still kept on the stretch, should be brought down between
the patient's legs until it points toward his feet. The thumb and
forefinger of the right hand should, at the same time, balance the
instrument, and, instead of pushing it, it should be allowed to
progress downward by reason of its own weight. The operator
should really feel with the beak of the instrument for the begin-
ning of the opening of the fixed portion of the urethra ; he should

rarely use much force
in pushing the instru-
ment, and, above all,
he should avoid push-
ing its beak into the
floor of the urethra.
At times slight spasm
of the compressor ure-
thras muscle exists;
this may often be over-
come, after the instru-
ment has been brought
over so that its beak
points toward the
place where the open-
ing of the fixed part of
the canal should be,
by keeping the handle
well depressed between the legs with the left hand, and pressing
down on the abdomen with the right.

When the beak of the instrument has entered the curved por-
tion of the urethra, the left hand, which has been holding the penis
and keeping it on the stretch, should be removed, and the instru-
ment grasped at its upper extremity between the thumb and
forefinger of the left hand, and allowed to enter the bladder. It
must be repeated that little, if any, downward pressure is to be
made when the instrument is first moved. From lying with its
shaft parallel to the abdomen it is brought up to an angle and made

Fig. 21. — Illustrating third position in passing sound.

CATHETERIZATION

47

to describe an arc, so that when it finally enters the bladder, its
upper outer extremity is descending toward the toes of the patient.
During this procedure it should constantly be borne in mind that
an attempt is being made to pass a curved instrument into a
curved canal, not a straight instrument through a straight canal.
The operator must be careful and diligent in searching with the
beak of the instrument for the opening in the fixed canal. In
passing coude catheters, cystoscopes, and dilators with very
short curves the necessity for depressing the penis while on the
stretch farther between the legs, in order to make the curved por-
tion enter the curved portion of the canal, is greater than in the
case of the ordinary instruments. In the presence of stricture, the

Fig. 22. — Illustrating fourth position in passing sound.

expert can be somewhat more heroic in his methods of pushing an
instrument through the obstruction into the bladder than one with
less experience. In such cases, however, it is a fairly safe rule to
let the beak of the instrument hug the roof of the urethra closely.

There is a general impression that attempts at passing a soft-
rubber catheter, whether made by patient or by surgeon, can
result in no harm, even if the efforts to make it enter the bladder
are futile. This view is an erroneous one, for the soft-rubber
catheter is inclined to double up at the bulbomembranous junction,
and, if force is exerted, may result in traumatism, which, although
slight, may be sufficient to start up an infective process. If it is
found impossible, either for the operator or the patient, to pass a

48 GENERAL EXAMINATION OF PATIENTS

soft-rubber catheter, an attempt should be made to pass either a
coud^ catheter or one of the flexible olive-pointed French silk
catheters.

Occasionally, any difficulty that may be experienced in passing
a catheter or sound with the patient in the prone position may be
overcome by having him assume the erect posture. This latter
position may be preferable in two classes of patients — those in
whom a spasm of the compressor urethrae muscle exists, and those
in whom a pocket at the bulbomembranous junction occurs.
Some patients, especially neurotics, are more successful in passing
the sound or catheter themselves than is the attendant, and ac-
complish it with less distress.

In those individuals who have a pocket at the bulbomembran-
ous junction, the instrument, when its handle is depressed, seems
to engage in the pocket instead of entering the fixed portion of
the curved urethra; if, while the handle is depressed, the instru-
ment is pulled very gently sUghtly outward for about a quarter
of an inch, so that the beak is pulled up a little more on the roof
of the urethra, and the handle is again depressed, the beak will not
infrequently find its way into the curved canal. Pressure with
the fingers of the left hand on the perineum over the beak of the
instrument aids in such conditions. These are often found in old
men in whom the urethra exhibits a tendency to sag down at the
bulb.

For descriptive purposes, the methods of passing the catheter
or sound may be divided into three stages: To recapitulate, in
the first stage the instrument is introduced as far as the bulbo-
membranous junction and is placed with its shaft parallel to the
abdomen and its upper extremity below the umbilicus; in the
second stage it is brought over in a curve, so that its upper ex-
tremity points toward the feet of the patient ; the third stage repre-
sents its progress through the prostatic urethra into the bladder.
When the instrument has been brought into such position that its
shaft is parallel with the abdomen, care should be taken to see
that, by stretching the penis, the urethra is well pulled up on the
instrument. This is particularly necessary with those inclined
to corpulency.

Time and gentleness are th§ two important factors in passing

CATHETERIZATION 49

an instrument through the urethra, either for purposes of ex-
amination or to empty the bladder. Patients who are obhged
to catheterize themselves will, after a time, generally find the
catheter that is best adapted to their needs. We have previously
stated that, in these cases, the soft-rubber catheter, of as small a
caliber as seems practicable, or the silk coude catheter, will be
found most suitable. The English silk catheters with stylets, so
popular in the past, have proved dangerous in both the patient's
and the practitioner's hands, and have fallen into disuse. They
possess all the disadvantages of the steel instrument, and, besides,
being made of silk, are likely to be handled carelessly.

CHAPTER II

ENDOSCOPY.-CYSTOSCOPY.-CATHETERIZATION OF
THE URETERS

ENDOSCOPY

With the invention, within recent years, of a small electric
light that does not give off heat and that can be placed at the end
of a tube introduced into the urethra, this method of making
urethral examinations has come largely into favor. The tubes
used for making endoscopic or urethroscopic examinations are
procurable in a variety of lengths, and the various manufacturers
have projected numerous modifications of the original. The
principle of most of them, however, is the same. The endoscope
in general use is a metal tube fitted with a mandarin for introduc-
tion ; the tube being inserted into the urethra to the desired point,
the mandarin is removed, and a tiny electric light is introduced
on its groove to the distal extremity of the tube.

In order properly to examine the urethra by means of the en-
doscope the patient should lie on a high table, in a semirecumbent
position, his legs, from the knees down, hanging below the table,
and rest on two supports or chairs. The examiner should sit on
a stool at his feet. The bladder should be emptied previous to
examination, and about one dram of a 2 per cent, cocain solution
be injected into the deep urethra. If the size of the meatus will
admit, the endoscopic tube is easily passed as far as the bulbo-
membranous junction. If, when a more extensive examination
is demanded, it is desired to introduce the tube beyond the bulbo-
membranous junction, it is necessary to depress the outer end of
the endoscope to a very marked degree. This is best done in all
cases, especially when the instrument is used for diagnostic pur-
poses, for it is only by allowing the end of the tube to pass a little
beyond the bulbomembranous junction that the colliculus can
well be made out and a fair conception be had of the appearance

50

ENDOSCOPY

51

of the deep urethra. For these purposes, and more especially
for that first mentioned, a tube somewhat smaller than that
required for examining the pendulous urethra alone should be
selected. Curved endoscopic tubes, though easier to introduce
into the posterior urethra, have not, as a rule, been found to be of
much practical value. A straight tube, by being well depressed,
can be introduced with comparative ease so far into the posterior
urethra that the colliculus, especially if enlarged, can be seen at the
distal end of the tube. When this is seen, the tube is slowly
withdrawn, and various portions of the urethra from the colliculus
out can be examined as the tube is removed. Pledgets of cotton
wound on the end of long slender applicators should be frequently

Fig. 23.— F. C. Valentine's electric endo-
scope.

introduced through the tube in order to remove the constantly
accumulating mucus, which would otherwise obstruct the view.
It is only after considerable practice in the examination of healthy
urethras by the endoscopic method that one becomes thoroughly
familiar with the normal urethral picture. An endoscopic ex-
amination will reveal to the surgeon the conditions that exist from
the colliculus outward, and it should always be made in those
cases in which the ordinary treatment for chronic inflammatory
conditions of the urethra fails to give good results. The presence
of vegetations or of internal chancre may be ascertained through
an endoscopic examination. The effect of treatment may,
if desired, likewise occasionally be observed. A persistent
localized lesion also may be treated by means of the endoscope

52 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

in a satisfactory manner. This is particularly true of those cases
in which infection of the follicles exists, pus being easily seen
exuding from them. For the treatment of such conditions as
infected follicles, a fine-pointed galvanocautery probe can be intro-
duced through the endoscope in a line vertical to the base of the
follicle, which is then destroyed by means of the current. Not
more than two or three follicles should be destroyed at one sit-
ting, and the operation should not be repeated oftener than once

Fig. 24. — Galvanocautery point.

a week. Small knives devised for the purpose may be used to open
up infected glands and for other purposes, such as the removal
of vegetations.

Applications made through the endoscope seem to be of practi-
cal use in reducing hypertrophy of the colliculus. This hyper-
trophy is frequently accompanied by loss of sexual vigor. Once
seen through the endoscope, the colliculus is easily recognized

Fig. 24 a. — Kollmann's probe.

subsequently. It projects, as a small pillar, from the

bottom of the urethra into the endoscopic field, and

in color and appearance somewhat resembles a small

preserved mushroom. When hypertrophied, the

mound appears much higher. This hypertrophy may be reduced

and the sexual tone restored by applying a strong solution of silver

nitrate (from 30 to 60 grains to the ounce) for a moment on a pledget

of cotton to the colliculus. This method of treatment has also been

recommended by some German writers as an excellent one for the

relief of neurasthenia of urethral origin.

Most of the endoscopes for sale in this country have a tube
that is cut off straight at its lower end. A much better field for
observation is obtained through an endoscope having the tube

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DESCRIPTION OF PLATE I
Endoscopic Appearances

Fig. 1. — Normal appearance of the verumontanum at the point of its greatest
size (Luys).

Fig. 2. — Hypertrophied verumontanum.

Fig. 3. — Normal appearance of the urethral bulb. The central opening takes
the form of a vertical slit (Luys).

Fig. 4. — Normal V-shaped appearance of a large lacuna of Morgagni (Luys).

Fig. 5. — Soft infiltration of the bulbar region. The swollen masses of mucous
membrane present the appearance of hemorrhoids (Luys).

Fig. 6. — Stricture of the urethra. The mucous membrane is stiffened by the
growth of fibrous tissue and has lost all suppleness. It presents a funnel-
shaped appearance (Luys).

Fig. 7. — Glands of Littrfe with purulent contents.

Fig. 8. — An enormous cystic gland of Littr^ which would be easily ruj)tured
by forcible dilatations (Luys).

PLATE I

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Fig. 6.

Fig. 7.

Fig. 8.

ENDOSCOPY

53

cut off at an angle at its lower end, as shown in the illustration.
Several years ago Dr. W. K. Otis, of New York, devised an endo-
scope having the light at its outer end, the Ught being reflected into
the tube. Recently he devised another, based on the same
principle as the first, but by which a much better illumination is
afforded. The advantage of having the Ught at the outer orifice is
that the light and its carrier do not infringe on the lumen of the
tube, and thus appHcations are more easily made through it.

It can easily be seen how valuable, under certain conditions,
treatment through the endoscope may be. At the same time
it is well to remember that most of the obstinate or serious inflam-
matory urethral conditions are situated in the deep urethra, and
although such conditions as infected follicles in the pendulous
urethra may be treated individually, any existing inflammatory
condition situated further along the urethral tract must not be
neglected. In other words, no good results will follow the treat-
ment of the minor lesions if the more serious ones are overlooked.
George Luys has written a very interesting book on the practical
use of the endoscope.^

There are certain things that should be remembered by those
who attempt practical work with the endoscope. The two
things to be especially noticed in the endoscopic picture are the
central figure and the mucous surface. The central figure or win-
dow varies according to the location of the endoscope in the urethra.
In the glans the central figure is a little oval, perpendicular at the
pendulous portion, like a point at the bulb, like a vertical window
at the verumontanum, crescent-shaped in the prostatic urethra.
The mucous surface varies in its appearance normally, as regards
its folds and striations, according to the size of tube used and the
pressure. It and the shape of the central figure as well are
changed by disease. As an illustration, in soft infiltration the
longitudinal folds are changed, diminished in number, and the
striations lost in the tumefactions, while the central figure is
shortened. This condition is most apt to be found in what may
be termed beginning chronic urethritis.

In hard infiltration as may be supposed, the color is paler, the
striations may have disappeared, the window opening gives more
^ "Endoscopic de I'urfetre et de la vessie," Paris, 1904.

54 ENDOSCOPY. — CYSTOSCOPY. URETER CATHETERIZATION

the appearance of an opening into a funnel, and the whole condition
of the urethral wall has become inelastic. This condition of hard
infiltration is what is met with in true stricture, and is due to the
formation of connective-tissue fibers. The glands of Littr^ and
the lacunae of Morgagni are apt to become cystic through the effect
of this connective-tissue formation ; their mouths may be open and
swollen, surrounded by inflammatory zones, or closed by the
fibrous tissue, and the cyst thereby become subepithelial. These
two conditions of hard and soft infiltration naturally merge the
one into the other and are not generally seen as two distinct entities.

CYSTOSCOPY
The illumination and inspection of the human bladder by
means of the cystoscope furnish a means of diagnosing diseases of
that viscus. The history of cystoscopy dates back to 1807, when

Fig. 25. — Nitze's cystoscope for observation of bladder.

a German physician, Dr. Bozzini, published an article on "The
Light Contractor, or a Description of a Simple Contrivance for
Illuminating the Internal Cavities of the Human Body." His
instrument, as illustrated in the article just named, consisted
chiefly of the chamber that contained the light, and of various Ught
conductors, shaped for use in different organs. His object was to
throw the light through the conductor into the various cavities,
and reflect from its wall into the observer's eye. The instrument
did not receive general recognition, but it certainly marked the
beginning of the many well-developed cystoscopic methods of the
present day. Next along this line of invention came the " Specu-
lum Urethro-cysticum," devised by Dr. Sagalas, and presented
to the French Academy of Medicine in 1826. In 1853 Dr. Desor-
maux brought his endoscope, a modification of the foregoing instru-
ment, to the attention of the Academic de M^decine of Paris. Later
Dr. Bruck, a German dentist, examined the bladder by means of

CYSTOSCOPY

55

a tube introduced into it through the urethra, and a strong, white-
hot platinum wire in the rectum, controlUng the heat produced
by this wire by means of a continuous circulation of cold water
around it. Through this tube he was able to inspect the highly
illuminated interior of the bladder.

The first actual cystoscope, however,
was that evolved by the late Dr. Max
Nitze, aided by Joseph Leiter, a well-
known instrument-maker of Vienna.
Dr. Nitze presented his instrument to
the Society of Physicians in Vienna in
1879 ; he later added improvements to it,
the outcome being the irrigating cysto-
scope and the various catheterizing and
operating instruments that are in use at
the present day. All his, are prism or in-
direct cystoscopes.

Since the introduction of Dr. Nitze's
instrument, many modifications of it
have been devised by operators in vari-
ous parts of the world. Chief among
them are the straight cystoscope and the
air cystoscope. These are constructed
on the same principle as is the Nitze in-
strument, but each has some peculiar ad-
vantage of its own.

An examining cystoscope, to be a good
one, should fulfil several requirements.
It should present as large a visual field as
possible. It should be of a caliber not
too large to pass easily through the ure-
thra, and it should, if possible, be of such
shape as to permit practically the entire
bladder- wall to be examined. A thorough
examination of the bladder may be made by using either of the
two different types of ureter-catheter cystoscopes, which will be
described later on, the latest Otis exploring cystoscope, designed
by Dr. W. K. Otis, of New York, or the exploring cystoscope

Fig. 26.— Willy Meyer cysto-
scope.

56 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

recently designed by Dr. S. W. Schapira. The two last-named in-
struments are made by the Wappler Electric Controller Company,
of New York, and have been found very useful. The curve of a
still later exploring cystoscope made by them, invented by Dr.
Willy Meyer, seems practical. Undoubtedly, there are many other
good exploring cystoscopes made by the various manufacturers in
this country and abroad, but we are not familiar with their use.
Operating cystoscopes are commencing to be used in which a

Fig. 27. — Showing field in Nilze's exploring cystoscope (Berger and Hartmann).

snare is placed for the purpose of removing bladder tumors, or a
lithotrite added so that calculi may be crushed under observation.

Practical Cystoscopy

Position of Patient. — For examination of the bladder, the pa-
tient may be placed flat on the back in the lithotomy position,
the illustrations below (p. 58) showing the proper supports and
correct angle of legs to body.

The genitals are then cleansed, and a sterilized catheter is in-
serted into the bladder. The contents of the bladder are evacuated,
and if the urine is not clear, the bladder is washed repeatedly

CYSTOSCOPY

57

until the fluid comes away clear; the viscus is then filled with a
2 per cent, boric-acid solution and the catheter withdrawn.

The proper instrument having been chosen, the light of the
cystoscope is adjusted, and the instrument intended for inspec-

Fig. 28. — The Schapira exploring cystoscope. The line A B shows inclination of lens.

tion is well lubricated and inserted into the bladder; the light is
turned on, and by rotation the anterior wall of the bladder, the
roof, the floor, and the sides are thoroughly examined.

Cystoscopic Appearances. — Acute Cystitis. — The picture varies

Mt^K"'

Fig. 29.— The Nitze operating cystoscope.

according to the degree of inflammation present. A general hy-
peremic condition is noticed, most marked at neck of bladder
with dilated blood-vessels.

Chronic Cystitis. — The mucous membrane may be pale or dark

58 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

gray, and the bladder folds so thickened that if the thickened
condition is localized, it may at times be differentiated with diffi-
culty from a tumor.

Fig. 30. — Table showing Bierhoff supports for legs in cystoscopy.

Fig. 31. — Position for cystoscopy.

Non-tubercular Ulcerative Cystitis. — This may be due to the
ingestion of certain drugs or to repeated attacks of cystitis, and
occurs most often in women. It is present only in rare grave

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DESCRIPTION OF PLATR II
Cystorcopic Appearances

Fig. 1. — Mouth of ureter.

Fig. 2. — Right ureteral papilla and mouth of ureter.

Fig. 3. — Showing ureteral opening and papilloma.

Fig.- 4.— A jet of bloody urine burst from the tiny opening.

Fig. 5. — Pus discharging from ureter.

Fig. 6. — Tubercular cystitis; primary stage. Numerous minute ecchymo.ses
surrounded by a hyperemic spot ; many ramified vessels.

Fig. 7. — Marked bilateral hypertrophy of the prostate — trabecular bladder.

Fig. 8. — Partial hypertrophy of the prostate. Enlarged median lol)e project-
ing into the bladder.

Fig. JJ. — Pf*i lion for o-«'"

V-'tt 'a^r^'tJar Ulcerative Cystitis. — .

rtaiii drugs or to repeated ai
t often m women. It is present

PLATE II

Fig. 1.

Fig. 2.

Fig. 3.

Fig. 4.

Fig. 5.

Fig. 6.

Fig. 7.

Fig. 8.

PLATE III

Fig. 9. — Encysted multiple stones
— four only are shown.

Fig. 10. — -Trabecular bladder;
verticulum of lateral wall.

di-

Fig. 11. — Pin fixed in the ante-
rior wall of the bladder near its
vertex; shadow on the opposite
wall.

Fig. 12. — Silk ligature adherent
to the wall of the bladder, near
its vertex; shadow on the opposite
wall

Fig. 13. — Two fragments of stone
which remained in the bladder
after lithotrity; in the larger one
the nucleus of uric acid is seen.

Fig. 14.

-Catheter covered by urine
concretions.

Cystoscopic Appearances

PLATE IV

Fig. 15.

-Catheter doubled
itself.

upon Fig.

16. — Cauliflower
bladder.

tumor of

Fig. 17. — Villous epitheliotria. Fig. 15

-Cancerous sessile tumor
of the bladder

Fig. 19. — I^obulated epithelioma. Fig. 20. — Tumor of Ijladder.

Fig. 21. — Small smooth tumor with long pedicle.
Cystoscopic Appe.ar.^nces

CYSTOSCOPY

59

forms of vesical disease. The bladder is always very irritable,
and will rarely hold more than one ounce of fluid. One or more
characteristic ulcers may be seen on an otherwise perfectly healthy
mucous membrane.

Tubercular Cystitis. — In this condition the cystoscope reveals
localized hyperemic spots of vesical mucous membrane, with
distinct tubercles.

There may also be distinct tubercular ulcerations, the edges of
which are somewhat elevated, in contradistinction to those of the
ordinary cystic ulcer.

Foreign Bodies in the Bladder. — Foreign substances that cannot
be detected by the sound, even in the hands of an experienced
surgeon, may be easily seen and localized by means of the cysto-
scope.

Stone in the Bladder. — The cystoscope plainly reveals stones in
the bladder, the observer being able to determine their size, shape,
and mobility, and to percuss them with the beak of the cystoscope,
guided by his eye.

Tumors in the Bladder. — It is in tumors of the bladder that the
cystoscope finds its greatest field of usefulness, the presence of
such growths being generally clearly detectable by its use, the
isolated tumors being more distinct than those made up of diffuse
vegetations.

Ordinarily, the exploring cystoscope should not remain in the
bladder for more than fifteen minutes without the light being
turned off ; care should also be taken to see that the lamps do not
become too hot, that the amount of fluid is not too slight, and
that the cystoscope is not pulled too far forward lest the neck
of the bladder be injured.

It may be well here to repeat the statement made in describing
the use of the endoscope, namely, that, like this latter instrument,
the exploring cystoscope may lend great aid in making a diagnosis,
but before he attempts to diagnose diseased conditions by its aid,
the examiner should, if possible, famiUarize himself with the ap-
pearance of the normal bladder.

Cystoscopic diagnosis is not always easily made, much patience
and considerable experience being necessary to avoid error. By
its means a typical growth or a glistening stone is readily recog-

6o ENDOSCOPY. — CYSTOSCOPY. URETER CATHETERIZATION

nized, but the inexperienced cystoscopist will frequently be misled
and perplexed by the appearance which the mucous membrane
is wont to assume under the varying conditions of infiltration,
relaxation, extravasation, and congestion. He may often, under
the mistaken belief that he is dealing with a new-growth, be
tempted to interfere operatively, to his patient's detriment.

INSTRUMENTAL EXAMINATION OF THE KIDNEY
Within the past few years much reliable scientific work has
been done to show the condition of each kidney, by collecting the
secretion of each of these organs separately. Many new tests,
such as the phloridzin and the methylene-blue, have been ex-
ploited to show the permeability of the kidney, and much has been
done, particularly abroad, to show the normal amount of the uri-
nary constituents by such methods as cryoscopy. These methods,
together with the examination of the blood, and particularly of
the blood pressure, have greatly increased our facilities for esti-
mating more accurately the total amount of work done by each
or by both kidneys. Of late it has become more and more the
custom to decry the aid furnished by the presence or absence of
albumin or casts in diagnosing disease of the kidney. The writers
believe that their presence or absence is often of small diagnostic
value, and attaches more importance in many cases to the test for
kidney permeability and to the information derived from ureter
catheterization as showing the condition of these organs. The
methods that will be considered in detail here are those that practi-
cal experience has proved to be of value — that can be commended
from personal observation ; those measures that have been found
to be impracticable or unsuitable for general work will not be
exhaustively considered.

Catheterization of the Ureters
By persistent efforts during the past ten years, and more
particularly during the past three, a few men, to whom great
credit is due, have given the practice of catheterizing the ureters
by means of ureteral catheter cystoscopes so great a stimulus that
the operation is now performed successfully in a large number of
cases. Undoubtedly the modifications and variety of forms of

INSTRUMENTAL EXAMINATION OF THE KIDNEY

6l

the instrument have played a part in the increased facility with
which ureteral catheterization can now be performed — the im-

Fig. 32. — Bierhoff's cystoscope for the simultaneous catheterization of both ureters.

provements in lights, in lenses, and, above all, in its skilful appli-
cation, have helped considerably to make it a success.

I

Fig. 33.— Bransford Lewis' double male ureter-cystoscope.

Roughly speaking, catheterizing ureter-cystoscopes are of two
types — the straight, of which the Brenner cystoscope is a type,
and the concave
or reverse type,
represented by the
Nitze or Albarran
cystoscope. For
the purpose of ure-
teral catheterization we personally prefer the
straight type, and recommend the instrument made
by the Wappler Manufacturing Co., of New York,
called the F. Tilden Brown modification of the
Brenner cystoscope. Of the concave or reverse
type, the cystoscope made by the Kny-Scheerer
Co., and called the Bierhoff modification of the
Nitze-Albarran cystoscope, is to be recommended.
There are many other similar instruments on the markets, in both
this country and Europe, that may excel in some one particular or

62 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

be superior to those just mentioned, but the writers are unfamiliar
with them, and believe that each of the two recommended is a
good representative of its class. Dr. FoUen Cabot has devised
a modification of the Brown instrument in which the catheter

■""^Si^Q

Fig- 35-— F- Tilden Brown's ureter-catheter cystoscope.

chambers are removed from the telescope and replaced by a short
single bridge at the distal end. This arrangement permits the
use of ureteral catheters and also a curet and forceps devised
by him for minor bladder surgery. The illustration shows these

Fig. 36. — Dr. Follen Cabot's curet and forceps for bladder-work for use with cystoscope.

small instruments. A new type of cystoscope is coming somewhat
into use, of which the Bransford Lewis is an example. Air
may be used in this type to distend the bladder. Air-distention
is sometimes of use where it is desirable to make local applications
to bladder ulcerations. As has been stated, for the mere purpose

INSTRUMENTAL EXAMINATION OF THE KIDNEY 63

of locating the ureters and catheterizing them the straight type
of cystoscope is to be preferred; but it would be very difficult to
examine the roof and the anterior walls of the bladder with a
straight instrument if the bladder were distended. It has also
been found, by practical experience, rather difficult to find the
mouth of the ureter with a straight instrument when, as occa-
sionally happens, the orifice is situated high up along the bladder-
wall instead of in its usual place along the border of the trigone;
while with the reverse type it is impossible to examine the posterior
wall of the bladder.

Many of the ureteral catheter cystoscopes that are manufactured
at the present time are recommended for use as ordinary cysto-
scopes for examination of the bladder- walls, as well as for catheter-
izing the ureters. For this purpose the concave is ordinarily pre-
ferable to the straight type, since through it the roof and the walls
of the bladder, with the exception of the posterior one, may more
easily be seen. The general practitioner will find it well to purchase
a good instrument of each of the.above-mentioned types. Once in
possession of these, the ordinary exploring bladder cystoscope, used
simply for examining the bladder-walls, is unnecessary. If, how-
ever, an instrument for that purpose is desired, the simple bladder-
exploring cystoscope previously mentioned can be recommended.
These cystoscopes have so small a shaft that they can be introduced
very easily into the bladder through a urethra of comparatively
narrow caliber without causing pain, and, consequently, by their
use, the patient is less likely to become frightened. It is some-
times necessary, in order to obtain a correct conception of the
position and appearance of the mouths of the ureters, to use the
ordinary exploring cystoscope before employing the ureteral
catheter cystoscope. Then, too, something is accomplished by
accustoming the patient to the use of the cystoscope, particularly
if the examiner believes that the ureters are to be catheterized
more than once. For this purpose, also, the preliminary use of
the ordinary exploring cystoscope is to be recommended.

How to Catheterize the Ureters with the Ureteral Catheter Cyst-
oscope of the Straight Type. — So long as the operator is not thor-
oughly familiar with the method of catheterizing the ureters, as
well as for descriptive purposes, the bladder may, for practical

64 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

purposes in using the catheter, be considered not exactly as a
modification of a round body, but as a dome- shaped organ, having
a bottom inclined to be flat and triangular in shape. This triangle
is represented by the folds of the trigone on each side, while the
prostate represents the apex.

One very important point that should be constantly borne in
mind in using a catheter cystoscope of the straight type is that the
instrument should never be rotated when it is desired to catheterize
the ureters ; rotation, in the observation of the writers, is perhaps
the most common of all errors made by those who first attempt
to catheterize the ureters with this cystoscope. The instrument
should be used more as a lever. Always remember that the top
of the beak should point toward the top of the bladder. An-
other important point that should be borne in mind is the part
played by bladder folds. It is for the purpose of overcoming these
folds as far as possible that we distend the bladder with fluid
previous to the introduction of the instrument. The cystoscope,
handled as a lever, with the bottom of the end of the shaft always
firmly pressed on the floor of the bladder, prevents the folds of the
prostate, or of the trigonal portion of the bladder, from rising too
much and obscuring the view, and thus keeps the orifice of the
ureter from getting behind the fold of the trigone to such an ex-
tent as to make introduction of the ureteral catheter impossible.

This latter annoyance will often vex the observer when the
fluid placed in the bladder has escaped during the attempt at cathe-
terization of the ureters.

In order to properly use the instrument, the bladder, emptied
of urine, should be filled with from 8 to 12 ounces of a colorless
aseptic fluid. It may be well to remark here that if urethritis or
cystitis has been present, the bladder must be washed several
times in succession so as to be perfectly free from shreds or mucus,
which would tend to make the urine cloudy. With a clear and
clean field, and about as much fluid in the bladder as it will com-
fortably hold, the instrument should be passed through the ure-
thra in the classic manner, depressing the handle of the cysto-
scope well between the patient's legs before attempting to pass it
into the bladder. This having been accomplished, the mandarin
removed, the light inserted, and the connection between the cysto-

INSTRUMENTAL EXAMINATION OF THE KIDNEY 65

scope and the battery having been made, the current should be
turned on until the light of the lamp is almost white. The cyst-
oscope should then be pushed backward until it meets the pos-
terior wall of the bladder.

In looking through the eye-piece, the back wall of the bladder
will be found to be a comparatively clear, light-colored field.
The beak of the instrument should now be brought forward a
little — not pulled straight outward, but brought forward — ^by
raising the outer end of the instrument slightly toward the um-
bilicus and keeping the beak in the bladder well pressed down
toward the bladder floor, the instrument being held in the median
line, with the roof of the beak always pointing toward the roof of
the bladder. A dark ridge will soon make its appearance at the
bottom of the field as observed through the eye-piece. This is
the apex of the prostate, and is also the apex of the triangle, which,
for the inexpert, must be located before searching for the mouths
of the ureters. Now, if the instrument is carried a little to one side,
the dark-colored ridge of the trigone will be seen running off in a
diagonal direction from this apex ; and if the instrument is carried
a little to the other side, but not rotated, a similar ridge will be
seen. This ridge is a dark fold, — almost as dark as the apex of
the prostate, — and a distinct line of demarcation exists between
it and the lighter colored bladder-wall. About half way up this
ridge, following along the edge of it (along the line of demarcation
between it and the bladder- wall) , and about an inch from the
apex of the prostate, the mouth of the ureter is ordinarily to be
found, but is at times located only after taxing the patience and
watchfulness of the observer. It appears as a small elevation or
slight blur. Occasionally the urine may be seen coming from it
like a little puff of smoke. Having found the mouth of the ureter,
or, if this has not been possible, having found the place where ordi-
narily it should be, the next point is to introduce the catheter.
This is accomplished with more ease if the bladder is well distended
with fluid. One difficulty may be met here — namely, the de-
termining of the proper focus: the focus must be adjusted to
each pair of eyes, and, as with an opera glass, the right focus for
one person, is not necessarily that for another. The proper focus
must be obtained either by pushing the instrument a little more
5

66 ENDOSCOPY. — CYSTOSCOPY, — URETER CATHETERIZATION

firmly against the bladder-wall or by drawing it outward, taking
care to avoid lateral or rotary movement. This focusing is, as has
been said, one of the most difficult parts of the operation, and
requires practice and experience.

The catheter, on being pushed gently forward, no force having
been used, and the proper focus having been found, except as in
cases of malposition or of ureteral stricture, it enters the ureter.
If in doubt, leave the catheter in position, withdraw the instru-
ment a Uttle, and, looking through the eye-piece, observe whether
it has entered the ureter or is doubled up in the bladder.

The catheter having been introduced into the ureter on one
side, the instrument should then be returned to the apex of the
prostate and run along the border of the trigone on the other side
until the orifice of the other ureter is found and the catheter in-
troduced there. Then the shaft of the instrument may be taken
out, leaving the two catheters in position, or, instead of introduc-
ing the catheter into the second ureter, it is preferable, in many
cases, the fluid in the bladder having been entirely withdrawn,
to allow the end of the catheter to remain in the bladder, while
the other catheter would remain in the ureter. The urine from
the other kidney would naturally flow through the catheter re-
maining in the bladder, provided no leakage from the kidney
occurs around the first catheter placed in that organ. The two
catheters having been left in this position, the patient's legs may
be released from the rests, and he may be allowed to rest quietly
and comfortably on his back while the urine passes through the
catheters for half an hour or more.

The position of the legs of the patient while the catheter cysto-
scope is being used is an important feature. A pair of uprights
should be placed on the table, from which are suspended two can-
vas stirrups for the patient's feet; the patient's body should be
brought to the edge of the table, and, when adjusted, the lowest
part of the canvas stirrups should be about sixteen inches higher
than the edge of the table. Still better than the stirrups are the
rests shown in our illustrations (Figs. 30 and 31).

How to Catheterize the Ureter with the Reverse Cystoscope. — The
Bierhoff Modification of the Nitze-Alharran Cystoscope. — In using
this instrument the position of the patient and the intensity of

INSTRUMENTAL EXAMINATION OF THE KIDNEY 67

the light should be the same as with the instrument previously
described, but the operator does not see straight ahead with it,
however, and with this form of cystoscope rotation is necessary.
The field of vision is about that shown by us in the illustration of
the field of vision of the Nitze exploring bladder cystoscope (p. 56).
The cystoscope having been introduced with its beak pointing up-
ward, the roof of the bladder will naturally first be seen. The
instrument should now be rotated through an angle of about
75° and pushed slightly to one side. The field of vision now
includes the point at which the ureters should be found. It may
be advisable to turn the instrument completely about, so that the
apex of the beak points directly downward to find the prostate
and trigone ridge, and through the aid furnished by observation
of their position, locate the ureter. The prostate and the trigone
ridge in the use of this cystoscope will appear at the upper part
of the cystoscopic field instead of at the lower part, as in the
cystoscope of the straight type. The mouths of the ureters being
located, the catheter should be pushed forward until its end
strikes the mouth of the ureter. This extension of the catheter
takes place under the eye of the observer. The instrument
should then be very slightly withdrawn, and an attempt made,
through bringing into use the metal finger on the instrument, to
introduce the catheter into the ureter. One catheter having been
introduced, search should be made for the mouth of the other
ureter and the procedure repeated. Two manipulations should
now be performed before withdrawing the cystoscope and leaving
the catheters in position. The first consists in replacing the
metal finger by means of the screw attachment, so it will not
protrude in the withdrawal, as otherwise the urethra would be
torn. The second step consists in loosening the screw at the
outer end of the cystoscope, so that the beak can be rotated
until it points upward without rotating the sheath that holds
the catheters. Through this procedure the instrument may be
withdrawn without pulling the catheters out of the ureters, as
they will still be in the dependent portion of the instrument
until it is removed. Constant practice and good eye-sight are
important factors in making one expert in catheterizing the
ureters. Many of the difficulties previously encountered, such as

68 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

large shafts to the instruments, inferior lenses, inadequate light-
ing facilities, and defective lamps that would easily burn out, have
now been overcome by enterprising manufacturers. Very recently
the Wappler Manufacturing Co. have, at our suggestion, made
a single indirect ureter catheter cystoscope, which, while it can-
not be recommended in preference to those already mentioned,
is comparatively inexpensive and seems a useful and practical
instrument.

Methods of Separating the Urine from Each Kidney

WITHOUT CaTHETERIZING THE UrETERS

A year or two ago the consideration of the different methods
of urine separation by the aid of various separators would have
consumed more space than is at present demanded. So long as
the difficulties of catheterization of the ureters seemed almost
insurmountable, any new methods of separating the urine were
received with decided enthusiasm; since, however, it has been
learned that, once one is familiar with the process of catheteriz-
ing the ureters, the simple operation may be repeated as often as
occasion demands, the various urinary segregators and separators
have somewhat fallen into disuse and come to be considered un-
important. As time goes on it may be demonstrated that we
are in error in making this observation. The fact remains,
nevertheless, that at present an ideal segregator or separator does
not exist; and although some of these instruments that are now
in use are of value, and attest to the very commendable mechanical
ingenuity of their inventors, still, the writers' experience and
that of other investigators places them in favor of catheteriza-
tion. It is the writer's belief that, in order properly to understand
the use of segregators and separators, as much perseverance
and skill are necessary as are required for catheterizing the
ureters; and, from clinical experience, it would seem to be about
as easy to obtain consent for performing catheterization as for
using the segregators. In exceptional cases, where the process of
catheterizing the ureters has been so painful to the patient that
he objects to further attempts at it, the segregators may be used.
It is by no means intended to convey the idea that these segrega-

TESTS SHOWING PERMEABILITY OF THE KIDNEY 69

tors are valueless, for this is not the case. The Harris segregator
is an instrument for which the profession should feel grateful.
By its use, years ago, when it was first placed upon the market,
the writers found unilateral albuminuria in cases of chronic neph-
ritis, also casts in the secretion of only one kidney. At that time
its use demonstrated how Uttle was then known as to the nature of
B right's disease.

The Cathelin instrument has been used by the house staff of
the City Hospital of New York with apparently satisfactory re-
sults in some cases. In a recent work entitled "Considerations sur
la Methode de la Separation Intra- vesicale des Urines" ("Extrait
des Annales des Maladies des Organes Genito-urinaires," 15. Jan-
vier, 1906) Dr. Georges Luys has considered the different segrega-
tors very exhaustively. In general, segregators are of two kinds:
first, those in which an instrument introduced into the rectum
makes a bridge in the bladder; this is combined with a sound-
shaped instrument that separates into two finger-like projections
and presses the bladder into two pockets ; the Harris instrument is
of such a type ; second, those on the order of the Luys or Cath-
elin instruments, which are sound shaped, but in which there is
a rubber membrane that divides the bladder into two chambers.

TESTS SHOWING PERMEABILITY OF THE KIDNEY

A very important question for the modern practitioner is the
value of the various tests for the permeability of the kidney.
Some workers are inclined to entirely discard these tests, since they
admittedly do not accurately indicate the degree of renal disease
in some cases. Especially important in surgical work where
nephrectomy is contemplated is the question whether the relative
degree of disease on the two sides is shown. This can be answered
in the affirmative. They do not, however, show whether a kidney
is healthy or not, but they demonstrate which organ functionates
the best of the two, and are, therefore, of great value, when
considered together with all the other signs and symptoms of the
case. The methods are also of great use in post-operative and
convalescent states, particularly from a prognostic standpoint,
since they indicate more accurately than any other means at our

70 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

disposal the amount and physiologic capability of the remaining
kidney tissue.

Of the tests which must, in most instances, be combined with
ureter catheterization, the most useful have been found to be the
phloridzin, the methylene-blue test, the indigo-carmin, and best
of all the physiologic polyuria test, recently described by Albarran.
In cases of great difficulty or unusual importance it is well to
utilize more than one of these tests.

Phloridzin Test. — Inject hypodermatically into the gluteal re-
gion, or whatever portion of the body may be selected, 6 milli-
grams of a sterilized solution of phloridzin, i : 200 ; in normal
individuals glucose can be discovered in the urine in half an hour
after the injection has been made; nevertheless, even if the glu-
cose is discovered at the stipulated time, this, as Casper has
remarked, is not necessarily positive proof that the permeability
of both kidneys is intact, for, as mentioned in the chapter on
the Pathology of Kidney Diseases, there are affections that be-
come localized in a single kidney, at least during some time in
the course of their development; this is particularly true of the
toxic and infectious forms of nephritis, tuberculosis, cancer, hydro-
nephrosis, perinephritis, and perhaps some forms of movable kidney.
Therefore if, when the ureters are catheterized half an hour after
the phloridzin has been injected, the glucose appears in the urine
from one kidney, but does not appear in that time in the urine
from the other kidney, the permeability of the second organ is gen-
erally affected. If, however, the ureters have not been catheter-
ized, then, though one kidney is diseased, glucose will be present in
the secretion from the normal kidney; the value of this test, there-
fore, will be greatly increased when used in conjunction with
ureteral catheterization. This test may often aid us in determin-
ing whether a given albuminuria is due to the heart or to the kid-
neys. Leon Bernard has recently published a work^ dealing most
exhaustively with the value of this test. A most interesting and
suggestive study by Edwin Beer, who used the phloridzin test in
seven well-selected cases before and after nephrectomy, tends to
show that the mere presence of diseased kidney tissue modifies
the functionating power of the other and relatively healthy organ,

' "La M^thode d' Exploration de la Permeability des Reins," Paris, 1904.

TESTS SHOWING PERMEABILITY OF THE KIDNEY 7 1

manifesting this by retarding the reaction. After removal of the
most diseased organ the functional power of the remaining organ,
as determined by the phloridzin test, was increased.'

The Methylene-blue Test. — This is, in the opinion of the writers,
of lesser diagnostic value than the phloridzin test. It is con-
ducted as follows:

Inject one cubic centimeter of a sterile solution of methylene-
blue, I : 20, into the gluteal region, the bladder of the patient
being empty. The urine is then collected every half -hour until it
begins to take on a blue color, when it is collected every two
or three hours. The time at which it first begins to become blue
should be in from three-quarters of an hour to one hour after the
injection of the solution, the urine continuing to be blue for from
thirty-six to forty-eight hours. At first it is slightly blue, the color
later becoming more intense, and then gradually becoming paler
until, at the end of the time stated, it becomes normal again. As a
rule, when there is delay in the appearance of the blueness or a pro-
longed continuation of it, it tends to show some lack of permeability
of the kidneys. It has been studied exhaustively by Archard and
Castaigne,^ who elaborated the following method of using it: the
urine of four hours was collected and no test made; then the
urine of twenty-four hours was collected after the injection, and
a few drops of a solution of known strength of methylene-blue were
added to collection No. i. It was then noted how large an amount
was required to obtain the same intensity of color as that in col-
lection No. 2, and the strength of the original injection being
already known, they were enabled to estimate the amount of
methylene-blue that was excreted in twenty-four hours. Nor-
mally, they found it to be from 25 to 40 milligrams the first twenty-
four hours, the entire amount being from 35 to 40 milligrams.
Quite elaborate tables have been drawn up showing that in cer-
tain forms of nephritis the blue color may appear remarkably.
early and that in other forms it may be delayed. These tables
have been omitted because of the writer's inability to verify them,
and because of a belief that those who compiled them have not

^ "Observations on the Phloridzin Test, with special reference to the
influence excited by a diseased kidney upon the excretory activity of the
second kidney and its bearing on functional kidney tests," by Edwin Beer,
"Transactions of the New York Academy of Medicine," April 14, 1908.

* " L'Examination Clinique des Fonctions Renales," Paris, 1900.

72 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

been able to verify their conclusions regarding the pathologic con-
dition of the kidney, except as revealed by urinary examinations,
and these arc, as is well known, sometimes misleading. The evi-
dence furnished by autopsies has not confirmed their findings.
Not infrequently, owing to some chemic change in the urine, a
greenish hue takes the place of the blue, and sometimes, although
the drug is normally excreted, chemical reactions in the urine
entirely dissipate the color.

Occasionally an intermittent excretion, believed to be due to
some nervous condition, has been observed. This test has some
practical value if the observer, by repeated practice, has perfected
himself in its use and educated his eye so that it will recognize
the normal color, for the value of the test as a means of showing
the permeability of the kidneys is, of course, dependent upon
color changes. When this experience has been obtained, it will
prove a useful rough test as showing the distinction, through
delayed excretion, between kidney or heart disease, even when
the drug be given by the mouth.

In order to ascertain the value of these two tests — the phloridzin
and the methylene-blue — a series of experiments on patients
under various conditions were conducted by the writers. In this
work they were ably aided by Dr. S. W. Schapira and by the house
staff and nurses of the City Hospital, New York. In one series
of experiments seven men with healthy kidneys were used as
subjects; the same amount of blue was injected into each, and
the urines of each collected every half-hour for many hours. The
same shade of color was apparent in all but one, in which it was
much lighter. This exception was found on investigation to be
due to the fact that the patient was a heavy water-drinker, the
amount of water consumed by the other subjects being much
smaller. Another series of experiments was carried on by Dr.
Schapira on five persons with healthy kidneys; in these methy-
lene-blue was given by the mouth and was injected hypodermati-
cally; phloridzin was also injected hypodermatically, and in all
cases the ureters were catheterized. The results in all showed
practically little variation; methylene-blue and phloridzin were
discovered in the urine obtained by catheterizing the ureters
in thirty minutes or sooner. A third series of experiments on

TESTS SHOWING PERMEABILITY OF THE KIDNEY 73

four cases with lesions of the kidney was made. The results
were found to coincide with those obtained by Casper and Richter,
there being invariably delayed excretion from the diseased kid-
ney. The deductions to be drawn from the foregoing experi-
ments are as follows: first, that these tests are of some value
without catheterization of the ureters; second, when catheteriza-
tion of the ureters is performed at the same time that these tests
are made, their value, for diagnostic purposes, is much increased,
third, in the writers' experience no cases of personal idiosyncrasy
causing a delay in the elimination of the methylene-blue or the
phloridzin have been met ; fourth, in cases of delayed transmission
of phloridzin or of weakened color, as shown by the methylene-
blue test, where there is no apparent physical reason, such as
excessive water-drinking, to account for it, it should be considered
as pointing strongly to some diseased condition of the kidneys.

As regards the amount of work done by the kidneys as a whole,
probably the most practical results are obtained by ascertaining
the entire amount of urine excreted in the twenty-four hours.
This method is very simple. The patient urinates at 12 o'clock,
say, the urine obtained at that time being discarded. All the
urine excreted during the next twenty-four hours, including that
passed the next day at 12 o'clock, is to be collected, and a quantity
of the whole twenty-four-hour amount sent to the examining
physician. The specific gravity is taken, and the amount noted.
The last two figures of the specific gravity are multiplied by 2^,
which will give approximately the amount of solids in 1000 c.c. or
one quart ; knowing how many quarts or fractions of quarts have
been passed in twenty-four hours, the amount of solids eliminated
by the kidneys is readily estimated. As the average is about 70
grams, it can be ascertained in a rough way whether the kidneys
are doing their normal amount of work, less than their normal
amount, or whether they are being overworked. As a general
thing it will be found that they are being overtaxed. It now
remains to ascertain whether this overtaxing is due to the ingestion
of more food than is required or to the presence, in large quantities,
of such substances as sugar or phosphates.

As to the amount of work done by each kidney, individually
and by the two together, Casper, in his valuable work, shows each

74 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

healthy kidney to be doing practically an equal amount of work,
and, as previously mentioned, the phloridzin test, in conjunction
with ureter catheterization, will give the same information. Some
recent work of Albarran's tends to show that while there is some
natural discrepancy between the amount of work done by each
kidney, it is apparently not enough to afifect the practical results
obtained by the use of the phloridzin test. We may conclude then
with him that any loss of kidney permeability therefore indicates
some lesion of the kidney, or, at least, of the heart or kidney.
In estimating the work of the two kidneys the blood pressure
and the results of physical examination of the kidney should also
be taken into consideration; in order to estimate properly the
amount of work that is or can be done by either or both organs,
several factors must be considered, and it is unwise to depend on
any one test alone.

Indigo -carmin Test.' — Voelcker and Joseph, who devised this
test, found that indigo-carmin injected hypodermatically is
excreted by the kidneys as a blue coloring-matter. They dis-
solved 0.4 gm. of carmin in 10 cm. of physiologic salt solution
and injected 4 cm. into the gluteal muscle. The coloring-matter
normally makes its appearance in the urine about ten minutes
after the injection. In order that the urine may be concentrated
they limit the fluid intake before the test. Later the injection of
20 cm. was recommended, in which case the reaction occurred in
from three to five minutes and the height of excretion was at-
tained in from one-half to three-quarters of an hour. Delayed
reaction indicates renal insufficiency. Kapsammer states that the
power of the kidney to excrete may be also advantageously tested
by reducing or increasing the concentration of the solution. We
have had no personal experience with the method.

Experimental Polyuria Test. — This ingenious method of
estimating the excretory activity of the kidneys was devised by
Professor Albarran,^ who has done so much to advance our knowl-
edge of genito- urinary science. Very briefly stated, the theory is
based on the well-recognized fact that if an increased excretory

' " Erkrankungen der Niere," Vienna and Leipzig, 1907, Kapsammer,
p. 28.

* "Exploration des Functions Renales," Paris, 1905.

TESTS SHOWING PERMEABILITY OF THE KIDNEY 75

demand be put upon kidneys only one of which may be diseased,
the less diseased organ will show a proportionately greater increase
in activity. Thus, if a large amount of water be given and the
urine collected separately from each organ, the less diseased kidney
should excrete the larger total amount of both fluid and solids,
although proportionately the percentage of solids will be decreased
with this viscus. Albarran lays down several laws in regard to
this matter as follows:

The diseased kidney has a functional possibility much more
constant than the healthy one, and the more its parenchyma is
destroyed, the less will its functions vary from moment to
moment.

When one of the kidneys is alone diseased, or is more so than
the other, if the urinary function becomes disturbed, it shows less
modification than the other. The excretory balance between
the two kidneys is greatly exaggerated by more marked variations
in the physiologic functional activity of the more normal organ.
The procedure is as follows:

A ureteral catheter is placed in one of the ureters for a distance
of ID cm. A No. 13 catheter is also introduced, but extends only
into the empty bladder. Fifteen minutes' time is then allowed
in order to be sure that the bladder is perfectly empty and to allow
the reflex polyuria following the ureteral catheterization to
subside. If a phloridzin test is also desired, the drug should be
injected fifteen minutes before. The urine from both sides is
then collected separately at half-hour intervals for from four to
six times. The patient then drinks three glasses of Evian water
or of dog-grass tea (1.3 grams of dog-grass to a cup of boiling
water). The urines are again separately collected at half -hour
intervals. The examinations are made as regards — the quantity
of unne; the molecular concentration, which may be deter-
mined by the electric conductivity, by cryoscopy, or by the usual
volumetric methods; the quantity of urea, estimated by liter
and centigrams; the sodium chlorid^ estimated by liter and cen-
tigrams; the sugar (if phloridzin has been given), estimated by
liter and in centigrams.

The first tubes of urine collected serve for comparison to study
with the relative quantitative and qualitative variations in those

76 ENDOSCOPY. — CYSTOSCOPY. — URETER CATHETERIZATION

taken subsequent to the administration of the fluid or of the fluid
plus the phloridzin.

In the healthier organ there will be more polyuria and the urea
and chlorids by Hter will be diminished, but by quantity increased.

The method permits one to ascertain with some surety the
superactivity of which a kidney is capable, and to indicate the
facility with which it is able to accommodate itself to increased
excretory demands. By it may be shown which kidney func-
tionates best, the approximate relationship in the functional
capacity of each organ, but the test does not and cannot tell
whether either or both organs are entirely normal or not.

Many criticisms of this method have been made, but it unques-
tionably stands as one of the most satisfactory of all the tests for
renal permeability, especially since by it renal permeability to
certain special substances, as to alcohol or other drugs, may be
most readily shown.

CHAPTER III

THE CARE OF URETHRAL INSTRUMENTS.— PREPARA-
TION OF PATIENT AND SURGEON FOR OPERATION

THE CARE OF URETHRAL INSTRUMENTS
Casper has well stated that many aseptic conditions in the
urinary tract may be rendered septic by uncleanly instrumenta-
tion. Zuckerkandl insists that catheterization should be regarded
in the light of a surgical operation, and that preparations for
carrying it out should be made with the same precaution as re-
gards asepsis as are observed in performing operations on other
portions of the body. It may be stated, also, that no amount of
aseptic care regarding the hands of the operator, the sterilization
of the instruments, or the preparation of the field of operation
will render a trauma in the urethral tract caused by instrumen-
tation harmless. The ease with which instrumentation can be
carried out depends largely on the personality of the operator.
Some men, even those of large experience are apparently regular
bunglers in this respect. As regards cleanliness, sterilization of
instruments, and preparation of the field of operation, however,
personal equation is not a factor, since these procedures can be
carried out by any operator who will give to the matter the time
and patience required.

Sterilization should not, however, be carried to the point of
excess. In following the instructions laid down by some writers
one is likely to produce irritation in the too strenuous effort to
secure cleanliness. Illustrative of this overanxiety to obtain an
aseptic field is the much-recommended practice, previous to in-
serting a catheter into the bladder, of washing out the anterior
urethra with a solution of silver nitrate (one or two grains to the
ounce) in the hope of rendering sterile any shreds that may remain
in contact with the urethral walls. The too prolonged applica-
tion of soap poultices for the purpose of loosening up the layers

77

78 CARE OF INSTRUMENTS AND PREPARATION OF PATIENT

of the superficial epithelium preparatory to operating will also
prove irritating.

The following method for the care and sterilization of instru-
ments and for the preparation of patients, in use in the City Hos-
pital of New York, has stood the test of time and is easily fol-
lowed.

Soft-rubber instruments, such as soft-rubber catheters, are
boiled for five minutes in water to which washing-soda has been
added, the proportion being a teaspoonful of soda to the gallon.
They are then wrapped in sterilized gauze and kept in covered
glass jars. Before being used they may be soaked for five minutes
in I : 20 phenol solution, this to be washed off in a 4 per cent,
boric-acid solution.

Not only the soft-rubber instruments, but also silk catheters
and bougies may be boiled. The best way to do this is to wrap
them in a piece of sterile gauze before boiling. When boiled,
remove them still wrapped in the gauze with the fingers and place
them in a cool solution. Boiling softens the lacquer that covers
the silk instruments, and they are likely to suffer indentation if,
while hot, another instrument is allowed to come in contact with
them. This can be avoided by the use of the procedure mentioned
above. Silk instruments may also be disinfected by immersing
them for five minutes in a i : 20 phenol solution and then washing
in boric acid 4 per cent., or they may be soaked in a i : 10 of i per
cent, formaldehyd solution. It is recommended by many — and has
come to be quite the general custom — that catheters be disinfected
by preserving them in a glass jar having formaldehyd at the bottom,
formaldehyd gas being generated; or that they be kept continually
soaking in a 0.5 per cent, formaldehyd solution. Experience at
the City Hospital seems to show that when either rubber or silk
instruments are continually exposed to the fumes of formaldehyd
vapor, or are immersed in a solution of formaldehyd of a strength
of 0.5 per cent, or stronger, they soon become worthless. In private
practice the writers have disinfected rubber and soft instruments
by subjecting them to the action of formaldehyd vapor in the
sterilizer described below, the vapor being generated by the heating
of a formaldehyd lozenge. After a few minutes the instrument is
removed and wrapped in sterile gauze. When time will not permit,

care; of urethral instruments

79

or when the ordinary forms of sterihzation are not available, a
strong solution (2 to 4 per cent.) of formaldehyd may be used and
immediately washed off. When frequent irrigations are to be made
through a small olive-pointed gum silk catheter, a plan to be rec-
ommended in private practice is that of keeping each patient's
instrument separate, thus reducing the danger of carrying infec-
tion by means of the catheter from one patient to another.

Steel instruments are sterilized by boiling them for five minutes

Fig. 37.— Formaldehyd sterilizer for catheters and small instruments.

in a solution composed of a teaspoonful of soda to a gallon of
water; they are then dried, wrapped in sterilized gauze, and
placed in a glass jar with a cover ; they may be then soaked in a
I : 20 phenol solution for five minutes, being washed off, just before
using, in a 4 per cent, boric-acid solution. For office practice, a
small steam instrument-sterilizer works very well.

A sterilizer is used by the writers in which steam is generated ;
it is heated by means of an electric worm on the inside of the ster-
ilizer, which is brought into immediate contact with the water.

8o CARE OF INSTRUMENTS AND PREPARATION OF PATIENT

The coil running from this apparatus is easily attached to the
electric- light fixture, and the instrument has proved very practi-
cal. Care should be taken, however, that water is always present
in the sterilizer.

Some advise the addition of a small amount of ammonium
chlorid to the water in which instruments are to be boiled. A
solution of mercury bichlorid (from i : 5000 to i : 3000) is a useful
disinfectant, but has the disadvantage of turning metal instru-
ments dark and of eroding their surfaces. A strong solution of
formaldehyd in glycerin may also be used. The vapor of sulphu-

Fig. 38.— Showing electric coil for boiling water in sterilizer.

rous acid has been employed as a disinfectant, but the simplest
and most satisfactory method of sterilization is that accomplished
by boiling water.

Cystoscopes may be disinfected by soaking them in i : 20 phenol
solution, care being taken not to wet the inside of the lenses;
before using, the instrument may be washed oflf in a 4 per cent,
boric-acid solution. Cystoscopes are best disinfected by allowing
them to remain for a short time in the formaldehyd vapor gene-
rated in the formaldehyd steriUzer previously described.

CARE OF URETHRAL INSTRUMENTS 8 1

After use, instead of allowing it to lie in the phenol and boric-
acid solutions, the cystoscope may be again subjected to the
action of formaldehyd gas, washed off with soap, and then with
a solution of ether or lysol.

Urethral catheter cystoscopes are difficult to clean, and every
part must receive separate and careful attention.

Cystoscopes may be rubbed with green-soap spirit, and after-
ward with alcohol to remove the green soap. Removable parts
should be boiled. Fresh solutions for each disinfection should
be made up from a stock solution.

The general rule in use for the sterilization of cystoscopes is
applicable to lithotrites and their evacuators and to Kohlmann
dilators. Some of the evacuators on the market, such as the new
Kraus, the Otis, and the Chismore, are comparatively easy to
sterilize, whereas others are so constructed as to present greater
difficulty.

In the case of dilators that are covered with rubber, it is neces-
sary to sterilize the rubber as well. This may be done in various
ways — by immersion in solutions of phenol, followed by immer-
sion in boric acid; by the application of formaldehyd vapor,
the rubber being placed over one of the combs in the formaldehyd
sterilizer, according to the method shown in fig. 37, By keep-
ing different rubber coverings for individual cases the danger of
carrying infection is minimized.

Lubricants. — The ideal lubricant for the passage of urethral
instruments is yet to be discovered. If it were desired merely to
make the instrument slip into the urethra with ease, vaselin or
the various oils distilled from the coal-tar products would answer
the purpose. As is well known, however, these substances form
a coating in the urethra that hinders the penetration of any med-
icament it may be desired to apply to the urethral wall. Gly-
cerin with boric acid is an excellent lubricant. For this purpose
it is the writers' custom to use Price's English Glycerin, as this
seems to have more body than the ordinary glycerin of commerce.
The fact that glycerin acts as an irritant on some persons, com-
bined with the fact that instruments lubricated with it will not
penetrate quite so easily as those lubricated with vaselin, lessens
6

82 CARE OF INSTRUMENTS AND PREPARATION OF PATIENT

its usefulness. In this country, at present, a great many prepara-
tions are being used that have Irish moss as a base, formaldehyd
in varying proportions being added for its antiseptic properties.
These are proprietary articles, and in most cases the formulas are
not definitely given. Their disadvantage Hes in the fact that the
jelly of the Irish moss may be lumpy, and that the preparation is
not so easily removed from instruments as is glycerin. In private
practice the writers occasionally use a preparation called formical,
manufactured by John Carl and Sons, New York city; in this
the purified chondrin jelly made from Irish moss is combined with
a certain proportion of a formaldehyd solution.

The following formula (known as " Katheterpurine") is pre-
scribed by Casper, and is used to some extent in this country. It
has occasionally given rise to irritation of the urethra when the
membranes were very sensitive; it should be made weaker:

I^. Oxycyanid of mercury, 0.246

Glycerin, 20.

Gum tragacanth 3.

Water, 100 M.

Kraus uses gum tragacanth, 2.5 per cent., glycerin, 10 per cent.,
and a 3 per cent, solution of phenol. Owing to the quantity of
water it contains, this can easily be washed off.

Guyon's pomade is made of equal parts of glycerin, water, and
soap.

In Germany oxycyanid of mercury is being used extensively
in lubricants. For cysto.scopes the glycerin and boric acid is
probably the best. Cleanliness should be observed as regards the
bottles or other receptacles in which lubricants or substances to
be used for purposes of irrigation or instillation are to be kept.
Dust should not be allowed to accumulate .on the outside or on
the inside. The receptacles should be of a type that can be boiled.
Silver nitrate solutions should, of course, be kept in covered dark
bottles.

PREPARATION OF PATIENT FOR OPERATION 83

PREPARATION OF PATIENT FOR OPERATION

At the City Hospital the method of preparing patients for
operation is as follows: When catheterization or simply an ex-
amination of the urethra is to be carried out, the glans penis and
the neighboring parts are washed off with a bichlorid solution
1 : 5000 or 1 : 3000, and sterilized towels and a piece of sterilized
gauze placed around the base of the shaft of the penis.

As previously stated, neither in hospital work nor in private
practice is it necessary or advisable, previous to the introduction
of an instrument, to attempt disinfection of the urethra by means
of irrigations or disinfecting fluids, particularly silver nitrate
solutions. Neither is it necessary, as a routine measure, if it is
desired to pass fluid beyond the compressor urethrae muscle, to
overcome the contraction of the muscle by forcibly distending the
anterior urethra by fluid. In examining the bladder, it is the
writers' general practice to introduce into it an antiseptic solu-
tion, such as boric acid or oxycyanid of mercury, through a small
olive-pointed French gum catheter. If some more serious opera-
tion than simple examination of the bladder or urethra is to be
performed, the method of procedure is as follows:

A few hours before operation the instruments are properly
sterilized, the field of operation washed with soap and water, and
the parts scrubbed with tincture of green soap and water for ten
minutes. A poultice of green soap paste is applied for three
hours for the purpose of loosening the epidermis. After the soap
poultice is removed the field of operation is again scrubbed with
the green soap and water for ten minutes, followed by alcohol and
then by ether ; a wet dressing of bichlorid i : 3000 or a dry sterile
dressing is then applied until the patient is taken to the operating
room. This is the general plan followed for all operations in the
region of the kidneys. Just before operating the field is again
scrubbed with soap, alcohol, ether, and bichlorid solution, and,
lastly, a saline solution of one dram to the pint. After operating
on the kidneys sterile gauze or dry sheet gauze is then applied,
this being covered with fluff gauze; next a combined dressing is
applied, consisting of absorbent cotton placed between two pieces
of sterile gauze; this is covered with a many-tailed bandage. If

84 CARE OF INSTRUMENTS AND PREPARATION OF PATIENT

a tube is introduced, additional dressing is required. In the prep-
aration of a patient for perineal section alcohol and ether should

Fig. 39.— Plate to secure catheter in suprapubic drainage.

not be used about the genitals, but, instead, bichlorid i : 2000
should be employed.

For suprapubic section the field of operation is also prepared as
in the manner above described. If a drainage-tube is introduced

through the su-
prapubic open-
ing into the
bladder and it
drains well, the
dressing need
be changed but
once a day ;
where there is
much leakage
around the
tube, the dress-
ing should be changed
more frequently. Strip
gauze should be placed
around the tube, covered
by plenty of fluff gauze,
and a combined dressing
with a hole in the center
applied, being retained
in place by strips of adhesive plaster over and on each side of the
tube. If no tube is inserted in the suprapubic opening, or after
removal of the tube, it is necessary to change the dressing every
three or four hours. Frequent change of dressings should follow

Fig. 40.— Dressing for perineal section.

PREPARATION OF PATIENT FOR OPERATION

85

suprapubic cystotomy to prevent the formation of suprapubic
fistula.

In operations on the testicle the dressing consists of fluff gauze
placed over the wound, combined dressing over this, and a hand-
kerchief bandage support covering all. This handkerchief ban-
dage support or triangular bandage is very serviceable, and is
probably so well known that a description is unnecessary.

Zuckerkandl advocates cleansing the pubes, glans penis, and mea-
tus with soap and water, fo lowed by a bichlorid wash, and, as
before stated, washing out the anterior urethra with a silver nitrate
solution 1 : 2000, so as to render any shreds that may be present

Fig. 41 .— Diessint; for pciiiiL-al section.

in the anterior urethra antiseptic; these shreds would otherwise,
if washed back into the bladder, start up an inflammatory process.
He advises that catheters be not sterilized until immediately
before use. His method of applying the spica bandage over
the shaft of the penis, over the glans, running down on to the
shaft of a retention catheter, the other end of the catheter
being in a container passed through sterile cotton in its neck, has
been elsewhere described. He considers that retention catheters
will occasionally start up not only a urethritis, but a diphtheric
inflammation of the urethra as well.

For bladder washings he recommends oxycyanid of mercury

86 CARE OF INSTRUMENTS AND PREPARATION OK PATIENT

1 : 5000 in place of boric acid. He considers that antiseptic bladder
washings before the introduction of such an instrument as a cys-
toscope will sometimes obviate the necessity of resorting to anti-
septic bladder washings after the removal of the instrument.
His suggestions as regards the sterilization of ' instruments before
performing lithotrity are of value. He recommends that the pumps
be steriUzed and placed in bottles filled with bichlorid solution,
where they should be left until required. Just before opera-
tion the bichlorid can be removed and boric acid solution substi-
tuted as a washing-out fluid. He quotes Guyon as advocating
silver nitrate i : 5000 for steriUzing the pumps. Kraus has invented
a glass pump that is now on the market that should be easily
rendered sterile.

The measures advocated by Zuckerkandl for preparing the
patient for the operation of litholapaxy are as extensive as those
followed when a serious operation is to be performed. Beginning
with the usual bichlorid solution, soap poultices, etc., disinfec-
tion of the hands of, and the wearing of sterile clothes by, the
operator, he recommends the prolonged washing-out of the urethra
and bladder with the boric-acid solution before the lithotrite is
introduced; his general recommendation as regards the frequent
washings of the bladder during litholapaxy are somewhat at vari-
ance with the recommendations of Chismore, quoted elsewhere.
Zuckerkandl, who has written extensively on asepsis in connec-
tion with surgery of the urinary organs, recommends that, even
for so simple an operation as urethrotomy, the antiseptic details
should be the same as in operations of greater consequence.

Anesthesia. — Ether is the safest for the more serious operations
on the urinary organs. It is preferably given by the drop method.
When possible, the services of a professional anesthetist should
be procured. We operated on the perineum several times under
spinal anesthesia about ten years ago, but discontinued the pro-
cedure on account of a serious secondary hemorrhage occurring in
one case some four hours after an external urethrotomy, due
apparently to the after-effects of the anesthetic. Local anes-
thesia with 2 per cent, cocain and a chlorid of ethyl spray has
been used, when necessity required, for the radical operation for
the cure of double hydrocele and for perineal section. We

PREPARATION OF THE SURGEON 8/

advise against the use of some of the more recently exploited
local anesthetics on account of reports that have reached us of
necrosis following after their use.

PREPARATION OF THE SURGEON
In private practice, if the work to be done is at all extensive,
the precautions as regards asepsis are carried out with some diffi-
culty. The frequent changing of sterile clothing during consulta-
tion hours is not a very practicable method. It is well, however,
for the surgeon to wear a sterile gown ; this need not, however, be
when its use is indicated by the requirement of any particular
case. It is a good plan to use sterile rubber gloves in all examina-
tions, even for so simple an operation as the instrumental examina-
tion of the urethra or bladder. The general practitioner may find
some of the foregoing

details suggested some- ,^^"'^I^v:Q j^-ssj^

what impracticable, and
he must, therefore, adopt
such modifications as
may seem most sensible.
The methods here ad-
vocated are those that

, \_ r ■, , Fig. 42. — R. H. Ferguson's drop apparatus for ad-

have been found most ministration of ether or chloroform.

useful, and are generally

in accord with the directions laid down in the text-books
on modern surgery, reference to which may furnish many
valuable hints. A thorough asepsis and the use of antiseptic
liiethods in the surgery of the urinary organs has undoubt-
edly done much to lessen the frequency and the severity of
catheter fever. If the necessity for taking proper aseptic and
antiseptic precautions in the surgery of the urinary organs is
sufficiently borne in mind, benefit will accrue in two ways: first,
by reducing the number of infectious conditions that may occur
after urethral and vesical instrumentation; and second, because
of the detail required for the proper carrying out of such precau-
tions, by placing a curb on those who are overzealous in introduc-
ing instruments into the urinary canal.

CHAPTER IV

EXAMINATION OF THE URINE AND URETHRAL
EXUDATE

EXAMINATION OF THE URINE

The technic of urinary examination is now so fully discussed
in numerous special text-books that, with the limited space at our
disposal, it seems unnecessary to consider this subject in detail;
our attention will, therefore, be devoted, instead, to a considera-
tion of the value and appUcation of urinary diagnosis.

There is, perhaps, no field of diagnosis in renal disease in which
greater error may result than from the making of isolated urinary
examinations, though they may seem to afford the most accurate
and direct evidence as to the action of the kidneys. This possi-
bility of error is largely the result of the fact that not only does
the normal constitution of the urine vary markedly in different
subjects, but it may vary also in the same subject under many
differing physiologic as well as pathologic states. The urinary
characteristics are also very largely and directly dependent upon
the nature of the food and drink, a fact that is too frequently
overlooked in estimating the significance of any urinary examina-
tion. Finally, it should not be forgotten that a diagnosis should
never be based solely on the urinary findings, and that these find-
ings are to be looked upon only as symptoms and considered with
all the clinical aspects of the case. It must not, moreover, be
overlooked that just as marked variation exists in the urinary
picture as in any other of the symptomatic manifestations of
diseases of the urinary passages.

Collection of Specimen. — It is best, whenever practicable, for
the physician to secure the specimen himself, receiving the same in
a clean vessel, and, when desired for bacteriologic examination,
under sterile precautions. Very serious errors in diagnosis and in
subsequent treatment have followed a lack of attention to these
manifestly important details. Unusual foreign substances in
the urine should always be looked upon as contaminations until
they can definitely be shown to have actually been voided by the

EXAMINATION OF THE URINE 89

patient. When considerable importance is to be attached to the
urinary analysis, a statement of the patient's diet should be fur-
nished with the specimen. In every case the specimen selected for
examination should, if possible, be taken from the entire twenty-
four hours' urine, the total quantity of which should further, of
course, have been determined.

When considerable time must elapse between the collection of
the specimen and the examination, the urine should be kept in
the ice-box or a few grains of chloral should be placed in it.
Chloroform or formalin may also be added for the same purpose.

Amount. — The amount of urine passed should always be consid-
ered in conjunction with the quantity of liquid nourishment taken
and also with the water excreted by the bowels and skin. Only
when these factors have been considered may the quantity of urine
passed be regarded as a means of pointing out possible disease.
In important cases a fluid and urine chart is very useful, since it
graphically demonstrates any gross retention and at the same
time is a most excellent control of the effects of treatment in
local or general edemas. The amount of urine may vary normally
between 800 c.c. and 3000 c.c. in twenty-four hours, this being
dependent somewhat on the sex and the body weight; a fair
statement of the average amount would be about 1500 c.c. Patho-
logic polyuria occurs in diabetes, both with and without glycosuria,
and in interstitial nephritis. A temporary polyuria is a frequent
accompaniment of many nervous and mental disorders, of shock,
and of like conditions.

Decrease in the amount of urine is found in practically all condi-
tions where blood pressure is lowered, as, for example, in various
types of cardiac insuihciency. It is a very marked symptom of
acute nephritis, where it may amount to actual suppression, and
it is also seen in many nervous conditions, as in some cases of
hysteria, epilepsy, and the like. As has been stated, it is of the
greatest importance always to consider the quantity of urine ex-
creted in connection with the amount of liquid ingested and that
excreted by other emunctory organs.

Specific Gravity. — The specific gravity of urine is very closely
associated with the amount excreted and with the total solids
thus thrown out of the body. It may, therefore, be taken more
or less accurately as a measure of the solids excreted. In order

90 EXAMINATION OF URINE AND URETHRAL EXUDATE

that conclusive data as to the excretion of soUds may be drawn
from an examination of the urine, by any method, it is absolutely
necessary that the entire twenty-four hours' amount be collected
and the specific gravity determined from this.

Reaction. — The reaction of the urine is normally acid. It may,
however, become amphoteric, neutral, or alkaline under the in-
fluence of medication, from the use of certain foods, and under
some physiologic as well as in many pathologic conditions. In
itself the reaction of any individual specimen has but little impor-
tance. When, however, the reaction of the fresh entire twenty-
four hours' specimen is altered, the cause for this change must be
ascertained. For example, after severe nervous strain, especially
if prolonged, the urine may become intensely acid, due to excessive
excretion of acid phosphates. A diet almost purely vegetarian
leads, in many cases, to the excretion of an amphoteric or alkaline
urine, whereas a diet rich in animal food, as a rule, gives rise to a
highly acid urine. Frequently the reaction of the urine may cause
more or less marked disturbances. Thus a highly acid urine may
account for vesical irritation and for frequent and painful urina-
tion. Less often a strongly alkaline urine may cause similar
manifestations. Where the reaction of the urine only is at fault,
the condition is usually easily corrected by giving attention to the
diet or by simple corrective medication.

Urinary Constituents

Urea. — The amount of urea present in the urinary output should
be determined as a matter of routine in all urinary examinations,
for this substance is the most important element given off as a
result of nitrogenous decomposition in the human body. Unfor-
tunately, the amount of urea excreted under various physiologic
as well as pathologic states varies, being largely associated with
the amount of nitrogen thrown out in the form of other nitrog-
enous compounds, such as uric acid, kreatinin, xanthin bases, and
the like ; the total nitrogenous metabolism of the body can there-
fore be accurately estimated only when the presence of all these
are determined, as by the method of Kjeldahl. For comparative
clinical use the methods of urea determination as obtained by the
Doremus or the Einhorn ureometer are sufficiently accurate in
most cases. The amount of nitrogen ingested and the relative

EXAMINATION OF THE URINE 91

amount excreted with the feces must be taken into consideration.
Tissue destruction resulting in increased urea excretion can be
ascertained only when comparison of the amount of urea excreted
is found to be in excess of the relative amount of chlorids in the
urine, for in health the chlorids equal about one-half the amount of
urea excreted.

Nearly all febrile conditions, and whenever excessive tissue
waste is taking place, are accompanied by an increase in urea
excretion. Urea is diminished in such diseases as acute yellow
atrophy, Weil's disease, and in other conditions where serious
destruction of the liver parenchyma is taking place, under which
circumstances ammonia compounds appear in relatively excessive
amounts.

Uric Acid. — Uric acid occurs in the urine only as a result of the
destruction of the nucleins of the food or of the body. There can
be but little doubt that the amount of uric acid found in the urine
has but slight clinical significance in most cases, except when
due to the high acidity of the urine or to some other cause, it is
precipitated in the form of fine crystals that, acting as foreign
bodies, may give rise to marked local irritation. The amount of
uric acid found in this form is, however, no measure of the quantity
excreted, for crystals maybe found abundantly even when little or
no uric acid remains in solution, whereas, on the other hand, no
crystals may be found in the urinary sediment when the acid may
be present in large amounts held in solution. It is normally present
in relation to urea in a ratio of about i : 60.

A relationship between numerous clinical manifestations that
are commonly known as the uric acid diathesis and actual uric
acid excretion has never been satisfactorily established.

Chlorids. — Under normal conditions the chlorids of the urine are
a measure of the chlorids present in the food ingested ; they occur
mostly in the form of sodium chlorid. They are diminished in
practically all acute febrile conditions, particularly in lobar pneu-
monia and in many forms of nephritic diseases where the amount
of water excreted is also diminished, for it has been shown that
the amount of chlorids thrown off bears some relation to the ex-
cretion of water; hence the importance of restricting the intake
of sodium chlorid in nephritic diseases. The estimation of the
amount of chlorids in the urine forms a fairly accurate estimate of

92 EXAMINATION OF URINE AND URETHRAL EXUDATE

the digestive and absorptive powers in any given instance. It
should be remembered that in some cases of nephritis chlorid ex-
cretion is greatly retarded.

In purely clinical studies an accurate estimation of the chlorids
is rarely essential, and a fairly satisfactory comparative method
is that afforded by adding a certain number of drops of silver
nitrate to a definite amount of urine, and observing the character
and density of the precipitate of silver chlorid that forms.

Phosphorus. — The presence of phosphoric acid in the urine, like
the chlorids, is also dependent in considerable degree on the quantity
of this substance taken in as food, only a small amount being the
result of tissue destruction. This view does not, however, meet
with universal acceptance. Phosphorus is found chiefly in the
form of salts of sodium, potassium, calcium, and magnesium, and
it is chiefly these substances that give the acid reaction to normal
urine.

The excretion of phosphorus is diminished in most febrile dis-
eases, and the decrease is more or less dependent on the severity
of the disease. It is a matter of common clinical observation
that severe nervous conditions are generally associated with an
increased output; in leukemia the excretion is also, as a rule,
greatly augmented.

The detection and determination of phosphates in the urine are
possible only by the usual qualitative and quantitative chemic tests.

Sulphur. — The sulphur found in the urine is the result of the
breaking down of albuminous substances in the body, only a small
amount being accounted for by the inorganic salts of sulphuric
acid taken in the food. The greater amount exists in the form of
inorganic salts, known as preformed sulphates; whereas the remain-
der occur as combinations of sulphur and certain aromatic bodies
and are designated as conjugate sulphates.

The sulphur compounds are normally found increased when
tissue decomposition is taking place, and the conjugate sulphates
are increased particularly when intestinal fermentation is going
on. Certain drugs, such as morphin, the bromids, and the saHcy-
lates, cause an increased elimination of sulphur, whereas ingestion
of alcohol results in a diminution.

Both qualitative and quantitative determinations of the sulphur
compounds of the urine depend on the precipitation of barium sul-

EXAMINATION OF THE URINE 93

phate; when a properly prepared solution of barium chlorid is
added to the urine, the sulphur is deposited in the form of barium
sulphate and the precipitate is then weighed.

Albumin. — The presence of albumin in the urine has long been
regarded as indicating, for the most part, disease of the kidneys or
vascular system; cases are, however, occasionally met in which
albumin appears to be excreted physiologically in the urine. This
applies in a general way only to specific forms of albumin, such as
egg-albumen or the albumin of other special articles of diet. From
this it may be seen that the amount of albumin present in the urine
may be definitely dependent on the character of the food ingested
and on the condition of the absorptive and digestive functions. In
nephritis, the amount of albumin excreted must not be taken as a
measure of the progress of the disease, although this is very com-
monly believed to be the case. In certain forms of renal disease,
particularly in those chiefly characterized by the production of scar
tissue in the kidneys, the amount of albumin excreted is usually
small, and therefore cannot, of course, be regarded as a measure
of the gravity of the case. On the other hand, it will sometimes be
found that a case presenting markedly favorable symptoms may
yet persistently show large quantities of albumin in the urine.
It must, therefore, be conceded that the finding of albumin in the
urine has but slight value beyond that of aiding in diagnosis.
Its disappearance in no way indicates that the disease is abating,
nor does its persistence indicate -further progress of the disease.
An exception to this rule, however, must be made when the albu-
min present is found to be due to blood; then the quantity and
fluctuation are often of great prognostic value.

The occurrence of special forms of albumin is often of consider-
able significance, and in obscure cases detailed chemic investiga-
tions will prove of marked service; thus the presence of Bence-
Jones albumin is apparently definitely diagnostic of multiple mye-
loma, the chemic reactions determining its identity are simple
and easily demonstrated.

As a rule, the Heller test, made with cold nitric acid, has been
found one of the most satisfactory for the routine detection of
albumin. When doubt exists as to its presence or absence, other
tests should be employed, the potassium ferrocyanid test being
one of the most delicate. For ordinary clinical purposes the

94 EXAMINATION OF URINE AND URETHRAL EXUDATE

quantitative determination of albumin can be made by the famil-
iar Esbach method, which gives sufficiently accurate results.

Sugar. — This is often found in the urine of entirely normal
persons under special dietetic conditions, as when sugar has been
taken in abnormal quantities or when special foms of it to which
the individual's tissues seem to be intolerant, have been ingested.
When large quantities of certain forms of sugar have been taken
and small quantities of it appear in the urine, this may in most
cases be ignored as an indication of disease ; it may, however, as
pointed out by von Noorden, signify a lessened ability on the part
of the tissues to burn up sugar, and an increased inclination
toward the development of diabetes. The detection of sugar,
then, even when apparently of physiologic origin, often becomes a
matter of considerable import in the preventive treatment of
diabetes. For a more complete discussion of the appearance of
sugar in the urine the reader is referred to the treatises dealing
with diabetes.

Since there are a considerable number of substances that may
give a reaction simulating the reduction tests with Fehling's
solution, reUance should never be placed on this test alone, — at
least in a prehminary examination, — but the fermentation test or
that with phenylhydrazin, preferably the former, should also be
employed. Quantitative tests are most satisfactorily made with
Fehling's solution or with Whitney's reagent, the presence of
other reducing bodies, of course,- having first been disproved.

Acetone. — Acetone should always be sought for in cases of gly-
cosuria, although its occurrence is not limited strictly to this
state. It is often found also in apparently purely physiologic
conditions, although its presence is usually associated either with
gastro-intestinal or hepatic disturbance or with true diabetes.
The test that has been found most satisfactory for the detection of
acetone is that of Lieben. (A few cubic centimeters of the first dis-
tillate of the urine are treated with several drops of dilute solution
of iodopotassic iodid and sodium hydroxid, when, even if small
quantities of acetone are present, a precipitation of iodoform oc-
curs.) In cases of diabetes considerable amounts of acetone are
of marked prognostic value and are generally of grave significance.

Indican. — Indican occurs in the urine chiefly when absorption
from retained intestinal contents is taking place or when abnormal

MICROSCOPIC EXAMINATION OF THE) URIFE 95

intestinal fermentation is going on ; it is therefore seen in cases of
constipation and in tyrotoxicon and other forms of ptomain poison-
ing. It is found in greater or smaller amounts in nearly all urines,
and is of importance only when taken in consideration with other
manifestations of intestinal absorption. It may be detected in the
course of Heller's test for albumin, a variegated brown or purple
line forming just above the acid zone. A more accurate test is
made by shaking a few cubic centimeters of the suspected urine
with a solution of ferric chlorid with hydrochloric acid, to which
a small quantity of chloroform is added, which then, on separa-
tion, takes on the characteristic blue or purple color.

Bile -pigments. — Bile-pigments are usually found in the urine
in cases of obstruction to the common duct, when hepatogenous
pigmentation is present, or sometimes when extensive destruction
of the blood is taking place. It is manifest chiefly in cases of
jaundice due to any cause. In marked cases it is easily recognized
by the deep color of the urine and by its power of staining filter-
paper a typical bile color. It may also be detected by the addition
of tincture of iodin in the form of a layer above the urine in a test-
tube. If bilirubin is present, an emerald-green color will form at
the point of contact. When nitric acid is added to the urine in a
test-tube, as in the ordinary Heller's test for albumin, a color play,
green predominating, will result.

Fat. — Fat never occurs normally in the urine. It is found,
however, in cases of extensive destruction of the fatty tissues of
the body, notably of the bone-marrow. It is occasionally seen
after the administration of large quantities of fat either by the
mouth or by inunction. The term chyluria is applied to a condi-
tion in which the fat present in the urine gives it a milky appear-
ance. This condition is present most frequently in cases of fila-
rial infection, though it may also occur when chyle enters the
urine through fistulae or in any other manner.

MICROSCOPIC EXAMINATION OF THE URINE

When possible, the urine should be thoroughly centrifu gated
before microscopic examination is undertaken. When a centri-
fuge is not at hand, the urine may be allowed to stand for a consid-
erable length of time in a conic sedimentihg glass, after which

96

EXAMINATION OF URINE AND URETHRAL EXUDATE

the material collecting at the bottom may be pipeted off and ex-
amined.

The urinary sediment must always be considered in conjunction
with the chemic characteristics of the urine; thus a highly acid
urine may cause a precipitation of uric acid, even though this
substance is present only in normal quantity. On the other hand,
alkaline fermentation, which may take place entirely after the
urine has been voided, may, unless this fact is known, lead to
erroneous conclusions as to the conditions really present in the
urinary tract.

It must always be remembered that the urine is very susceptible
to contamination, which may be brought about either wilfully or
by accident, and that foreign bodies of all kinds may be present
in it — pus from the vaginal secretion, bits of lint from the clothing,

or particles of many kinds
derived from the dust and
the air; they may also have
been present in the vessel in
which the specimen was re-
ceived.

The microscopic examina-
tion of the urine must be con-
sidered along with, and not
aside from, the general clinical
manifestations of the case. It
must never be lost sight of that
microscopic diagnosis, just as
all other forms of diagnosis, is
open to error, and this is par-
ticularly likely to occur when conclusions too sweeping are
attempted from mere microscopic examination.

Fig. 43.— Red blood-corpuscles in urine (Jakob).

The crenation shown by many of these cells is

quite characteristic.

Organized Deposits

Red blood-corpuscles are found in the urine whenever hemor-
rhage from any cause is taking place from any portion of the uri-
nary tract. The source of the blood can be traced quite accurately,
as a rule, from the clinical history or manifestations, by the
presence of other tissue, as bits of papillomatous tumors or ne-
crotic tubercles in the urine, which may, from their association,

MICROSCOPIC EXAMINATION OF THE URINE

97

indicate the probable nature and source of the hemorrhage. The
quantity of blood present is, of course, a matter of considerable
importance; when bright red and fresh in color, it is, for example,
more likely to have originated from the urethra than from the upper
tract.

Leukocytes or pus-cells, when they appear in the urine, are indi-
cative of inflammatory or suppurative disease. As a rule, they
are accompanied by the discharge of bits of tissue, such as flakes of
epithelial cells or necrotic connective tissue which may, in a certain
number of cases, indicate their probable origin. When associated
with crystals, they may point to the possibility of calculus.

Mucus in considerable amounts is often found in the urine under
normal conditions, particularly when the secretion of the seminal
vesicles or prostate gland is
present in large quantity. The
presence of numerous shreds of
mucus in the urine is strongly
indicative of an existing pros-
tatitis. Mucus in large quan-
tities is also generally found in
cases of pelvic stone, and is
then often mixed with more or
less pus.

Epithelium. — Much has been
written about the diagnostic
possibilities of microscopic ex-
amination of the urine from
the character of the epithelial
cells found. A wide diversity

of opinion exists as to the value of this procedure, and it is note-
worthy that those who are least familiar with the normal histology
of the mucosa of the genito-urinary tract are the firmest believers in
its diagnostic importance. It should never be forgotten that the
pelves of the kidney, ureter, bladder, and prostatic urethra are lined
by a type of epithelium that is absolutely identical in all. A
differentiation, even between masses of cells from these localities, is
therefore impossible from the microscopic findings alone, and the
clinician must form his decision as to the origin of the cells largely
from other manifestations. Sometimes when cells occur in masses
7

Fig. 44.— Squamous epithelium from urethra
and bladder (Jakob).
The superficial layers of the bladder con-
tain large squamous epitlielial cells (a), the
deeper layer club-shaped cells with tenuous
extremities.

98

EXAMINATION OF URINE AND URETHRAL EXUDATE

those desquamated from the mucosa of the external genitals can
be distinguished by their more squamous character from the
typical "transitional" cells seen in the epithelium from the mucosa

of the urinary tract proper.
Cells from the renal tubules
may also occasionally be differ-
entiated from those of the
lower layers of the transitional
epithelium mainly by the par-
enchymatous character of the
renal cells. A diagnosis should
never be based on an exam-
ination of isolated cells.

Fragments of tumors are oc-
casionally found in the urine,
and they may be of sufificient
size to make a probable diagno-
sis possible. This should, however, be made very cautiously, unless
the fragments are sufficiently large to permit of proper orientation

Fig. 45.— Renal epithelium (Jakob).

/

,/'

^-. " ■' " ' "

— ^

'^^

■mp^^lk:;''

' .^--'"

J

"fB

i

(ll «

M^PI

^^H

L

\

lfl|

BB^^W^yWffS

I

'

'" \ *

l"^ .,»3BB

aEy ^. ■ \

V

i

i '..-•■

aXBT-JC^

-mc-iaonB

Fig. 46.— Urinary tube-casts (Jakob). In the upper portion of the figure are shown cylin-
droids (a), which are without significance. Below are hyaline tube-casts (d), which occur in
conjunction with all diseases of the kidney (inflammation, stasis, irritation by toxins) in the
form of narrow or broad cylinders. They occur as the result of a form of exudation into the
uriniferous tubules. They are frequently the seat of white blood-corpuscles (t) or of renal
epithelium (rf). The latter relation is significant of profound disturbance.

and sectioning. Tubercular or gummatous involvement of the
urinary tract may also occasionally be diagnosed from necrotic
masses of tissue in the urine.

MICROSCOPIC EXAMINATION OF THE URINE

99

Fig- 47-

-Coarsely and finely granular tube-
casts (Jakob).

Spermatozoa or the secretion from the seminal vesicles, pros-
tate, or other sexual glands may occasionally be found in the
urine. Their value in diagnosis is dependent on the constancy
of their appearance, and they ,

can be considered as a deter-
mining factor only after a care-
ful history of the case has been
taken and their probable rela-
tionship to disease suggested.
Cylindroids are long, usually
more or less convoluted, shreds
of mucus, which are to be dis-
tinguished from true hyaline
casts by the filamentous ends
of the former. Their manner
of formation is uncertain.

Casts. — The occurrence of
casts in the urine is, as a rule,

considered of too much importance in diagnosis, and is really valu-
able only when considered in conjunction with the entire aspect of
the case. They are, however, a more certain index of renal disease

than the presence of albumin.
Thus they may appear in
considerable numbers in the
beginning of active diuresis,
without indicating actual dis-
ease of the kidney. On the
other hand, they are sometimes
entirely absent in serious cases
of nephritis. When they are
present constantly in numbers
they may be looked upon as
probably the one most absolute
diagnostic symptom of nephri-
tic disease, although this dis-
ease may be confined exclusively to one kidney or even to a
portion of one or both organs. The character of the casts is of
much importance in this relation.

Fig. 48. — Waxy tube-casts (Jakob).

lOO EXAMINATION OF URINE AND URETHRAL EXUDATE

Fig.49.— Blood-casls (Jakob'

Hyaline casts are clear, transparent, narrow, though sometimes
broad, cylindric bodies. They are, at times, found in practically
all specimens of urine. When constantly present in considerable

number, they are strongly in-
dicative of nephritis, partic-
ularly of the diffuse interstitial
variety. Their size depends
on the caliber of the tube in
which they are formed.

Granular casts occur more
constantly associated with dis-
ease of the renal parenchyma.
Their granular character is
probably the result of the de-
tritus following parenchyma-
tous degeneration and disinte-
gration of the renal epithe-
lium. They are classed as coarsely or finely granular or accord-
ing to their size.

Epithelial casts appear in the urine when desquamation of the
tubular epithelium is taking place. They consist of a hyaline cast
to which epithelial cells are
clinging in greater or less
number.

A myloid or waxy casts, which
respond to microchemic reac-
tions for amyloid, are found
chiefly, though perhaps not
exclusively, as the result of
amyloid degeneration of the
kidney.

Pus- and blood-casts are de-
fined by their names, and are
diagnostic of renal suppuration
and hemorrhage respectively.

Fatty casts are seen where fatty degeneration of marked degree
is present, or in chyluria.

Fig. 50.— Fatty casts (Jakob).

MICROSCOPIC EXAMINATION OF THE URINE

lOI

Fig. 51.— Uric acid crystals (Jakob).

Crystalline Deposits in the Urine
It must be remembered primarily that the occurrence of crys-
talUne deposits in a specimen presented for examination is by no
means an unfaiHng indication
that those substances are pres-
ent in abnormal quantities, for
unless they are passed as
strictly abnormal substances,
they may be precipitated as a
result of the chemic character-
istics of the urine, rather than
as an evidence of oversatura-
tion or from changes which
have taken place in the urine
after it has been voided. These
substances are, for convenience
of description, best considered

under two headings — those found in acid and those present in alka-
line urines.

Substances Found in Acid Urine. — One of the most frequent pre-
cipitates found in acid urine, particularly that of a highly acid char-
acter, is the familiar reddish or
brick-colored deposit of uric
acid or of the urates of sodium
or potassium. Although their
occurrence may not be strictly
pathologic, they indicate a ten-
dency toward the formation of
uric-acid calculi, particularly
when associated with certain
colloidal substances. The va-
riety of crystalline forms as-
sumed by uric acid and its salts
in the urinary deposit is large,
and it must be remembered
that these crystals are not always of the characteristic reddish
color (For a detailed description of the forms that uric acid may

Fig.52.— Sodium urate (Jakob).

I02 EXAMINATION OF URINE AND URETHRAL EXUDATE

Fig. 53.— Calcium-oxalate crystals (Jakob).

take on, the reader is referred to the special works on urinary
diagnosis.)

Calcium-oxalate crystals are one of the most frequent forms of

urinary sediment. They are
occasionally seen in urines that
have undergone slight alkaline
fermentation, although usu-
ally they occur only in acid
urine. Macroscopically, cal-
cium-oxalate appears as a
hazy mucoid cloud settling
slightly at the bottom of the
receptacle. It occurs as the
result of certain dietetic dis-
orders or after the ingestion
of certain foods rich in oxa-
lates. It is also quite con-
stantly found associated with some forms of nervous disease,
as neurasthenia, but the condition is chiefly important as pointing
to the possibility of renal or cystic calculus formation.

Cystin is a chemic substance rarely appearing in the urine.
It occurs in the form of highly
refractive six-sided plates. It
is a product of proteid metab-
olism, and beyond the fact that
it may form the nucleus of a
calculus, is of slight clinical
significance.

Leucin and tyrosin are crys-
talline substances the ultimate
recognition of which must
depend on chemic reactions.
They occur in the urine as the
result of serious metabolic dis-
turbances of the liver, partic-
ularly in acute yellow atrophy.

Large quantities of amorphous phosphates may occur in either
acid or alkaline urine. They are found most abundantly in febrile

Fig. 54-— Tyrosin crystals (Jakob).

MICROSCOPIC EXAMINATION OF THE URINE

103

Fig. 55.— Leucin (Jakob).

urine, after pronounced tissue destruction, when the phosphates of
the urine are greatly increased as a result of the diet, and occa-
sionally after severe mental or
nervous disturbances.

Substances Found in Alkaline
Urine. — The most frequent
crystalHne body that appears
in alkaline urine is the famihar
cof!in-lid-shaped crystal of
ammonio - viagnesiuvi phos-
phate. It may occur whenever
alkaline fermentation is tak-
ing place, and though the crys-
tals are commonly of the shape
just mentioned, other forms
are occasionally seen.

Calcium carbonate appears at times in the urine as large globular
masses. Its clinical significance has not been definitely determined.

Ammonium urate occurs in alkaline urine under conditions simi-
lar to those under which the other salts of uric acid may be found,
and not infrequently represents acid salts of uric acid in urines

that have undergone alkaline
fermentation.

Bacteria in the Urine
The most important of the
bacteria commonly found in
the urine are those that are
concerned in the various in-
fectious processes attacking
the genito-urinary organs.

The gonococcus is, of course,
found in cases of genito-uri-
nary gonorrhea, its recogni-
tion, both clinically and micro-
scopically, usually being easy. Streptococci, staphylococci, and
green-pus bacilli occur more or less frequently as primary infecting
organisms, or, more commonly, in the course of mixed infections,

Fig. 56.— Crystals of cystin (Jakob).

I04 EXAMINATION OF URINE AND URETHRAL EXUDATE

as in cases of gonorrheal or tubercular disease. The proteus and
colon bacilli are very frequently found in the more chronic inflam-
matory diseases of the genito-urinary tract.

As will be more fully discussed under the proper heading, the
recognition of the tubercle bacillus in the urine is often a matter
of considerable difficulty. Except when it occurs in large numbers,
mere morphologic and microchemic reactions are neither positively
nor negatively satisfactory, the findings in every case requiring
substantiation by animal inoculation. The recognition of the
tubercle bacillus is particularly difficult because of its close simi-
larity, in microchemic reactions, to certain forms of the smegma
and timothy hay bacilli, which very commonly infest the genito-
urinary secretion.

Actinomyces fungi are occa-
sionally found in the urine, an
indication, of course, that gen-
ito-urinary actinomycosis ex-
ists.

Echinococcus-hooklets are
found in some cases of echino-
coccus cysts, and the embryos
of the filaria sanguinis hominis
are occasionally found in cases
of chyluria due to filarial in-
fection.

The trichomonas vaginalis
and cercomonas intestinalis are occasionally seen, usually
associated with chronic inflammatory diseases.

Still other micro-organisms appear in the urine from time to
time in specific types of disease or accidental infections of the
genito-urinary tract.

F'g" 57'— Ammoniomagnesium phosphate crys-
tals (Jakob).

EXAMINATION OF THE URETHRAL EXUDATE

Whenever possible, the physician should himself collect the
specimen for examination, for at this time the gross appearance,
exact point of origin, odor, reaction, and the amount of discharge
can best be ascertained. Oftentimes a brief history of the case will
at once suggest the portion of the urinary tract that is the source
of the discharge; when the amount obtained for examination is

EXAMINATION OF THE URETHRAL EXUDATE 1 05

small, the history will likewise determine the methods best calcu-
lated to demonstrate the points in question and no waste of
material need follow.

Whenever the amount and character of the material permit, an
examination should be made of the fresh specimen ; this is done by
placing a drop on a clean slide, and allowing a well-cleansed cover-
glass to fall upon it, thus flattening it out sufficiently for micro-
scopic study. Examination with a dry lens, a No. 6 or 7 Leitz, or
DD Zeiss, will usually reveal the nature of the discharge.

In order to properly study a specimen it is necessary, in almost
all cases, to eventually resort to staining methods. As a prelimin-
ary step in the preparation of such a specimen it is customary to
spread the material over the surface of a clean slide. This is best
effected by collecting the exudate in a drop near the end of a well-
cleaned slide; a second slide is then approximated obliquely to
this drop, causing it to spread along the whole line of contact; the
upper slide is then drawn steadily across the first slide, spreading
the exudate as a thin film over the greater part of the surface of the
first slide. This process is the same as that usually employed in the
making of a blood-slide. The specimen should then be allowed to
dry in the air. The subsequent method of fixation to be employed is
dependent entirely on the nature of the material, as determined
from the gross and from the microscopic examination of the fresh spe-
cimen, and on the facts likely to be derived from microscopic study.

Purulent Discharges. — Acute purulent discharges are, as a rule,
opaque, thick, and creamy. They spread easily and regularly
under the pressure of the cover-glass, and are not uncommonly
tinged with blood. The color is dependent largely on the char-
acter of the organisms present; thus when the pus is due to an
infection with the staphylococcus pyogenes aureus, it is yellow
or golden in color; when due to a white staphylococcus, it is
light gray or white; when the green-pus bacillus is present, it is
greenish in color. When large portions of the exudate are made
up of mucus, as from uterine or prostatic discharges, this fact is
at once manifest from the tenacious nature of the discharge and
the difficulty with which it is spread on the slide.

In examining purulent discharges, the slide is best fixed by heat-
ing it on the copper plate or by holding it above the Bunsen or

106 EXAMINATION OF URINE AND URETHRAL EXUDATE

alcohol-lamp flame until the surface becomes too hot to be held
comfortably, but not until the upper or prepared side becomes
browned, or the specimen is ruined. Slides may also be fixed by
immersing the well-dried slide in a solution of chemically pure
methyl-alcohol for from two to ten seconds; as a rule, however,
heat fixation is more generally satisfactory.

After the slide has been fixed, the examiner selects the most
suitable method of staining according to the points that are to be
elucidated by the examination.

When but a general knowledge of the discharge and of the
organisms present is desired, the best method, perhaps, is to
stain the specimen with the familiar alkaline solution of methylene-
blue known as Lofiler's methylene-blue. The fixed slide may be
immersed in a jar filled with this stain, or the stain may be dropped
on the slide, the latter being gently heated over the flame to has-
ten the staining process. By this means bacteria and all chro-
matic elements are stained a deep blue, the nuclei of epithelial
and connective-tissue cells being similarly stained; the cyto-
plasm is stained a Ughter shade. If the specimen is stained too
deeply, the excess of color may be removed by immersing in 70
per cent, alcohol for a few seconds. If desired, the slide may
similarly be stained by one of the aqueous forms of polychrome
methylene-blue, which gives a much wider color scheme to the
elements of the specimen; in order to use this dye satisfactorily,
however, the specimen must first have been fixed with methyl-
alcohol. After the staining process has been completed, the
slide may be dried rapidly by waving it to and fro in the air after
first draining off the water in which it was washed, or it may be
dried between two sheets of filter-paper, and placed for a minute
in the hot oven, or it may be held above the Bunsen flame until
it is entirely dry. The slide may then be examined with the
oil lens, by simply allowing a drop of cedar oil to fall on the speci-
men where the lens is to be approximated. When it is desired to
preserve the specimen for future reference or study, it is best, after
drying, to cover it with Canada balsam or damar and place it
under a cover-glass, after which the examination may be made.
Specimens prepared in this manner are practically indestructible,
whereas when no cover- glass is used, they soon begin to fade.

EXAMINATION OF THE URETHRAL EXUDATE 107

When the presence of tubercle bacilli is suspected, the slide
should first be stained with the usual carbol-fuchsin, which should
be rendered more intense by the addition of heat until a vapor
arises from the dye. The stain is then to be removed by first
washing in water and then in 2 per cent, hydrochloric acid in a
solution of 70 per cent, alcohol until the specimen becomes gray in
color. The acid alcohol is next removed by washing in water, and
the specimen may be counterstained by methylene-blue. If the
tubercle, leprosy, or certain other special organisms are present,
they appear as bright-red bodies, all the other tissues and bacteria
being stained blue. One must be particularly careful in drawing
conclusions from this purely morphologic method. Very commonly
the smegma bacillus, which is found abundantly about the genitals,
is mistaken for the tubercle bacillus. Ordinarily, the smegma
bacillus is decolorized by acid alcohol, but occasionally this is not
the case; in order, therefore, to obtain absolute results in sus-
pected tubercular disease the abdominal cavity of a guinea-pig
should be inoculated with the exudate, and after a period of six
weeks the animal should be killed. If the suspected material
contained living tubercle bacilli, the peritoneum, liver, and spleen
will be found studded with tubercles. This carbol-fuchsin staining
method acts very satisfactorily not alone for the demonstration of
the tubercle bacillus, but it also serves to demonstrate clearly
the general character and bacterial content of simple exudates and
may be well employed as a routine method.

Another important method of staining is that known as Gram's
method; by means of this it is possible to differentiate bacteria
that do not decolorize from those that do. The method is valua-
ble chiefly in genito-urinary work for eliminating or identifying
the gonococcus, which might otherwise be mistaken for the dip-
lococcus catarrhalis or, in some cases, for the pneumococcus.

After heat fixation the specimen is to be stained with anilin
water gentian- violet solution, and the excess o^ stain removed by
rinsing in water, after which it is transferred to Gram's solution
(iodin, I gm. ; potassium iodid, 2 gm. ; water, 300 c.c). The
specimen is allowed to remain in this solution for from one to two
minutes, when it is removed and rinsed in 80 per cent, alcohol
until no trace of the violet color remains. For this purpose it

Io8 EXAMINATION OF URINE AND URETHRAL EXUDATE

may be necessary to return the specimen for a few minutes to
the iodin solution. The preparation may then be counterstained,
if desired, with Bismarck-brown, eosin, or some other contrasting
dye. By this method "Gram-positive organisms," such as the
ordinary cocci, retain the deep violet color, and "Gram-negative
organisms," such as the gonococcus, take up the contrasting dye.
Since, in this method, many technical errors are likely to occur,
it is well first to place on the specimen, side by side with the sus-
pected discharge, a pure culture of some well-known Gram-posi-
tive organism, such as the staphylococcus; by means of this
control test it can be learned to a certainty whether or not the
process has been managed correctly.

Simple Urethritis. — The exudate in simple or nonspecific ure-
thritis often so closely resembles that seen in gonorrhea that it
can be distinguished only by making a bacterial examination of
the discharge. The amount of pus found in the specimen neces-
sarily varies — when the infecting organisms are of an actively pyo-
genic character, the number of pus-cells is large ; when, on the con-
trary, the organisms depart from this type, as, for example, in the
case of the streptococcus, the specimen will be found to be made
up largely of mucus and serum in which pus-cells naturally min-
gle, but are less abundant. As a rule, the pus-cells found are of
the polynuclear neutrophilic variety, but small lymphocytes may
be found, particularly in exudates of long standing, and some-
times in preponderating numbers. Eosinophilic pus-cells are
occasionally seen, being not uncommonly present in the exudate
of specific urethritis.

Epithelial cells are found in the discharge in greater or less
number, being much more abundant in the more acute discharges.
To a certain limited degree the character of the cells will point to
the seat of greatest inflammation — thus, for example, when the
process is limited chiefly to the fossa navicularis, squamous cells
predominate ; when to the penile urethra, columnar cells. When
the process has been of long standing, as a rule epithelial cells,
if found at all, are present in but very small numbers.

Red blood-cells may be found in small numbers in nearly all
discharges, but as a matter of course they are most common in
acute and active processes.

EXAMINATION OF THE URETHRAL EXUDATE 109

One of the most important points to be learned by the micro-
scopic examination of the urethral discharge is that of ascertaining
the bacterial content. In most cases staphylococci or strepto-
cocci will be found to be present; if the latter, the disease will
generally be found to be an active one. Occasionally the diplo-
coccus catarrhalis is present. This Organism is distinguished
with considerable difficulty from the gonococcus, and its recogni-
tion is often of great importance in questionable infections.
It may be recognized chiefly by its great variability in size, its
diminished tendency toward a diplococcus arrangement, and its
less flattened surfaces where the pairs are opposed. It may be
both intra- and extra-cellular. Further, it is not decolorized by
Gram's method, and in doubtful cases it may readily be differen-
tiated by cultural methods, for the diplococcus catarrhalis grows
readily on ordinary media, whereas the gonococcus does not.

When the discharge is of long standing, as a rule, the bac-
terial content will be found mixed, bacilli of various forms being
present. The colon and proteus groups are particularly likely
to be seen in these exudates, and the discharge is generally of a
highly mucoid or serous character.

When the preparations for examination are made as soon as
the discharge is removed from the urethra, we are justified in
attributing an etiologic significance to the bacteria demonstrated
by an examination of th2 smear; in long-standing infec-
tions, however, it must be remembered that extensive mixing
with contaminating, and very likely unimportant, organisms
takes place. Cultures are important only when some special
organism is sought or desired for purposes of identification, but
they are often very misleading, inasmuch as the organisms that
grow most actively on artificial media may have the least
significance in the causation of the discharge.

The student should not be content with a single examination,
particularly in long-standing urethritis, and it is often necessary
to make several investigations under varying conditions before
the true nature of the discharge will become evident. This is
particularly true when gonorrhea is to be excluded, a matter to
be discussed more fully further on.

Gonorrheal Urethritis. — The discharge in acute gonorrheal

no EXAMINATION OF URINE AND URETHRAL EXUDATE

urethritis is typically purulent in character. Pus-cells are very
abundant; as a rule, they are of the polynuclear neutrophilic
variety, but in some cases eosinophilic pus-cells appear to pre-
dominate. Epithelial cells are present in large numbers, particu-
larly after the exudate has become well established, for at first
the discharge appears only as a mucoid secretion in which a few
pus-cells and desquamated epithelial cells are found. The cells
seen in the early stages are chiefly of the squamous variety, and
their origin is unquestionably in the fossa navicularis; later, as
the penile portion of the urethra and the glands of Littre become

involved, they become more

^>^ rare and are chiefly of the

■^ ; columnar type. Both pus-

\J^f- cells and epithelial cells often

'rj^/' ^j^ show marked hydropic de-

^^ , J^ ^9 generation, and unless the

" * .'w^ ' ^ t^ * ' specimen is prepared soon

• * ^ ^ after the discharge is col-

?'^ ji # •• , , Z^ . lected, such extensive necro-

i^.v.Tjy sis may take place in all the

flfef- ' structures found as greatly

'%% "* <|^^ to lessen the accuracy and

value of the examination.

Fig 58.-Gonorrheal exudate from a case MucUS is present in modcr-

ol eight days' standing, showing presence of ^

EiXocuiarNri'.'' o^J^'^"^^ ^' oi"-"- ate amounts ; in the early

stages, as has been men-
tioned, it may predominate, but in most cases the purulent
elements are so abundant that the mucus is not evident. Blood-
cells are almost constantly present in acute cases, especially
when extensive infiltration of the urethral walls or of the urethral
glands is taking place. When chordee is present, or when undue
mechanic traumatism is inflicted, the amount of blood is found
to be increased.

The detection of the gonococcus is, of course, the most impor-
tant finding to be elicited from a microscopic examination of the
exudate. As a rule, gonococci appear in large numbers even in
specimens collected in the very early stages, before the discharge
has become markedly purulent; it is, therefore, possible to diag-

EXAMINATION OF THE URETHRAL EXUDATE III

nose a gonorrheal urethritis before important cUnical symptoms
develop, by the detection of gonococci. In these very early cases
the gonococci are found, for the greater part, free in the mucus
that is present in the fossa navicularis, although they are gener-
ally found also in the cytoplasm of such pus-cells as may be present.
As the exudate becomes more abundant and typically purulent,
gonococci are found in very large numbers in both the mucous and
the serous elements of the discharge and in the cytoplasm of the pus-
cells, Where they may appear in such enormous numbers as com-
pletely to obscure the nucleus and granulation of the cells. The
morphology of the gonococcus is, fortunately, in itself sufficiently
characteristic to permit of its recognition, in most cases, without
special technical difficulties. This does not hold, as we shall see
in the examination of the exudate in chronic gonorrheal urethritis.

The gonococci occur in the form of biscuit-shaped organisms.
They are commonly found in pairs, the apposed portions of which
show characteristic flattening. As a result of division, groups of
four, eight, or more are seen, and occasionally masses are found
that render recognition somewhat more difficult. As a rule, the
"coffee-bean" shape is well preserved, and, even in atypical cases,
the diplococcoid arrangement is evident.

In the early stages of most cases of acute gonorrhea, bacteria
other than the gonococcus are absent or scanty, and even in those
cases of some weeks' standing the number of gonococci so over-
whelmingly exceeds that of any other contaminating organism
that little doubt as to the etiologic relationship to the clinical
signs and as to the specific nature of the organism can exist.
When, however, the original infection has been a highly mixed
one, as when filthy conditions have been associated with the
primary gonorrhea, other organisms may be present in such num-
bers as to render the making of a purely morphologic diagnosis
somewhat difficult, besides altering the clinical aspects of the
case. In these cases of acute gonorrhea it may become necessary
to employ more compUcated differential methods for the absolute
identification of the gonococcus; ordinarily, however, specimens
stained by the methylene-blue method give quite satisfactory
results. Whenever any doubt exists or the disease must be
viewed from a medicolegal standpoint, the specimens must be

112 EXAMINATION OF URINE AND URETHRAL EXUDATE

stained by Gram's method; when this is done, the gonococci are
decolorized and the other infecting cocci retain the gentian-violet
color. This latter test, however, is not absolute, and when medico-
legal identification is demanded, it may be necessary to resort to
culture-methods; these require a considerable amount of techni-
cal skill, for the gonococcus grows sparsely even on the most
carefully prepared soil, and negative results, even in well-identified
cases, are more frequent than positive. When the organisms
grow on ordinary culture-media, it may be taken as positive
evidence that they are not gonococci. As has already been stated,
it is rarely necessary, for clinical purposes, to resort to these
methods; it is usually quite sufficient to employ the ordinary
methods for staining, followed, if any question arises, by Gram's
method.

The exudate of chronic gonorrheal urethritis does not differ in
appearance from that seen in simple chronic urethritis. Mixed
infection is the rule, and in these long-standing cases it is often
impossible to decide, from the examination of specimens, as to
the relative etiologic significance of the bacteria shown to be
present. Occasionally gonococci may still be found in consider-
able numbers, and no difficulty may be experienced in recognizing
them. In other cases, where the discharge is of a distinctly gleety
character, the most conscientious search may fail to reveal the
presence of a single definite gonococcus. In cases of this nature,
particularly when the subject contemplates marriage, repeated
• examinations should be made; in important cases it is well to
excite a more or less acute inflammatory reaction in the urethra,
since by these means the gonococci may occasionally reappear
in recognizable form and numbers. It is to be remembered that
in many of these chronic cases the organisms do not present their
typical form. They are less diplococcoid in arrangement, the
biscuit shape is less evident, and their size is often considerably
reduced. In very many cases they are entirely unrecognizable
morphologically, although, when inoculated on a normal mucous
membrane, they readily set up a typical inflammation. In these
cases, therefore, repeated examinations should be made and the
preparations gone over by means of a mechanic stage ; the speci-
mens should also be taken under varying conditions. Cultural

EXAMINATION OF THE URETHRAL EXUDATE II 3

methods are, in the opinion of the writers, of little or no assistance
in these cases. In important clinical cases and in those which
must be considered socially, it is best to consider the gonococcus
as present until absolutely negative conclusions have shown it to
be absent. In medicolegal cases, the opposite standpoint should
be taken.

The Secretion in Prostatitis. — Although in by far the larger
number of cases prostatitis is preceded by posterior urethritis,
which ordinarily persists throughout the course of the disease,
this is not invariably the case.

Acute prostatitis is, as a rule, accompanied by acute urethritis,
and when this association occurs, the condition is readily recog-
nized from the general clinical aspects, although the secretion
may present but little that is of diagnostic importance. When
the prostate becomes involved, shreds of mucus and mucopus
formed in the prostatic acini and ducts generally appear in the
urine; these may, however, become confused with similar bodies
that are not uncommonly formed in the ducts of the glands of
lyittre. Corpora amylacea may also appear, but, as previously
stated, it is most difficult definitely to determine, from the micro-
scopic or gross examination of the exudate, whether or not inva-
sion of the prostate has taken place. When bacteria appear in
the shreds of mucopus it will, as a rule, be found that these or-
ganisms bear some etiologic relationship to the disease.

In the absence of urethritis, evidence of the existence of inflam-
matory disease of the prostate may be secured by first cleansing
the urethra by urination or mechanic washing, and then, by
massaging the prostate, forcing the secretion from its acini into
the posterior urethra, from which, by voiding a small amount of
urine, the specimen may be secured for examination. Conclu-
sions must be carefully drawn from the examination of specimens
obtained in this manner, for it must be remembered that the pros-
tatic secretion so obtained normally contains elements that might
erroneously be regarded as indicative of inflammatory disease.
Thus, under normal conditions, there will be found leukocytes in
considerable numbers; mucus, largely in the form of shreds;
and corpora amylacea, with masses of isolated epithelial cells of the
columnar variety. When, however, pus-cells are found in abun-

114 EXAMINATION OF URINE AND URETHRAL EXUDATE

dance and blood occurs in more than minute quantities, and
when bacteria are found to be present, disease of greater or less
extent may safely be said to exist. Enough has already been
said in regard to the examination of the urethral exudates con-
cerning the character of these bacteria and the methods for
demonstrating their presence, but mixed infections are not the
rule. The examination of the prostatic secretion is particularly
advised in cases of supposedly healed gonorrhea, for a few infected
acini of the prostate gland, although quite sufficient to cause infec-
tion of another individual, may exist indefinitely without exciting
symptoms that would attract the attention of the ordinary patient.
No case of gonorrhea should be discharged as cured until such an
examination has been made and no gonococci found.

Whenever pus is discharged from the prostate in considerable
quantities, abscess of the gland is to be suspected, and in each case
the character of the exudate should be thoroughly investigated.
In simple inflammation of the prostate, as a rule, but little pus is
present, and this is, for the most part, arranged in the shred-like
mucoid masses previously described. When an abscess is present,
the discharge of pus is much more abundant and may practically
be continuous. In long-standing simple prostatitis, whatever its
etiologic origin, members of the colon and proteus groups of
bacteria are commonly present. Absolute identification of these
organisms is possible only as the result of cultural experiments;
this step is, however, rarely necessary for mere clinical purposes,
since the morphologic and microchemic characteristics of these
organisms are usually sufficient for their identification. When,
however, tubercular disease is suspected, a special examination
should be made. As has been stated, the absolute recognition of
the tubercle bacillus is occasionally a matter of difficulty when
staining methods alone are utilized, and it may be necessary
to resort to animal inoculation, but, as a rule, the accompanying
symptoms aid in the diagnosis. Thus, in tubercular prostatitis
masses of necrotic tubercular tissue may be discharged from the
gland into the urethra, from which canal they may be washed out
by the urine and submitted to histologic examination.

Vesiculitis. — The specimens intended for examination are to be
obtained in a similar manner to those secured from the prostate.

EXAMINATION OF THE URETHRAL EXUDATE II 5

except that after the urethra has been cleared, massage is to be
appHed over the seminal vesicles. Inflammatory disease of the
seminal vesicles is a relatively frequent condition, and occurs as
a complication of gonorrheal urethritis. The normal secretion
of the seminal vesicles is composed of a mucoid material, desqua-
mated cylindric epithelium, and may even contain a few corpora
amylacea. In addition, spermatozoa in greater or less numbers
can always be expelled from the seminal vesicles. When the
specimen secured after massage is found to contain no spermato-
zoa, it is probably fair, in the adult, to assume that some obstruc-
tion of the vas on that side exists which prevents the escape of sper-
matozoa.

The methods of investigation of the exudate and the nature of
the processes being similar to those that have just been discussed
in regard to the prostate, no further description is necessary.

Cowperitis. — Although inflammation of Cowper's gland is a not
uncommon complication of urethritis, and the body of the gland
oftens remains, for a long time, a nidus of infection in which gono-
cocci may persist indefinitely, it is impossible to obtain this secre-
tion unmixed for purposes of examination, though where the
duct remains permeable, the discharge doubtless escapes into the
urethra.

Examination of the vSeminal Secretion

Examination of the seminal secretion is not only of utility in
diagnosing diseased conditions, but is useful also to determine the
normal character, to establish the absence or presence of possible
infecting organisms, to demonstrate the presence and viability
of the spermatozoa, and in the conduct of certain medicolegal in-
vestigations.

In order to determine the viability and impregnating powers
of the spermatozoa the examination should be made as soon as
possible after the specimen has been obtained. These qualities
are in part dependent on the motility of the spermatozoa, and
while under the natural conditions of warmth and moisture in the
genital tract, these bodies may remain motile for hours and prob-
ably for days or even weeks, when the specimen becomes cold,
or when, through a process somewhat analogous to clot forma-

Il6 EXAMINATION OF URINE AND URETHRAL EXUDATE

tion, changes in the chemic nature of the liquid take place, little
can definitely be learned as to the vital character of the secretion.
It is to be remembered that the mere recognition of seminal fluid
as such is a very simple matter. Spermatozoa may be demon-
strated in seminal stains months old on removal by washing in salt
solution.

The seminal fluid is the combined secretion of several glands,
and it must be borne in mind that foreign or disease elements may
enter from any or all of these. As received in the vagina of the
female, the seminal secretion is made up of spermatozoa and cells
from the testicles, mucoid and serous secretion, with leukocytes
and epithelial cells from the seminal vesicles and prostate mingled
with Boettcher's crystals, mucus, and a few red blood-cells from
ruptured capillaries from the glands of Cowper and from the numer-
ous acini of Littre's glands.

Normally, the fluid is alkaline in reaction, and gives off a pecu-
liar and altogether characteristic odor. It produces a yellowish
stain on white fabrics. Microscopically the fluid can be identi-
fied by demonstrating the presence of spermatozoa. This is
determined most easily by simply placing a drop of the fresh
secretion between a warm slide ^and cover-glass, when, in normal
specimens, examination with a No. 6 or 7 lens will demonstrate
the presence of spermatozoa in very great numbers. They will be
seen to be actively motile, their serpentine mode of progression
being very characteristic. Specimens may be spread on a slide,
dried, and fixed by heat or by means of methyl-alcohol, formalin
in 10 per cent, solution, alcohol, or other fixing reagents. Slides
so prepared may then be stained with practically any of the chro-
matic dyes, of which methylene-blue, fuchsin, or gentian-violet
are perhaps the best. When a sightly preparation is desired, the
specimens may be stained by Boehmer's hematoxylin and counter-
stained by eosin.

Chemically, the secretion may be identified by the use of Flor-
ence's reagent (iodin, 2.54 gm. ; potassium iodid, 1.63 gm. ; dis-
tilled water, 30 c.c). A drop of this reagent is added to the
specimen, and the mixture is placed on a slide and examined
under low power. Dark-brown crystals are formed, some of
which are lance shaped and arranged in rosets, others being of a

EXAMINATION OF THE URETHRAL EXUDATE II 7

rhomboid or pyramidal shape. Old seminal stains also respond
to this reaction.

In spermatorrhea the sediment of the urine contains spermato-
zoa, leukocytes, and mucus; these may readily be recognized by
making a microscopic examination of the fresh specimen.

Constant absence of spermatozoa from the seminal secretion
indicates either serious disease of the testicles or occlusion of the
vas or some other portion of the channel. When the spermatozoa
are found only in small numbers, this suggests obliteration of the
passage on one side or perhaps faulty secretion. Malformed
spermatozoa are seen in many general and local diseases of the
testis. In excessive stimulation of the sexual function the sper-
matozoa are found in diminished numbers, the motility is less active,
and many of the cells present exhibit defects of development. One
of the most frequent of these, in the writers' experience, is a faulty
development of the tail of the cell, which may be present only as a
short, stump-like appendage. The head of the cell also presents
many variations in these cases, one of the most common being
that it has a spheric instead of an ovoid shape, and that it is, as
a rule, considerably larger than normal; chromatic stains also
show a lack of, or the presence of abnormal chromatic elements
in this body.

Red blood-cells are found normally in greater or less numbers
in the seminal secretion, but when inflammatory conditions are
present in any portion of the genital tract, the amount of blood
may become much increased — so much so, in fact, that it is readily
seen with the naked eye.

Pus appears in the semen in suppurative disease of any portion
of the tract, but is comparatively rare in actual suppurations of
the testis, the lumen of the vas on the diseased side being com-
monly obliterated in these instances. For this reason it is rarely
possible to diagnose the character of the testicular inflammation
from an examination of the secretion, except when other por-
tions of the genital tract are similarly involved. When, how-
ever, the secretion is found to contain pus or other abnormal
elements, the tests previously mentioned should be applied, al-
though positive results in most cases point to disease outside of the
testicle.

ii8

EXAMINATION OF URINE AND URETHRAL EXUDATE

Urorrhea. — In this condition, due to excessive activity of the
urethral glands, the absence microscopically of any other elements
renders the diagnosis easy, the secretion from the urethral glands
consisting of long, slender, urethral threads of mucus, epithelium,
and a few leukocytes.

F'S- 59 — Smear from the vaginal discharge of a gonorrheal woman, shortly after coitus,
showing the presence of pus-cells, desquamated vaginal epithelium, and spermatozoa, a.
Pus-cells with gonococci ; 6, pus-cells without gonococci ; c, gonococci in mucoid dis-
charge ; rf, desquamated vaginal epithelium ; e, spermatozoa ; y, red blood-cells.

Examination of Secretions and Exudates from the
Female Genitals

The examination of these secretions is of particular importance
only in cases of suspected infectious disease. In these instances
the examination must, in every instance, be very thoroughly
made, and the physician must not content himself with examining
a single specimen of exudate taken from any one portion of the
vulva or vagina. In the case of suspected gonorrhea, particu-

EXAMINATION OF THE URETHRAL EXUDATE 1 19

larly, the examination should be systematic, and should begin
with exposure of the cervix uteri and inspection and microscopic
examination of the cervical secretion. This is normally a clear
mucoid material, resembling the white of an &^g. Under many
physiologic conditions, as just before, during, and after menstrua-
tion, this secretion becomes turbid from the presence of broken-
down blood, leukocytes, and necrotic endometrium. When in-
flammatory disease of either the cervical glands or the endome-
trium is present, the cervical discharge becomes more or less tur-
bid and white, yellowish, or green in color, according to the organ-
isms present. Examination of smears of this discharge, as of the
exudate of the male urethra, reveals the nature of the organisms
involved in the process. Cervical gonorrhea is not frequent,
except in acute cases or when a gonorrheal endometritis or salpin-
gitis is present, when the secretion may trickle down from above.

Normally the vaginal secretion is small in amount, and con-
sists chiefly of desquamated epithelial cells of the squamous
variety and of serum and mucus. In inflammatory diseases
there are added to these pus or leukocytes, and in active cases
blood and such bacteria as are primarily or secondarily concerned
in the process.

Diffuse gonorrheal vaginitis is rare, except in those cases of
acute infection in which the process involves all portions of the tract.

The chief site of persistent chronic gonorrheal infection in the
female is the vulvovaginal gland, and in all suspected cases the
secretion should be expressed from these saccules and examined
microscopically. It must be remembered, as was stated in con-
sidering the examination of chronic discharges in the male, that
in chronic gonorrhea of the glands of Bartholin the gonococci do
not at all times present typical forms, but involution types only
may be seen.

In vulvitis the discharge from about the urethra should always
be examined, as frequently the folds of mucosa about this orifice
harbor infectious material. Similarly, the sebaceous secretion
about the prepuce and clitoris should also be examined.

In all cases it must be remembered that the secretion of the
external female genitals may be said normally to harbor bacteria,
but the organisms usually found here are, for the greater part,

I20 EXAMINATION OF URINE AND URETHRAL EXUDATE

members of the putrefactive group, and have but Httle chnical
significance. Infection and vulvitis caused by intestinal bacteria
are obviously likely to take place, particularly where proper clean-
liness of these parts is not observed.

Examination for the Spiroch^ta Pallida

Recent investigations have apparently fully established a
definite relationship between the spirochaeta pallida of Hoffman
and Schaudinn and syphilis. That this is the sole and essential
organism concerned in the production of syphilis has not as yet
been demonstrated satisfactorily, but the relationship has at
least become sufficiently established to make the discovery of
this spirillum of great value in the early diagnosis of syphilis.
In order to demonstrate the presence of this organism a certain
amount of technical skill is demanded, and negative findings can-
not as yet be considered as of much import, since errors of tech-
nic are so frequent; practice, nevertheless, renders the technical
difficulties fewer and more easily surmounted. Besides, the pos-
sibility of forming an early and apparently correct diagnosis is
often well worth the time necessary for demonstrating the presence
of the organism.

As yet no methods for the successful culture of this germ have
been discovered, and it is hence necessary for us to rely entirely
on the morphologic aspects. These are at times misleading,
for the germ may, unfortunately, readily be confused with other
spirochetae ; by practice, however, the examiner will be enabled
to exclude these organisms.

The mode in which the material is collected for examination
is of the greatest importance, for unless great care is exercised to
free the specimen from blood and pus, the demonstration of the
spirillum is rendered very difficult.

The surface of the suspected primary or secondary lesion should
be cleansed thoroughly from blood and exudate, and the investing
epithelium should be carefully curetted away. A small drop of
the exuding serum is then collected directly on the surface of a
thoroughly clean slide, or it may be transferred to the slide by a
sterile platinum loop — it is absolutely necessary that the smear

EXAMINATION OF THE URETHRAL EXUDATE 121

be made as thin as possible. A drop of serum may also be secured
from a suspected lymph-node by means of a hypodermatic needle
and aspiration. The cover-glass preparation is then allowed to
dry in dust-free air.

Several methods of staining have been successfully employed,
but most of them, such as the method of Giemsa, by which the
organism was first successfully demonstrated, are long and very
complicated. The writers have found the method of Goldhorn
by far the most satisfactory. This consists in the use of Gold-
horn's preparation of polychrome methylene-blue.^

A small amount of the dye is dropped on the specimen without
previous fixation, and after two or four seconds it is poured off
and the preparation slowly immersed in water. It is important,
in doing this, to prevent the deposition of sediment on the speci-
men; the slide must hence be introduced into the water in a
slanting direction, with the preparation side down; after a second
or two the slide may be waved to and fro until it is free from stain,
when it should be removed from the water and placed in a slanting
position to drain. It is allowed to dry naturally, but it is im-
portant that the air of the room be free from dust, or the resulting
specimen will be difficult to study.

The organism is a very faintly stained spirillum, characterized
by its more or less sharp-pointed ends and by its acute angular
flexures or turns. It varies in length from half that of a red
corpuscle to as much as 25 microns. When stained in the manner
directed, the germ is of a purplish-black color; it can be rendered
a deep black by washing the stained specimen for from ten to
fifteen seconds in Gram's iodin solution. The specimen is mounted
and examined with an oil-immersion lens in the usual manner;
a persistent search is often necessary to reveal the presence of the
spirillum. Impregnation staining methods employing solutions
of silver nitrate and subsequent exposure to light are now used
with great success and supply us with the simplest means for the
recognition of the organism. For examination of smear prepara-
tions, however, the polychrome dyes have as yet proved most

* The methods for preparing this were detailed in the " Journal of Experi-
mental Medicine," March, 1906; also in less detail in the "N. Y. Post -Grad-
uate," February, 1906.

122 EXAMINATION OF URINE AND URETHRAL EXUDATE

accurate in our hands, but for section staining the silver nitrate
methods are most satisfactory.

Recently, dark field illumination, which requires, however,
special and expensive apparatus, makes it possible to easily
demonstrate the organism in fresh and unstained specimens. It
is also highly probable that the serum reaction of Wassermann and
Levaditi will finally largely replace the other methods for the early
absolute diagnosis of syphiUs.

CHAPTER V

THE KIDNEY: ITS EMBRYOLOGY, ANATOMY, AND
PHYSIOLOGY

EMBRYOLOGY

In the development of the body the kidney is preceded by the
formation of two kidney-Uke structures in the intermediate cell
mass, the pronephros and the mesonephros, both of which originate
from portions of the Wolffian body. These organs contain glomer-
uli and tubules, not unUke those subsequently seen in the true
kidney, and open into the Wolffian duct. In the male the nephros
later becomes atrophied, but persistent remains form the parova-
rium in the female, and parts of the epididymis in the male.

The anlage for the true kidney, or metanephros, appears during
about the seventh week of intra-uterine life. Its mode of develop-
ment is very similar to that of the Wolffian body, and it is simi-
larly formed, chiefly in the intermediate cell-mass of the meso-
derm. The tubules are shaped within this tissue, appearing first
as blind sacculations in the formation of which the primitive peri-
toneum now appears to take no part. One extremity of each
tube becomes dilated into a spheric body, into which capilla-
ries grow, thus invaginating the walls of the spherule, and so
forming the Malpighian body and the capsule of Bovnnan. Only
the cortical portions of the kidneys are developed from the inter-
mediate cell-mass in this manner. The pelvis, the medulla, and
the ureters are formed from protrusions of the posterior extremity
of the dilated Wolffian duct; these outgrowths pass toward the
intermediate mass, and subsequently the tubules of the cortex
unite with those that represent the conducting portions of the
urinary passages, which are thus derived from entirely different
structures. McMurrich states, however, that the entire renal
tubule is derived from this outgrowth of the Wolffian duct, and
that the intermediate cell-mass contributes only the supporting
tissue and the blood-vessels.

124

THE KIDNEY

The glomeruli appear at about the eighth week, and in the third
month the papillae are formed (Quain). At about the tenth week
the surface of the kidney becomes lobulated. The further develop-
ment and elaboration proceeds along the lines of simple growth.

ANATOMY

The kidneys are two bean-shaped organs, lying in the posterior

portion of the abdominal cavity,
outside the peritoneum, one being
on each side of the spinal column,
and on a level with the last dorsal
and the upper two or three lumbar
vertebrae. Usually the right kidney
lies somewhat lower than the left,
probably due to the pressure on this
side exerted by the right lobe of the
liver, the inferior surface of which
frequently presents a depression
corresponding to its point of appli-
cation to the kidney.

The kidneys are so arranged in
the abdominal cavity that their an-
terior surfaces are slightly everted,
looking forward and outward, their
posterior aspects being correspond-
ingly arranged in the contrary
planes. The normal kidney has an
average size of about four inches
in length; two and a half inches
in breadth ; and one and a quarter
to one and a half in thickness
(Quain) ; as a rule, however, the
right kidney is somewhat longer and
thinner than the left. The average weight is about four and one-
half ounces, but both size and weight vary quite constantly, under
normal conditions, with the body weight; thus the largest kid-
neys are generally seen in the largest bodies. Probably on account
of this fairly definite relationship between body weight and the

Fig. 60. — Longiludinal section of
human fetus of twenty-six days' gesta-
tion, showing the pronephros or earliest
anlage of renal tissue, a, Wolflfian
duct ; A, b, developing glomeruli of pro-
nephros ; c, neural canal ; rf, posterior
root ganglion. Authors' specimen.

ANATOMY 125

size of the renal organs the average size of the kidney in the
female is somewhat smaller than that of the male.

The kidneys lie posterior to the peritoneum; the anterior sur-
faces are directly covered by this membrane, except in stout
subjects, where separation by a deposit of fat over the anterior
surface of the kidneys often occurs in marked degree. The other
aspects of the kidney are, in well-nourished subjects, embedded

Fig. 61. -Kidney from a human fetus of four months' gestation, indicating the differentiation in
development between the cortex and medulla. Authors' specimen.

in a thick layer of adipose and areolar tissue, which serves to retain
the organ in place and doubtless acts as a very efficient protective
layer or insulator, particularly against sudden chills or trauma.

The surface of the adult human kidney is smooth and of a deep-
red color. Not infrequently, however, it is seen to be more or less
lobulated, simulating the kidneys of the fetus and certain of the
lower animals.

Anteriorly, the left kidney region is crossed by the pancreas, and
the splenic vessel lies just about at the level of the hilum. Above,

126 THE KIDNEY

it lies behind a portion of the stomach and a few coils of small
intestine.

The right kidney is situated posterior to a portion of the duo-
denum, whereas the ascending colon on the right side and the
splenic flexure and descending colon on the left are found at the
lower and outer parts of the right and left organs respectively.
The upper portions of both kidneys are surmounted by the adrenal
bodies.

When in their normal position, the kidneys cannot ordinarily
be palpated in well-nourished subjects. In emaciated individuals
or in those in whom the abdominal walls are very much relaxed,
the kidneys may be felt on deep palpation, particularly when
they have left their proper position and taken a lower one. Renal
palpation, however, becomes easier as experience is gained.

The blood-supply of the kidneys is derived from the short and
nearly straight renal arteries, which are given off directly from
the aorta. As a result of this anatomic arrangement it will be
seen that the kidneys receive a very direct blood-supply, and one
in which the pressure is practically the same as that in the aorta.
The large size of these arteries also insures an abundant blood-
supply for these organs. The renal arteries are, however, some-
what protected from the direct systolic blow of the heart by a
very thick and well-developed tunica media, the amount of blood
entering them being also in part thus controlled. The blood is re-
turned from the kidneys by the large renal veins, which enter di-
rectly into the inferior vena cava. In addition to this blood-supply
the kidneys also receive a certain amount of blood through small
vessels that penetrate the capsule from the surrounding areolar
tissue, anastomosing with the terminals of the interlobular arte-
rioles. A venous return also takes place along the same channels.
Under normal conditions this additional blood-supply is relatively
unimportant, but in some diseased states it may become of con-
siderable value, serving at such times to nourish the organs and
even to maintain a certain amount of renal excretion, as, for ex-
ample, in thrombosis of the renal artery.

The lymphatics of the kidney are made up of a deep and a super-
ficial set. Uniting with those of the adrenal bodies, they pass
toward the median line along the course of the renal blood-vessels,

PLATE V

£3

ANATOMY 127

where they drain into a group of lymph-nodes that he about those
vessels and that are connected with the lumbar retroperitoneal
lymph-nodes.

The sensory nerve-supply of the kidneys is probably derived
from the tenth, eleventh, and twelfth dorsal spinal nerve-trunks,
the fibers being transmitted through the sympathetic plexuses
(Head). By far the more important nerve-supply for the kidney,
however, is that which controls the vasomotor impulses; both
constrictor and dilator fibers, according to Bayliss and Sterling,
probably originate from the dorsal nerves from the sixth spinal
segment downward. Constrictor fibers are also probably derived
from the two upper lumbar trunks. All these fibers probably blend
in the ganglia of the renal plexuses.

Structurally, the kidney is a highly modified compound tubular
gland. Much of its finer construction, especially the gross dis-
tribution of the tissues that carry on the specialized functions of
the organ, is apparent to the unaided eye. Anatomically, thfe
viscus may readily be divided into the capsule, the cortex, the
medulla, and the pelvis.

The fibrotis capsule that incloses the kidney can, when the
organ is normal, be separated from the cortex of that organ
with but little difficulty. This capsule is loosely united to the
surrounding adipose tissue in which the organs are embedded, and
is made up of a fairly thin layer of mixed connective tissue and a
thin stratum of smooth muscle that incloses the entire organ,
being attached to the cortex by delicate strands of connective
tissue that convey minute blood-vessels. At the hilum the cap-
sule becomes continuous with the adventitia of the renal vessels.

The cortex is made up of a layer of dark-red tissue, about one-
half inch in thickness, that surrounds the central portion of the
organ except at the hilum, where it first becomes thin and then
disappears. Projecting up into the cortex from the medulla
are bands of striations that extend nearly, but not quite through,
the cortical tissue; these, from their fascicular appearance, are
known as the medullary rays. The remainder of the cortex is
composed of the labyrinth, and it is in this portion of the kidney
that its most important activities take place.

The medulla of the kidney is formed by the pyramids and the

128 THE KIDNEY

columns of Bertini. The pyramids are masses of tissue that, to
the unaided eye, show a coarse striation radiating from the bases,
which He against the cortex, toward the apex of the pyramid.
When divided either longitudinally or transversely the pyramids
resemble in appearance a miniature fan, the framework of which
is represented by the radiating striations. The narrow tongues of
striation, the medullary rays, which are continued into the cortex
and which have just been described, are simply narrow prolonga-
tions of the pyramidal structure into the cortex. The columns
of Bertini are strands of connective tissue that support the blood-
vessels and lymphatics as they pass from the central portion of
the kidney toward the cortex; to the naked eye they appear as
continuations . of the cortex, highly vascularized, dipping down
between the pyramids.

The pelvis of the kidney is a large, funnel-shaped receptacle
whose narrowest portion begins at the hilum, spreading out at its
base into bay-like dilatations known as the calices, into which
the papillae of the pyramids open — usually only one, but two or
three may open into the calyx. The pelvis is lined by a layer
of transitional epithelium that is continued over the papillae.
It is supported by a basement membrane of connective tissue,
over which is arranged a longitudinal and a circular stratum of
smooth muscle — a continuation of the muscle layers of the ure-
ter. The coats are completed by an outer fibrous sheath in the
structure of which many yellow elastic fibers enter.

Microscopically, the greater bulk of the renal tissue is made up
of long epithelial tubes (highly modified tubular glands) that
secrete the urine and conduct it to the pelvis of the kidney. Every
urinary tubule, it must be remembered, is not thus fully devel-
oped, for they vary greatly in length, many being quite short.

The urinary tubule begins in the labyrinth of the cortex as the
capsule of Bowman, which is formed of the dilated and invagi-
nated end of the tube. The cavity thus formed is occupied by a
tuft of capillaries. The capsule of Bowman is lined down as far
as the constriction, known as the neck, by a layer of thin simple
squamous epithelium. The entire mass of capillaries and its epi-
thelial envelop are known as the Malpighian body. Below the neck
(a narrow straight passage Uned by small cubical cells) the tubule

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ANATOMY 129

opens out into a wider channel, lined by larger cubical or columnar
epithelium and thrown into many folds; this portion, which is
still contained in the labyrinth, constitutes the proximal convoluted
tubule. The tube then enters the medullary ray, passing down-
ward toward the medulla in a tortuous manner, where it is known
as the spiral tube. As it approaches the juncture of the cortex
and the pyramid the tube suddenly narrows, its epithelium now
being made up of flattened cells with larger nuclei; this portion
constitutes what is known as the descending limb of Henle. After
continuing downward for a certain distance within the pyramid
the tube becomes larger, its epithelium cubical, and it curves on
itself, forming the loop of Henle; it is then continued upward,
being lined by cubical cells until it again passes, now as the ascend-
ing limb of Henle, into the cortex, as an irregular convoluted
tube of larger lumen known as the irregular tubule. This chan-
nel leads directly into a tube precisely similar in structure to the
first or proximal convoluted tubule, and known as the distal
or second convoluted tube. This leads through the arched collect-
ing tubule toward the medullary rays, where it empties into a
tube of free lumen, lined by cubical epithelium, named the col-
lecting tubule. The collecting tubules unite to form other and
larger ducts, all continuing downward toward the urinary papilla,
where they finally open out into the pelvis of the kidney.

The minute anatomy of the blood-supply of the kidney is of con-
siderable importance for the correct understanding of renal disease.
As the renal artery enters the hilum of the kidney it commonly
breaks up into two or more smaller trunks, which pass, external
to the sheath of the pelvis, toward the columns of Bertini, where
they again form smaller trunks, at least one of which is continued
up toward the cortex through the column. At the junction of
cortex and medulla anastomosing lateral branches are given off,
forming a series of vascular arches known as the arterial arcade.
From these small branches, the arteria rectce, which pass straight
downward through the pyramids, supplying their nourishment,
are given off. Another series of branches pass upward, where
they are distributed to the tissues of the cortex. As the trunks
course upward they give off lateral branches, which become
smaller and smaller, finally terminating just beneath the capsule,
9

I30 THE KIDNEY

The lateral branches pass to the capsules of Bowman, which they
enter, then break up into a complicated mass of anastomosing
capillaries — the glomerulus. The entering arteriole is known as
the afferent artery, and the blood, still arterial, is collected from
the Malpighian bodies, leaving it in a separate arteriole, the
efferent artery. The efferent artery then passes to the convo-
luted tubules, about which it breaks up into a very complicated
capillary network. The blood from these capillaries is collected
by a vein that empties into successively larger venules and veins,
corresponding in name and location to the accompanying arteries,
finally escaping from the kidney through the renal vein. The
capillaries of the minute terminal arterioles that penetrate to the
capsule nourish this structure and then return the blood by a
corresponding venous tract. Occasionally, particularly under
diseased conditions, these vesssels may anastomose with trunks
penetrating from the areolar tissue surrounding the kidney; in
this manner a secondary and distinctly separate blood-supply
of the kidney is formed.

PHYSIOLOGY

The kidney is the chief excretory organ of the body. Although
other organs, more especially the skin and bowel, are concerned
in the work of excretion, experimental and clinical observation
has demonstrated that the presence of renal tissue is necessary
for the maintenance of life, and that a certain and quite definite
amount of kidney substance must be present. Thus it has been
shown that if an amount of kidney substance equal to three-fourths
of the entire weight of the organs be removed, death follows.
This occurs even though the amount of water, urea, and other
urinary salts be increased, in partial extirpation of the kidney, and
it may be taken as an indication that, in addition to its excretory
function, the kidney is also concerned in some internal secretory
process that is essential, in part at least, for the maintenance of
Ufe.

It was formerly believed that the kidney merely served as a
filter for the blood of the body; repeated studies have, however,
demonstrated beyond question that its function is far more com-

PHYSIOLOGY 131

plicated, though governed in large degree, nevertheless, by the
state of the blood-vessels, the pressure in them, and the amount
and character of the circulating blood. Starling, of late, has in
particular shown, both experimentally on animals and in man as
well, that the kidney automatically adjusts its relative excretion
to the .momentary needs of the body. Thus, where water is
introduced in overabundance, the excretion of water by the
kidney is heightened, or if various salts become relatively too
abundant, these bodies are automatically thrown out with greater
relative rapidity. This vital adjustment of the kidney to the
special needs of each individual has been most decisively demon-
strated by Starling and his pupils.

Unquestionably, the greater part of the water and inorganic
salts of the urine are excreted by the action of the Malpighian
bodies. It is still an unsettled question as to whether the secre-
tion of these constituents of the urine is entirely a mechanic
process, — one of osmosis dependent solely on blood pressure,
osmotic tension, and on the rapidity of the circulation, — or whether,
in addition to this, the cells of the capsule of Bowman, and perhaps
those of the capillary tuft also, take an active part in the excretory
process. There is little doubt, however, but that the chief function
of the Malpighian bodies is a mechanic and not a secretory one, and
in those conditions in which the excretion of fluid and inorganic
salts is defective, the lesions are chiefly found in the circulatory
mechanism of the Malpighian bodies. A direct relationship
between blood pressure, for example, and the watery secretion
of the urine has been thoroughly established. In addition, how-
ever, a large amount of the albumin in albuminuria and of the
sugar in glycosuria is probably excreted through the Malpighian
bodies, and it is likely that in these conditions at least the
epithelium of the capsule of Bowman does play an active secretory
role.

Abundant researches have shown that the epithelium of the
convoluted tubules — and with these we include the spiral and the
irregular tubules — is active in the excretion of urea and allied bodies.
Relatively, the function of these portions of the renal parenchyma
is more important than is that of the Malpighian bodies, for urea
and its allied substances constitute the most important waste-

132 THE KIDNEY

products of the body — those most actively poisonous to the
tissues, and the excretion of which is dependent largely on a
healthy condition of the renal tissue. Hence is those diseases of the
kidney chiefly characterized by toxic symptoms, or in which auto-
toxemia plays an important primary or symptomatic part, that the
activity of these tubules is found defective. Although the question
of blood pressure also enters largely into the functional require-
ments of these tubes, their activity is chiefly dependent on the
primary action of the tubular epithelial cells.

Notwithstanding the fact that the renal epithelium has a sepa-
rate nerve supply (Berkeley), the chief nervous control of the
kidney is supplied through fibers distributed to the vessels. The
influence of central nervous control on the renal function is too well
known to require a detailed discussion here.

Although the possibility of the existence of an internal renal
secretion cannot be disproved, the chief function of the kidney
is the excretion of urine; this, as previously stated, is a very
complex process.

The quantity of urine voided is dependent primarily on the
amount of water taken with the food or as drink, and, secondarily,
on the quantity of fluid excreted by other organs, such as the
bowel or by the skin. Ordinarily, the amount varies between
1200 c.c. and 1800 c.c. daily, though it may be much smaller,
as, for instance, in profuse diaphoresis; or, on the other hand, it
may exceed this amount, as, for example, when large quantities
of water or other fluids are taken.

Experiments carried on by means of catheterization of the
ureters show that in normal kidneys, provided the size is the
same, each kidney secretes in a given space of time almost exactly
the same amount of urine, although they do not necessarily act
synchronously. The amount of fluid and of solid constituents
from each kidney separately will not vary much over 10 per
cent.

The Urine. — Immediately after being passed, and while still at
the temperature of the body, the urine should be perfectly clear,
a turbidity at this time indicating some unnatural or diseased
•condition; on being allowed to stand, however, a precipitate
may form, when, after cooling, elements may be precipitated

PHYSIOI^OGY 133

out that are not abnormal to the urine; or, on undergoing fer-
mentation, the chemic characters may be altogether altered,
causing the precipitation of various substances, such as the alka-
line phosphates.

Normally, the color of the urine is some shade of yellow, —
"straw color," — the degree of pigmentation being dependent on
many conditions, and varying greatly not only in intensity, but
also in color. The degree of pigmentation is due to the presence
of four substances — urochrome, urobilin, uroerythrin, and hemato-
porphyrin — which are chiefly derivatives of the blood and bile.

Normal urine is acid in reaction, the acidity being due to an
excess of diacid sodium phosphate. The reaction fluctuates
considerably under normal conditions, being largely dependent
on the food ingested and on the amount of the urinary fluid.

The specific gravity of normal urine varies greatly under many
physiologic as well as pathologic conditions. It is dependent in
large measure on the relative amount of liquids and solids ingested.
Roughly, it may be said normally to fluctuate between 1.012 and
1.025.

The normal chemic composition of the urine is dependent,
naturally, on the nature and amount of food and drink taken,
on the action of the tissues of the body under normal or abnormal
conditions, and on the amount of tissue-waste.

Bunge gives the following tables, based on a diet of beef with
salt and water, and on a diet of bread, butter, and water, com-
puted as the result of an analysis of the total twenty-four-hour
urine of a healthy young man :

Meat Diet. Bread Diet.

Total amount 1672 c.c 1920 c.c.

Urea 67.2 gm. 20.3 gin.

Creatinin 2.163 " 0.961

Uric acid 1.398 " 9.253

Sulphuric acid (total) 4.674 " 1.265

Phosphoric acid 3.437 " 1.658

Calcium 0.328 " 0.339

Magnesium 0.294 " 0. 139

Potassium 3.308 " 1.314

Sodium 3.391 " 3.923

Chlorin 3.817 " 4.996

134 ^^^ KIDNEY

Urea, the most important inorganic salt of the urine, is the
end-product of the decomposition of the albuminoids of the food
and of the proteid metabolism of the body. It exists in the blood,
is not a renal product, and its only relation to the kidney seems
to be that it is normally excreted in greater part in this gland.
The amount of urea found in the urine, minus that derived from
the decomposition of the albuminous portions of the absorbed food,
may be taken as a measure of the proteid metabolic waste of the
body. The amount of urea is increased particularly in the acute
febrile diseases and in diabetes. It is often entirely absent in
acute yellow atrophy of the liver, where it is represented by less
highly oxidized bodies, as leucin and tyrosin. (Concerning the
chemistry of urea, the reader is referred to works on physiologic
chemistry.)

The determination of the amount of urea present in the urine
is often very important in clinical medicine. In determining this,
however, as pointed out by Cabot, insufficient attention is often
paid to the amount of albuminous food taken in as compared
with the amount excreted.

Uric acid is formed as the result of the decomposition of the
nucleins either of the food or of the body-tissues. It is formed
in most of the organs of the body. It appears normally in the
urine in small quantities, being derived chiefly, according to
Horbaczewski, from the nuclei of the leukocytes. In man the
uric acid derived from the purin substances is largely transformed
into the more soluble urea; the amount excreted, therefore, also
depends partly on the extent to which this oxidation takes place.

COMPENSATION IN RENAL DISEASE
Although the kidney is the chief excretory organ of the body,
its relationship and connection with certain other excretory
organs have been well established. This is particularly true as
regards the skin and the intestine, it being well known that these
may take on the renal functions, at least to a limited degree,
when the function of the kidney becomes impaired. In man and
the higher mammals it seems probable that the other excretory
organs cannot assume the renal function completely, though in
certain of the lower forms of animals this seems to be possible.

COMPENSATION IN RENAL DISEASE I35

It has been shown that bilateral nephrectomy, ligation of both
ureters, or, in other words, total annihilation of the renal func-
tion, results in death in from seven to fourteen days (Martin),
notwithstanding the fact that the other excretory organs have
reached their highest degree of activity.

Conversely, the kidney may assume the function of the other
excretory organs; this takes place not only in disease, but also
in certain physiologic states. Thus in cold weather when the
superficial capillaries are contracted and the excretion of water
in the form of sweat is diminished, urinary excretion is markedly
augmented; on the other hand, during hot weather, when the
perspiration is abundant, the urine is excreted in small amounts;
this takes place also in diarrhea, when the amount of water dis-
charged by the bowel is great. These facts are often taken advan-
tage of in the treatment of renal, intestinal, and dermal affections.
Thus in severe constipation, intestinal obstruction, or in other
conditions when the bowel is no longer able fully to carry on its
function, the kidney may, to a certain degree, temporarily assume
some of the activities of the affected organ. Clinically, when the
above-mentioned conditions exist, it is well to maintain the renal
activity at its highest point; at the same time every possible
care must be exercised to guard against overactivity lest the
function of the renal organs become impaired and suppression of
the urinary secretion follow.

In cases of grave nephritic disease the bowel also casts off,
although perhaps incompletely, certain of the substances that
would normally be thrown off by the kidney; in nearly all forms
of renal disorder, therefore, it is particularly necessary to see that
the excretory functions of the bowel and skin be maintained at
their highest point of efficiency. In spite of this close interde-
pendence of function it is doubtless true that when one organ does
not act in a normal manner, poisons are thrown into the blood
and lymph that may produce most serious disease of the functionat-
ing parenchyma of the other; thus, for example, in intestinal ob-
struction, in toxic dysentery, and in other similar conditions grave
nephritic complications are particularly likely to occur.

A remarkable fact, in this connection, is that, occasionally,
in spite of extensive disease of the kidney, resulting in some cases

136 THE KIDNEY

in almost complete destruction of the parenchyma, the patient
may continue to live in apparent health. This is well exemplified
in congenital cystic kidney, when, as in the case illustrated in
fig. 78, apparently the entire normal renal tissue may be absent
and yet life continue until an intercurrent affection arises that
may unbalance the well-compensated excretion carried on, for
the most part, by the bowel and skin. Perhaps one of the most
familiar illustrations of this is seen in cases of severe chronic inter-
stitial nephritis, in which the urine secreted by the extensively
diseased kidneys differs from normal urine in so far that the waste-
products of cell-metabolism are largely absent. Undoubtedly,
in some of these cases, a too unfavorable prognosis is given ; this
would be modified somewhat if, in each particular instance, the
compensatory action of the other excretory viscera was thoroughly
considered.

In contradistinction to what has been said, it is surprising what
minute renal lesions may result in speedy death. This is most
likely to occur in acute cases, as, for example, in acute eclampsia,
where the subsidiary organs are unprepared to take on compensa-
tory action ; in these cases the efforts should be directed toward
establishing compensatory action by other excretory organs, rather
than toward stimulating an already overworked and extensively
diseased kidney.

When, because of disease of the other excretory organs, the kid-
ney is suddenly called upon to assume compensatory activity, it
may be unprepared to respond to the demand and acute nephritis
and uremia may follow as a consequence. This is probably best
illustrated by those cases in which the secretion of sweat is sud-
denly arrested, as when the surface of the body has been quickly
chilled, by the familiar example of the boy who was coated with
gold-leaf, or, as has been personally observed, after early or too pro-
longed sea-bathing. As a frequent illustration may also be cited
cases of extensive burns, where large areas of skin have been in-
jured or destroyed, death usually following from acute nephritis.
In these cases the development of renal lesions is not dependent
so much on the degree of severity of the burns as on their extent,
this latter affecting the amount of sporadic activity suddenly
demanded of the renal tissues. Death caused by nephritis follow-

COMPENSATION IX RENAL DISEASE 137

ing but limited burns is probably not uncommonly due to a pre-
viously impaired renal activity. That this failure on the part of
the kidneys to respond is due to the abruptness of the demand
is well illustrated by the fact that nephritis with fatal termination
does not generally occur when the excretory powers of the skin
or bowel are slowly obtunded, as in stricture of the bowel result-
ing from gradual occlusion due to peritoneal or neoplastic adhe-
sions; nor from suppression of the dermal excretion in morphea
or scleroderma when the excretory functions of the skin are slowly
obliterated. In short, it would appear that the kidney must be
given time to accommodate itself to the increased demands upon
its functional capacity. This is a most important fact to be borne
in mind in considering the treatment of these conditions, it being
evident that certain changes must take place in the organ before
it is able thus vicariously to functionate.

As has been stated, the size of the normal kidney is propor-
tionate to the body weight; the larger the man, therefore, the
greater the amount of renal tissue necessary to carry on the excre-
tory process. From this it would appear that there is a certain
definite relation between kidney bulk and kidney function, and
it may be assumed that when increased function is demanded of
the organ, an increase in the parenchymatous epithelium takes
place. That this occurs has been abundantly proved by studies
in pathologic anatomy and in experimental pathology.

Compensatory hyperplasia of the kidney may take place in the
fetus; for if, because of some defect, the anlage for one kidney is
insufficiently nourished, the other organ will show a compensa-
tory hyperplasia of the epithelium. This is well exemplified
by those cases in which but a single kidney exists, the one organ
being found to bear approximately the relative weight to the
body that the two kidneys bear in normal cases. Compensatory
hyperplasia is by no means limited to the fetal condition. When
it becomes necessary, therefore, to remove one kidney, the re-
maining organ, if healthy, may be expected to show an increase
in its parenchyma and eventually to carry on the entire renal
function in a satisfactory manner. In a young and healthy
subject the remaining organ will eventually attain a weight equal
to that normal for the two kidneys. From what has been said it

138 THE KIDNEY

is clear that a certain length of time is necessarily required to
eflfect epithelial hyperplasia, and in these cases it is essential that
means be devised for facilitating compensatory excretion on the
part of other organs until sufficient time has elapsed for the neces-
sary epithelial growth to take place. This epithelial hyperplasia
undoubtedly occurs in most of the compensatory conditions that
have been considered. If sufficient time has not elapsed for
this to take place, the organ is suddenly overwhelmed with poison-
ous waste-materials, which it is unable to handle, and which, con-
sequently, act on the renal cells as cytotoxins.

Compensatory hyperplasia is a process that is not limited to
any particular portion of the cortex. For instance, if infarction
destroys a portion of the cortex of one kidney, compensatory
hyperplasia may take place in the opposite organ or in other por-
tions of the cortex of the injured viscus. The degree of hyper-
plasia varies greatly. In healing scarlatinal nephritis, where
extensive desquamation of tubular epithelium has taken place,
the process may consist merely of replacement of the diseased cells
by newly formed ones on the old basement membrane; or, on
the other hand, the actual formation of new tubes may occur.
This latter fact has been disputed by some observers, but has been
thoroughly substantiated by experimental work.

Naturally, compensatory hyperplasia is most likely to take
place during youth and when the kidneys themselves are in a
comparatively normal condition; nevertheless, it often occurs
in old age and in diseased conditions where it is least expected.
Hyperplasia is, of course, limited largely to the parenchyma and
chiefly to the cortex. It is most unlikely to occur when pro-
nounced interstitial alterations have occurred. It is the essential
change in nearly all healing processes that follow any of the types
of nephritis, and the process is undoubtedly accelerated by the
various methods shown by experience to be valuable in the treat-
ment of patients convalescent from renal disorders.

CHAPTER VI

THE BLOOD IN DISEASES OF THE KIDNEY

Examination of the blood is of diagnostic value in but a very
limited group of renal diseases, but the condition of this tissue
is, nevertheless, often of great and even paramount importance.
This is particularly true in considering the treatment of renal
disease. In nephritis, for example, anemia often becomes the
dominating feature, and the success of the entire treatment is
largely dependent on the correction of this condition.

It is perhaps well to state here that great diversity of opinion
exists among various observers regarding the relation between
the blood state and renal diseases. It must, therefore, be remem-
bered that no hard-and-fast distinctions can be drawn, chiefly
for the reason that many diseased conditions may so complicate
and obscure kidney disorders as to render a conclusion as to the
precise hemic state dependent on the renal disease alone largely
problematic. Then, again, the blood picture is, with but few ex-
ceptions, secondary not only to the disease of the kidney, but also
to the several general and visceral disorders consequent upon the
existence of kidney lesions; thus the cardiac and vascular de-
rangements that occur in so many cases of nephritis almost
invariably obscure the blood-findings that might otherwise be
considered characteristic of the kidney disease only.

As has been stated, the blood examination is valuable in the
diagnosis of kidney diseases only to a very limited degree. Un-
questionably, its greatest diagnostic usefulness, determining, as it
does, the presence or absence of leukocytosis, is in suspected renal
suppuration.

Polynuclear leukoc5rtosis is generally concomitant with suppura-
tive diseases of the kidney, except when the drainage from the
suppurative focus is free; it has then been found, as a rule, that
leukocytosis, at least in marked degree, is often absent. In these
instances, when pus escapes freely, the question as to the pres-

139

I40 THE BLOOD IN DISEASES OF THE KIDNEY

ence or absence of suppuration can be readily settled since pus
is found in the urine or escaping through a fistulous opening.
When the pus does not escape, the poly nuclear leukocytes are
commonly increased, the degree of leukocytosis depending, in
the writers' experience, on the extent and virulence of the puru-
lent process. As exceptions to this general rule may be cited
the absence of leukocytosis in old and well-localized pus-forma-
tions, also in those rarer instances where the infective process is
so overwhelming that the production of leukocytosis seems to be
inhibited. In suppurative disease localized to the kidneys the
number of leukocytes rarely exceeds 20,000, and is more often in
the neighborhood of from 12,000 to 15,000.

In tubercular nephritis, as a rule, the leukocytes are not increased
unless the tubercular process is complicated by a mixed infection
with other pyogenic bacteria. On the contrary, hypoleukocy-
tosis may be present, and a differential count of the leukocytes
may show a relative increase in the mononuclear elements, al-
though not so regularly as in general tubercular disease.

In new-growths of the kidneys the blood shows the same general
characteristics seen in new-growths elsewhere, but the cachectic
type of anemia may serve, in a certain number of cases, to distin-
guish renal growths from abscesses or non-neoplastic hypertrophy.

Nephritis furnishes some of the most important blood changes
in renal disease, such changes occurring, of course, secondarily;
in pernicious and other severe anemias, however, nephritis itself
often arises as a secondary condition.

In acute nephritis an anemia occurs that is usually characterized
by a proportionate reduction in hemoglobin and red cells. It
is commonly believed to be due directly to the loss of blood with
the urine, but it is often too marked in degree to be accounted
for on this basis alone ; besides, it develops in some cases in which
no loss of blood can be demonstrated. Leukocytosis with a
count of 20,000 has been noted by some observers (Cabot), but,
in the writers' experience, it is not constant or sufficiently fre-
quent to render it of diagnostic value. It is probable, at least
in a certain number of cases, that this leukocytosis is a relative
one only, and due to loss of the red corpuscles.

When edema of considerable degree is present, hydremia may

THE BLOOD IN DISEASES OF THE KIDNEY 141

often be found a symptom of much importance. Although, as a
rule, the coagulability of the blood is not altered in markedly
hydremic cases, it maybe markedly decreased ; at the same time,
when the loss of blood from renal hemorrhage has been consider-
able, coagulability may be increased.

The alkalinity of the blood sometimes falls below normal;
in the acute diseases, as a rule, it has been found to be unaffected.
Unquestionably, profound chemic alterations take place in the
blood in acute nephritis, but these are as yet but little understood,
and our knowledge of the chemistry of the blood is too limited
to permit the drawing of definite conclusions. From the general
manifestations of the blood, it seems that in certain cases of
albuminuria the blood-serum becomes greatly changed.

In subacute or chronic parenchymatous nephritis, when the par-
enchyma of the kidneys is chiefly affected, the most characteristic
forms of anemia develop. In certain cases, however, the anemic
condition is more apparent than real, and pallor of the skin and
mucosae may be found associated with practically normal blood-
findings. It is quite probable, in at least some of these cases, that
though the blood itself is normal in its commonly recognized char-
acteristics, there is an inability on the part of the tissues to take
up the requisite amount of oxygen and nourishment from the
circulating stream.

The hemoglobin is markedly reduced, occasionally falling as
low as from 30 to 40 per cent., whereas the number of red cor-
puscles, though generally somewhat lowered, is proportionately
less so. This gives a blood-picture not unlike that of chlorosis,
a disease that is frequently confused with nephritis, and, when
the examination is not thorough, nephritis is often mistaken
for chlorosis.

As a rule, in those cases, the leukocytes are somewhat increased
relatively, though they rarely exceed from 10,000 to 12,000, and
a differential count establishes the fact that the relative percentage
is normal, thus differentiating this condition from one of absolute
leukocytosis.

The alkalinity of the blood is generally somewhat reduced;
this is quite a constant finding in this type of nephritis. As in
the acute form of the disease, coagulability may be lowered.

142 THE BLOOD IN DISEASES OF THE KIDNEY

Anemia often becomes a matter of grave significance in
nephritis of this form, and its treatment is of the utmost im-
portance. There can be no doubt, in a certain number of cases
at least, that the dietetic restrictions that form part of the treat-
ment of the renal condition are in some measure responsible for
the anemia.

In chronic interstitial nephritis the blood, as a rule, shows no
variations that are directly attributable to the renal disease. When
the circulation has become slowed, as in certain of the circulatory
and cardiac manifestations of nephritis of this type, the hemo-
globin percentage and the red-cell count may even be increased
and a true oligocythemia develop. In these cases, naturally,
if secondary conditions play an important role, as when epistaxis
is frequent, anemia may develop secondarily. When due to
other and perhaps primary conditions, anemia may also produce
an entirely different blood-picture. Thus in the chronic intersti-
tial nephritis that occurs in lead-poisoning a profound anemia
is a prominent symptom; occasionally it simulates a primary
anemia, and is generally evinced by marked granular degenerative
alterations in the red cells.

In uremia the blood may show any of the changes associated
with the special type of nephritis that is present, but an almost con-
stant manifestation is a marked reduction in alkaUnity, falling
rapidly as the case becomes more grave and increasing as the
uremic symptoms disappear. The leukocytes are also rather
constantly increased in uremia (Ewing). Pieraccini has found
that the number of eosinophile leukocytes is considerably dimin-
ished in uremia, this diminution corresponding to the severity
of the case and to the decrease preceding the development of
uremic symptoms; its occurrence, therefore, may be regarded as
a symptom of some prognostic value.

The treatment of hemic disturbances arising in the course of
renal disease practically resolves itself into a treatment of the
nephritic anemia. The course pursued in similar conditions
arising independently or occurring during the progress of many
other diseases must be considerably modified in nephritis. This
is particularly true of dietetic measures, for the food that is
indicated in other types of anemia must, because of its delete-

THE BLOOD IN DISEASES OF THE KIDNEY 1 43

rious action on the kidney, be forbidden in nephritis. Thus
it may be necessary to limit eggs, beef-juice, and foods of a similar
nature. Milk, which acts very beneficially in anemia generally,
may be employed in these cases with actual benefit to the renal
tissue and often with markedly good effects on the anemia. The
outdoor treatment of nephritic anemia is also attended with ex-
cellent results. Patients should be encouraged to spend as much
time as possible out-of-doors, particularly in the sunshine; and
suitable exercise, as indicated by the existing conditions, should
be prescribed.

lyike the anemia of chlorosis, which it so closely simulates in
many respects, the anemia of nephritis, as a rule, responds
promptly to ferrous medication. In most cases the writers have
found that the inorganic preparations of iron act more beneficially
than the organic; in certain cases, however, better results have
been attained by the employment of organic ferrous compounds.
The two preparations that, in the writers' experience, have proved
most efficacious have been the tincture of the chlorid and the
familiar " Basham's mixture," both given in large doses. The sul-
phate or carbonate, or the combination in the form of Blaud's
pill, also acts very beneficially. The tartrate of iron and potash
is especially efficient, since in addition to its ferruginous qualities
it does not constipate. In other respects the treatment is to be
directed toward the underlying nephritis.

When the case is not of too long standing and is uncomplicated
by other diseases, as a rule, nephritic anemia responds promptly
to well-directed treatment. Oftentimes the treatment, though
entirely ferruginous and directed to the correction of the anemia,
results in a marked improvement in the general renal disturbance.
This has been found to be particularly true of those cases of
nephritis complicating the convalescence from the infectious
diseases. As a result of iron medication albuminuria tends to
disappear more rapidly, edema subsides, and the general vascular
tone improves so markedly that, in some cases of nephritis, apart
from its effect on the anemia, iron seems to be almost a specific.

144

THE BLOOD IN DISEASES OF THE KIDNEY

THE BLOOD-PRESSURE IN RENAL DISEASE

That there is an increased blood-pressure in many types of
renal disturbances is a fact that has long been recognized, but our
knowledge in regard to the constancy of its occurrence in certain
diseases and the clinical methods devised for accurately deter-
mining its existence are recent acquisitions to this branch of study.
For these we are indebted in large measure to the recent admirable

Fig. 62.— The Janeway sphygmomanometer.

contribution of T. C. Janeway, "The Clinical Study of Blood-
pressure," where this important manifestation has been most
completely discussed in all its aspects. The writers have found,
by constant routine employment of the sphygmomanometer for
the past year and a half, that we possess in this instrument not
only one of the most definite and constant means of diagnosing ob-
scure cases of nephritis, but also valuable aid in the prognosis of
renal disease, and an accurate and certain method of determining
the effects of treatment.

THE BLOOD-PRESSURE IN RENAL DISEASE I45

For clinical purposes the instrument known as the Janeway,
or Kaplan's modification of this instrument, is to be recommended
for the use of the general practitioner. Of the other instruments
suitable for general clinical use, the Riva-Rocci has given the
best results in the writers' hands. Recently a very coijvenient
instrument has been designed by Dr. O. H. Rogers. The pressure
is registered by a circular spring dial, virtually an aneroid. Thus
far the apparatus has proved accurate in our hands; most instru
ments depending on this principle have, however, not proved
satisfactory heretofore.

Experience has corroborated the statements made by Janeway
and the other observers quoted by him. To secure accurate
results with the instrument, a certain amount of practice is neces-
sary, although the technic essential for its efficient employment
is readily acquired. In order to obtain accurate results, several
determinations should be made, at different times and under
varying conditions, as with the patient sitting, standing, or lying
down; this, particularly with a view to avoiding the possibility
of psychic stimulation, which might, in some cases, lead to erro-
neous conclusions.

The blood-pressure cannot be satisfactorily estimated merely
from an examination of the pulse, even by the most skilful clinician.
Repeated experiments designed to demonstrate the value of this
as a guide to ascertaining the amount of blood-pressure have
shown that but little reliance is to be placed on this method alone.
The estimates of most reliable clinicians have varied from the
sphygmomanometric determination as much as from 60 to 100
mm. of mercury.

In acute nephritis the blood-pressure variations are marked.
In the early stages of the disease there is commonly, and often
a considerable, increase, but there may be a decrease, even to the
subnormal, particularly when cardiac failure is imminent. In
the nephritis complicating the acute infections experience has
shown that the pressure is either normal or subnormal, and that
if increased, it is but slightly so. In these conditions the deter-
mination of the blood-pressure is of little value excepting in so far
as it may be used to differentiate between the acute exacerbation
of a chronic nephritis and an acute nephritis; in the former con-
10

146

THE BLOOD IN DISEASES OF THE KIDNEY

dition the blood-pressure is constantly high, and in the latter it
is usually but little altered, although occasional acute cases are
seen in which the pressure is as high as in chronic cases.

In chronic or subacute nephritis, in which the parenchymatous
portions of the kidney chiefly are involved, the pressure is, as a

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rule, high, although in the writers' experience it rarely exceeds
1 70 to 200 mm. Hg°. In certain cases, however, especially when
there is a loss of vascular tone, as in myocarditis or disease of
the arterial media, the pressure may be below normal, reaching
as low as 85 mm. Hg° (systolic pressure). In those forms of renal
disease in which edema is present, it must be borne in mind that
an edematous condition of the arm may materially alter the results
of the determination, and in such cases no absolute reliance can
be placed on the data secured by the sphygmomanometer.

The blood-pressure is constantly increased in that type of renal
disease chiefly characterized by fibrous hyperplasia, and it is
immaterial whether this occurs in the small granular, so-called

THE BLOOD-PRESSURE IN RENAL DISEASE 1 47

" sclerotic " kidney, or in the large red organ; the latter, in the
writers' opinion, very of ten precedes the sclerotic, and represents one
of the early stages in the development of the small hard kidney.

In these conditions the blood-pressure is almost invariably
increased, often reaching above 250 mm. of Hg°. This can fre-
quently be detected by means of the blood-pressure apparatus,
long before it is possible to discover definite alterations in the
heart or liver by the usual clinical methods of examination. This
increase of pressure often also renders a diagnosis of renal disease
possible even when oft-repeated and careful urinary examinations
fail to demonstrate the presence of any definite kidney lesion.

In the prognosis of renal diseases blood-pressure determina-
tions have also given satisfactory aid. In nearly all forms of
renal diseases, and particularly in those cases in which fibrous
hyperplasia is the most dominant change, the blood-pressure
varies but little when the patient is progressing favorably, and in
these cases it has been known to drop almost to the normal,
invariably to rise again before any acute manifestations of renewed
disease appear. A continuously high pressure should, of course,
warn the physician of the danger of arterial rupture, and a sudden
or marked fall is a serious prognostic sign.

In the treatment of renal disease the blood-pressure has also
been found a very satisfactory means of gaging the progress
made. Thus, a reduction of an abnormally high blood-pressure
may be observed after the prolonged administration of potas-
sium iodid or following the use of chloral or other vasodilators
and overstimulation with such drugs as caffein, digitalis, ergot,
and strychnin is suggested by a raise in pressure. All in all, a
regularly kept blood-pressure and pulse chart plotted with the
fluid and urine curves is, in our experience, a most helpful guide
in the course of a case of nephritis.

CHAPTER VII
THE OCULAR MANIFESTATIONS OF RENAL DISEASES

By RICHARD KALISH, A.M., M.D.,

NEW YORK

The ocular manifestations are of signal importance as aids to
the diagnosis of renal disease.

Edema of the lower eyelids has, by some writers, been consid-
ered indicative of beginning nephritis, but in the early stages of
the disease this is of only a transitory nature, and as it likewise
occurs in the course of many other systemic maladies, it has little
diagnostic significance. In the terminal stages of nephritis,
when the edema of the eyelids has become a permanent feature,
the marked general ascites is so distinctive that the presence or
absence of involvement of the eyelids has no diagnostic value.

Edema of the conjunctiva has also been attributed to nephritis ;
when this condition accompanies intra-ocular inflammation and
its severity is disproportioned to the mildness of the deeper seated
trouble, suspicion should be aroused. In a case seen by the
writer a mild attack of rheumatic iritis was complicated by so
intense a chemosis as to prevent apposition of the eyelids. Uri-
nalysis then disclosed that the patient was passing through the
early stage of an unsuspected interstitial nephritis.

In patients who have passed their fortieth year both subcon-
junctival and subcutaneous hemorrhages, especially of the lower
eyelid, if recurrent, demand an examination of the kidneys. The
hemorrhages usually come on during the night and cause no pain ;
the left eye is the one usually affected. Recurrence may ensue
at longer or shorter intervals, often but a few weeks intervening
between the attacks. Occasionally they are the only manifes-
tations of the systemic disease, and precede, by quite an interval,
the usual and classic symptoms; they may also be associated
with other hemorrhages incident to nephritis, such as purpura.

OCULAR MANIFESTATIONS OF RENAL DISEASES 1 49

epistaxis, retinal hemorrhage, etc., caused by a general arterio-
sclerosis, even if this condition is riot discernible in the superficial
arteries.

Exophthalmos due to effusion in Tenon's capsule has been
observed in the course of albuminuria.

External ophthalmoplegia has occasionally been observed
among the terminal symptoms, but it sometimes occurs early in
nephritis, and in this event recovery is rapid, although relapse
is common, and muscles may be involved successively. These
paralyses are undoubtedly indicative of changes in the cerebral
vessels identical with those in the retina.

The intraocular appearances accompanying or produced by
nephritis are often the first evidences of renal disease, and lead
to a recognition of the malady before any general symptoms
arise. The most important condition is albuminuric retinitis,
the ophthalmic picture of which is easily recognized. The retina
usually appears as an edematous, light-gray membrane, with or
without patches of exudation and with darker stripes traversing
its posterior part.

The arteries are reduced in size, thin, bright colored, and fre-
quently defined by whitish stripes; the veins are broad, flattened,
twisted, and dark red in color, and may be covered by the exudate
or may pass over it.

The outline of the nerve-head is hazy, and in some cases indis-
tinguishable, the optic disc apparently going over into the retina
with no perceptible line of demarcation. It appears reddish,
swollen, and opaque. Around the nerve-head, and several times
its diameter, is often found a zone marked by extravasation of
blood, bright flaming red in color, with well-defined rounded
spots or broad, flat stripes, which vary in size and number. White
or yellowish spots, often surrounding the optic nerve, are likewise
seen in this band, and small, shiny, silvery points are scattered
over the retina. The macula is usually red, and surrounded by a
band studded with white spots, or with the characteristic halo
or star-like arrangement of small bands or spots. It is generally
accepted that there is but one kind of nephritic retinitis, and
that the different forms and changes observed are indicative
only of various stages of edema, hemorrhage, exudation, and

I50 OCULAR MANIFESTATIONS OF RENAL DISEASES

degeneration. Albuminuric retinitis is generally bilateral, but
may not begin in both eyes at the same time nor develop equally.
It may occur at any time, but comes on most frequently between
the ages of fifty and sixty, the youngest recorded case occurring
in a child live years of age.

The form of nephritis most frequently complicated with reti-
nitis is the chronic interstitial variety, but retinitis may develop
in any form of renal disease, even in the acute, as in scarlatina
or in the course of pregnancy. In short, it may arise in any
variety of renal disease that can cause albuminuria, and is found,
though rarely, in. the course of carbuncle, diphtheria, erysipelas,
the intermittent fevers, measles, smallpox, typhus, and in poi-
soning by alcohol, cantharides, croton-oil, or lead. Albuminuric
retinitis occurs in from 9 to ii per cent, of the cases of nephritis.

The extent of the retinitis bears no relation to the intensity
of the renal affection or to the amount of albumin contained
in the urine.

The degree of the visual impairment depends upon the extent
and location of the hemorrhages and deposits, rather than upon
the stage of the malady, and varies from a slight impairment of
sight to complete blindness, although this latter is extremely
rare. Hemorrhage into the macula produces a marked diminu-
tion of vision, as does optic neuritis which causes subsequent
atrophy of the nerve ; but, as a rule, visual reduction is markedly
disproportioned to the ophthalmoscopic picture.

The prognosis as regards life is always grave. Many die during
the first and few live beyond the second year. These patients are
usually seen late in the disease, after the lesions have existed for
some time before being discovered by the oculist ; so it is reason-
able to infer that the limit of two years from the first occurrence
of the retinal complication is hardly accurate.

Although various forms of albuminuric retinitis, albuminuric
neuritis, and albuminuric neuroretinitis have been classified by
clinicians, they cannot at times be differentiated, and may glide
insensibly into one another, and can frequently be seen to merge.
The limitations of this article forbid their consideration.

Uremic amaurosis or amblyopia, although less common, is
more conspicuous than the retinal complications. Loss of sight

SYLLABUS OF NEPHRITIC CONDITIONS 151

in this is sudden, complete, and usually bilateral, or one eye may
be affected primarily, the other becoming blind in a few hours;
in rare instances some light perception is retained. The reaction
of the pupil to light is generally unimpaired. The condition
of the pupil itself varies : sometimes it is dilated, at other times
it is contracted, and often it remains unaffected. The result of
ophthalmoscopic examination is usually negative, but occasion-
ally a combination with retinitis exists ; in this event the retinitis
antedates the amblyopia. The urine is scanty or may be sup-
pressed, the specific gravity is high, albumin being present in
large quantities. Uremic amaurosis is more common in the
forms of nephritis accompanied by uremic attacks, as scarlet
fever, pregnancy, acute exacerbation of the chronic form, etc.
Restoration of sight is generally sudden and complete, varying in
time from a few hours to three or four days. Permanent blind-
ness does not occur except in cases in which there has been a
prior retinitis. Recurrence indicates an unfavorable outcome.

SYLLABUS OF CONDITIONS ACCOMPANYING OR PRODUCED BY
THE DIFFERENT TYPES OF NEPHRITIS

1. Intense conjunctival chemosis occurring with or without
intra-ocular inflammatory diseases.

2. Circumorbital subcutaneous and subconjunctival hemor-
rhages, if recurrent and in patients over forty years of age.

3. Successive external ophthalmoplegias.

4. Iritis, choroiditis, and iridochoroiditis, when not assignable
to other causes.

5. Edematous, pale-gray retina, with exudate.

6. Hemorrhages and deposits in and on the retina.

7. Many forms of retinitis, neuritis, and neuroretinitis showing
the "albuminuric" picture on ophthalmoscopic examination.

8. Contracted, silver-streaked arteries and dilated, flattened,
tortuous veins.

9. Amblyopia or amaurosis with sudden complete blindness,
temporary in character, without retinal damage or ophthalmo-
scopic evidence of intra-ocular disease.

CHAPTER VIII

THE KIDNEY IN ACUTE INFECTIOUS DISEASES.-SUP-
PURATIVE NEPHRITIS

THE KIDNEY IN ACUTE INFECTIOUS DISEASES

Relatively few diseases really arise primarily in the kidney ; as
a rule, the renal lesion occurs secondarily and as a complication of
some other pathologic condition. For this reason it is deemed
best to consider briefly the action of the kidney in some of the
more common ailments. Among these, the infectious diseases
are probably the most important, both because of the common
occurrence and serious nature of this class of diseases and also
because of the fact that serious renal complications are particu-
larly prone to arise at some time during their course.

Although the relative frequency of kidney lesions in the acute
infectious diseases varies greatly, being, for example, very com-
mon and severe in scarlatina, it is not deemed practicable to
consider the relationship of the lesion to each individual disease,
more particularly since the variations that occur apparently
affect the degree or frequency more often than they do the patho-
logic changes.

There are certain fundamental reasons why renal disease so
commonly arises in the infectious processes. In these conditions,
in addition to the usual poisons elaborated by the metabolism
of the body, the renal tissue is required to excrete toxins generated
by bacterial or protozoan growth, together with those elaborated
by a disordered metabolism. The poisonous substances that the
kidney is called upon to excrete, therefore, are not those to which
it has been accustomed, and thus renal irritation or incompetency
is readily brought about.

In the acute exanthemata, in addition to getting rid of these
foreign toxins, the kidney is called upon to accomplish, by com-
pensatory excretion, the function normally carried on by the skin,
and at the same time the diseased skin presents a large surface

152

THE KIDNEY IN ACUTE INFECTIOUS DISEASES 1 53

for the elaboration of poisons. A practically analogous condition
obtains in such diseases as typhoid and dysentery, the excretory
powers of the bowel being not only lessened or entirely lost, but
also affording a large surface for the development of abnormal
metabolic substances with perhaps actual toxin formation. The
same conditions also obtain in lobar pneumonia, in which, in
addition to toxin production and diminished respiratory excretion,
a certain amount of cellular depression must result from limited
oxidation.

Before considering the actual lesions of the kidney that com-
monly originate in the course of the infections, it must constantly
be borne in mind that albuminuria and even the presence of casts
and blood in the urine, without actual nephritis existing, are of
common occurrence in the early stages of the infectious diseases.
Thus in nearly all the acute infections a preliminary stage of en-
gorgement occurs; during this period albumin and, in the more
severe cases, blood and casts as well, may appear in the urine,
but under favorable conditions they disappear in the course of
a few hours or days, as the circulatory conditions become ad-
justed. This, as stated, is manifest at the onset of nearly all the
acute infections. Under ordinary conditions, as proper circula-
tion becomes reestablished, these elements disappear from the
urine ; if, however, they remain present over long periods, or if a
secondary inflammatory disease is set up in the kidney, a true
nephritis may be ushered in.

The complications that arise as a result of the action of
infectious diseases on the kidney may be divided into two groups:
those that originate in acute and those that develop in chronic
or long-standing cases. A more minute classification is also
possible, and the conditions that appear during the course of the
acute infections may be grouped as those that are produced
by septicemia, from the mere fact of the presence of bacteria
circulating in the blood, and those that seem to be caused chiefly
by the action of toxins. The most common condition in which
the former occurs is in septicemia or pyemia from any cause
whatever, as in puerperal sepsis, endocarditis, and the like. How-
ever, it must be remembered that the mere presence of bacteria
in the blood is not the sole or final factor, for in all these conditions

154 ACUTE infections; suppurative nephritis

toxins, at least in part, also play a role; it is rare, indeed, that
bacteria act only in a mechanic or simple biologic capacity.

The most important renal lesion occurring in septic conditions
is that of infarction. This is ordinarily manifested by pain in
the region of the affected kidney, and by the sudden appearance
of blood and albumin in the urine. Often, however, the condi-
tion passes unnoticed, unless the infarct is of considerable size;
this may happen also when other clinical symptoms tend to
obscure those of infarction. The blood ordinarily soon disap-
pears from the urine, and the condition is rarely diagnosticated.
The infarctions are, as a rule, small, and involve chiefly the corti-
cal portions of the kidney, for the reason that the causative
embolus commonly lodges in one of the terminal or interlobular
arterioles. The area involved may, however, be sufficiently large
to result in necrosis of considerable portions of tissue, and the
particular danger in these cases is that bacterial growth terminat-
ing in renal abscess may occur in this necrotic medium. If the
infarctions are of small size, no symptoms may be present beyond
perhaps the sporadic occurrence of albumin and pus in the urine,
but this depends largely on the nature of the infecting organisms ;
if they are tubercular, a general or local tubercular nephritis may
arise; in streptococcus septicemia a diffuse septic inflammation
of the entire renal substance is likely to occur, while in gonorrheal
infections, an active suppuration, usually more or less localized,
is most likely to take place. In pneumonia, according to the
writers' observation, a diffuse process simulating that seen in
streptococcal infections most frequently occurs.

When the general disease is characterized chiefly by the active
production of virulent toxins, as in scarlatina, diphtheria, and
in certain instances of lobar pneumonia, a diffuse hyperemia of
the kidney takes place first, accompanied by albuminuria and
casts that, even in the most favorable cases, persist longer than
in simple hyperemic conditions. If the toxemia is sufficiently
active, this may proceed until a diffuse nephritis occurs, and the
inflammatory process may become so marked that a hemor-
rhagic infiltration is set up. Albumin, blood, and epithelial
casts appear in the urine, which is also diminished in quantity,
and all the other manifestations of an acute hemorrhagic nephritis

THE KIDNEY IN ACUTE INFECTIOUS DISEASES 1 55

become evident. This is the picture most likely to arise in scar-
latina and in smallpox. Even in the milder cases a diffuse paren-
chymatous nephritis is very prone to develop, and this is one of
the most frequent causes of death occurring at the onset of these
acute infections, although it may also develop at any stage of the
process. Not uncommonly it is found at autopsy that a single
kidney is so affected. When but one kidney is the seat of disease,
the work of excretion is thrown on the remaining organ, which
may, in consequence, undergo compensatory hyperplasia or, on
the other hand, it may, in turn, become diseased, in which case
a fatal termination generally ensues.

The treatment of nephritis arising in the course of the acute
infections varies according to conditions present in each case.
In general it is identical with that demanded in the pure nephritic
condition. When abscess of the kidney occurs, it may become
necessary to open and drain, but this is rarely the case in the
course of the acute general disease. If a diffuse suppuration is
present, which, as occasionally happens, transforms the entire
substance of one kidney into an abscess cavity, nephrectomy may
be imperative. The ordinary methods of treating renal diseases
may, however, safely be employed in the acute infections; thus
the hot pack, diaphoretics, and remedies tending to stimulate excre-
tion by the bowel are measures that have been found, of decided
benefit. The dietetic restrictions ordinarily prescribed in the
various forms of acute nephritis are indicated here. When ascites,
hydrothorax, and similar conditions arise, the treatment should
first consist of tapping or the employment of other mechanic
measures rather than of medicinal means.

The prognosis is entirely dependent on the individual character-
istics of each particular case, and no general statements in regard
to it are, therefore, possible.

In these renal complications, as in primary nephritis, the acute
condition is very prone to become chronic, and interstitial changes
are likely to take place; this is seen, for example, in many cases
of typhoid fever. When the infection is of long standing, it is
impossible to determine antemortem, either from a clinical or a
pathologic standpoint, whether parenchymatous or interstitial
changes predominate. As a rule, the lesions go hand in hand.

156 ACUTE infections; suppurative nephritis

although interstitial hyperplasia is more prominent in prolonged
diseases or when the blood-vessels are extensively involved.

When the infection is in itself primarily of a chronic character,
as, for example, in syphilis, interstitial manifestations are the
predominating characteristics of the renal complications. Thus
is brought about the small sclerotic kidney or, less commonly,
the large red kidney. In these cases, as in the protracted sub-
acute or acute infections, the degenerative alterations are more com-
monly of the fatty type, differing in this respect from the changes
seen in the more active disease, in which albuminous degenera-
tion is the dominant feature. Fatty degeneration may follow
the parenchymatous, or it may originate itself as a primary
change. Amyloid degeneration also occurs, especially in syphilis,
tuberculosis, and chronic suppurative processes, such as osteo-
myelitis.

These renal complications, except when they occur in tubercu-
losis, are clinically of much less importance in the chronic infec-
tious diseases than in the acute, for they are not so often the
immediate cause of death, unless, as is not uncommon, an acute
nephritis becomes ingrafted upon the chronic. The onset of
chronic renal complications is so insidious that it is rarely sus-
pected early; prophylaxis should, however, be provided by
giving particular attention to the bowel and to the general
subsidiary excretory functions of the body in all long-standing
infections.

The diagnosis must rest entirely on the usual manifestations
of renal disease — albuminuria, polyuria, casts, edema, and the
other cardinal symptoms of chronic nephritic lesions.

The treatment differs in no way from that employed in uncom-
plicating nephritis of the chronic type. Acute nephritis is, how-
ever, very likely to arise as a second complication, and may de-
mand special attention.

Prognosis. — As a rule, renal involvement does not materially
alter the immediate prognosis of chronic infectious disease, al-
though it greatly diminishes the probability of ultimate complete
recovery. Unlike the acute form, it rarely acts as the immediate
cause of death except when it finally becomes acute.

SUPPURATIVE NEPHRITIS 157

SUPPURATIVE NEPHRITIS

Under this heading will be considered all the processes generally
classed under the heads of exudative pyelitis, pyonephrosis, and
suppuration of the kidney. Tuberculosis, although coming prop-
erlv under this head, will, because of its importance, be considered
separately. This plan has been adopted for the reason that,
clinically, the conditions are practically similar, the various
changes that occur being often but different stages of the same
general process.

Suppurative inflammation of the kidney may be brought about
by four different methods of inoculation: first, by ascending in-
fection from the lower urinary tract; second, by embolic infarc-
tion, as in general septicemia; third, by infection taking place in
the course of what may be regarded as the normal excretion of
bacteria by the urinary tract; and fourth, by the extension of
suppurative processes into the kidney from without. Suppura-
tion in the kidney may be localized in any portion of the organ,
or it may be diffuse, the former condition being the more common.

In a large series of postmortems the writers found ascending
infection to be by far the most frequent cause of suppuration. It
may arise in any condition or disease in which infection of the
lower portion of the urinary tract has taken place, as, for example,
in the exudative urethritis of gonorrhea ; in cystitis or suppurative
disease of the ureters, and, finally, in pyelitis. As a rule, the
infection travels upward from the urethra, prostate, or bladder,
infecting the various portions of the excretory canal as it advances.

The mere presence of bacteria, regardless of the variety of organ-
isms, in any of these portions of the urinary tract is not suihcient
in itself to set up the process. Another and probably a more
important factor, that of predisposition, must also be present.
Thus pathogenic bacteria are often found in the urine under
physiologic conditions, and, as a matter of fact, bacteria are often
excreted by the urine in both pathologic and physiologic states
without producing any local disease. This is particularly shown
in regard to the colon bacillus, which is not uncommonly found
in the urine, especially in constipation and in certain intestinal
fermentations. Two such cases recently came under the care of
the writers. In each case purgation caused a temporary disap-
pearance of the colon bacillus from the urine, which reappeared

158 ACUTE INFECTIONS; SUPPURATIVE NEPHRITIS

later. It is quite possible, as asserted by Nichols, of Montreal,
that organisms so excreted may occasionally set up nephritis.

W. H. Thomson ' has recently reported a series of cases in which
colon infection of the kidney set up a diffuse nephritis manifested
by the urinary findings of an active acute parenchymatous
nephritis, but with symptoms of much less degree. Colon bacilli

Fig. 64. — Double pyonephrosis (one-lhird natural size).
Originating from a primary cystitis and showing thickening of bladder wall, dilatation
of both ureters, and extensive necrosis of renal tissue. Left kidney not opened. From a
specimen in the museum of Carnegie Laboratory.

are found in abundance in the urine of these cases, which, not-
withstanding their very serious appearance, Thomson finds
recovery quite promptly under medication with urinary dis-
infectants, notably urotropin. A case under the observation of
one of us seems to bear out Thomson's statements.

The most frequent factor predisposing in the development
^ "New York Medical Record," March 21, 1908.

SUPPURATIVE NEPHRITIS

159

of suppurative nephritis is hydronephrosis. This may be induced
by any cause whatever, as when abnormal retention occurs, as in
alcoholic stupor or other comatose conditions, in obstruction to
the urinary passages, as from impaction of a calculus, in enlarged
prostate, urethral stricture, and the like. In all these conditions,
when the urine is retained until abnormal distention of the bladder,
ureters, and renal pelvis takes place, the integrity of the epithelial

Fip. 65.— Diffuse type of exudative or suppurative nephritis occurring in a pneumococcus
septicemia. Complete necrosis and replacement of tubules is shown in the field : a, Malpig-
hian body ; b, infiltrating leukocytes.

lining of these cavities becomes so much impaired that, if bacteria
are present in the urine, the hydronephrosis is very prone to be
converted into a pyonephrosis. Pyonephrosis may, however, be
excited by a mechanic irritant; thus the excretion of highly
irritating urine, the presence of renal calculi, or other similar
conditions may act as factors in its production. From this it
must not, however, be concluded that every case of pyelitis or

i6o ACUTE infections; suppurative nephritis

even of pyonephrosis leads to suppurative nephritis. Recent
observations made with the aid of the cystoscope have demon-
strated that these conditions frequently exist and undergo spon-
taneous cure, or are relieved by catheterization and flushing of
the ureters and pelvis.

When extension into the body of the kidney takes place from
these ascending infections, it occurs through the secretory tubes
of the medulla. Irl these cases the pyramids may be soon trans-
formed into abscess cavities that retain the pyramidal shape
and are continuous with the distended pelvis of the kidney. This
process may continue until the entire medulla of the kidney is
involved or until the cortex itself has become gradually necrosed
and the entire kidney transformed into an abscess cavity inclosed
in the thickened capsule, which, in most cases, acts as a limiting
membrane to the suppurative process. If drainage is good and
if but one organ is involved, as is frequently the case, the process
may gradually be checked and very slight constitutional distur-
bance may result. The condition may often be unsuspected until
a urinary examination is made, which will reveal the constant
presence of pus in abundant quantities. It is remarkable, how-
ever, to what a limited degree urinary excretion is hampered,
even when both kidneys are involved; in these cases uremia is
very rare, and a double pyonephrosis has been known to exist
for years without interfering with the business activity and often
with but little inconvenience to the patient. Apparently, such
a result is dependent on the amount of drainage and, to a certain
extent, on the bacterial character of the inflammation.

Embolic infarction of the kidney is rather frequent, owing to
the numerous terminal arterioles that are given off to the cortical
portions of the kidney, and which are particularly prone to be the
seat of emboli. Embolic infarctions occur most frequently in
pyemia or in septicemia. In most cases the infarct precedes
suppuration, the latter process being, however, greatly favored
by the necrotic material present in the obstructed area. In a
considerable number of cases, particularly in malignant endo-
carditis and puerperal sepsis, suppuration seems to occur inde-
pendently of the existence of an infarct.

Suppurative nephritis due to the presence of emboli often runs a
very mild course. Not infrequently these localized abscesses of the

SUPPURATIVE NEPHRITIS l6l

kidney become encapsulated and give rise to but slight if any clini-
cal manifestation ; ordinarily, unless the abscess is very large, or if,
as is unlikely, suppuration spreads, pyuria is absent. In short,
abscess formation in the kidney does not display so marked a
tendency toward extension or destruction of tissue as is the case
with similar processes elsewhere. In a few cases these cavities
may drain through one of the large tubules; when this occurs,
pus may be found in small quantities in the urine. As a rule,
however, in the writers' experience, the condition commonly goes
unsuspected, except in a small number of cases in which the abscess
is sufficiently large to present a palpable tumor or severe pain is
present.

Infection due to the presence of pathogenic organisms in the
urine is not commonly mentioned as a cause of suppuration, but
it is, nevertheless, one of the possible factors in its production.
In constipation, in general septic conditions, in infective icterus,
and in many other pathologic states bacteria are expelled from
the body with the urine. Ordinarily, this takes place without
serious consequences to the kidney, but instances undoubtedly
occur in which bacteria are brought to the organ, and probably
because of some mechanic state or a lowered resistance of
the renal tissue, an inflammatory process is set up. Thus areas
of suppuration are occasionally found in the kidney when no
general sepsis has existed and when ascending infection may,
with reasonable certainty, be excluded. Such cases usually fol-
low the same course as embolic infarction, although occasionally,
as in Weil's disease, diffuse suppurative nephritis may arise.

Suppurative nephritis originating from extension of the process
into the kidney from outside sources is somewhat uncommon,
except as a sequel to traumatism of the kidney; it is quite rare
even in cases of perinephritic suppuration. Occurring under
these conditions it resembles perinephritic abscess, and is per-
haps best described under that head.

Perinephritic suppuration may arise as the result of rupture of
a renal abscess into the perinephritic tissues, or as an extension of
a diffuse suppuration of the kidney into this tissue. These are
among the more infrequent causes, although rupture of a pelvic
abscess, particularly when pelvic calculi are present, is relatively
frequent. Most commonly it follows injuries received in this

i62 ACUTE infections; suppurative nephritis

region or as the result of extension of suppuration, as in spinal
caries or from subdiaphragmatic drainage of an empyema.
Most frequently, perhaps, it follows ulceration and perforation of
the intestine, generally of some portion of the colon or appendix.
It may also arise in marasmic conditions, particularly in chil-
dren, and in cases of prolonged illness, where a generally depressed
state of the tissues, especially of the fatty variety, is present.

As a general rule, the bacteria found in perinephritic suppura-
tions are not of the most virulent type. The colon and the pro-
teus bacillus are among those most frequently observed, although,
of course, any member of the intestinal group may be present.
As a consequence the pus evacuated from these abscesses gives
off a very foul odor, and yet may remain in the body for a long
time without producing sepsis.

Perinephritic abscesses may drain in various directions, this
depending largely on the position habitually assumed by the
patient during the course of the disease. The pus may burrow
upward into the pleural cavity, producing an empyema on the
same or on the opposite side. The abscess may rupture into the
peritoneal cavity, or the pus may even work its way across the
retroperitoneal tissues to the same region on the opposite side,
double perinephritic abscess being by no means rare. Probably
one of the most common routes of extension is along the sheath
of the psoas muscle, finally presenting in the groin. Another
course, which renders attack easy, is for the abscess to point through
the muscle of the back or side.

Diagnosis. — Unless pus can be demonstrated in the urine col-
lected before bladder contamination has been possible, the diagno-
sis of suppurative nephritis is, as has been stated previously,
very difficult and often impossible. When pus is present, it may
be found in but small amount, particularly in the diffuse forms;
when it escapes from a localized abscess, it may be present at one
time and absent at another. Blood is rarely seen except in the
early stages of traumatic cases, and casts may or may not be
present; pus-casts are occasionally found, however, even when
free pus-cells seem to exist only in very small numbers. The
urine may be either acid or alkaline in reaction, this depending
largely on the nature of the organisms present ; usually, when the
infection is an ascending one, it is alkaline. As a rule, there is

SUPPURATIVE NEPHRITIS 1 63

no change in the amount of urine secreted, and at times it may
contain particles of necrotic renal tissue, the nature of which may
be recognized under the microscope.

When the infection has been ascending, the diagnosis is, as a
rule, greatly facilitated by the history of the case, by the presence
of urethritis or cystitis, and by the discovery of an obstruction
to the ureter or to the outflow from the bladder. It will occa-
sionally be found, strangely enough, that no cystitis or inflamma-
tory disease of the lower urinary passages exists (having under-
gone cure), whereas the pyonephrosis or pyelitis that occurred sec-
ondarily is still present. From this it will be seen that a normal
condition of the lower urinary passages does not exclude the possi-
bility of these channels having been the original seat of infection.

Although the condition of the urine is by far our most important
aid in the diagnosis of this disease, other factors are to be consid-
ered. For example, fever may be present, either with or without
the occurrence of pyuria; on the other hand, this appears to be
largely dependent on the bacterial nature of the process; thus
extensive renal suppuration, usually of a more or less chronic
type, has frequently been found without any hyperpyrexia occur-
ring. A more constant finding is a polynuclear leukocytosis,
although this may also be absent, and, more particularly, in the
very cases in which pyrexia is likewise absent.

There are no symptoms that are characteristic of renal suppura-
tion other than those common to a suppurative process occurring
elsewhere in the body. Except when the urinary findings indicate
the probable seat of the process, or the somewhat unusual symp-
toms of renal tumor or fluctuation in the kidney region are present,
a diagnosis is not generally possible. Occasionally, however,
the patient will complain of severe pain in the renal region, and
while this is not of much value in the diagnosis, it is a point to be
considered.

The tendency for a patient to draw up the leg on the affected
side is somewhat indicative of pus either in or around the kidney.
Catheterization of the ureters furnishes one of the surest, if not
the safest, means of diagnosing pus within the kidney. Some
experience is necessary, however, in performing this operation,
and in interpreting the findings from it correctly, for the passage
of the catheter itself will often cause enough irritation to render

164

ACUTE infections; suppurative nephritis

the urine slightly cloudy. Microscopically, a few pus-cells may
be found, but this alone does not necessarily indicate that a
suppurative nephritis is present. In small kidney abscesses, in

Fig. 66.— Method of expressing pus from kidney pelvis into the bladder.

which there is good drainage, it should be remembered, sponta-
neous cure often results; when, therefore, a small quantity of

Fig. 67.— Method of expressing pus from the kidney pelvis into the bladder, continuation of

figure 66.

true pus is found in the urine obtained by ureter catheteriza-
tion, this is not necessarily an indication for the performance of

Fig. 68. — Vibratory method of expressing or massaging pus from the renal pelvis into the

bladder.

nephrectomy, or even of lavage of the pelvis of the kidney by
means of the ureter catheter.

SUPPURATIVE NEPHRITIS 1 65

A valuable method, and one coming into more general use, for
diagnosing the presence of pus in the kidney is that of making an
examination of the urine before and after performing massage
of the kidney region and along the course of the ureter. The
writers' attention was very recently directed to the value of this
diagnostic measure by the House Staff at the City Hospital of
New York. In one case the massage forced so large an amount
of pus from the kidney into the bladder that the gross appearance
of the urine was materially altered. This, together with the occur-
rence of the general symptoms of sepsis, was considered evidence
enough to warrant operative interference, which disclosed a large
abscess of the kidney. If this method demonstrates the presence
of a considerable amount of pus, nephrectomy is, as a rule^ indicated.
This method as a means of diagnosis has been advocated by Gior-
dano, of Venice.* This observer places the patient at rest, emp-
ties the bladder, performs massages over the kidney and along the
course of the ureter, and then collects the urine. After this he
washes out the bladder, performs massage of the other side, and
collects the urine again. When the urine of one side is bloody,
he considers this an indication of the presence of renal calculus.
G. Nicholich, another Italian observer, advocates the leaving of a
catheter in the previously washed-out bladder and massaging
first one side, and then the other.

As has previously been mentioned, the writers consider this
massage or the making of pressure over the kidney and along the
course of the ureter as one of the most valuable diagnostic aids
at our command, and recommend its use not only for the purpose
of demonstrating the presence or absence of pus in the kidney,
but as furnishing evidence of the presence of renal calculi, besides
giving general information as to the conditions of these organs.

Treatment. — Ordinarily the treatment of an abscess in or
around the kidney, when not hygienic, is surgical and consists in
the performance of either nephrotomy or nephrectomy; opera-
tions which will be described in detail further on (p. 252).

»"La Semaine M^d.," March 30, 1904.

CHAPTER IX
BRIGHT'S DISEASE

THE PATHOLOGY OF BRIGHT'S DISEASE

There is no more difficult problem in medicine than to make
a comprehensive and accurate determination, from the clinical
aspects, of the existence of Bright's disease, and to tell, from these,
the precise lesions that occur in the kidney, or vice versa. Not
uncommonly cases that appeared cUnically to be examples of
typical acute nephritis are shown at autopsy to have been but
an acute exacerbation of a chronic or subacute one. On the other
hand, cases running a slow and relatively mild course, typical
of the chronic form of the disease, may be found to be due to
purely acute and active lesions. While Cabot, in his recent con-
clusions, may take too extreme a view when he declares that we
can tell nothing of the character of the lesion from the clinical
aspects presented and from an examination of the urine, yet
those who have followed cases from onset to autopsy cannot but
agree with him in the main. It must be acknowledged that to
Cabot, perhaps more than to any other observer, is due the credit
for an honest, realization of the difficulties of making an exact
diagnosis in inflammatory and degenerative lesions of the kidney.

When accurate methods for examining the urine were first
introduced, it seemed as if, through them, some positive infor-
mation might be gained of renal disease. In the main this is
true, although it must be said that no broad-minded clinician
now feels that he can rely absolutely on even this aid in more
than the "average" case. Certainly Cabot's statistics, and those
of later observers in regard to this matter, must lead to the adop-
tion of even a more pessimistic view of diagnosis in this disease.

For this reason, the writers have long ago abandoned the
attempt to make an exact diagnosis in regard to the anatomic
condition of the kidney from the clinical findings or symptoms,
and rely chiefly on the determination of the physiologic possi-

i66

PATHOLOGY OF BRIGHT'S DISEASE 167

bilities, which, after all, are the more important, since on these,
and not on the exact anatomic changes, rests the hope of effecting
reparation and recovery of function. Nevertheless, the study
of the pathologic anatomy of the kidney in Bright's disease is
most important, particularly in considering the treatment of
mild or early cases, and in attempts at prophylaxis. It is neces-
sary, besides, to establish a basis of definite anatomic lesions on
which to erect our superstructure of symptomatology, and on
which to formulate our course of treatment.

All kidney lesions in Bright's disease are separable theoreti-
cally, practically, and anatomically into two large classes — (i)
Those in which true inflammatory lesions are present in the kid-
ney tissue; (2) those characterized by degenerative changes in
the parenchyma. In adopting this simple classification it must
be borne in mind, of course, that, though it may exist theoreti-
cally, one never sees a pure type of either class, and the division
holds only in that in most cases either degenerative or inflammatory
lesions predominate.

A further subdivision into acute and chronic is possible both
clinically and anatomically, and in this discussion an attempt
will be made to adhere as closely as possible to this simple classifi-
cation, beUeving it to be that most useful to the study and manage-
ment of cases of Bright's disease, and most helpful to a proper
understanding of the disease.

Acute Bright*s disease may be due to any agent or factor that
is productive either of acute inflammatory foci or of active paren-
chymatous degeneration in the substance of the kidney. It is-
hardly necessary to state that when the inflammatory process
amounts to actual suppuration, it should not be considered as
Bright's disease, but as a suppurative nephritis.

Among the agents most commonly productive of such inflam-
matory lesions in the substance of the kidney must be mentioned
those vascular disturbances that give rise to sudden hyperemic
conditions of the organs; this may be, in a certain number of
cases, of neural origin, or it may be due to those vague, but none
the less important, derangements of the vascular supply that
follow exposure to excessive cold, heat, or physical or mental
strain. Although the complete theoretic understanding of these

1 68

bright's disease

factors may be unsatisfactory, clinical experience has shown
beyond doubt that they cause acute nephritis.

Sudden checking of the function of other excretory organs, as
the skin or bowel, with the resulting hyperemia, may be followed
— and, in fact, often is followed — by the development of
inflammatory changes in the renal tissue, in this way setting up a
true acute nephritis. Irritants circulating in the blood, such as
the metallic poisons, alcohol, spices, and condiments, may also
act in a similar manner. More frequently we find that poisons

h ggPJ

Fig. 69 — Acute hemorrhagic nephritis, occurring in a case of scarlet fever. The urine
contained large quantities of blood: a, Malpighiaii body; 6, extensive interstitial hemor-
rhage causing isolation of tubules ; c, hemorrhage into lumen of convoluted tubule.

generated in the course of the various infectious processes, and
brought to the kidney for excretion, act as inflammatory exci-
tants, although in most cases these agents affect chiefly the renal
epithelium, causing degenerative disease and resulting in that
type of nephritis which we are attempting to separate from the
true inflammatory form. More often than is generally conceded,
metabolic substances that result from the abnormal breaking up
of normal food products or tissue, or those that follow from the
natural disintegration of abnormal metabolic substances, — ma-

PATHOLOGY OF BRIGHT 'S DISEASE 1 69

terials exciting inflammatory reactions, — are brought to the kid-
ney. There can be little doubt but that many of the apparently
idiopathic cases of nephritis are really brought about in this
manner, and it becomes the duty of the physician to study the
metabolic functions of his patient as fully as possible. By mak-
ing frequent examinations of the urine and the feces and with
close attention to the digestive functions, metabolic disturbance
may usually be detected early and corrected, thus preventing
the onset of renal complications.

The actual changes in the kidney substance in this inflamma-
tory type of Bright's disease vary greatly according to virulence
and the rapidity of action of the etiologic agent, and doubtless
according to the natural resistance offered by the renal tissue.

In general it may be stated that renal lesions may manifest
all the types of inflammation seen elsewhere in the body. In a
certain number of cases, particularly in those of sudden onset,
intense hyperemia develops, often with diapedesis of the white
and red blood-corpuscles, which may then appear in the urine.
Naturally, cell-infiltration is found to be most marked about the
blood-vessels, and particularly in the cortex of the organs, where
the capillary distribution is most abundant. Proliferation of
the connective-tissue cells in the adventitia of the larger vessels
and the interstitium of the kidney tissue follows, and areas of
small round-cell infiltration appear about the vessels and lym-
phatics. Serum may be thrown out in abundance, and at post-
mortem examination the cut sections of many such kidneys drip
serum in great quantities. Associated with these changes more
or less degeneration and desquamation of renal epithelium take
place, and these fragmented cells, together with serum and blood,
collect in the tubules and are washed out as casts of various
types.

The vessels remain hyperemic throughout, and even gross in-
spection of the organ is sufficient to demonstrate the engorged
capillaries.

In this type of nephritis healing presupposes, of course, the
removal of the etiologic causes, the reestablishment of nor-
mal circulation, absorption, by the blood and lymph, of the liquid
portions of the inflammatory exudate, and the disintegration of

I70

BRIGHT'S DISEASE

the extravasated blood-cells, broken-down epithelium, and con-
nective tissue, which may either be carried off in the urine or be
picked up by phagocytic leukocytes and endotheUal cells and
then may be taken away by the lymph-stream. With the re-
moval of the exciting factors and of the inflammatory exudate
restitution of the desquamated epithelium by a multiplication
of the remaining cells readily takes place, and the lesions of the
urinary tubes are quickly repaired. Quite another and more
serious matter is the disposition of the newly formed connective-
tissue cells, for, with the growth of
this tissue, new blood-vessels have
developed and a definite structure
has been built up that is best de-
scribed, perhaps, as a type of gran-
ulation tissue. Assuming that the
acute inflammation has entirely sub-
sided, either this newly formed tis-
sue must break down and become
absorbed,— a result that the writers
believe but rarely takes place, —
or it must pass on to the formation
of adult, that is scar, tissue, with
its well-known tendency to con-
traction. In this manner the chronic
sclerotic type of nephritis may read-
ily follow the acute disease.

It has appeared impracticable
to attempt the still further division
of this form of nephritis into sub-
classes, since the type in each case
depends not on essential alterations in the cause or nature of the
disease, but rather on the form or degree to which the inflam-
matory process progresses.

The second type of acute nephritis, or Bright's disease, accord-
ing to our classification, comprises those cases that are chiefly
typified not by inflammatory, but by degenerative, alterations;
although, as has previously been stated, these two processes are
usually associated. The degenerative type of nephritis occurs

Fig. 70.— Chronic interstitial ne-
phritis. (One-half natural size.) Both
organs from same subject. Case of
chronic lead-poisoning. Specimens in
museum of Carnegie Laboratory.

PATHOLOGY OF BRIGHT S DISEASE

171

most commonly as a result of toxemia, particularly that resulting
from such processes as diphtheria, sepsis, and certain cases of
typhoid fever. It occurs also, and even more commonly than the
inflammatory type, in cases of metabolic disturbances. The
process is often ushered in without exhibiting the slightest inflam-
matory manifestations in the renal tissue, and solely by the
degenerative changes in the epithelium.

As is naturally to be expected, the disease affects particularly
the cells of the convoluted tubules, and is first manifested by

Fig. 71. — Chronic interstitial nephritis, showing adherence of capsule and roughened
surface. Natural size.

evidences, in these cells, of an acute parenchymatous or albumi-
nous, later associated with a fatty, degeneration. The cyto-
plasm of the cells, and, in more severe instances, the nucleus as
well, becomes turbid and swollen from the transformation of the
normal cell-substances into lower albuminous granules. When
the process becomes sufficiently marked, the cell begins to disinte-
grate, and fragments are thrown off into the urine ; or, in a more
active process, the entire cell may thus be desquamated, and if
fragments appear in abundance in the urine, unaccompanied by
blood-cells or other inflammatory products, this is more or less
diagnostic of this form of renal disease. Casts form, as in the first

172

BRIGHT S DISEASE

variety, for associated with the degenerative changes in the renal
cells is a similar process affecting the endothelium of the capilla-
ries and lymphatics.

Changes in the connective tissues arise in this form only as
complications, and the healing process is so much simpler that
the cases are quite distinctly differentiated from the former class
by their relatively rapid and permanent recovery, under proper
conditions. The heaUng process consists simply in the complete

Fig. 72.— Combined parenchymatous and fatty degeneration of kidney, from a case of
puerperal eclampsia : a, Convoluted tubules showing extensive degeneration; b, collecting
tubules ; c, cells showing profoutid parenchymatous degeneration ; d, oil globules in cytoplasm
of degenerated cells.

desquamation of those cells that are too much diseased to permit
restitution to take place, and the replacement of these discarded
cells by others that arise by cell division from the remaining and
relatively normal cells. This process is readily brought about in
most cases, and may result in such complete repair that the organs
become relatively normal again. This rarely or never occurs in
cases associated with true inflammatory alterations.

When more or less complete destruction of the parenchyma has
taken place, new tubules, supporting tissue, and even glomeruli

PLATE VII

Large white kidney. (Two-thirds natural size.) (From a specitnen in the
Museum of Carnegie Laboratory.)

PATHOIvOGY OF BRIGHT's DISEASE

173

may all be reformed; the same manner of repair may also take
place, though in lesser degree, in the inflammatory forms. It
must, however, be repeated that pure instances of the degenerative
types of nephritis are rare.

As a rule, the chronic inflammatory variety of nephritis is a
sequel to the acute disease of the same type, although it may
follow the degenerative form, particularly when it is long con-
tinued and associated with extensive destruction of tissue. In
this chronic type of inflammatory nephritis several classifications

Fig- 73-— Profound degree of parenchymatous degeneration of the kidney occurring in a
case of toxic lobar pneumonia : a, a, Congested capillaries ; 6, b, convoluted tubules showing
advanced parenchymatous degeneration with necrosis and desquamation of the epithelium ;
injected glomerulus.

are commonly made, the organ being denominated as the large
red kidney, the small sclerotic kidney, and so on. It is the writers'
belief that it is absolutely impossible to differentiate these types
clinically, and since they really represent but modifications of
the same pathologic process, a minute classification accord-
ing to mere gradations of the identical disease process seems
unnecessary. When the disease is characterized by active hyper-
plasia of the interstitial tissue, often associated, it is true, with
parenchymatous degeneration and hyperplasia as well, the size
of the organ increases, this increase being chiefly due to the pro-

174

BRIGHT'S DISEASE

duction of granulation tissue in the organ ; if, on the other hand,
this hyperplastic process is less active, the newly formed tissue is
allowed to develop until it assumes a more adult type, becoming,
namely, cicatricial tissue, and the small or sclerotic form of kid-
ney results. In either case the functionating epithelium and the
vessels are compressed, and both venous and lymphatic return
flow is impeded. This greatly diminishes the functional possi-

1

3%*' 9' •. t ■ t - V • .^

,'#

%. «i

il«

g^

^'~

F'K- 74 — Kidney of rat showing profound fatty degeneration following experimental
arsenical poisoning; section stained with osniic acid : a, Convoluted tubules with fat globules
stained black ; d, Malpighian body.

bilities of the organs, and the excretory process, In so far as the
kidneys are concerned, becomes more nearly a simple filtration
or osmosis, as is shown by the chemic nature of the urine. The
overgrowth of connective tissue chiefly works harm by effecting
direct compression and consequent atrophy of the secreting tubes.
Occasionally the newly formed tissue chiefly compresses the col-
lecting tubules, and, as continued secretion takes place, the tube
above the point of stricture becomes dilated and the formation

PATHOLOGY OF BRIGHT 'S DISEASE 175

of cysts, often of great size, and closely simulating those of con-
genital cystic kidney, occurs.

It is obvious that the constantly progressive hyperplasia of the
connective tissue, with or without resulting contraction, causes
serious inhibition of the renal function, even though the interstitial
hyperplasia is occasionally associated with parenchymatous pro-
liferation in limited degree. It is, therefore, found that in this
disease compensatory excretion is carried on by the other excre-

Fig- 75' — Chronic interstitial nephritis, from a case of chronic alcoholism: a. Glomerulus
replaced by hyperplastic connective tissue; d, diffuse hyperplasia of stroma ; c, compressed and
atrophied tubules filled by degenerated epithelial cells.

tory organs, particularly by the skin and bowel, so it frequently
happens that when either of these also become diseased, the addi-
tional work thrown on the crippled kidneys may set up an acute
hyperemia and an exacerbation of the inflammatory process, a
common termination to this form of renal disease.

It is unusual to find the chronic degenerative type of Bright's
disease entirely uncomplicated by inflammatory lesions, and
the presence or absence of these changes determines, to a large

176 bright's disease

degree, the activity of the morbid process. When the generation
of new parenchyma cells keeps pace with their destruction, the
process may be continued indefinitely until some other factor
arises that interferes with this compensation, resulting commonly
in acute outbreaks of nephritis. One can readily understand how,
in nearly pure cases of this kind, the disease may run a prolonged
course, albumin being constantly found in the urine, and yet the
kidney may be able to carry on its functions in a relatively nor-
mal manner. As a rule, unless inflammatory changes intervene,

Fig. 76. — Chronic diffuse nephritis, showing diffuse production of fibrous connective tis-
sue with replacement of the glomeruli and many large hyaline casts in the tubules: a, a.
Glomeruli showing fibroid substitution ; d, b, diffuse growth of connective tissue ; c, c, hyaline
casts in tubules.

these cases do not terminate fatally; patients so afflicted may
pass through infectious diseases and other similar processes quite
as successfully as those whose kidneys are supposedly normal.

Although in many cases the kidney manifestations dominate
the disease-picture, it is surprising to find how relatively rare it is
for Bright's disease to appear as an independent process. As has
been shown elsewhere, the condition commonly originates as a
result of some other disease process, and in its chronic as well as
in its acute form the most important guide to its proper under-
standing and treatment lies, not in the consideration of the kid-

SYMPTOMS, DIAGNOSIS, COURSE, AND PROGNOSIS 1 77

neys alone, but in understanding thoroughly the entire system and
the workings of quite independent viscera. Thus nearly all cases
of chronic, and many of acute, Bright's disease are associated
with serious disturbances of the vascular apparatus. More or less
arteriosclerosis is present concomitantly, and in the inflammatory
forms of the disease particularly this is manifested by an increase
in the general blood- pressure, a fact that is often of considerable
diagnostic importance. This in turn leads to cardiac hyper-
trophy, myocarditis, and eventually to cardiac dilatation, incom-
petence, and secondary circulatory changes in the liver and gastro-
intestinal tract — and, finally, in practically every vital organ of the
body. It is often most difficult to determine in any case the order
or sequence of these changes. Not infrequently it seems that the
renal lesions, although dominating the case, are but secondary,
for example, to a myocarditis or to valvular lesions of the heart
that originally led to renal congestion. This but emphasizes the
importance of considering each case individually, and of treating
not the renal lesion, but the patient.

THE SYMPTOMS, DIAGNOSIS, COURSE, AND PROGNOSIS OF
BRIGHT'S DISEASE

In acute Bright's disease the onset is sudden. The patient may
first observe that the amount of urine is diminished, or that the
ankles, wrists, or face become swollen at times. Not uncommonly
the first observed symptom, particularly in the degenerative type,
is an enlarged abdomen, due to ascites. In a small number of
cases the disease is inaugurated with a chill, and may be charac-
terized throughout the early stages by a mild pyrexia ; this is par-
ticularly true in the inflammatory form. The pulse is rapid and
hard, and the blood pressure is considerably raised, although
this is not so constant in the cases in which the changes are chiefly
of a degenerative nature. Sudden dilatation of the heart may
follow this raising of the blood pressure, particularly when myo-
carditis has preexisted. As a rule, the dropsy is somewhat slight,
in the acute cases, and, instead of being general, it is oftentimes
curiously locaUzed to certain areas. In the beginning of the
disease perspiration is generally checked and the skin becomes
harsh and dry. Occasionally the onset is early manifested by

1 78 bright's disease

the occurrence of uremia, and active maniacal symptoms or con-
vulsions may develop, to be succeeded by a somnolent or coma-
tose state. These uremic symptoms are particularly frequent
in acute exacerbations of chronic cases.

The amount of urine is greatly diminished, as a rule, or it may
become entirely suppressed. It is usually dark in color, often
smoky from the presence of blood-pigment, and turbid with phos-
phates, blood, casts, and epithelial cells. The specific gravity is
generally high, although, on account of the diminution in the
amount secreted, the total solids so eliminated are also diminished.
Occasionally, however, the amount of urea present is normal.
Albumin generally appears in large amounts, and its presence
may cause a lowering of the specific gravity. The quantity is no
indication of the gravity of the case.

In some cases, particularly those in which inflammatory lesions
predominate, the onset is marked by severe pains in the back,
which may be mistaken for those of a myalgia. Persistent
nausea or vomiting and occasional diarrhea are not uncommon
premonitory or initial symptoms.

Anemia and dyspnea develop early in the course of the disease.
The former appears to be due not so much to the actual loss of
blood, as to a probable hemolysis taking place in the blood-
stream as a result of excrementitious substances which are cir-
culating in this tissue. This may in some cases give rise to a
pronounced hemoglobinuria.

The course of the disease depends largely on the general con-
dition of the patient, and, naturally, on the degree of the process,
and particularly on the amount of urine excreted and on the
activity of the subsidiary excretory organs.

The disease is easily diagnosed, but it is not so easy to decide
whether the condition is a primary or a secondary manifestation.

The symptoms may be confusing and the diagnosis of chronic
Bright's disease is made with much greater difficulty. The old
theory that the chemic and microscopic examination of the urine
is a safe guide has now become to a great extent obsolete. Al-
though it is possible, within proper limitations, to draw valuable
information from such aids as ureteral catheterization, the phlorid-
zin and methylene-blue tests as to permeability, and from the

SYMPTOMS, DIAGNOSIS, COURSE, AND PROGNOSIS 1 79

use of the sphygmomanometer, still absolute diagnostic evidence
may be entirely wanting in some cases. The early diagnosis of
so insidious a disease as diffuse interstitial nephritis, which causes
thousands of deaths annually and which, according to statistics,
is increasing, is a feature the importance of which the profession
is only now beginning to realize. Recognized early, either as a
primary condition or as the result of some preexisting lesion of
the kidney or other viscera, much can be done toward arresting
the disease and prolonging the Hfe and usefulness of the individual.

The part played by heredity, as shown by the family history
of the patient, may or may not be of importance. Gout seems
to be hereditary in some families and is, of course, a frequent
causative factor in the production of chronic nephritis. Inherited
nervous weakness, to use a general term, seems to predispose to
the development of an early interstitial nephritis, owing to the
intimate relationship existing between the nervous system and
the kidneys. The offspring of neurasthenic parents, it might be
predicted, would have kidneys that would not withstand the
strain easily borne by those of more fortunate nervous inheritance.

More important than the family history is the personal record
of the patient — a history of the occurrence and course of infectious
or venereal diseases, of the general habits of life, and of excesses in
drinking or eating. Of great importance in this respect — since
it is, the writers believe, a common cause of nephritis — is the
presence of nerve-strain. It seems to be the general opinion
among the profession as well as among the laity that far-advanced
cases of B right's disease remain unrecognized until a very short
time before death, the patients suffering no discomfort and com-
plaining of no symptoms. This has not been borne out by the
writers' clinical experience, which shows that the cases of chronic
nephritis that have not presented, long before death occurred,
symptoms of ill health apparent to an intelligent observer, are
few indeed. Headache is, of course, a common symptom ; it may
be of any variety, the only one at all typical being the intense
general orbital distress occasionally met in patients with acute
Bright' s disease and in the later stages of the chronic form. The
ophthalmic manifestations have been discussed in a previous
chapter. Indigestion of various forms is very commonly com-

i8o bright's disease

plained of. Sudden attacks of vertigo or of dyspnea, without
sufficient accompanying vigorous physical exercise to justify its
occurrence, are suspicious symptoms. The symptoms of so-called
cardiac asthma are almost pathognomonic of a serious renal con-
dition, and are often unassociated with cardiac murmurs and
hypertrophy of the heart.

The condition of the hair, which is dry and brittle, and the
state of the skin, which may be the seat of the more common
forms of eruptions, such as the many varieties of eczema, are
recognized as being sometimes associated with forms of renal
insufficiency. Pains in the back are, by the laity, often attrib-
uted to kidney lesions, and are of such common occurrence in
certain cases as to have, the writers believe, a diagnostic signifi-
cance. Edema of one or both of the lower extremities, transitory,
it may be, can be detected on examination; or, when not dis-
covered, a history of its previous existence may be given. Much
information may sometimes be gained from careful palpation and
manual manipulation of the kidney region.

The estimate of the solids of the twenty-four-hour urine is of
considerable value. If this is found permanently below 70 grams
daily, and if no other explanation for it exists, — as an unusual
diet or amount of exercise, — a suspicion of interstitial nephritis
may be entertained. If the solids run habitually much in excess
of this amount, it denotes that the kidneys are being overworked,
generally as the result of overeating, or that tissue destruction
is taking place. In cases where the blood pressure is found to be
high (in the neighborhood of 250 or more) and other causative
lesions can be eliminated, the diagnosis of Bright's disease can
often safely be made, whether or not albumin or casts are demon-
strated by the chemic and microscopic examination of the urine.
Catheterization of the ureters is also useful, since it may demon-
strate a relative deficiency in the amount of work that each
kidney is doing.

The prognosis in Bright's disease can be given only after many
factors have been considered. Acute Bright's disease, so far as
immediate danger to life is concerned, ordinarily presents a fairly
good prognosis, when it is not grafted on a previously existing
chronic condition. It often, however, leaves as a sequel persistent
inflammation, which in turn may set up a fibrosis, and the va-

TREATMENT OF NEPHRITIS l^I

nous forms of parenchymatous and mixed kidney inflammation
ensue. The prognosis in these cases is dependent to a great
extent on the amount of tissue involved and on whether one or
both kidneys are affected. Although such an applicant is im-
mediately rejected by life insurance companies, he frequently
exhibits a fair state of general health, and may live for many
years.

In attempting to prognosticate the outcome of such conditions,
aid may be obtained from ureteral catheterization, the phloridzin
or Albarran's tests, and the like. Generally, in such cases, if the
kidneys and other excretory organs are doing their work and if
the patient can be kept amid good hygienic surroundings, and the
habits of life, particularly regarding diet, can be regulated, the
prognosis is fairly good.

When a diagnosis of chronic interstitial nephritis is made,
and it is found that the kidneys are not eliminating the average
amount of solids in twenty-four hours, and that a persistent blood
pressure of 200 or more is present, the prognosis is bad. If general
edema has already set in, in almost every case death ensues
within a few months at the latest. When the blood pressure in
such cases is within normal limits, even if general edema has
already appeared, the prognosis, although extremely grave, is
not so serious. Under proper treatment, and particularly by
lessening the work of the kidneys, such patients may live for
years. The correctness of the prognosis is dependent to a great
extent upon the accuracy with which the diagnosis was made;
as has been demonstrated, this cannot be formed from an exami-
nation of the urine alone, but all other aids must be employed,
that, properly interpreted, will in most cases assure a fairly certain
diagnosis.

THE TREATMENT OF NEPHRITIS

There is no more severe test of the skill of the physician than
the management of cases of Bright's disease. In no class of
disorders is it more certain that each case must be treated individ-
ually, and therefore no routine method of treatment can safely
be adopted.

It is particularly important in the care of nephritic patients

1 82 BRIGHT'S DISEASE

that all the viscera of the body be well considered in each step of
the treatment, for interdependence of the various body functions
is a most important factor in this group of diseases. Furthermore,
it often becomes absolutely necessary to change the entire line of
treatment in a case that may have progressed favorably up to a
certain point. Continual vigilance is imperative if the best
results are to be attained.

Acute Nephritis. — In the treatment of acute nephritis the gen-
eral or non-medicinal side plays a most essential part. For ex-
ample, the writers believe that one of the most important features
of the treatment is the securing of rest. The patient should in all
cases be ordered to bed, preferably clad in light woollen sleeping
garments, so devised that they may be changed or removed when
necessary without unduly exposing the body. Night-gowns that
open at the side or in front, fastening with tapes instead of but-
tons, have been found very convenient. The sick-room should
be kept at a uniform temperature, and although an abundance of
fresh air must be insured, the patient should be carefully protected
from sudden changes and shielded from drafts that may suddenly
chill the body. It has been found advantageous in most cases to
keep the room-temperature somewhat higher than is required in
most other diseases — from 68° to 72° F., for example.

Not only is mere physical rest demanded, but absolute mental
quiet is also most essential. To insure this, visitors should generally
be excluded, at least in the early and critical stages of the disease,
and only those should be allowed to see the patient who, it is
found, have a good effect on his psychic state. The patient must
especially be freed from business and social worry. These are
matters, it is believed, that are of critical value. When it becomes
necessary to relieve pain, the writers prefer to use, for this purpose,
mechanic rather than medicinal measures, when the former can
be made to suffice; thus cupping or the application of leeches to
the loins often gives relief from the severe backache which is
sometimes a prominent symptom of the disease. When neces-
sary, however, the writers do not hesitate to give morphin in
small doses, or when a mere sedative is demanded, chloral in small
doses, given by the rectum, has been found to be not only harm-
less, but actually beneficial.

TREATMENT OF NEPHRITIS 1 83

The diet is a matter of paramount importance. Since the acute
course is often short, and since, as a rule, the kidneys are aheady
overworked, there should be no hesitation in limiting the amount
of food to be given in early and active cases to the minimum.
In these instances the only food for several days should be milk, ad-
ministered in quantities of from i to 1.5 liters. For this purpose
the writers prefer, as a rule, to give peptonized milk. Although
they do not approve of a strict milk diet in nephritis of any grade
except that just mentioned, still there can be no doubt but that
it should form the basis and most essential portion of the nephritic
diet. The quantity of water that it contains is in some cases
very beneficial; in others, however, this fluid is positively injur-
ious, as it throws too great a strain on the congested and over-
worked organs.

Oatmeal, arrowroot, and barley gruels are acceptable foods,
and they may be given with cream, which, in the acute phases of
nephritis, the writers believe to be beneficial, especially in those
cases in which the amount of food allowed is, and should be, small.

The white meats are not contraindicated, and the writers have
frequently used them; moreover, in certain cases, especially
when food stimulation seems necessary, they do not hesitate to
employ red meat in small amounts or expressed meat-juice,
slightly cooked, and given with some digestive. The writers desire,
however, to warn particularly against the use of the meat-extrac-
tives, such as beef-tea and mutton and chicken broths. The
amount of nourishment contained in these substances is relatively
small, and the extractives that make up the greater part of their
oxidizable elements are often intensely irritating to the kidney.

During convalescence, bread and butter, toast, milk-toast,
green vegetables, spinach, celery, and the like may be given. It
is also necessary, in this stage of the disease, to give more freely
of meat and other nitrogenous foods, but the return to a normal
diet must be made slowly, each advance being well considered
before being undertaken.

One of the most disputed points in the treatment of acute ne-
phritis lies in the quantity of water to be drunk. Many clinicians
advise the use of large amounts of water, even in cases where the
tissues are soaked with edematous fluid and where ascites is pres-

184 BRIGHT'S DISEASE

ent. The water, they contend, dilutes the poisons formed by
the disease, promotes the activity of the skin and bowel, and finally
stimulates diuresis. There can be no question but that, in occa-
sional instances, the free drinking of water is a most useful measure ;
the writers have seen many cases, however, in which it resulted
in increase of edema, gastro-intestinal disturbance, and aggrava-
tion of the renal disease. They prescribe water in excess only
in those cases in which edema is not present and in which the
toxic manifestations dominate the disease picture. In these cases
careful note must always be made of the liquid intake and of the
amount excreted with the urine and feces, and if it is found that
any considerable portion of the water is being retained, or if the
amount of urinary excretion is not immediately increased, it
often becomes necessary to go to the opposite extreme, and allow
only such small quantities of fluid as may be contained in the food
or as may be necessary to obviate actual suffering. When the use
of water seems desirable, the writers often prescribe it in the form
of the no longer fashionable "hot herb tea," which they believe
exerts a demulcent action that is frequently of considerable bene-
fit. Thus they employ an infusion of 2 drams of violet flowers
steeped for about five minutes in a pint of boiling water — this
may be given two or three times daily; besides stimulating dia-
phoresis and diuresis, this infusion sometimes appears to act also
as a soporific. Flaxseed and elder-flower tea, flavored with lico-
rice root, may likewise be used with benefit.

Whether water be given in large or small amounts, it is custo-
mary for the writers to restrict the amount of NaCl ingested^
for they believe that this substance inevitably throws an increased
amount of work on the kidney, and, by concentrating the body-
serum, favors dropsy. Obviously, all renal irritants, such as the
condiments, are contraindicated, although in cases in which
anuria is present, minute doses of tincture of cantharides have
been advocated. The writers have never obtained good results
from the use of such drugs, and they also condemn the indis-
criminate use of most diuretics, with the exception of that just
mentioned, namely, water.

One of the first and most essential steps in the treatment of
acute nephritis consists in establishing free diaphoresis and cathar-

TREATMENT OF NEPHRITIS 1 85

sis. The former is particularly indicated when edema or dropsy
is present. In the writers' opinion, diaphoresis is best stimulated
by the use of the hot pack or the employment of dry heat. When
either of these measures is used, attention must be paid to the
action of the heart, and not infrequently, in cases of anuria, diure-
sis as well as diaphoresis may be satisfactorily established simply
by regulating the circulatory apparatus. Aconite may be em-
ployed with advantage when overactivity of the heart exists, and
sometimes, particularly in the degenerative type of nephritis,
digitalis or one of the preparations of strophanthus may be used.

The results following the use of pilocarpin to stimulate diapho-
resis has not justified its recommendation, except as an extreme
measure.

Catharsis is best promoted by the preliminary use of calomel in
those cases in which internal medication is not contraindicated.
Jalap and elaterium have an excellent eJBfect at times, and the
concentrated solutions of magnesium sulphate, either given by
the mouth or used as an enema, generally prove most satisfactory.

In the presence of coma, elaterium, jaborandi, and pilocarpin
may be necessary, but even here the greatest reliance is to be
placed on the hot pack or on the hot-air treatment, on stimula-
tion of the heart when necessary, and on the maintenance of free
catharsis.

In those cases in which effusions of serum into the pleural and
peritoneal cavities exist, the writers believe the proper treat-
ment to consist of early and, if necessary, frequent aspiration;
the same measure — that is, puncture and occasionally the use of
cannulas — may also be employed in those cases in which excessive
edema of the extremities is present. Particular care must be
exercised to guard against infection. Pulmonary edema may be
treated by cupping or by the use of atropin and cardiac stimulants.

Throughout the entire course of the disease symptomatic treat-
ment is constantly necessary, but, whenever possible, drugs
should be avoided, since they have a tendency, in most cases,
to increase the work of the kidney. Care directed to the action
and conservation of the heart and vascular apparatus is secondary
in importance only to that of the kidney itself; acute dilatation
of the heart must be looked for and guarded against; excessive

1 86 bright's disease

blood pressure must be detected and relieved — which is best
accomplished by the temporary use of the nitrites, nitroglycerin,
or sometimes by chloral; and, on the other hand, sudden or
marked decrease in the blood pressure must be looked for and,
if possible ,^ prevented.

The management of the convalescence of acute nephritis applies
practically to the early treatment of chronic nephritis, since all,
or nearly all, attacks of acute nephritis leave in the kidney cer-
tain inflammatory or degenerative lesions that persist for months
after the acute symptoms of the disease have disappeared, but
which must, nevertheless, be constantly borne in mind by the
discreet clinician.

The Treatment of Chronic Bright's Disease. — The medicinal
treatment of chronic nephritis has been sufficiently considered
under the head of the active treatment of acute types of the
disease, for in the chronic form, as a rule, little or no medication
is required except when symptoms of a subacute nature aaise or
acute exacerbations appear. Such instances are to be managed
precisely as in the acute disease in so far as the use of drugs and
general therapeutic measures are concerned. As a matter of fact,
active manifestations in the chronic course differ but little from
the acute disease except that, as a rule, the prognosis is not so good
and response to treatment is rather less rapid. The sooner thera-
peutic measures are resorted to, the more favorable the prognosis
and the earlier restoration to health, or rather to comparative
bealth, for it must be remembered that in chronic nephritis the
lesions inflicted on the kidney are essentially of a permanent char-
acter, though clinical recovery is, of course, by no means rare.

The most important phase of the management of cases of chronic
Bright's disease, either of the degenerative or interstitial type, is
the prophylactic measures employed, as a result of which acute or
subacute symptoms are obviated and the progress of the dis-
ease becomes checked. A most careful study of the patient, and
particularly of his relationship to his surroundings, is therefore
absolutely essential. Only the most general rules can be laid
down in this regard, for not only does each case differ in itself,
but also in the necessary conditions of life which surround it.
These latter often determine, even more than the actual ana-

TREATMENT OF NEPHRITIS 1 87

tomic lesion, the course of the case, and successful treatment,
therefore, presupposes a thorough study of the individual and
his obligations.

Personal Hygiene. — One of the most serious matters of per-
sonal hygiene is the selection of occupation. In most cases we
find in this regard that necessity lays down rules over which the
physician may not trespass, but in nearly all cases, even the most
unfavorable, ameliorating conditions may be so introduced as to
work great relief to the patient without the ruin of his business
prospects. The hours for work should, if possible, be limited;
this is, in our opinion, more necessary for professional men than
for the laboring and business classes, on account of the demand
for emergency work and great nervous strain coupled with most
professional vocations. Good ventilation of the office or work-
room is important, and the air must be freed in so far as possible
from dust and any irritating gases, for the importance of healthy
pulmonary excretion is universally recognized for all cases of
crippled kidneys. Sunlight is also desirable, and obviously work
by day is more advisable than night occupation. Work in damp,
dark basements or in improperly warmed quarters is very dele-
terious, and these are conditions which we find very often asso-
ciated with the most serious types of the disease as we see it,
particularly in the great cities.

Occupations which are in themselves dangerous for the renal
function must be given up ; such as, for example, in chemical works
or factories where absorption of irritating substances may occur,
the excretion of which excites renal disease. Excitement and
nervous strain are to be eliminated in so far as possible; worry
is in itself one of the most common productive factors of chronic
nephritis, and the patient must be, therefore, relieved in this
respect.

The clothing should not be too heavy, but it should be suffi-
cient for requisite protection of the body. Extremes of heat or
cold imposed by climatic necessities should in all cases be prop-
erly considered in the choice of clothing. As a rule, we have
found that light wools are best for the undergarments, even for
summer wear, and in all climates, even in the tropics, for night
.use. Silk may be also so worn.

1 88 BRIGHT'S DISEASE

The outer clothing should be selected with direct reference
to the climatic conditions. In the temperate climates light
wools of medium grade should be selected according to the season^
and in the tropics linen or cotton is commonly desirable. Over-
coats should always be at hand where sudden changes in the tem-
perature or humidity are to be expected, and the patient must
avoid chilling of the body surface.

The question of baths is a most important one, and is to a large
degree determined by the condition of the circulatory system of
the patient. When no contraindications exist, frequent warm
or even hot baths are desirable, so that the skin may be kept free
and clean with its excretory possibilities at the maximum. Hot
baths should not be taken except immediately before going to bed
or if they be terminated by gradual transition to cold water of a
temperature not over that of the outside air. Except in the case
of stout persons where the cardiac condition is excellent, we do not
advise the Turkish bath, and we consider it a dangerous proce-
dure in a very large number of cases, especially where the heart
is in doubtful condition. The same effects may be safely achieved
by the hot pack, which may be given at regular intervals in
appropriate cases. We do not recommend the cold plunge,
although there may be instances where good reaction follows and
in which the observation of the individual case demonstrates
that it is beneficial. The spray, shower, or needle bath as a
general thing possesses all the stimulating effects of the plunge
without the sudden shock.

Massage is a very beneficial measure, especially for patients of
sedentary habit. Properly administered, it stimulates the periph-
eral circulation, improves the excretory powers of the skin, and
keeps the skeletal muscles in good tone. It is not and cannot
become a satisfactory substitute for actual physical exercise,
though it may be a very convenient makeshift, especially for bed-
ridden cases and when, from the nature or demands of life or occu-
pation, physical exercise is impracticable.

Exercise of one kind or another should be insisted upon in all
except bed cases — the amount and nature of the work must, how-
ever, vary according to the needs of the case. In the determination
of what form is most beneficial one must particularly consider the

TREATMENT OF NEPHRITIS 1 89

usual habits of the patient, the state of his circulatory system,
and, often most important of all, what the patient is willing to
do. We have found, especially in this matter of exercise, that the
inclination of the patient must be largely considered, if the neces-
sary persistent continuation of the exercise is to be obtained.

Walking, when it does not consume too much time, is often
very desirable. One can very readily grade the amount of this
exercise, increasing or diminishing the length and the slope to be
mounted, after the plan devised by Oertel. Golf is a most agree-
able vehicle of exercise for many patients, and here also exact
gradation of the amount is readily arranged. All violent forms
are generally to be avoided, but each case must be considered alone
in this regard and the amount and form of exercise can be best
determined by observation of the effect on the patient, and in
this matter the opinion of the patient as to the conditions under
which he feels best are oftentimes of paramount importance.

Although it is impossible to lay down any hard and fast rules
in regard to the climatic conditions most favorable for chronic neph-
ritic patients, certain general requirements may be quite defi-
nitely stated. Climates in which neither extreme of heat or cold
occurs, or in which the temperature changes take place gradually,
are always to be preferred. Nephritic patients, as a rule, do not
do well in the tropics; neither does the cold climate of such
localities as the Canadian Northwest nor the more northern por-
tions of the United States seem well adapted to most cases, though
some live in these places with comfort and without harm.

When the social and financial condition of the patient permits,
it is well to spend the winters in the mild climates, as in Florida
or Bermuda, and the summers in the north.

On the whole, the drier climates seem best adapted to the needs
of chronic cases, and a climate such as that of Arizona, Idaho, or
Montana seems favorable in most instances, though as, before
mentioned, some cases do very well in Bermuda or Florida. The
South Sea Islands have also been highly recommended.

Altitude in itself seems of little importance except in those cases
where cardiac and vascular lesions are matters of active concern.
In these instances the general rules for cases of myocarditis or
arteriosclerosis should apply.

I90 bright's disease

Food. — The question of proper food for cases of chronic Bright's
is a matter at once of the greatest importance and of the great-
est difficulty. The time has long passed when all cases of
Bright's disease are advised a strictly milk diet, though we can-
not deny but that some cases do best under this regime. In
the treatment of chronic nephritis more than in anything else
we should study the individual and his reaction under various
food combinations. In this regard, though we realize that the
amount of albumin in the urine is no measure of the gravity of a
case, it is well to watch closely the albuminuria, and when it in-
creases with certain articles of diet, or when blood or casts appear
or increase, these articles should be promptly eliminated.

It is a safe general rule to follow that the amount of nitroge-
nous food taken in should be governed by the facility with which
combustion takes place in the body. In this respect we shall find
great variation, and though in general the nitrogenous foods
should be kept low, yet the amount must be sufficient for the best
physical welfare of the patient. This is, of course, manifestly con-
trolled in part by the nature, occupation, and habits of life of the
patient. The diet necessary for a laboring man should, of course,
be more rich in nitrogen than that of an office worker, though it
will be found that certain men of sedentary habit also do best
on a diet relatively rich in nitrogen. It is foolish to restrict a
patient for the most part to carbohydrates when it is shown objec-
tively that these foods do not furnish the requisite amount of
energy for that person, or when they set up gastric or intestinal
fermentation, which in itself does far more harm to the kidneys
than a reasonable normal diet could. Briefly, then, we must
base our diet, not on theory or generalities, but entirely on the
effect in the individual case.

Condiments, such as pepper, and the highly spiced sauces must,
of course, be excluded. Alcohol is never to be taken except in
small amounts or when the drug is needed for its therapeutic
effect. Some cases, however, when habituated to alcohol lose
ground when entirely deprived of it, and, properly administered,
it may be but slightly or not at all irritating to the kidneys.

The amount of water demanded depends largely on the rate
of excretion in the urine, on diaphoresis, and on the effects on

TREATMENT OF NEPHRITIS I9I

the vascular organs. As a rule, it should be less rather than too
large, particularly in interstitial cases. Salt is always to be cur-
tailed, especially for those who normally desire large amounts of
this chemical or where edema is present. In cases associated
with gout and rheumatism it will, however, be found necessary to
be more liberal in the use of water, and in practically all cases
the occasional copious use of water, as suggested by von Noorden,
is beneficial.

Decortication of the kidney is discussed under the Surgery of
the Kidney. We do not advise it.

Cases of chronic Bright's disease should always be kept under
frequent observation. Timely symptomatic use of drugs, of the
diuretics, diaphoretics, saline cathartics, and a carefully regulated
life, usually so benefit that the disease is no longer thought in-
consistent with a long and relatively active life.

CHAPTER X

UREMIA

Inasmuch as uremia occasionally occurs independent of clini-
cally recognizable Bright's disease, it has seemed well to the
writers to discuss it as though it were a disease entity.

Because of the obscurity of the pathologic conditions under-
lying uremia it is deemed advisable first to consider the disease
from its clinical aspects.

For our purposes Osier's classification of the disease by its
symptoms will be adopted with a few modifications, and it will
be discussed under the headings of cerebral, dyspneic, gastro-
intestinal, and renal types.

The most striking symptoms of uremia are those of cerebral
origin. Of these, a more or less active mania is most commonly
seen ; this may manifest itself in talkativeness, which is generally
illogical and rambling, in marked physical and mental restlessness,
with insomnia, and sometimes by active emotional delirium,
persistent hallucinations, or perhaps melancholic delusions. All
these abnormal manifestations closely resemble those seen in
many cases of acute alcoholism.

Convulsive seizures are common, and not infrequently resemble
those characterizing mild attacks of Jacksonian epilepsy; there
may be sudden loss and as sudden recovery of vision, or con-
vulsive attacks of projectile vomiting may occur.

Coma is one of the most familiar of the cerebral evidences of
uremia. It may amount simply to sleepiness or torpor of longer
or shorter duration. Great difficulty will be experienced in
distinguishing this particular type of the disease from alcoholism,
but in this regard it must always be borne in mind that true ure-
mia frequently appears as a terminal complication of alcoholism.

Local palsies are very common in uremia, and many cases are
seen presenting first symptoms quite typical of hemiplegia or
of paralysis of individual muscles or groups of muscles. Ordi-

192

UREMIA 193

narily, such cases are easily distinguished from those of actual
paralysis by the incoherence of the symptoms and by their evanes-
cent character, as well as by the presence of manifestations
of renal insufficiency — points of paramount value in the dififer-
ential diagnosis of all types of uremia. Cases diagnosed as
cerebral hemorrhage or embolism are often found on postmortem
examination to have been purely uremic.

The patients presenting respiratory symptoms show in the
milder cases paroxysmal or alternating dyspnea and in the more
severe cases the breathing takes on the character of the Cheyne-
Stokes respiration.

The most common gastrointestinal symptom is nausea, which
is often very persistent, and is sometimes accompanied by pro-
pulsive vomiting, as in cerebral tumor. Diarrhea is also a frequent
symptom, but probably occurs only as an effort at compensatory
excretion on the part of the bowel. For the same reason, pro-
fuse sweating is often a marked symptom, and occasionally the
perspiration is loaded with urea and other excrementitious
products.

The kidney manifestations usually present in uremia may be
summarized as those of decreased renal activity, generally shown
by a relative decrease in the amount of solids, and particularly
in the amount of urea, excreted. Often the symptoms of active
renal disease accompany these indications of renal inactivity,
and albumin, casts, blood, and desquamated epithelium appear
in the urine. Acute suppression is quite frequent.

Although it is generally admitted that uremia is a condition
dependent on disease or inactivity of the kidney, the pathologic
conditions that produce this inactivity are obscure. Uremia oc-
curs not so very rarely when the quantity of urine excreted is nor-
mal, and when the urea and other solids are still apparently in
normal relation. We are therefore forced to the conclusion that
in these instances the condition may exist without evident renal
disease. In this regard it should be borne in mind that the state
of the urine is by no means always a positive determinative test
of the actual condition of the kidneys. Nevertheless, it is gener-
ally conceded that uremia is due in all cases to the presence of
renal lesions, and it remains for us to determine the manner in
13

194 UREMIA

which renal insufficiency may declare itself. Uremia is generally
regarded as the result of some form of poisoning, dependent on
deficient excretion, by the kidneys, of toxins formed in the course
of tissue metabolism.

The earliest belief was that the condition was caused by the
presence, in the blood, of an abnormally large amount of urea,
which should have been excreted from the body by the action of
the kidneys. As a matter of fact,- the blood in uremia usually
does contain an abnormally high percentage of urea ; exceptional
cases are met, however, in which the amount of urea present in
the blood has not increased when uremic symptoms manifested
themselves. Cases also occur in which there is an excessive
amount of urea in the blood without the development of uremia,
so that although urea is usually present in large amounts in the
blood and tissues of uremic subjects, this is not invariably the
rule, and the disease may arise without any abnormal increase.

Experimental evidence has proved that the introduction of
urea into the circulation is not productive of uremic symptoms;
if, however, this is complicated by injuries to the renal tissues,
some experimenters have asserted that symptoms resembling
those of uremia are produced. This statement has not received
sufficient corroboration to justify absolute acceptance. Urea
is used in the treatment of disease, especially as a diuretic, and
it is quite certain, from abundant experience, that the condition
is not due simply to the presence of urea in the blood.

The next and most natural supposition is that the poison of
uremia (for the condition is clinically a toxemia) is due to the
formation, in the blood, of bodies allied to, or derived from, urea.
Frerichs promulgated the theory that it was due to the presence
of ammonium carbonate, which was formed in the blood as the
result of fermentation, which had resulted in disintegration of
the urea molecule. This seemed for a time to adequately explain
the symptomatology, but later investigations showed that ammo-
nium carbonate, when introduced into the blood, does not pro-
duce the symptoms of uremia, even when, in addition, the kidney
tissue is subjected to traumatism and normal excretion is prevented.

The next supposition advanced was that the symptoms were
caused chiefly by other, perhaps unrecognizable, excrementitious

UREMIA 195

products in the blood. Investigations have also failed to demon-
strate this satisfactorily, for, as has previously been stated, the
symptoms occasionally arise in those cases in which the urine
and blood themselves are normal. It must be remembered, in
this connection, that information regarding the exact nature of
all these bodies is still wanting, and our knowledge of the chemis-
try of the blood and urine is not sufficiently complete to warrant
us in discrediting the foregoing statement. The fact that we
have as yet been unable to demonstrate its truth by no means
disproves its possibility.

Osier holds that interference with the renal functions leads to
a disturbance of the regular chemic changes in all parts of the
body; such a change is followed by alteration in the nutrition of
the tissue, showing itself in a loss of weight, in anemia, and in
cerebral disturbances. This theory is so indefinite and broad as
to be of no aid to us in explaining the cause or the course of the
disease, nor is it substantiated by clinical or by experimental
evidence.

Traube has presented a theory that the symptoms are really

due to morphologic lesions and not to chemic toxemia. He

*

asserts that interference with the renal functions, which all admit
is at the origin or root of the disease, leads to a thinning of the
blood-serum, to hypertrophy of the left ventricle of the heart,
and to excess of arterial pressure. Now, if by any accident or
circumstance the pressure is increased still more and the serum
still further thinned, anemia and edema of the brain follow, caus-
ing various uremic manifestations, according as certain portions
of the central nervous organs become affected. This theory is
founded on the assertion that the blood pressure is always in-
ceased in uremia, — a statement that is not invariably true, —
and that the specific gravity of the blood-serum is always dimin-
ished— a statement that is likewise not invariably, although
it is generally, true. Further, it is stated that anemia and edema
of the brain are not always present. Personally, the writers are
inclined to accept, to a certain extent, this theory, in so far as
the symptomatology is concerned, for in their own cases they
have found that a localized edema and anemia of the brain is
generally present ; and they know that in other similar conditions.

196 UREMIA

symptoms resembling those of uremia are induced by cerebral
edema.

Stengel advances the theory that the degenerated cells of the
kidney may in themselves liberate a poison that acts on the
brain-cells in the manner indicated by the symptoms of the disease ;
this is the theory of the formation of the nephrotoxins. There is
no absolute data on which this theory is based — it is purely specu-
lative.

In certain types of uremia we are unable to demonstrate at
postmortem any lesions in the kidney to account for the symp-
toms; for example, in the marked toxic uremia that takes place
during pregnancy and puerperal eclampsia no changes may be
found (Delafield). Of course, it is possible that our methods are not
sufficiently accurate to enable us to detect all important changes
that may, nevertheless, be present, but, notwithstanding this,
it must be admitted that certain classes of cases arise in which
the explanation founded on the basis of pure kidney lesions is
inadequate. In this relation it is well to consider the possibility
of the toxin being other than of renal origin. Its absence in purely
traumatic or quantitative kidney lesions is of much significance,
and it seems opportune here to review briefly some of the experi-
mental work on uremia in which ablation of kidney tissue has been
performed.

It has been found that when both kidneys are removed or totally
destroyed by disease life lasts seven to fourteen days. The chief
symptoms observed in these cases, aside, of course, from complete
anuria, are contraction of the pupils, muscular weakness, and sub-
normal temperature; severe vomiting is occasionally observed.
There is no loss of consciousness, and the convulsions so charac-
teristic of uremia are not present. Hence we find that uremia
is not typified by the same symptoms that follow complete absence
of renal tissue.

Again the question arises as to the possibility of uremia develop-
ing when a portion of the kidney substance is removed — an
experimental condition that much more closely approximates
those found in most diseased states. According to Bradford,
the only effect noted if part of one kidney is removed is an increase
in the amount of water secreted; no general symptoms appear.

UREMIA 197

If, in addition to the first operation, the other kidney is afterward
entirely removed, there is a persistent and great increase in the
amount of water secreted, but no other symptoms arise if one-
third of the normal kidney weight remains. Removal of three-
fourths of the kidney weight proves fatal, and the subject dies,
greatly emaciated, diarrhea and subnormal temperature being
occasionally observed as symptoms; there is a great accumula-
tion of urea in the blood and in the body tissues, and this probably
accounts for the polyuria. Coma, convulsions, and all other
symptoms typical of uremia are entirely wanting. Thus it may
be seen that uremia is apparently not due to a decrease in the
volume of functionating kidney tissue; neither is it due to the
presence of urea and allied bodies in the blood and tissue of the
body, even when this surplus urea is formed by the body-cells
in the normal manner and is not introduced artificially.

Lesions of the Kidneys Present in Uremia. — Uremia frequently
occurs as the immediate cause of death in scarlatinal nephritis,
in pneumonia, and in similar acute infectious diseases: it is
also seen as a sequel to alcoholism. In both infectious diseases
and in acute alcoholism it is associated with the lesions of acute
diffuse nephritis, which, arising from any cause whatever, are
very commonly followed by uremia. Uremia may further be
looked upon as the ordinary terminal condition in chronic intersti-
tial nephritis, especially in that variety in which the small sclerotic
kidney is found ; thus it may be seen in cases of chronic alcoholism,
in lead poisoning, and in gout. It also occurs, although somewhat
less frequently, in those cases in which a chronic interstitial
hyperplasia has taken place, as in chronic diffuse nephritis of the
interstitial type. It arises in all the degenerative, particularly
in all the chronic degenerative, processes, as in long-standing
amyloid degeneration, and especially in those long-standing cases
in which an acute complication or exacerbation intervenes.

On the other hand, as would commonly be inferred from the
experiments cited, uremia should not occur in such lesions as
pyonephrosis, renal calculus, hydronephrosis, nor in those changes
that are characterized by more or less simple destruction of renal
tissue.

The experiments of Bouchard and of others have shown that

198 UREMIA

normal urine, when experimentally introduced into animals,
possesses a more or less constant and definite degree of toxicity.
Other investigations, founded on those just mentioned, have also
shown that this degree of toxicity varies in different diseases in a
degree almost constant, being increased in certain conditions, as
in various infectious processes, and decreased in others, notably in
uremia. These observations apparently indicate that in uremia
certain toxins are either not formed at all or, if formed, are not
ehminated, but retained in the tissues of the body. This may be
construed to mean that in uremia these toxic bodies may be
responsible for the typical toxic symptoms. Ablation experiments
seem to show that these specific toxins are not formed nor retained
when morphologic destruction of the renal substance is effected,
and the renal lesions apparently show that they are present when
the pathologic lesions of the renal substance are of a degenerative
or hyperplastic character — as, for example, in renal tumors.

Assuming, though admittedly on insufficient evidence, that
uremia is solely due to some diseased condition or defective action
on the part of the kidneys, the lesions present in the other organs
must also be considered.

The principal symptoms of uremia are those affecting the
nervous system, chiefly those consequent upon disorders of the
cerebrum. The most marked and constant lesions seen in the
brain consist in the formation of a considerable serous exudate,
particularly in the subarachnoid space, and especially over the
vertex, although the exudation may be general over the entire
surface of the brain. Occasionally the exudate is localized to
some particular area of the membranes, thus accounting, perhaps,
for the localizing symptoms, almost Jacksonian in type, presented
by certain cases. This exudate is often sufficient to cause an
appreciable compression of the cortex. The vessels of the pia
are at times congested in one area and perhaps very anemic
and contracted in another.

The lesions of the brain tissue resemble those of the membranes
very closely in their general nature. Thus edema is usually
present in greater or less degree; often it is very extreme, and
large quantities of serum, usually very clear and limpid, drip
from the cut surface. The edema may be localized and this is

UREMIA 199

more common in the cortical than in the lower areas, thus bearing
out the clinical manifestations that the more pronounced cerebral
symptoms are those of cortical derangement. The blood-vessels
are often markedly congested, but they may vary greatly in this
particular, even in the same brain. Microscopically maceration
of the tissue immediately beneath the edematous membrane is
generally observed, and this is also sometimes well shown about
the perivascular lymph-spaces of the cerebral tissue. Arterio-
sclerosis is frequently seen, perhaps, because when present also
in the kidney it predisposes to the development of uremia.

If the case has been of long standing, or if the subject has had
previous attacks, thickening and hyperplasia of the connective
tissue of the pia, marking the site of old exudations, are found.
This is the cause, at least in some cases, of the areas of opalescence
which are found so often along the track of the chief meningeal
vessels in old nephritic cases. In the brain tissue proper this
process is represented by areas of gliomatosis, generally of very
slight extent. From a consideration of these lesions it can readily
be understood why uremia is so commonly mistaken for cerebral
hemorrhage, brain softening, embolism, and other similar grave
and permanent lesions. Changes have also been found in the
ganglion-cells; these may amount, in severe or prolonged cases,
to actual cell-destruction, but, as a rule, they do not extend beyond
degeneration, more or less pronounced, of the chromophyllic
plaques of the ganglion-cells.

The alterations that occur in the other viscera are neither con-
stant nor characteristic. As a rule, hypertrophy of the heart,
particularly of the left ventricle, is present; the blood-vessels are
thickened, at times dilated and at others much contracted.

The edema, which is quite generally present in the disease, is
usually due to the primary renal disease, although acute idio-
pathic edema often develops in uremia and acts as the immediate
cause of death. It is highly probable, however, that in this
condition lesions of the central nervous system are largely
responsible.

As a general rule, the cause of death in uremia is due to cardiac
failure or acute pulmonary edema. In the former the lesion of
the heart muscle may be looked upon as due, at least in part, to

200 UREMIA

the action of the toxins; or, on the other hand, a myocarditis
may arise following primary renal disease.

In summarizing, uremia may be defined as — a series of mani-
festations, chiefly nervous, developing in the course of Bright's
disease, and probably due to the retention or presence, in the
blood, of certain poisonous materials that most likely result from
the abnormal action of degenerated renal cells. This is in sub-
stance the definition proposed by Osier.

Diagnosis. — In well-developed, typical cases of uremia, when a
complete history of the case in question is available, the diagnosis
is easy. In its milder manifestations, when the symptoms are
but slightly developed, the diagnosis is difficult and often impos-
sible. A history of headache, edema, and particularly of a dimi-
nution, especially very recent, in the amount of urine excreted,
is of the greatest importance. When the disease is fully devel-
oped, such symptoms as vomiting, stertorous breathing, coma or
somnolence, less frequently maniacal symptoms, associated with
increased blood pressure, hypertrophy of the heart, particularly
of the left ventricle, and, perhaps most important of all, diminu-
tion in the amount of urine excreted, together with the appearance
in it of albumin, casts, renal epithelium, and probably blood,
leave little doubt as to the diagnosis. Nevertheless, circum-
stances may arise, even in the most typical case, that will greatly
complicate and confuse the diagnosis.

Perhaps one of the most characteristic manifestations of uremia,
and one which permits its differentiation, in the majority of cases,
from diseases manifesting similar symptoms, is the variability of
its clinical aspects. The pulse, which in the ordinary case is hard,
full, and bounding, may within a few hours become soft and feeble,
to be followed again, perhaps, by a return of the high pressure.
The occurrence and disappearance of edema, when present, is an
important differential sign.

There is no one feature of the disease that is of greater value,
and at the same time occasionally more misleading, than the con-
dition of the urine. In typical cases the amount of urine, and the
percentage of urea in particular, is considerably diminished; on
the other hand, some cases, especially those occurring in chronic
nephritis, are particularly likely to be associated with polyuria.

UREMIA 20I

Still more rarely the urine may be normal in amount, in chemic
content, and casts and epithelium may be entirely absent. Re-
peated examinations will usually, however, eventually corrobo-
rate the existence of nephritis. The differentiation is partic-
ularly difficult when albuminuria or a true nephritis occurs at
the onset of an acute infectious disease, the picture of which may
closely simulate uremia. As a rule, the temperature-curve in
any of the acute infections is more or less characteristic, and the
presence of a leukocytosis aids materially in the differential diag-
nosis. In typhoid, hypoleukocytosis, mononuclear increase, and
the presence of the Widal reaction make differentiation certain.
Miliary tuberculosis, particularly where early involvement of the
cerebral meninges takes place, is often distinguished with much
difficulty, and frequently a differentiation is impossible until
definite tubercular lesions can be demonstrated, as in the retina,
or until pleurisy or peritonitis develops. The differentiation
from septicemia associated with albuminuria may be possible
only when metastatic suppuration can be demonstrated.

Uremia is differentiated with particular difficulty from true
focal lesions of the brain, as in embolism, hemorrhage, or men-
ingitis. The character of the pulse is identical in many conditions,
and when, as is so often the case, nephritis preexisted, differen-
tiation may be impossible. This is particularly true in cerebral
hemorrhage. In nearly all these conditions a positive diagnosis
can be reached only when, as almost always happens in uremia,
the picture of the paralysis suddenly changes. There is almost
invariably a certain incoherence of symptoms when the case is
under careful observation, but when seen for the first time, an
absolute diagnosis is impossible. In this relation it is well to
remember that cerebral embolism and cerebral hemorrhage some-
times occur in uremia, a fact amply demonstrated in a series of
postmortems performed by the writers. The ophthalmic exami-
nation is often of great differential value, since the presence of
albuminuric retinitis, in the absence of definite urinary manifes-
tations, may decide the point in question.

The condition is very commonly confused, particularly in hos-
pital and city practice, with various forms of poisoning. This is
perhaps most true of alcoholism. Here the history of the case is

202 UREMIA

of the greatest importance. The examination of the urine and
the presence or absence of alcohoUc tremor may also often make
differentiation possible. As a rule, besides, the delirium of
alcoholism is of a more active type than is that of uremia. In
this regard, however, it must be remembered that uremia occurs
as a common terminal condition in alcoholism, as has been dem-
onstrated to the writers by a close study of the material derived
from the alcoholic wards of Bellevue Hospital. Opium-poisoning
is distinguished with even greater difficulty than alcoholism, when
the urine does not present characteristic findings. Ptomain-
poisoning and other similar conditions are often confused with
uremia, and their distinction may demand a most careful study
of the entire course of the disease before a positive diagnosis can
be arrived at.

Prognosis. — The prognosis in uremia is dependent on the degree
of disease that exists, on the length of time it has been present,
on the promptness with which treatment is begun, and on the
reaction of the patient to this treatment. It also depends largely
on the condition of the general organs of the body, and on the
readiness with which the underlying condition responds to treat-
ment. In general, the writers believe that the prognosis is more
favorable than is commonly supposed. The mild manifestations,
such as headache, decrease in the amount of urine voided, symp-
toms of early cortical irritation, edema, and the like can usually
be relieved; and when subsequent treatment, associated with a
careful control of the diet, exercise, and general habits of Ufe, is
possible, the prognosis is good. In those cases in which the
response to medication is not prompt, the prognosis is generally
bad. In any case recurrence, particularly when extra strain is
imposed upon the kidneys, may take place; and, although a
uremic patient may be restored to comparative health, subsequent
attacks are likely to develop at almost any time, the second or
third generally terminating fatally.

Treatment. — The cardinal feature in the treatment of uremia
should be the stimulation of secondary excretion. The bowels
should be freely opened, and oftentimes the most drastic agents
are necessary for this purpose. Elaterium, in doses of one-sixth
of a grain, is highly recommended; croton oil, in doses of from

UREMIA 203

one to three minims, repeated until the stools become watery,
is also useful. The action of the skin is to be stimulated by the
use of hot packs and the administration of pilocarpin, preferably
intramuscularly or hypodermatically, in doses of about one-eighth
of a grain; when edema lessens the absorptive powers of the skin,
it should be given by the mouth. When the condition of the
heart is unfavorable, pilocarpin is to be used with care. When
the pulse is hard and bounding, one of the most eflficient measures,
in the writers' experience, is the removal of a quantity of blood
and th'e substitution of saline solution. When necessary, strych-
nin and digitalin should be employed to support the heart action,
and vasodilators should be used freely when the blood-pressure is
high. Of the latter, nitroglycerin, in frequent and large doses,
is to be recommended for its immediate action, but more per-
manent benefit has been secured from the use of chloral, as
recommended by Peabody, Thompson, and others, the drug being
given preferably by the rectum in doses of from 30 to 45 grains.
Chloral, in our experience, is one of our most reliable vasodilators.

If convulsions are present, they are to be relieved by chloral
and bromids, given preferably by the rectum and in large doses.
Urethane has been highly recommended by Peabody for this
purpose, but the writers are not sufficiently familiar with it to
attest its value. It may be necessary in some cases to employ
chloroform for the relief of convulsions, but, except where imme-
diate relief was demanded, chloral has proved much more satis-
factory in the writers' hands. When the condition of the patient
permits, water may be given in large quantities, or saline enemata
or transfusions may be used when the patient is unconscious.

The after-treatment is that of chronic Bright's disease, atten-
tion being paid particularly to the diet and to the habits of life,
as detailed under the proper heading. It should constantly be
borne in mind that in the treatment of uremia promptness is of
the greatest importance, and when one measure fails to act, others
should be employed in its stead.

CHAPTER XI

TUBERCULOSIS OF THE KIDNEY.— THE KIDNEY IN

SYPHILIS

TUBERCULOSIS OF THE KIDNEY

There is probably no other diseased condition of the urinary
tract concerning which our knowledge is in a more confused state,
particularly as regards prognosis, than it is in respect to tubercu-
losis of the kidney.

Pathology. — Renal tuberculosis occurs as a not infrequent
condition or complication in cases of miliary or generalized tuber-
culosis. Horst Oertel, pathologist to the City Hospital, reports
that, of the seven cases showing renal tuberculosis which came to
autopsy at the City Hospital in the year 1904, five complicated
the pulmonary disease. In four of the seven cases both organs
were involved. Our personal statistics vary somewhat from these
in significance, since most of our cases except those of a clearly
terminal character have originated independent of detectable
pulmonary lesions, but were associated with tubercular lymph-
adenitis or with a primary tuberculosis of the lower urinary tract.
Differing from the ordinary general condition, tuberculosis of
the kidney as seen in the primary disease of the genito-urinary
tract is often found to be monolateral, and clinical observation
has convinced us that it may, when properly supervised, remain
so for long periods, provided that secondary infection of the
bladder or urethra does not take place. A sharp distinction must
therefore be made between those cases in which renal tuberculosis
arises as a terminal complication in a practically hopeless case of
tuberculosis, and where it originates in, and remains chiefly limited
to, the urinary organs. Joseph Walsh ' found renal tuberculosis
present in 43 per cent, of loi consecutive cases of fatal pul-
monary tuberculosis. In practically all these cases, however, in

' Third Annual Report, Phipps Institute.
204

TUBERCULOSIS OF THE KIDNEY 205

SO far as we can gather from the report, the kidney lesions were
purely terminal in nature. We believe it a matter of great impor-
tance that surgeons and pathologists in reporting cases of renal
tuberculosis realize this point, and that in their reports they lav
particular stress on the extent or limitation of the disease. It is
quite possible that accurate data so compiled may lead to profit-
able modifications in prognosis and treatment.

Infection takes place in two distinct ways, comparable to those
routes already discussed in regard to septic nephritis, which,
in many anatomic characteristics, closely resembles tubercular
disease :

Injection by ascending inoculation from tubercular lesions of
the lower urinary tract, as from the urethra, prostate, bladder, or
seminal vesicles, in any of which foci the disease may have origi-
nated, or from tuberculosis of the epididymis or testicle. The
anatomic pictures differ markedly in the two classes of cases. In
ascending infection, tubercular lesions can be usually found in the
lower tract and a distinct pyelitis or tubercular pyonephrosis is
demonstrable anatomically, and usually clinically as well.

Embolic or Descending Infection. — In embolic infection, unless,
as we have indicated, it take place in a wide-spread general
infection, the foci are more apt to be solitary, discrete, localized,
and may give rise clinically only to the symptoms of renal granu-
loma, varying in degree with the extent and size of the diseased
areas. In this type of infection the tubercles, if multiple, are
mostly found in the cortex of the organ, in the distribution of
the terminal interlobular arterioles, or in the columns of Bertini,
while primary pelvic invasion is the characteristic of the ascending
variety. In the former class the course of the disease and the
lesions as well are very like those seen in embolic septic processes,
and, as a rule, they pursue a relatively innocent course and, as will
be pointed out later, are not commonly diagnosed unless the
necrosis of the tissue becomes sufficiently extensive to cause
drainage into the pelvis or marked febrile symptoms. We except,
of course, in this discussion those cases of terminal infection which
should not be considered as under the head of renal tuberculosis.

Course. — As might be concluded from the pathologic anatomy,
many cases, particularly those of embolic type, pass along with

2o6 TUBERCULOSIS AND SYPHILIS OF THE KIDNEY

few disturbances which attract the attention either of the patient
or physician. The symptoms in these mild cases are those of minor
and indefinite renal disturbance, accompanied in some instances
by fever, which is dependent largely on the size of the foci or on
the presence of mixed infection. Small quantities of blood and
occasionally leukocytes appear in the urine, which also commonly
contains albumin. In case drainage into the pelvis takes place,
pus in greater or less quantity will appear in the urine and pus-
casts are also apt to be found. When independent of general
disease or other tubercular lesions, this class of cases gives little
trouble as long as the general health is kept in good condition, and
pathologists are perfectly familiar with frequent healed tubercu-
lar lesions in one or both kidneys without any evidence of renal
disease being suggested by the clinical history of the case. This
statement has been called in question, but our autopsy experience
has led us to feel that it is well founded.

When the infection is of the ascending type and a tubercular
pyelitis exists, the course of the disease is not to be distinguished
clinically from that of an ordinary pyonephrosis, except as we
may be able to demonstrate general tubercular lesions, foci of
infection in the lower urinary tract, or when examination of the
urine discloses the true nature of the infectious process. When
drainage of the pus is free, as a rule, the temperature does not run
high, the pulse is not accelerated, and but little indication of sep-
tic poisoning may be shown, and long periods may elapse during
which no pus or tubercle bacilli appear in the urine. Many of
these patients continue at their occupation without marked dis-
comfort except when the ureters become more or less plugged by
the necrosed tissue and pus-retention occurs. These cases may
even continue on for a very long time with tubercle bacilli con-
stantly present in the urine without causing reinfection of the
bladder, provided always that care be taken to prevent overdis-
tention or other secondary disease of this organ. The case- books
of some of the older practitioners who have had the opportunity of
observing kidney tuberculosis extending over a period of years
are very interesting. The writers are indebted to the late
Dr. George Chismore, of San Francisco, for the records of some
cases of this description. Several of his patients have been able

TUBERCULOSIS OF THE KIDNEY 207

to follow long and active business lives with relatively slight
inconvenience.

Diagnosis. — As we have already intimated, diagnosis in cases
of embolic infection can be made only with a certain degree of
probability when, in instances of possible tubercular infection,
renal disturbances, hematuria, albuminuria, and renal distress
without the symptoms of nephritis appear. Where drainage
of necrotic material or pus into the urine takes place, diagno-
sis rests on the detection of the tubercle bacillus in the urine.
Renal tumor and tenderness are points of importance in some
cases where other growths of the kidney may be reasonably
excluded and where no other lesions accounting for the fever
exist. In several such instances the writers have employed
the tuberculin test with gratifying success, but it is very unreliable
in those cases where septic conditions exist, and may confuse a
possible reaction. We have thus far found the Calraette con-
junctival and the dermal vaccination reactions unsatisfactory
for diagnostic purposes. The leukocyte count may be of con-
siderable differential value in some cases where mixed infection
is not pronounced. Thus, in the purely tubercular disease no, or
but a slight, increase in the total leukocytes is present and the
differential count shows a relative increase in mononuclear ele-
ments, whereas in ordinary infections the polynuclear leukocytes
are relatively increased.

The presence of tubercular lesions in other parts of the body
is often strongly presumptive evidence of the nature of the renal
process, but one must not allow himself to be overpersuaded
in this direction, for we have frequently found that in such in-
stances the renal lesions were nevertheless non-tubercular.

Where drainage of pus or recurrent or continuous hematuria
is present, together with renal tenderness and turnor, the final
test in diagnosis is the examination of the urine, which is of
crucial importance in all types of the disease. Hematuria is
notably less frequent and less profuse in the embolic than in the
cases of ascending infection.

In ascending infection we usually are able to secure a history of
gonorrheal or other types of inflammatory disease of the lower
urinary tract, and careful inspection may discover possible

2o8 TUBERCULOSIS AND SYPHILIS OF THE KIDNEY

primary lesions in the testicle, epididymis, urethra, prostate, or
bladder. In this class of cases the lesions are quite apt to be
monolateral. In addition to these, we have the symptoms and
signs of a pyonephrosis.

The recognition of the tubercle bacillus in the urine is by no
means so simple a matter as may appear on the face of it, for other
acid-fast organisms, morphologically similar to the tubercle bacil-
lus, are not uncommonly found in the urine, especially in cases of
pyonephrosis, and in our opinion the most careful microscopic
examination in which the identification of the bacillus depends en-
tirely on its tinctorial reactions is inconclusive unless backed by a
typical clinical picture and by a definite morphologic identity.
In every case of doubt — and most cases, in our experience, unless
in the late stages, are of this nature — absolute identification can
only be accomplished by inoculation of the questionable pus into
the peritoneal cavity of a guinea-pig or other susceptible animal.
A serious drawback to this procedure is that where mixed infec-
tions exist, as is commonly the case, the experimental animal
will be killed by the secondary infecting organisms before the
tuberculosis has sufficient time in which to develop. It is our
practice to inoculate several animals with graded doses, and in
case all survive two weeks, to kill the first after four weeks, a
second after five weeks, and so on until full six weeks to two
months has been allowed. The crucial test is the finding of
tubercular lesions in the Uver, spleen, and peritoneum of the
experimental animal. Of course, there are many cases in which
this procedure is unnecessary, but it is the only means to absolute
diagnosis in many cases while they are still in a curable condition.

Evidence furnished by ureteral catheterization is often of great
value, but the irritation from the insertion of the catheter may
cause the first urine passed to be cloudy with leukocytes and
blood, and may so mislead; furthermore, any mechanical irrita-
tion in these cases tends to inoculate new foci. Cystoscopic
examination may show tubercular lesions in the bladder, the
nature of which may be at once apparent.

Before making a cystoscopic examination in suspected cases of
tuberculosis of the kidney, it is the custom of a German investiga-
tor to observe the case for several weeks; to wash the bladder

TUBERCULOSIS OF THE KIDNEY 209

with a silver nitrate solution, i : 10,000, three times; to examine
the urine microscopically four or five times for the tubercle bacillus ;
and also to inject into two guinea-pigs the centrifugated sediment
of the twenty-four hours' urine.

A conclusive diagnosis of tuberculosis of the kidney should
never be made hastily.

Prognosis. — It would seem as though an earnest student with a
fairly large clinical experience should be able to give a more defi-
nite prognosis in cases of renal tuberculosis than that expressed
in the words of a well-known physician, "You can never tell";
but the more we see of the condition, the more conservative do
we become in prognosis. Much depends on not only the willing-
ness of the patient to submit to proper methods of treatment,
regulation of the habits of life, but also on his ability to do so.
The condition of allied viscera must be considered ; where serious
general infection is present, the prognosis is obviously unfavora-
ble, while where the general health is good and the lesion not
advancing rapidly, it is more favorable, or perhaps entirely good.
Every physician can call to mind cases of renal tuberculosis in
which reasonable care has permitted the patient to live until he
dies of some independent disease, and the number of cases which
appear on the autopsy table in which completely healed tuber-
culosis of the kidney is seen attests amply to the fact that, at
least in some cases, our prognosis should be favorable rather than
otherwise. We wish to particularly call attention to this fact,
since of late certain French surgeons have stated that healed
tuberculosis of the kidney is never seen at autopsy.

Treatment. — We have in the past neglected too much the les-
sons which have been taught us in regard to the management of
general tuberculosis when we come to apply them to cases of the
renal disease. Outdoor life, bracing but equable climates, and
good hygienic conditions are just as efficient in the treatment of
renal as pulmonary tuberculosis, and there are no conditions
advocated for the pulmonary disease in the hygienic or dietetic
direction which may not with equal propriety be utilized in renal
tuberculosis. Baths, well-regulated exercise, attention to the
digestive functions, and even mental happiness are important
factors in the management of these cases. We do not, however,
14

2IO TUBERCULOSIS AND SYPHILIS OF THE KIDNEY

Strongly indorse the absolute rest treatment now so popular in
the sanatorium management of general tuberculosis. Two cases
of renal tuberculosis now under the care of one of us have appar-
ently made complete cures under general hygienic measures
only, and in both instances without long confinement to bed and
the house. Both returned to their occupation as actresses inside
of one year after the beginning of treatment.

But little is to be expected from medicinal treatment. Some
urinary diluents or antiseptics may at times improve the condi-
tion of affairs, but such drugs as creasote, iodoform, and the like
are to be avoided as doing more harm than possible good. We
have personally met with no good results with tuberculin treat-
ment, and we have finally come to rely on general medical and sur-
gical methods, preferably of a conservative nature, associated with
the best of hygienic surroundings, carefully supervised but
generous diet, and a well-ordered and temperate life.

The writers do not advocate operative measures, especially
when both organs are involved, except when distinctly surgical
conditions, such as pyonephrosis, not amenable to medical or
local treatment, are present. On the other hand, a tubercular
pus cavity in the kidney is subject to the same surgical laws that
govern the treatment of a like lesion in any other organ, and where
symptoms of sepsis are developing or where drainage has ceased
to be satisfactory the surgeon must operate. The type of the
operation must, of course, depend on the conditions which he finds
on the exposure of the diseased organ. In most tuberculous
abscesses that are so extensive as to demand operative interference
the kidney should be removed, provided that the associated
organ is not also seriously involved. Partial nephrectomy in
carefully selected cases may, perhaps, fully comply with the
necessities of the conditions.

THE KIDNEY IN SYPHILIS

In an article on " Syphilis of the Kidney," * one of the writers
considered, somewhat exhaustively, the changes, properly attrib-
utable to syphilis, that are to be expected in the kidney. No

' Robert Holmes Greene in "Journal of Cutaneous and Genito-urinary
Diseases," 1898.

THE KIDNEY IN SYPHIUS 211

evidence has been offered since that time to warrant a change in
the views then expressed. Early syphilis is associated with renal
hyperemia just as occurs in the acute stage of other infectious
diseases. In those cases in which lesions already exist, perhaps
as the result of improper living or previous disease, the hypere-
mia may go on to the formation of true inflammatory or degen-
erative nephritis, which may even terminate in death, as in the
case reported by Fordyce.'

Syphilis may cause an increase of connective tissue in the
kidney, and interstitial nephritis is found associated with such
frequency as to warrant the belief that it is the cause, at least in a
certain proportion of cases. It probably acts primarily by setting
up changes in and about the blood-vessels.

Amyloid degeneration of the kidney is regularly caused by
chronic syphilis. Both amyloid degeneration and interstitial
hyperplasia, when due to syphilis, occasionally manifest a ten-
dency to attack one kidney chiefly, or solely.

Gumma of the kidney, while rare, is now reported more fre-
quently than formerly. They are usually confused with renal
neoplasms, or less commonly with stone. Hematuria is a frequent
symptom, as previously referred to. J. Israel^ has reported two
cases on which he performed nephrectomy in the belief that the
palpable tumor which proved to be syphilitic was malignant;
several similar instances have fallen under our personal observa-
tion.

Clinical experience in the treatment of syphilitic patients has
led the writers to conclude that the condition of the kidneys
should receive more routine attention in the treatment of this
disease. It should be remembered that while mercury is of the
greatest value in the treatment of syphilitic aflfections, the drug
is, to a considerable extent, eliminated through the kidneys,
where it may cause irritation, particularly if there is any preceding
kidney lesion. On the other hand, true syphilitic changes in the
kidney may be markedly benefited. In a case seen in the writers'
hospital service a kidney tumor half the size of the patient's

^ John A. Fordyce, "On the Occurrence of Nephritis in Early Syphilis,
with the Report of a Case Terminating Fatally," "Journal of Cutaneous and
Genito-urinary Diseases," 1897.

'"Deutsch. med. Woch.," Jan. 7, 1892.

212 TUBERCULOSIS AND SYPHILIS OF THE) KIDNEY

head responded promptly to mercurial treatment. The growth
had been variously diagnosed as tumor of the spleen and kidney.
Catheterization of the ureters demonstrated the presence of pus
in the urine of the diseased side, and the patient gave a history
of syphilis ten years back and of tumor of the left testicle. Mer-
curial injections were followed by complete disappearance of the
tumor in six weeks and return to perfect health.

Stimulation of the skin by means of baths and such daily exer-
cises as will induce free perspiration, and so aid in relieving the dis-
eased kidneys, is of benefit in these cases ; otherwise the treatment
is that of uncomplicated syphilis. Generally speaking, no opera-
tive procedure should be adopted for the relief of suspected tumor
or stone, whether or not accompanied by hemorrhage from the
kidney, until antisyphilitic treatment — i. e., the administration
of mercury or iodin — ^has been tried. Although the symptoms
present may be found but rarely to be due to syphilis, still when
this is the case, the immediate improvement that follows this
treatment is most gratifying.

CHAPTER XII

MALFORMATIONS AND DISPLACEMENTS OF THE
KIDNEY

CONGENITAL MALFORMATIONS

Congenital malformations of the kidney are comparatively
common. They usually result from flaws in the very early devel-
opment of the organ, and are of relatively little importance to the
physician, though often very confusing to the surgeon, who may
mistake them for new-growths, or whose anatomic relations may
thus be grievously displaced.

Absence of one kidney is not a particularly rare condition. As
a rule, in these cases (two of which have occurred in the writers'
practice), the single organ is practically equal in weight, size,
and in functional activity to those of the two organs of an ordi-
nary subject of the same body weight. This congenital anomaly
is also important chiefly to the surgeon, who may, in cases of
surgical disease, remove the single gland in the belief that both
organs are present, with, of course, an inevitably fatal result.
The surgeon should, therefore, make it a rule of practice never to
perform nephrectomy until he has proved, either by palpation
or inspection or by the use of the cystoscope, that both kidneys
are present, together with the relative degree of their lesions.

Congenital lobulation is a very frequent anomaly, but one that
is of but slight importance. Ordinarily it is shown by a simple
marking of the cortex, but in some cases it may be as complete
as in certain of the herbivora. Occasionally, the separation of the
lobules may be marked, and the lobules be entirely isolated.
This last condition may lead to error in diagnosis, it being some-
times mistaken for renal or other new-growths.

Fusion of both kidneys into a single mass is not uncommonly
seen. The most usual type of this deformity is that in which the
two organs are connected by an isthmus of renal tissue, the whole
forming a crescent-shaped mass that has received the name of

213

214

MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

"horseshoe kidney." In this condition, as a rule, both ureters
are present (see fig. 77), but occasionally there may be but one
excretory duct ; in either case its recognition is of but slight impor-
tance.

Congenital malpositions of one or both kidneys are not uncom-
monly seen. As a rule, they have but little importance cHnically,

although in certain cases,
as was noted by Osier
they may seriously com-
plicate diagnosis. Occa-
sionally, by impinging on .
other organs, they may
give rise to disease. This
is particularly true of pel-
vic kidneys when preg-
nancy occurs. In a case
occurring in the service
of the writers, both kid-
neys were congenitally
misplaced in the pelvic
cavity; acute nephritis
with fatal uremia fol-
lowed a twin pregnancy.
The woman had passed
through a previous single
pregnancy without
trouble, but in the twin
pregnancy the greatly

Fig. 77-Horseshoe kidney (one-third natural enlarged UtcrUS SO COm-

Llborai^'oT ^ "'^'""^" '" '"^ '^"'^"'" "^^^'"^^'^ prcsscd onc of the mis-
placed organs as to pro-
duce actual strangulation and gangrene with acute nephritis of
the other kidney. The condition was not suspected and was dis-
covered only at autopsy.

One of the most common and important congenital anomalies
is that of cystic kidney. Occasionally but a portion of one
kidney is so involved, but at times both are affected. The con-
dition results from the failure of the two portions of the fetal

CONGENITAL MALI^ORMATIONS

215

anlage to unite properly. One of these portions, representing,
in the fetus, the anlage for the pelvis and medulla, is developed
from the Wolffian duct; the tubules formed in the intermediate
cell-mass of the metanephros should eventually fuse with those of
the portion derived from the Wolffian duct. Secretion of a more or
less normal nature goes on in the blind tubules, with the result
that they become dilated into cystic cavities filled with inspis-
sated secretion. The writers believe that this is the mode of
origin of many of the isolated cysts of the kidney seen postmortem,

Fig. 78.— Congenital cystic kidney (one-third natural size). The accompanying- organ
•was similarly diseased and both had been removed surgically as supposed cystic ovaries.
Acute suppression of urine followed, terminated by death alter three days. No symptoms indic-
ative of renal disease had been manifested and the urine was reported as " normal." Speci-
men from the Museum of Carnegie Laboratory.

but it is not rare to find the entire kidney substance involved and
the organs forming tumors of very large size, the nature of which
may not be suspected even on ocular examination. It is astonish-
ing, as shown in the case illustrated in fig. 78, to what an extreme
degree this cystic change may exist and yet the kidneys remain
competent to fulfil their function. In the case illustrated, prac-
tically no trace of normal renal tissue could be found, and yet the
patient reached adult life, death occurring as the result of anuria

2l6 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

following removal of the cystic organs in the mistaken belief that
they were ovarian tumors. Before removing cystic tumors of
the abdominal region it is well, therefore, first to ascertain whether
or not they constitute the only renal tissue of which the patient
is possessed. Congenital cystic kidney is usually seen in mons-
ters, and marked cases rarely live beyond infancy. The condition
is not infrequently associated with sarcomatous growths.

Anomalies in the arterial supply of the kidneys are very
frequent, but are of interest chiefly to the anatomist.

MOVABLE AND FLOATING KIDNEY

It is a well-known fact that the kidneys are normally more or
less mobile, the movements being somewhat dependent upon the
amount of perirenal fat present. This amount of fat varies, of
course, in different individuals, and in the same individual from
time to time. The term "floating kidney" is applicable to those
cases in which the movement of the kidney has gone beyond
the physiologic limits; just what these physiologic limits are
is, however, a very difficult matter to determine, the personal
equation of the observer playing an important part here. For
example, a physician whose belief it is that a great many ills are
dependent upon floating kidney would naturally be led to regard
as a displacement or as excessively mobile, an organ that another
observer, of a more conservative type, would consider entirely
within the normal, or, when displacement actually had occurred,
would regard the matter as of no great importance.

Pathology. — Some movable kidneys are said to move inside
of the fatty capsule, from the absorption of fat between the true
kidney surface and the fatty capsule. Still another class is believed
to be abnormally mobile, owing to the absorption of fat from both
inside and outside the capsule. In women, tight lacing has by
some been held to be one of the reasons why the kidneys are more
often displaced in females than in males. Unquestionably the
relaxation of the abdomen following certain pregnant states also
predisposes women to this condition, and the lowering of intra-
abdominal pressure following relief from large tumors or even
the aspiration of ascitic exudates may bring about the same
result. There are also a certain number of cases which develop

MOVABLE AND FLOATING KIDNEY 217

after blows or injuries to the back or sides, and still more rarely
one occasionally may see other traumatic cases following severe
falls. The condition is almost always present in general entero-
ptosis.

The term "displaced kidney" is more properly used to describe
those cases in which the kidney remains quite permanently mis-
placed, while "floating kidney" should not, in our opinion, be

.F>g- 79-~piag:ram made from jr-ray photograph, showing metal ureter-catheters {A) in
position, and indicating how a displaced liidney may be diagnosed. The kidney on the right
side is displaced somewhat.

applied unless the organ drops a considerable distance from the
normal.

Diagnosis. — It would be impossible to describe here all the symp-
toms of which floating kidney is said to be the origin. It has been
discovered that many of these cases are associated with neuras-

2l8 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

thenia, and the symptoms of the two conditions cannot be wholly
separated. Albarran asserts that floating kidney uncomplicated
by any inflammatory lesions in or connected with the urinary tract,
and when free from pressure, will not cause systemic disturbances.
Weconsider this statement as too general to be universally accepted.
Typical cases manifest a symptom complex known as "Dietl's
crisis," which consists of sudden attacks of pain in the back and loin,
accompanied by nausea, vomiting, and suppression of urine, fol-
lowed, after a few hours, by the expulsion of a large amount of urine
and immediate relief from pain. These painful attacks are believed
to be due to pressure on, or to a kink in, the ureter, brought about
by a displacement of the kidney ; relief of this obstruction allows
the urine dammed back in the pelvis of the organ to be dis-
charged.

Malignant diseases of the kidney, ureter, or surrounding tissues
are hard to differentiate in some cases, as they also give rise to
similar attacks. Differential diagnosis must largely depend on
discovery of the malplaced organ by palpation and by rectal or
vaginal examination. An ;t-ray taken with a metal ureter catheter
in position, as shown in our illustration (fig. 79), will in cases of
doubt definitely establish the diagnosis. Our illustration is taken
from a case of this description. The writers' experience with
cases of displaced kidney has led them to adopt a rather conserva-
tive view regarding the amount of disturbance ordinarily pro-
duced by lesser displacements.

Treatment. — Given a patient who manifests Dietl's crisis, it
would seem evident that some procedure should be adopted to
correct the displacement in the hope of affording relief from these
distressing symptoms. Many cases are doubtless cured by the
persistent use of a properly fitted corset or support, or by the
combination of this method with such general measures as tend
to deposition of normal adipose about the organ, thus tending to
retain it in position. Where such measures fail, and they usually
do in pronounced cases, operation may be imperative. We do
not, however, advise operation merely upon the diagnosis of dis-
placed kidney when distinct symptoms of disturbance are wanting
and where less aggressive measures suffice. The operation should
not be done so much to correct the displacement as to attempt to

HYDRONEPHROSIS 219

relieve the obstruction to the ureter, which may, of course, be also
due to causes other than kidney displacement.

In a very large proportion of the many operations performed
in this country for the fixation of a displaced kidney, the symptoms
complained of have been those that are generally considered as
indicative of neurasthenia, and the operation has been performed
in the belief that the displaced kidney was the cause of the neu-
rasthenia. In a case that came under the observation of one of the
writers several years ago the patient, a young woman, was believed
to be suffering from tuberculosis of the kidney. The right kidney
was well down in the pelvic cavity, and was easily palpable. The
patient was thin, and it was seen that the organ was most mark-
edly displaced. The woman was of a nervous, impressionable
type, and her mind seemed to dwell on the subject of tuberculosis
of the kidney with such persistence that it had become a fixed
idea in her mind. When she was told that no indications of tuber-
culosis had been found, she was skeptical, and sought the advice
of a well-known practitioner, who subsequently removed one of
her kidneys. Curiously enough, however, he removed the left
kidney, allowing the right kidney, which, as previously stated,
was markedly displaced, to carry on the work of excretion. So
far as has been learned, the result on her mental condition has
been negative, but her general health is still good.

In most cases seen by the writers in which appliances of an ortho-
pedic type were beneficial, the patients were of the neurasthenic
variety, and it is doubtful whether the kidney displacement was in
itself the cause of the symptoms complained of. The writers believe
that displaced kidneys may be anchored in place with little or no
danger to the patient. Permanent replacement is afforded only as
the result of the operation of nephrorrhaphy, though general medi-
cal treatment, especially when designed to increase the perirenal fat,
as well as to relieve annoying symptoms, may give great and even
permanent relief.

HYDRONEPHROSIS

Hydronephrosis is a condition, the general importance of which
has been recognized by most practitioners in a more or less indefi-
nite way for a long time, but the discussion of the subject, except in

220 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

its bearing on other disorders of the urinary passages, has been
mostly confined to works on pathologic anatomy, and the clinical
appreciation of its importance has been very generally underesti-
mated, and is as yet but very inadequately discussed in some works
dealing chiefly with the clinical sides of diseases of the urinary
organs. Pathologic anatomists are universally familiar with the
subject, both because of its frequency of occurrence at the
autopsy table and also since it explains, in a very considerable
number of cases, the appearance of definite signs and symptoms
in the development of many diseased conditions of the kidney and
ureter.

Pathologic Anatomy. — The pathologic anatomy of hydro-
nephrosis is very simple ; briefly, it consists of a dilatation of the
pelvis of the organ by urine. The variations in the pathologic
anatomy are chiefly those of degree, and to a certain extent the
degree of the lesion is dependent on the length of time which the
condition has persisted and the nature of secondary changes
which may have taken place, either as secondary or concomitant
lesions.

In slight instances, the lesion may consist of little beyond
simple dilatation of the pelvis of the organ, usually with more or
less erosion and desquamation cf the pelvic epithelium. When
the change is more pronounced, the calices of the pelvis are widely
dilated and excavated and replacement of the pyramids is shown.
In very pronounced cases the organ may be greatly increased in
size — so much so as to be readily palpable. In such examples
renal tissue is reduced to but a narrow rim of cortex lying beneath
a greatly thickened limiting capsule of connective tissue (fig. 80).
Cases are often seen in which practically all renal parenchyma is
so replaced, and one only wonders that life can have persisted, for
occasionally even these pronounced lesions are bilateral.

Etiology, — The condition is brought about in all instances by
the mutual occurrence of obstruction to the urinary outflow and
continued secretion by the organ on the obstructed side. Com-
plete obstruction, especially when of acute origin, is much less
apt to produce the condition than incomplete or slowly develop-
ing obstruction, since where the obstruction is acute or acutely
complete, the increased intrapelvic pressure soon balances that in

HYDRONEPHROSIS

221

the capillaries of the obstructed organ, and circulation is slowed
and decreased and secretion finally completely checked. The
condition is much more apt to appear where partial escape of
the urine is possible, but as a result of which the intra pelvic pres-
sure is persistently increased, yet not so completely so as to stop
secretion. The disease is, therefore, seen most frequently in such
cases as show a gradually and slowly increasing obstruction to
urinary outflow.

The condition may be classified as congenital and acquired.

Fig. 80. — Hydronephrosis following monolateral stricture of the ureter (authors'

specimen).

Congenital hydronephrosis is seen as a result of incomplete or
abnormal development of the urinary tube, as a result of the pre-
cipitation within the urinary passages of urinary salts, or from
compression from abnormally placed viscera or vessels. A striking
example of the first-mentioned condition was recently shown
us by B. S. Crowell. The specimen was from an infant which
it was found impossible to deliver after the head had fully
descended. Finally, it was found necessary to do embryotomy,
and examination of the dismembered fetus showed enormous
distention of the abdomen and great general edema of all the

222 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

tissues. The abdominal tumor was found to consists of the two
tremendously distended kidneys, the urine from which had been
unable to pass into the bladder on account of almost complete
congenital stenosis of the ureters. This lesion was found asso-
ciated with other but irrelevant congenital defects.

Obstetricians and pediatrists frequently see cases where either
no urine or one very richly charged with precipitates of salts or
of free uric acid is present, and in such cases more or less obstruc-
tion results. In a notable number of instances this obstruction
is in the urethra in both female and male infants, and proper
manipulation may at once relieve the condition. In these cases
colloidal substances, found so richly in the urine of recently born
infants, of course, predispose to the precipitation.

Acquired hydronephrosis may follow obstructions within the
urethra, such, for example, as stricture from the lodgment of stone,
from the formation of inflammatory or neoplastic tumors. Need-
less to say, the most frequent cause of urethral obstruction is
stricture, and the relative percentage of cases of marked stricture
in which hydronephrosis develops is large.

Prostatic obstructions are, perhaps, the most frequent cause in
elderly men, and here also the growth of tumors or lodgment of
stone must be considered in the eliminative discussion.

Cystic lesions leading to hydronephrosis are chiefly of inflam-
matory or neoplastic origin. New-growths in the region of the
ureteral mouths or inflammatory or tubercular disease at the
entrance of these ducts are among the more frequent causes,
while occasionally the lodgment and encysting of a calculus in
this region effects the same result. Thus far the lesions concerned
in the production of acquired hydronephrosis are relatively easy
of determination by any careful physician, especially for one
skilled in the use of modern instruments of bladder search, but
the remaining causative factors can be only problematically diag-
nosticated except by abdominal exploration or by the use of
ureter catheterization.

Such, for example, are obstructions to the ureters. The most
frequent ureteral lesion productive of hydronephrosis in our
experience has been the kinking of the tubes in cases of malplaced
or floating kidneys. Compression by tumors, either inflammatory

HYDRONEPHROSIS 223

or otherwise, and either within or without the ureters, is also
found relatively common. We have thus found the condition
to originate in cases of tubercular peritonitis or even after bands
of adhesions following peritonitis or operative adhesions. It
was shown in a recent case of Hodgkin's disease, occurring in the
service of one of us, where the pressure resulted from the greatly
enlarged lymph-nodes about the ureters. The lesion is frequent
in cases of pelvic tumors and inflammations, especially in women
and in cases of appendicitis characterized by adhesion or marked
fibrotic formation. The obstruction to the ureters following
careless application of abdominal ligatures in peritoneal surgery
has been generally noted. Stone lodged in the ureters forms an
exception to the general rule as regards ureteral obstructions,
since in the majority of cases the symptoms are sufficiently char-
acteristic to permit of absolute diagnosis. Strange as it may
seem, stone lodged in the renal pelvis rarely causes these conditions.
Abdominal tumors, and especially pelvic growths of all varieties,
are very prone to produce hydronephrosis, and from the relatively
greater frequency of these lesions in women hydronephrosis has
been reported by Albarran to be most common in this sex.

One factor, important because it is so commonly ignored in the
etiology of hydronephrosis, is the frequency with which the con-
dition occurs as a result of the retention of urine due to mental
or habit disturbances. We have often seen the condition in those
moribund or ill with spinal or cerebral disorders in which the sen-
sations of an overdistended bladder were not appreciated. It
has been found common thus in hospitals, where proper catheteri-
zation of dying or comatous patients was neglected, and the fre-
quency with which this lesion arises, especially in alcoholism, dia-
betes, and uremia, should be borne in mind by every practitioner.

We have, furthermore, found hydronephrosis common, especially
in young women working in offices who, from feelings of delicacy
or from downright physical laziness, do not attend to their bladder
functions at regular or sufficiently frequent intervals. In our
opinion, with which a prominent gynecologist coincides, this
factor is one of the most frequent concerned in the production
of ill health, and especially of the backaches which are so commonly
complained of by young women.

224 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

The most serious results of hydronephrosis are dependent upon
nephritis, either in the involved organ or in cases of monolateral
disease, a compensatory nephritis in the other kidney, and second-
ary inflammatory disease, especially pyonephrosis. Concerning
the relationship to this last-mentioned condition, sufiicient mention
has been made under the head of Suppurative Diseases of the
Kidney (page 159).

The symptoms of hydronephrosis are those of the obstruction,
such, for example, as the colic which follows lodgment of a stone
in the ureter or urethra, or of the pressure from enlarged lobe of
the prostate or from a tight stricture, and those symptoms proper
of the dilated and isolated kidney.

Backache is one of the most constant of these symptoms. Slight
febrile manifestations may be present even in some non-infected
cases. Where a palpable tumor is present, tenderness is usually
present over it, and at times massage, gently performed, may cause
the evacuation into the bladder of a urine, light in specific gravity,
accompanied by reduction in the size of the renal tumor.

Diagnosis depends first on the recognition of conditions which
might induce hydronephrosis, for example, a tight stricture, prob-
able lodgment of a calculus, or detection of a floating kidney. In
this step instrumental examination with the sound and cystoscope
and the employment of ureteral catheterization may serve clearly
to establish the diagnosis. It must not be concluded, however,
where a ureteral catheter cannot be passed, even by a skilful opera-
tor, that obstruction of sufficient degree necessarily exists to
cause a hydronephrosis, since the stricture may be due but to
muscular spasm. Obviously, palpation of a renal tumor is pos-
sible only in pronounced cases, and the absence of definite renal
tumor must never be taken as negativing the diagnosis of hydro-
nephrosis. When, however, massage of a renal tumor causes the
descent into the bladder of a urinary fluid with corresponding
reduction in the size of the tumor, the diagnosis seems to be clear
and decisive, except in some cases of cystic kidney, where this sign
may also appear. Where the condition is monolateral, cystoscopy,
with the consequent demonstration, with or without catheteri-
zation, that fluid escapes but from a single side may be diagnos-
tically important. The symptoms of the condition, except as

HYDRONEPHROSIS 225

they indicate obstruction in some portion of the urinary tube,
are of but little assistance in diagnosis, largely because of their
indefinite nature and very inconstant apf)earance.

Treatment. — Treatment should be first prophylactic. In all
operative procedures on the urinary tube care should be taken
that nothing is done which causes compression, even of relatively
slight degree, of the passage. The importance of this step, espe-
cially in pelvic surgery, needs but mere mention. Wherever any
obstructions in the passage are present which are liable to become
more marked, they should receive immediate treatment. In
the early stages even unskilful massage along the course of the
ureter may dislodge a stone; cauterization of an ulcer at the
urinary papilla, with subsequent appropriate treatment, may pre-
vent the formation of a cicatrix likely later to cause stricture and
hydronephrosis. We should especially like to call the attention
of the practitioner to the necessity of proper and early dilatation
of urethral strictures, and to the early relief of cases of prostatic
hypertrophy which is accompanied by a high intra-urinary pres-
sure. Finally, we believe that it is very important to strongly
advise in all cases regular and habitual evacuation of the urine at
sufficiently frequent intervals, for we are convinced that negligence
in this matter is responsible for hydronephrosis in a very consider-
able number of cases.

Curative treatment necessarily lies chiefly along surgical fines.
True, in some cases, very simple measures, such as the replacement
of a dislodged kidney, may effect a cure, or massage and manipula-
tion dislodge a stone, but wherever actual physical obstructions
exist, they should, in all cases, except those manifestly moribund,
be removed as early as possible. It may thus become necessary
to open into the pelvis for the removal of stone, to fix the kidney
where displacement cannot be relieved by less drastic measures,
to release the ureters from cicatrizing adhesions, to enucleate
cystic tumors, or to dilate or cut strictures.

Where such relief is impracticable or impossible, it may be neces-
sary to open the tumor and drain externally. In cases sufficiently
marked to demand such measures, as a rule, secretion is very
slight in the diseased kidney and the organ generally contracts
down with absolute cessation of secretion, so that the external
15

226 MALFORMATIONS AND DISPLACEMENTS OF KIDNEY

drainage of urine is not often a permanent nuisance. Cases have
been reported where it was necessary to implant the ureters either
to another position on the bladder, to unite them with the gut, or
transfix them in the loin. The precise step in each case must be
decided by the conditions present, and good surgical judgment is as
indispensable here as in most operative procedures on the urinary
organs. The precise method employed must generally be selected in
the midst of the operation, and the ingenuity of the operator may be
severely taxed to produce the best possible result. Two things of
importance must be remembered: whatever is done should be
done as early as possible, and before closing the wound the surgeon
should be certain that all other portions of the tract are clear
from obstructions, especially in cases of stone. This can be
readily determined by the injection of sterile salt solution, pre-
ferably colored, which can be readily recognized as it appears in
the bladder or from the urethra. For a detailed description of
the surgical procedures strictly applicable to the relief of hydro-
nephrosis, reference is made to the chapter on the Surgery of
the Ureter, and for the Relief of Retained Renal Secretions.

CHAPTER XIII
WOUNDS AND INJURIES OF THE KIDNEY

WOUNDS OF THE KIDNEY

Wounds of the kidney are most generally due either to a knife-
thrust or to a bullet; more rarely they are the result of a fall on
some sharp instrument. When a wound of the kidney is very
large, a hernia of the kidney will take place into the wound. The
condition is readily diagnosed. Ordinarily, the kidney is very
tolerant of wounds, and if the knife or bullet that inflicted the
injury was clean, healing is generally rapid.

Wounds of the kidney are, as a rule, accompanied by more or
less shock ; it should also be remembered that internal hemorrhage
may take place and be so severe as to cause death before opera-
tive procedures can be resorted to. A chemical examination of
the blood coming from a wound in the kidney region will demon-
strate the presence of urine. A tumor in the loin may or may not
be present. If there is a free discharge of blood in the urine, the
tumor will not occur. Careful examination should be made to
see that no foreign bodies have been carried into the wound. Pain
similar to that of renal colic is apt to be associated with wounds
of the kidney. Hematuria is associated with most wounds of
the kidney. As sequels may be mentioned peritonitis, suppuration
of the kidney, cystitis, and, after healing, rheumatism, neuralgia,
and contraction of the muscles.

The prognosis as regards wounds of the kidney should be
guarded. In a series of 38 wounds of the kidney inflicted by
sharp instruments, 42 per cent. died. Gunshot wounds of the
kidney are more likely to result fatally than those made by cutting
instruments. The prognosis is not necessarily as serious from
the wound itself as it is from the fact that they are so often
associated with injury of other organs, and the impossibility of
telling how much infection is carried into the kidney by the wound-

227

228

WOUNDS AND INJURIES OF THE KIDNEY

making agent. These wounds of the kidney are apparently
becoming more frequent, in this city at least, stiletto wounds being
the most common type. The attached illustration (fig. 8i) rep-
resents the ordinary appearance of a stiletto wound in the kid-
ney, the patient dying from wounds through some of the larger
blood-vessels, in addition to those of the kidney. It is important
to note that wounds inflicted by modern high-power weapons are

Fig. 8i. — Stab-wound of kidney (authors' specimen).

quite different from those of the old black -powder guns. At
short range the modern projectile causes either a small clean-cut
wound, with little hemorrhage, or else a blasting effect, with exten-
sive laceration; at long range, a wound small and clean cut gen-
erally results; in either case the wound is generally aseptic.

The treatment of kidney wounds, when they are at all extensive,
is surgical. The operative procedures are dependent upon whether
the wound has involved the peritoneum or has only injured the
kidney outside of it. In wounds inside the peritoneum, laparot-

INJURIES OF THE KIDNEY 229

omy should be performed ; in those outside the cavity, an incision
should be made in the lumbar region and the kidney exposed.
In either case hemorrhage should be checked, the kidney wound
rendered aseptic and sutured, and good drainage established.
It is not always easy to thoroughly clean the retroperitoneal space
of any extensive hemorrhage which may have taken place. In
such cases especial care should be taken to see that thorough
drainage is established. Wounds of considerable extent should
be tamponed instead of sutured. The same conservatism as
regards operation should be shown for wounds as for general
injuries of the kidney, and nephrectomy should be considered as
the operation of last resort.

INJURIES OF THE KIDNEY

The causes of injuries to the kidney are various. They may be
due to a blow on the abdomen or to strains caused by lifting or jump-
ing. Now that automobile accidents are becoming so frequent,
injuries to the kidney may be expected to increase in a correspond-
ing degree. Curiously enough , a spontaneous rupture of the kidney
may occur from the bursting of a tumor, two cases having recently
been reported by Tuffier and Hartmann.' The subject of subparietal
injuries to the kidney has been must carefully studied by Francis
S. Watson, and a most exhaustive and valuable contribution to
the literature of the subject made by him."

Symptoms and Diagnosis of Injury of the Kidneys. —
Following a severe injury of the kidney, if recovery from the
shock has taken place, pain in the renal region is likely to follow.
This pain resembles that caused by a stone in the kidney, and
in the male radiates down the abdomen into the testicle. The
pain sometimes disappears soon after the injury, to return in the
form of nephritic colic, which vanishes when a clot is passed. In
addition to the pain, the most constant symptom is hematuria.
Blood which coagulates in the ureter often passes out in angle-
worm formed bodies. Such molds in the urine are diagnostic of
hemorrhage high up in the urinary tract. More or less swelling in

^ " Revue de Chirurgie," 1905.

^"Subparietal Injuries to the Kidney," "Boston Medical and Surgical
Journal," 1905.

230 WOUNDS AND INJURIES OF THE KIDNEY

the neighborhood of the injured kidney is generally associated
with the pain and hemorrhage. When the swelling is very marked
and diffuse, hemorrhage and urinary infiltration are probably tak-
ing place outside the kidney ; but if the swelling is more firm and
circumscribed than that just described, filling the kidney space, a
hemorrhage inside the capsule of the kidney may be suspected.

Ecchymoses are likely to form on the surface of the body at the
seat of the traumatism. At times these do not appear until several
days after the injury has taken place. If they appear in the lum-
bar or inguinal region, they are believed to possess some diagnostic
value. The urinary secretion is frequently disturbed, the quantity
of urine excreted being probably diminished. Ureter catheteriza-
tion is a valuable aid in determining the seat and extent of the in-
jury. Recovery is usually rapid from the injury when the kidney
surface has not been torn through. Even when the parenchyma
has been torn, the kidney manifests a tendency toward repair.
In the gravest cases death from internal hemorrhage or shock
is likely to be immediate. In mild injuries the pain disappears
and the trifling hemorrhage ceases in about forty-eight hours.
In severer cases the hemorrhage is more extensive, there is a
marked diminution in the quantity of urine excreted, and a swell-
ing is apt to appear in the lumbar region. When the contusion is
extremely severe, the kidney may be so lacerated as to re-
semble a pane of glass through which a stone has been thrown —
there are fissures running in all directions. Such severe injuries
are almost invariably fatal. Injuries of the kidney, if not too
extensive, have a tendency to heal spontaneously, but often
manifest unpleasant after-effects. It is possible that an injury
to the kidney so slight as almost to be overlooked may later give
rise to the formation of multiple abscesses, a single abscess, a cyst,
■or a calculus, or it may serve as the starting-point for a growth of
the kidney. There is a tendency on the part of the profession to
pay too little attention to the serious after-results of kidney injury.

Injuries of the kidney are not infrequently the cause, particularly
in women, of displaced kidney. They are often, through injury
to the ureter or the kidney pelvis itself, the cause of a hydro-
nephrosis. Particularly serious are injuries to the kidney if the
.accident occurs in kidneys that are not in normal state. Neu-

INJURIES OF THE KIDNEY 23I

man ^ states that he has seen pyonephrosis, pyonephritis, pyo-
cystic kidney, ureteritis, hydronephrosis, and papillary cystoma
of the kidney from injury. With the first three conditions he
believes gonorrhea to have been the exciting cause, and injury
to the kidney the contributing cause. Some very interesting
experiments concerning the effect of an injury to one kidney upon
the neighboring kidney have recently been made on dogs by
Castaigne.- Briefly, he found that a renal contusion caused for
a time a diminution in the total diuresis and sometimes abolishes
it for twenty-four hours or more. That later on the after-effect
on the uninjured side from a transmitted lesion of the other side
was to cause a condition of sclerosis in the well kidney, inter-
mingled with hypertrophic zones. He seemed to attribute the
condition which took place in the well kidney to the effect of the
absorption of kidney toxin from the diseased organ. There is
considerable clinical evidence which tends to support the views
of Castaigne, obtained by him from his experiments on animals.
Anuria through some reflex nervous influence following injury to
the kidney has been noticed. Also, particularly by the German
school of observers, has a form of nephritis, called traumatic
nephritis, been noticed to occur several months after an injury to
the kidney, the injury apparently being the only causative fac-
tor. This traumatic nephritis is stated by at least one observer
to be a mixture of a parenchymatous and interstitial nephritis;
his views are also corroborated by the very valuable work of
Beers, of New York, referred to earlier in the article on Tests of
the Permeability of the Kidney, his researches tending to show
that there was increased functional activity in the better kidney
following the removal of a diseased one.

The prognosis regarding injuries to the kidney should naturally
be guarded. Not only should it be guarded as regards the imme-
diate effect of the injury, but for its later after-effects, and neces-
sarily it is often rendered more difficult by injuries to the neighbor-
ing organs. Particularly should the prognosis be guarded if there
is any previous history of disease in the kidney, an injury naturally
tending to make any previous abnormal condition worse.

^ "Zeitsch. f. Chir.," 1906, No. 9.

^ "Gazette de Hopitaux," October, 1906.

232 WOUNDS AND INJURIES OF THE KIDNEY

The treatment of injuries of the kidney must be varied accord-
ing to the nature of the case. Not infrequently the shock follow-
ing injuries to the kidney is so severe that the patient dies, although
no other organ was involved ; one of the writers saw a case of this
kind at autopsy; in suspected injury of the kidney the ordinary
treatment for the relief of shock should be therefore instituted.
A careful examination should then be made. In a suspected
case of injury to the kidney, if the recovery from shock is rapid
and blood soon disappears from the urine, the kidney again
assuming its functions, little is required beyond rest in bed, the
application of an ice-bag to the injured region, and the adminis-
tration of a urinary antiseptic. The patient should be kept under
constant observation, so that operation may be performed at once
if untoward symptoms develop. After the patient has so far re-
covered from the injury as to be able to be up and about, he
should not be dismissed from observation, but should be exam-
ined at intervals for some period of time, so as to detect any
tendency toward the formation of untoward after-effects.

If the hemorrhage continues and a marked swelling appears
in the lumbar region, an exploratory incision should be made and
the field of injury carefully inspected. It is best, in doubtful
cases, to make an incision and examine the kidney. Such further
steps may then be taken as the exigencies of the case would seem
to indicate. Particularly should the presence of any tumor in
the loin be looked for and observed; it having appeared, it should
be watched carefully for a few days, and if no tendency to
absorption and no amelioration of the general symptoms have
appeared, operative procedures should be instituted. The oper-
ation may vary from tampon and suture to nephrectomy, varied
according to the conditions found to be present, or which may
develop. Nephrectomy should always be the operation of last re-
sort in uncomplicated cases, and in some cases at least, if required,
should follow a more conservative operation. The injuries of the
kidney offer a particularly good field for conservative surgery.
This is borne out by the statistics of Watson in his paper,
previously referred to, and very recently other cases have been
reported which tend to confirm this view. For instance, Chaput ^
^ " Revue de Chirurgie," 1905.

INJURIES OF THE KIDNEY 233

sutured a ruptured kidney which had a fracture extending the
entire length of the anterior surface ; he put a drainage-tube into
the pelvis, and blood passed through the incision for three weeks ;
hemorrhage then ceased, and perfect cure resulted.

Partial resection of the kidney maybe performed upon a ruptured
kidney. A. L. Franklin reports a most remarkable case. ^ A sixteen-
year-old girl felt something give way after a fall from a wagon.
Pain, vomiting, and hematuria followed ; then a state of gradual col-
lapse. Operation eighteen hours after the accident — laparotomy;
the left kidney was found torn to pieces, and the right kidney had
three transverse tears; the left kidney and three-fifths of right
kidney were removed. Six months later the patient was well and
excreted normal urine. Another interesting case has been recorded
by Chaput, in which a large portion of the kidney had to be re-
moved following injury, and in a few days the part of the remain-
ing organ was taken out and found to have hypertrophied to a
considerable extent. These two cases, narrated above, also tend
to demonstrate that the views advanced .from experiments on
animals are corroborated by clinical observations on man.

' "Rupture of Both Kidneys," "American Journal of Surgery," 1906.

CHAPTER XIV
RENAL CALCULUS

Under certain conditions stones are formed within the urinary
passages. CalcuU develop for the most part in the kidney, but
they may be found in any of the urinary passages into which
they have subsequently entered, where they may either be loose
or become encysted.

Pathology — One of the chief causes of the formation of renal
calculi is the presence of insufficient fluid in the urine to hold the
various organic and inorganic constituents that are normal to it in
solution ; they therefore become precipitated when the fluids of the
urine are reduced and become abnormally saturated with these
chemic substances. This condition may arise when the amount of
fluids furnished the body is deficient, or when, as in excessive pur-
gation or diaphoresis, the amount of fluid normally excreted
through the kidney is diminished. The familiar appearance of
calcium oxalate crystals under certain dietetic conditions, or asso-
ciated with excessive perspiration, is a common example of such a
state. The same result may follow when the chemic character of
the urine is altered, causing interaction and the precipitation of
certain bodies, either normally or abnormally present in the urine.
Thus excessive acidity of the urine may cause the precipitation of
uric-acid crysta's even though uric acid exist in but normal
amounts. In these respects the vital temperature acts very much
as heat does outside of the body, tending to prevent precipitation
to a certain degree, and to hold the salts in solution better than
after the urine has been allowed to cool.

Rainey, Ord, and Carter have shown, by an elaborate series of
experiments, that certain bodies in the urine, such as various
gums, albumins, and colloidal substances, also tend to cause pre-
cipitation of the salts of the urine; these do not, however, appear
in a crystalline form, but in a condition that they term submor-

234

RENAL CALCULUS 235

phous, and in which the precipitated particles, partly for mechanic
reasons, adhere to one another.

Certain foreign chemic bodies, taken in with the food or
drink, also tend to cause a deposition of the urinary salts; thus
Prout, Cadge, and others assert that this takes place when the
so-called hard drinking-waters are used, in this way accounting
for the frequent occurrence of renal calculi in certain districts, as
in some of the counties in England.

In some conditions associated with disordered metabolism the
urine is called upon to excrete either abnormal substances or nor-
mal substances in abnormal quantities, and in the course of this
excretory process the material may become deposited in the renal
tissues. This is well illustrated in certain cases of osteomalacia,
when the breaking-down of the bony tissue causes the deposition
of lime-salts in the tubules of the kidney.

Gross foreign bodies within the urine, particularly those of a
sticky or albuminous nature, seem to act as exciting causes;
thus the ova of parasites, echinococcus booklets, broken-down
tubercles, or portions of necrotic tissue originating from neo-
plasms, pyonephrosis, or other inflammatory and hemorrhagic
diseases of the kidney, tend to the accumulation of urinary salts
and the formation of calculi. This complication is particularly
likely to arise in suppurative processes in the pelvis of the kidney.

It is believed by some that malnutrition predisposes toward
the formation of renal calculi, since kidney stones are found most
frequently among the poorly nourished. This theory has not,
however, been sufficiently substantiated.

The chemic substances that go to make up these renal deposits
vary under different conditions and are dependent upon the
etiologic factor. Undoubtedly, the most common constituent is
uric acid, generally in crystalline form. Calcium oxalate, phos-
phate, and carbonate calculi are common, and when alkaline fer-
mentation has taken place, ammoniomagnesium phosphate calculi
occur. Xanthin, cystin, and other rare chemic bodies are also
occasionally the chief constituents of renal calculi. Sodium urate
is one of the more frequent types of calculi, particularly in gouty
subjects. As a rule, however, calculi are made up of mixed chemic
substances.

236

RENAL CALCULUS

The gross appearance of the stone varies, naturally, according
to its chemic constituents, and although most calculi contain more
or less mixed substances, the predominating chemic body gener-
ally gives a more or less distinct appearance to the calculus. The
size of the calculi varies: they may appear in the form of a dust-
like powder, or may attain a size sulhcient to fill the entire renal
pelvis or perhaps to erode the tissue of the kidney and replace
it with the mass of the calculus. The size and shape of the cal-

Fig. 82.— Kidney showing calculi lodged in the caliccs of the pelvis (natural size). From
a specimen in the Museum of Carnegie Laboratory.

cuius depend largely on the portion of the kidney in which it is
lodged, or on its etiology; thus the dust-like powder is most com-
mon in those cases of purely chemic origin.

Calculi may be found in the renal tubules or in the interstitial
framework of either the cortex or medulla or in the pelvis.

Stones found in the substance of the cortex or medulla are most
frequently of the fine granular variety and occur most commonly
in the form of sand-like deposit in the cells of the tubules of the
medulla. They are generally composed of uric acid or of urates,

RENAL CALCULUS 237

and are most prevalent in gouty subjects or in children from
two to fourteen years of age. The condition is known as uric-acid
infarction. In early infancy the urine will frequently be found to
be literally loaded with uric acid and urates. Postmortem the de-
posit is found present in the tubules of both medulla and cortex,
but more abundantly in the former, or perhaps entirely covering
the mucosa of the pelvis. In these cases acute suppression of
urine, followed by death, occasionally takes place. In uremia
and in some other diseases the ureters may be found occluded
with the material; as a rule, however, it disappears either spon-
taneously or under proper treatment, of which flushing of the
urinary tract with abundant water forms the most important
feature.

A condition morphologically similar to this sometimes occurs
in senile subjects or in such diseases as are accompanied by exten-
sive destruction of bone. Here, however, the deposit is made up
of calcium phosphate and carbonate, which is found deposited
chiefly in streaks outlining the medullary tubules.

As a rule, the calculi of larger size that are found in the renal
cortex or in the medulla have been formed as the result of the
agglutination of smaller particles about a nucleus that is not rarely
of quite a different nature from that of the succeeding laminae.
The small nucleus probably acts as a foreign body, causing the
formation, about it, of an inflammatory exudate composed of
blood or albuminous fluid, resulting in the precipitation of a sub-
morphous material that agglutinates and forms the calculus,
which occasionally takes on the greatly exaggerated form of a
urinary tubule or glomerulus. Generally, the uric-acid calculi
formed in this manner are very hard, smooth, and dark brown or
red in color; those made up 6f calcium oxalate are rough, covered
with sharp spicules or nodules, and are white in color, although
stained more or less with blood-pigments. The larger phosphatic
calculi are rarely found in this portion of the kidney, but usually
lodge in the pelvis, although oftentimes their nuclei, probably
formed in the cortex or medulla, consist of urates or oxalates.

Pelvic calculi may be of large or small size, or, as previously
stated, may take the form of a sand-like deposit. When they
are retained in the pelvis for any considerable length of time they

238 RENAL CALCULUS

tend to increase rapidly in size, this being largely due, probably,
to the secretion of mucus excited by their presence in this portion
of the urinary tract. They are extremely likely to set up suppu-
ration, and when alkaline fermentation is added to the existing
elements that predispose toward calculus formation, the stone will
increase rapidly in size, so that the entire pelvis may be found to
be occupied by a laminated calculus that forms a perfect mold of
the cavity.

If the calculi are small, they will very possibly be passed through
the urinary tract without the patient's knowledge, or slight pain,
hematuria, and the like may accompany their exit; at other
times they may become encysted in the renal tissue. In the male
they frequently pass into the bladder, being retained there; in
the female, owing to the different anatomic conditions, they are
more commonly passed; this probably explains the greater fre-
quency with which cystic calculi occur in men. Not rarely the
calculus, in its passage through the ureter, may become lodged
there, causing obstruction of that canal. If this takes place, it
necessarily interferes, to more or less of a degree, with the urinary
outflow. The immediate results of this obstruction, beyond the
disturbance caused by pain, may not be serious. The late after-
results, if the obstruction by the calculus is confined to one
ureter, will be hydronephrosis or renal atrophy on the affected
side. Beyond a certain amount of pain, but little disturbance
may result. If, however, calculi become lodged in both ureters,
death will follow unless prompt operative measures be taken.

Symptoms. — Renal calculus may be present without giving rise
to any symptoms. Stones of considerable size are not infrequently
found at autopsy, embedded in the kidney substance or inclosed
in the pelvis, that gave no manifestations of their presence during
life. In typical cases the patient complains of pains in the renal
region, commonly radiating downward toward the bladder or
groin and into the testicle; occasionally they are referred to the
opposite side. These pains, accompanied by a sensation of weight,
are exaggerated on violent exercise.

As a rule, crystals or renal sand are found in the urine with more
or less regularity ; leukocytes and red blood-cells are also commonly
present, particularly following active exercise. Pus may also be

RENAL CALCULUS 239

present when, as is generally the case, infection has taken place.
When obstruction of the ureter occurs from time to time, the urine
is excreted in small amounts until the calculus is displaced, when
there is a sudden gush of urine, which is usually clouded with
leukocytes, and most probably with sand and desquamated pelvic
or ureteral epithelium, and with large quantities of mucus.

Paroxysmal pain occasionally manifests itself, even when the
stone is too large to engage in the ureter; this pain is sometimes
so severe as closely to simulate the renal colic that develops
when stones enter the ureters and pass downward toward the blad-
der. Renal colic is particularly prone to devblop after exercise
or from any cause that tends to displace the stone. It is ushered
in with extremely severe, cramp-Hke pains, generally in the renal
region of the affected side, and radiating from this point outward,
principally downward along the urinary tract ; it is often localized
at the head of the penis or in the testicles. Severe chill, nausea
and vomiting, and sometimes violent diarrhea may appear; the
pulse becomes weak and rapid, and the skin bathed in a cold
perspiration. These symptoms abate only when the stone has
passed into the bladder or when the contractions of the ureter
have ceased. One occasionally sees cases at autopsy in which the
calculus has paused in its transit, obstructing the ureter, and
becoming encysted in this region. When the stone has been
passed, there is usually a gush of blood-stained urine, which is
turbid with cells from the urethral mucosa and with mucus and
leukocytes.

Although the characteristics of renal colic are quite marked,
the condition may occasionally be mistaken for gall-stone colic;
the diagnosis can be verified only by an examination of the urine
following the attack. The calculus may be discovered by means
of the cystoscope or sound in the bladder, or when the stone is
forced out through the urethra, the patient, if a male, generally
becomes aware of the fact.

Diagnosis. — As previously indicated, the diagnosis of the con-
dition is based on the pain, the examination of the urine, the
cystoscopic findings, and the determination of existing obstruc-
tion in the ureters. Harrison believes it possible to detect the
presence of a renal calculus by a peculiar grating sensation that

240 RENAL CALCULUS

is conveyed to the hand when the kidney is palpated. The writers
have never been able to verify this.

The ;c-ray now affords a means by which the larger renal calculi
may easily be located. The character of the stone, however, has
much to do with its clear definition by the rays, and the result
depends largely upon the experience and skill of the photographer.
Some photographers, particularly in the larger cities, are becoming
so skilful in this line of work that they seldom fail in their efforts
if the stone is of any considerable size.

The ureter catheter or bougie, having its tip coated with wax,
is of great diagnostic aid in renal calculus. A stone in the ureter
or pelvis of the kidney will betray its presence by the feel and by
the scratches it makes upon the wax.

As mentioned in a previous chapter, massage over the region of
the suspected kidney and ureter, for the purpose of forcing their
contents into the bladder, followed by immediate examination of
the urine, may aid in making a diagnosis, particularly if, after
such massage, the urine is bloody.

Treatment. — The treatment divides itself naturally into three
parts: (i) The prophylactic treatment; (2) treatment of stones
lodged in the renal tissue or pelvis; (3) the treatment of renal
colic.

When a predisposition to the formation of calculi is known to
exist, or when the urine is frequently clouded with uric-acid crys-
tals or with calcium oxalate, the patient should be directed to
drink large quantities of water ; for this purpose distilled water or
any of the alkaline waters may be used with benefit, the good
results being probably due more to the quantity of fluid passed
than to the character of the water taken ; by the use of the alka-
line waters, however, as in the special instances just mentioned,
the chemic nature of the urine may become so altered as to hold
in solution certain crystalline bodies that might otherwise become
precipitated into the substance of the kidney. Good effects have
been reported from the use of large doses of glycerin given by
stomach. Those acid fruits and vegetables that are known to
increase the presence of calcium oxalate crystals in the urine
should be avoided, and, in the case of uric-acid crystals, such

' RENAL CALCULUS 24I

dietetic rules should be observed as will minimize the danger of
an excessive output. In certain cases good results are obtained
from the use of lithia or sodium or potassium bicarbonate in full
doses. On the whole, however, the most important feature
of the treatment is the drinking of increased quantities of water.
Once a calculus of considerable size has formed in the renal tissue
or in the pelvis of the kidney, it is very doubtful whether any of
these measures are of benefit, although certain waters are said to
possess remarkable curative powers in this direction. When alka-
line fermentation, associated with infection, has taken place,
urinary disinfectants, such as salol, urotropin, and the salicylates,
have been used with benefit.

The first step in the treatment of renal colic consists in reliev-
ing the intolerable pain. As a rule, hypodermatic injections of
morphin will be required, or, when these fail to give sufficient
relief, chloroform inhalations may be demanded. Hot sitz-baths,
hot poultices to the renal region, and the drinking of hot water are all
useful measures. In several instances the writers have employed
atropin hypodermatically with excellent results, both as regards
relief from pain and as a means of preventing the muscular spasm
which is apparently largely responsible for the pain. At the same
time this relief seems to facilitate, at least in some cases, the pas-
sage of the stone. When the acute attack begins to subside, lithia
citrate or sodium bicarbonate, with abundant quantities of water,
associated with a diet tending to reduce the urinary solids, and par-
ticularly those elements that make up the stone, is to be recom-
mended. After these attacks, the stone should always be sought for
in the urine or, if necessary, in the bladder, for a knowledge of its
nature serves as an excellent guide to the most appropriate sub-
sequent treatment, both dietetic and medicinal.

As to the best method of effecting removal of a calculus, each
case is, in a way, a law unto itself. Fortunately, nephrotomy for
the removal of stone is not usually a very serious operation ; much,
of course, depends upon the condition of the patient and upon
the size and location of the stone Edebohls' incision, which will
be described further on, is the one ordinarily to be recommended.
After the kidney has been exposed, the stone should be searched
for by means of needles run through the kidney in various direc-
16

242 RENAL CALCULUS

tions. Once found, it is generally comparatively easily removed
with forceps through an incision, followed by packing the wound
if hemorrhage is severe. If the opportunity presents itself during
the operation, the permeability of the ureter may be ascertained
at this time, or this may subsequently be learned by ureteral
catheterization.

CHAPTER XV

TUMORS OF THE KIDNEY

Renal tumors are relatively rare; this is particularly true of
those neoplasms that affect the kidney primarily, and it is with
these primary growths that we are chiefly concerned, for secondary
renal growths are seldom of much clinical importance, and usually
occur but as a local manifestation of a fatal generalized disease;
but little is, therefore, gained by their treatment.

The new-growths of the kidney are best divided into three
classes — granulomatous, parasitic, and neoplastic. The first
includes isolated tubercles, gumma, and actinomycotic foci. As
regards the relative occurrence of tumors of the kidney Kelynack,
in an analysis of 306 primary renal growths, found 115 sarcomata,
22 myosarcomata, 145 carcinomata, 15 fibromata or lipomata, and
12 adenomata. In this series the author failed to consider the
hypernephroma, which probably formed a considerable propor-
tion of the tumors listed as sarcoma or carcinoma.

Tuberculosis and gumma of the kidney are more appropriately
discussed elsewhere under special heads. Actinomycosis is very
rare, and has never, in so far as we have been able to learn, been
found primarily in the kidney.

Parasitic tumors are seen, due to the action of the echinococcus
and to the Cysticercus cellulosae. Hydatid cysts of the kidney
are not particularly uncommon where hydatid disease is frequent,
but it has been but rarely reported in this country, and we have
seen but a single case. The cysts present nothing of special
note, and may be either large or small. The condition is commonly
found associated with other cysts elsewhere. The Cysticercus
cellulosae is exceedingly rare, and in so far as we can learn, has
never been observed in America.

The true neoplasms of the kidney are most conveniently classed
as innocent and malignant. The benign tumors of the kidney
are of relatively little importance, and there is surprisingly little
general or local disturbance following their development in the

243

244

TUMORS OF THE KIDNEY

renal tissue. Named in their relative order of occurrence, the
chief innocent tumors of the kidney are fibroma, lipoma, myomata,
and angioma. Fibromata occur most commonly in the cortical
portions of the organ, less frequently in the capsule. They are
usually round, and appear as small, rarely large masses of connec-
tive-tissue fibrils arranged usually in whorl-like bodies. In some
cases they appear to have originated about tiny blood-vessels,

Fig. 83. — Lipoma of kidney (authors' case).

perhaps as a result of inflammatory hyperplasia, but in other
instances they are unquestionably truly neoplastic. As a rule,
they are not well differentiated from the stroma of the organ.
Lipomata are growths from the capsule in practically all
instances. They may, as illustrated in fig. 83, be of considerable
size, and though well differentiated from the renal tissue, they

TUMORS OF THE KIDNEY 245

may cause considerable pressure atrophy or erosion of the renal
tissue, as was the case with the Upoma illustrated. Myomata
are of two classes — leiomyoma and rhabdomyoma. The former
growth is commonly found in the capsule and is of small size.
Occasional isolated smooth muscle-cells may be found in some
fibromata. Rhabdomyomata, or striped muscle tumors, are
most frequently found in infants, and they are associated in most
cases with sarcomatous or teratomatous neoplasms. They are
often of large size, and infiltrate the renal tissue dififusely, so as
to make enucleation impossible without total nephrectomy.
iManifestly, they are usually more or less malignant, and in most
of such cases they grow rapidly and set up fairly early metastases.
As growths which also possess a semi-malignant nature at times
are the adenoma and papilloma. Adenomata are reported by the
older authors as relatively frequent, but as we grow more familiar
with the hypernephromata, most of us are inclined to place among
these many or most of the tumors previously considered as ade-
nomata. Thus two cases of adenomata of the kidney reported
by one of us have been subsequently classified as hypernephro-
mata. True adenomata of the kidney are probably rare. They
occur as well-encapsulated masses of tissue, made up of tubular-
like arrangements of epithelial cells, which resemble but do not
fuse with the tubes of the renal parenchyma. Adenomata are
chiefly reported as occurring in the cortex. Papilloma ta of the
kidney are seen almost exclusively in the pelvis. They are of
considerable importance, since relatively frequent and because
calculi are apt to form about them. They also probably even-
tually become malignant in a considerable percentage of cases.
Angiomata are usually found in the cortex of the kidney and are
commonly of small size. They are most likely to be found in
conjunction with hemangiomata in other organs, notably in the
liver, heart, or skin. They are probably mostly congenital in
origin, but may follow inflammation or the necrosis subsequent
to embolic infarction.

According to Kelynack, of all malignant tumors, those occur-
ring primarily in the kidney form but 3 per cent, of the total, but
Virchow reports, however, that 5 per cent, so occur.

A point of considerable interest is the fact that, of malignant

246 TUMORS OF THE KIDNEY

growths of the kidney, by far the larger percentage, even of the
carcinomata, are stated to occur in children, usually under fifteen
years of age. The writers' experience has been chiefly limited to
adults, which may account for the fact that renal new-growths
have been found so rarely by them. Thus in 656 consecutive
complete postmortem examinations, 40 cases of malignant tumor
were found, but three — one sarcoma and two hypernephromata —
of which occurred primarily in the kidney.

Carcinoma. — Carcinomata of the kidney are, as a rule, of the
tubular variety. They are often of the so-called roseate form,
and to the unaided eye appear to have a firm, dense, white center,
from which branches radiate like the spokes of a wheel. They
are frequently seen to be distinctly encapsulated, although micro-
scopically the tumor-cells are commonly found to have penetrated
this enveloping membrane. There can be no question but that
some cases reported as renal carcinomata are in reality hyper-
nephromata. Two instances originally reported by one of the
writers as primary carcinomata have been, in the light of more
recent research, properly included under the hypernephromata.
It is doubtless true, as has often been claimed, that renal calculi,
and particularly pelvic stone, play a part in the production
of carcinoma, generally of the epitheliomatous variety. Pelvic
epitheliomata, which are relatively frequent, originate from the
mucosa of the pelvis, and also arise from papillomata; indeed, this
possibility is, in the writers' opinion, one of the principal reasons
why operative procedure is so strongly indicated in these cases of
pelvic papillomata.

Sarcomata of the kidney are commonly seen in childhood, and
are generally of congenital origin ; they may be found well developed
at birth. As is naturally to be expected, these congenital sarco-
mata assume many of the characteristics of the teratomata. Thus
a considerable number of them are myosarcomata, often of the
class of rhabdomyosarcomata, and they contain elements character-
izing them as congenital neoplasms, and indicating that they origi-
nate as the result of improper fetal development of the intermediate
cell-mass. So far as the writers' experience with this class of
tumors goes, epithelial elements in the tumor are wanting; but
Larkin has recently shown such a tumor primary in or about the

TUMORS OF THE KIDNEY

247

kidney, and in which distinct gland-like acini and other unmistak-
able epithelial structures were present.'

As a rule, in sarcomata, both in the congenital and in the adult
variety as well, the general contour of the kidney is preserved,
although it is somewhat nodular. In the early stages, however,
the growths may be discrete and even encysted. Both kidneys
are involved in a surprisingly large number of cases. Cystic
sarcomata are relatively frequent, and in most cases they are
also of congenital origin. Round-cell, spindle-cell, and mixed-
cell sarcomata are also found to some extent, and angiosarcomata

and peritheliomata are

likewise known to oc-
cur. In some cases of
lymphosarcoma, or
Hodgkin's disease, sec-
ondary tumor-masses
histologically like
those of true sarcoma
appear in the kidney.
In a recent case of one
of the writers the
lymphomatous masses
were so sharply differ-
entiated from the renal
tissue in color and gross
structure that they ap-
peared to be distinct
and well-defined neo-
plasms. As with other secondary tumors of the kidney, these
growths are of little or no clinical importance. Endotheliomata
occur only as metastases.

There can be no question but that the most frequent tumor
that occurs as a primary growth in the kidney is that known
as the hypernephroma, or the " struma Upomatodes aberratae
renis " of Grawitz. A careful study of the tumors included in
the series of Kelynack, and even the descriptions of renal cancer,
adenoma, sarcoma, endothelioma, and the Uke, cannot but convince
1 "Transactions New York Pathological Society," March, 1908.

Fig. 84.— Microscopic structure of a h>-pertiephroma.
Authors' case (see text). Note varieties in size and shape
of cells.

248 TUMORS OF THE KIDNEY

one that many of these tumors really belong to this large but ill-
defined class of new-growths. The hypernephromata are said to
spring from bits of fetal tissue originally intended to develop into
adrenal bodies, but which become detached and incorporated in
the anlage for the kidney. In the larger number of cases, un-
doubtedly, they remain as harmless bodies in the kidney tissue,
and are often discovered postmortem in the form of round or oval
masses of pinkish or grayish tissue generally found in the cortical
portions of the organs, and usually well differentiated from the
remainder of the renal substance. Microscopic examination of
these bodies shows them to be made up of columns, sometimes
alveoli of large cells, rich in protoplasm, in which coarse oil-globules
appear. Pigment granules are often seen. The close resemblance
these cells bear to those of the adrenal body, particularly to the
cells of the zona glomerulosa, is often striking. It has long been
customary to describe such small growths as adenomata.

Under certain conditions, which are no better understood than
are the causes of other neoplastic growths, these islands of aber-
rant tissue begin to proliferate. At times the increase in size is
so rapid as to be easily discerned by a weekly palpation of the
abdomen. As an exception to this customary rapid progress may
be mentioned a case, recently reported by Richard Weil, in which
the growth extended over a period of fourteen years before general
or fatal metastases resulted. The writers have seen five cases of
this growth postmortem, and each has differed markedly, both
in clinical and in anatomic aspects, from the others. Only in
the histologic character of the new-growth could similarity be
traced.

Metastases are apparently transmitted both by the lymph-
channels and by the blood-vessels. Those the result of direct
extension have not been frequently seen in the writers' experi-
ence. As has been stated elsewhere, the malignancy of these
tumors and the rapidity with which metastases are formed render
prognosis in these cases particularly difficult. Great diversity exists
in the distribution of the metastases. Three of the five cases seen
postmortem by the writers showed early cerebral metastases,
whereas in one of the remaining two the first discoverable second-
ary growth appeared in the corpora cavernosa, the venous erectile

PLATE VIII

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DIAGNOSIS 249

Spaces of which became, within a few weeks, Hterally packed with
tumor-cells.

Frequently the primary growth in the kidney remains small,
although the general infection may be rapid. On the other hand,
the tumor may become of enormous size, and the general infection
be either slight or entirely absent.

As is to be expected from their origin, the growths may occur
either in youth or in adult life.

It is because of the great variety of the histologic pictures pre-
sented that these growths have frequently been reported as ade-
nomata, carcinomata, sarcomata, and epitheliomata. It is indeed
difficult to draw a picture typical of a structure whose chief char-
acteristic is its variability, for in certain cases the growth
closely resembles carcinoma; in others it simulates sarcoma; and
occasionally cells resembling syncytial cells are seen. Only by a
study of the structure of all the lesions presented, and largely by
excluding other growths, can the postmortem diagnosis be made
in those cases in which rapid growth and general infection have
taken place. When the tumors are small and localized in the
kidney or liver, the diagnosis is made easier from the close resem-
blance they bear to the normal adrenal structure.

DIAGNOSIS

As has previously been intimated, in a considerable number of
renal tumors, particularly when they are of small size, of slow
growth, or are situated in the capsule or the cortex, diagnosis is
impossible. As a rule, an early diagnosis of pelvic growths may
be made from the appearance of blood in the urine, which is
an almost constant symptom; and, in the case of papillomata,
from the presence, in the urine, of bits of the new-growth. The
chief feature in the diagnosis obviously is the presence of the tumor,
and this cannot, of course, be demonstrated until the growth has
reached a palpable size. Its renal origin may be distinguished
by the usually immovable fixation of the growth, its relation-
ship to the kidney region, and fairly often by its reniform shape.
The fact that it lies posterior to the intestine can usually be elicited,
if necessary, by the- inflation of the gut with air, and in some cases
a more pronounced bulging posteriorly than anteriorly serves as

250 TUMORS OF THE KIDNEY

an important diagnostic point. The firm and compact nature of
the tumor also helps to distinguish it from cystic kidney. Even
in those cases in which the tumors do not impinge directly on the
pelvis, hematuria is generally present. As a rule, it occurs peri-
odically, although when the growth is of considerable size, or when
it reaches the pelvis, hematuria may be a constant manifestation.
In those cases in which satisfactory palpation is not possible,
cystoscopy and catheterization of the ureters may determine
which is the diseased side.

As a rule, there are no marked symptoms. Pain in the renal
region, with a feeling of weight, may be complained of. This
pressure may cause more or less venous congestion of the superfi-
cial abdominal or of the spermatic plexus of veins; or perhaps
edema of the lower extremities may develop.

Radiography is often a most satisfactory means of making a
diagnosis, and occasionally a carefully prepared plate shows
a fairly clearly outlined shadow, and may indicate the extent
and location of the growth very satisfactorily even in obese sub-
jects.

When metastases have developed, their distribution and con-
nection with the direct vascular system or the lymphatic groups
of the kidney may be of some assistance, although, as stated
elsewhere, the most frequent renal tumor, the hypernephroma, is
very erratic in its selection of points for metastases. In some
rare instances the distribution and nature of these secondary
growths may even make clear the precise type of the tumor;
and when nodules are superficially located, as, for example, in the
inguinal lymph-nodes, removal of small bits of tissue for the pur-
pose of determining its character is certainly justifiable. In con-
sidering these renal growths, gumma of the kidney should always
be thought of as a possibiHty, although it occurs but very rarely.
Exploratory operation and direct palpation of the kidneys are
often demanded, and, considering the comparative safety of these
surgical measures, it is the writers' belief that recourse should be
more frequently had to this means of formulating an absolute
diagnosis.

Cachexia may or may not be present, and its absence, as well
as the absence of the anemia usually accompanying new-growths,

TREATMENT 25 1

is not to be considered as a contraindication that malignancy-
exists, since the sarcomata and hypemephromata often show
the gravest manifestations before severe cachexia or anemia de-
velops.

The precise variety of the growth can often be determined only
by a microscopic examination of bits of the affected tissue or by
inspection of the involved organs; yet, as a rule, we are justified
in diagnosing those tumors that occur in early life as either sar-
comata or hypemephromata, whereas those that appear later in
life are either carcinomata or hypemephromata.

TREATMENT

Ordinarily treatment for renal tumors is surgical, and should
be instituted as early as possible after a reasonably certain diag-
nosis has been made. The possibility of the growth being syphi-
litic should not, however, be forgotten, and a brisk antisyphilitic
treatment with careful observation of the result should precede
surgical intervention. Several cases on record in which Israel
removed gummatous kidney, having considered them malignant,
and two cases of our own, in which the growth disappeared under
mercurial inunctions, give face to this view. Clinically, the
increase in size of renal tumors is occasionally slow. One case of
probable hypernephroma in both kidneys without increase in
size has been under our observation two years. Surgical treat-
ment being refused, arsenic may be administered in the hope of
retarding the rapidity of growth. Direct inspection of the kidney
is justifiable if the existence of tumor can be reasonably demon-
strated, and if it can first be shown that the other organ is relatively
healthy, and that compensatory hyperplasia may be expected to
take place; nephrectomy is the operation of choice.

The use of the x-ray in the treatment of these new-growths has
not been attended with success. In considering this method as a
means of treatment we must take into account the probable effect
of this powerful agent, not only on the cells of the tumor itself,
but also on the highly specialized excretory epithelium of the kid-
ney tissue.

CHAPTER XVI

THE SURGERY OF THE KIDNEY

The examination of the kidney for diagnostic purposes has been
discussed in previous chapters. To repeat, percussion and bal-
lottement over the kidney area may give useful information.
Bimanually, the kidney region should be examined by having the
patient lie on his back on a table, with the legs drawn up, one
hand of the surgeon being placed under the back in the space be-

Fig. 85.— Bimanual examination of the kidney.

tween the border of the last rib and the crest of the ilium.the other
hand occupying the corresponding space over the abdomen in
front. The kidney may thus be examined between the two hands,
the surgeon increasing pressure as the patient exhales, the abdom-
inal muscle being contracted as little as possible. Another
similar procedure is that of having the patient lie over a table or
chair, the kidney being felt for bimanually, in the manner previ-
ously directed. It has been stated that in cases of pelvic tumors

252

THE SURGERY OF THE KIDNEY

253

if the pelvis is elevated, the tumor tends to fall toward the source
of its origin, and that by this method a differential diagnosis may
be made between a tumor of the kidney and one of some other
organ. The writers have not found this procedure of any value.
It has been their experience that, for the physical examination
of the kidney bimanually, that method with which the surgeon
is most familiar will yield the most information; that the ease
with which information can be acquired by physical examination

Fig. 86. — Examination of kidney with patient lying on side.

is very much increased by practice. Now that a keener interest
has been awakened in determining the physical condition of the
kidneys, it is to be hoped that the general practitioner will examine
the kidneys bimanually as a matter of routine more frequently
than was done in the past. Kidney dissections and operations on
the cadaver are of particular value in familiarizing one with the
situation and surroundings of these organs. In spite of the various
aids to diagnosis previously mentioned, some surgical conditions
will remain in doubt until the question be solved by an explor-
atory operation. This is particularly true of tumors of the kid-
ney, and more especially of those tumors that are either on or
connected with the organ, and yet interfere so little with the kidney
function that information cannot be obtained by means of urinary
examination or ureteral catheterization. This is not infrequently
the case when there is a question of stone or of tuberculosis.

254

THE SURGERY oF THE KIDNEY

In this chapter the following of)erations will be considered:
(i) The operation for the exploration of the kidney. (2) Neph-
ropexy, the operation of anchoring a displaced kidney. (3) Neph-
rotomy, the operation of opening the kidney for abscess, stone,
and similar conditions, (4) Nephrectomy, the operation of re-
moving the kidney, either in whole or in part. (5) The oper-
ation for performing ablation of the kidney. (6) Operations for

Fig. 87. — A, Loin incision; B, Edebohls' incision; C, Fig. 88. — Showing continuation
Israel's incision ; D, transverse incision. of Israel's incision.

the treatment of Bright's disease. (7) The operation for per-
forming lavage of the pelvis of the kidney.

OPERATIONS FOR THE EXPLORATION OF THE KIDNEY

The incision through the loin is the one that is ordinarily recom-
mended for exploring the kidney. The following is the descrip-

OPERATIONS FOR EXPLORATION OF KIDNEY

255

tion of the operation as laid down in the standard text-books,
with supplementary remarks as to such special details as have
proved most satisfactory in the hands of the writers.

Fig.qo.— Edebolils' pad for operations on kidney.

Fig. 89. — Illustrating the " Mayo" attachment to surgical table for operations on the kidney.

Before making the incision in the loin, the patient is placed upon
the side opposite
the one that is to
be incised. The
flank to be operated
upon is elevated by
sand-bags or, bet-
ter, by placing an
Edebohls bag under the opposite side. The guiding points are the
twelfth rib, the crest of the ilium, and the external border of the
erector spinae muscle. The incision should be begun about half an
inch below the twelfth rib, close to the border of the erector spinae,
and descend obliquely downward and forward until it is about a
finger's breadth from the crest of the ilium. (This incision is shown
in the illustration, fig. 91.) After dividing the skin, the superfi-
cial fascia, fat, and the latissimus dorsi, the internal border of the
external oblique muscle is exposed. Being incised, the internal
oblique and the posterior aponeurosis of the transverse muscle are
laid bare. Cutting through the aponeurosis, the yellow fat of the
perirenal tissues appears in the fatty capsule. This fat is much
more evident on the posterior than on the anterior surface of the

256

THE SURGERY OF THE KIDNEY

kidney. At times it resembles the peritoneum. This opened, the
operator should proceed with great care to remove the fatty cap-

Fig. 91. — Ordinary exploratory loin incision for exposing the kidney.

sule from the posterior surface of the kidney, feeling his way
with the finger until, experiencing a sensation of resistance, he
knows that he has reached the surface of the kidney. This
having been done, it is a very easy matter to palpate the vis-
cus. With the aid of a small pledget of gauze wrapped around
the finger the kidney may be lifted and its general appearance
observed; it may be brought up into the opening, and punctures
made with needles. It can be spUt longitudinally by the so-
called postmortem incision, and its cut surfaces examined, and,
if deemed advisable, it may be sewed up again with Lembert
sutures and returned, or smaller incisions may be made, as in the
operator's judgment may seem best. By the postmortem incision
the kidney may be split from pole to pole along a line continuous
with the convex surface, as shown in the illustration (fig. 98),
or various modifications of this incision may be made. If desired,
the operation may now be carried still further and the kidney
op>ened or removed. The Edebohls incision is also useful for
purposes of examination, or the abdominal incision mentioned
further on may also be employed.

These exploratory operations are becoming more and more
popular, and deservedly so; not only are they of value in ascer-

OPERATIONS FOR EXPLORATION OF KIDNEY 257

taining the nature of the process in the suspected kidney, but they
are of special value in enabling the condition of the other kidney
to be ascertained. Such operations are particularly useful, where,
if the one kidney is known to be diseased, a trace of albumin or

Fig. 92. — Illustrating loin incision for exploration of kidney. Appearance after incision of
skin and fatty cellular tissue.

some other indication be detected, which would indicate a possi-
bility of the other kidney being in an unhealthy condition.

It is being suggested of late, in certain conditions where the
kidneys are being explored, that it is well to resect a portion of any

Fig. 93-— After section of latissimus dorsi. Cross showing position of incision of the aponeu-
rosis of the transverse muscle.

tumor, or of the parenchyma of the kidney in certain cases, and
have a quick microscopic examination made which should give aid
in the diagnosis. Such procedures, unfortunately, are at present
17

258

THE SURGERY OF THE KIDNEY

to some extent more of a theoretic than they are of practical
value. The reason is that while the hasty examination in cer-
tain cases may be of benefit, in such conditions as tumors of
mixed form, quite a prolonged examination will be necessary in
order to determine the nature of the growth.

NEPHROPEXY

In performing the operation for fixation of movable or floating
kidney the patient should be placed on the abdomen over a sand-

Fig. 94. — The aponeurosis of the transverse muscle having been incised.

bag or an Edebohls pad. Make an incision that starts about two
and one-half inches from the spine, extending from the lower
border of the twelfth rib to the crest of the ilium, and nearly
parallel with the spine. The inventor of this incision suggests
that if this does not give room enough, the outer margin of the
quadratus lumborum be nicked, very near its insertion into the
crest of the ilium. An incision is made through the muscles until
the perirenal fat is reached, and carried through this until the
capsule of the kidney is exposed ; the patient's feet are then seized
and the body drawn toward the foot of the table. The Edebohls
pad, well inflated, is thus brought under the margin of the lower
ribs, and tends, in most cases, to press the organ up through the
incision and thus aid in exposing its posterior aspect.

It is difficult to advise as to the best method of anchoring the
kidney. The various operators all have different views on the

NEPHROPEXY

259

subject, and to make the matter still more confusing, from time
to time these views are modified and different methods suggested

F'g-9S-~"Edeboh]s' incision for exposing the kidney.

Fig. g6.-Sho\ving method of introducing sutures into exposed kidney, capsule having been
rolled back (Edebohls).

from those previously practised. Generally speaking, the opera-
tion of anchoring the kidney in its proper position used at present

26o THE SURGERY OF THE KIDNEY

consists in one of two methods — that in which the sutures are
placed through the true kidney tissue, and that in which they are
placed through the true capsule of the kidney. There are various
modifications of these methods, based on whether the capsule
should be removed entire or in part. The evidence is very con-
vincing as to the permanent retention of the kidney in this position
after fixation by the method advised by Dr. George M. Edebohls
and described by him in an article entitled " The Technics of
Nephropexy as an Operation per se and as Modified by Com-
bination with Lumbar Appendicectomy and Lumbar Exploration
of the Bile-passages," "Annals of Surgery," February, 1902. His
method is practically as follows :

The kidney having been exposed through the incision previously
mentioned, and freed, so far as necessary, by blunt dissection, is
delivered through the wound on to the back. The fatty capsule
is dissected off so as to expose the capsule proper through its entire
extent, and the kidney palpated. The iliohypogastric nerve is
drawn to one side out of reach of injury. If this cannot be done,
and the nerve must be divided, reunite the severed ends with cat-
gut after anchoring the kidney and before closing the wound.
Then a nick is made in the capsule proper near the middle of its
convex border, large enough to admit the tip of a grooved director,
and upon it the capsule proper is divided along the entire length
of the convex border of the kidney to a point half-way between
the upper and lower poles of the organ, and the capsule, by blunt
dissection on each side of the incision, is reflected forward and
backward toward the renal pelvis to a point about midway be-
tween the external and internal borders of the kidney. This will
leave one-half of the kidney denuded, the capsule being turned
back upon it like the lapel of a coat. Two sutures are then placed,
as is shown in the illustration (fig. 96) , on the anterior surface of
the kidney — one at the middle of the upper and one at the middle
of the lower half of the organ. Two other sutures are placed at
corresponding points on the posterior surface of the kidney.
Each suture runs parallel to the long axis of the kidney, and is
passed through the reflected capsule close to the line of the reflec-
tion, then through the underlying attached capsule, and runs along
beneath the latter between the capsule and the kidney substance for
a distance of two or three centimeters, when it again emerges through

NEPHROPEXY 261

the attached and reflected layers of the capsule. A Hagedorn
needle with a broad surface should be used, running it flatwise
between the capsule proper and the kidney substance to avoid
penetration of the latter. These sutures are then brought out to
and through the muscles, but not through the skin, to a position
corresponding to that in which they have been inserted. The
wounds of the muscles and fascia are closed by from four to six
sutures of forty-day catgut, passed in such a manner as to turn
the raw surface of the quadratus lumborum toward the exposed
kidney surface. This is effected by suturing the latissimus dorsi
and the lumbar fascia forming the outer lips of the wound to the
latissimus dorsi, the sheath of the erector spinae, and the outer lip
of the open sheath of the quadratus lumborum at the inner mar-
gin of the incision. Then the eight ends of the fixation sutures
are drawn tight so as to bring the denuded aspect of the kidney
in contact with the raw surface of the quadratus lumborum, and
the two ends of each of the four suspension sutures are tied to one
another. The suspension and muscle sutures are buried by clos-
ing the skin over them with the intracuticular suture. By this
method the denuded cortex of the outer half of the kidney is in
snug contact with the raw quadratus lumborum through the
entire length of the latter from rib to ilium. The dressing is
placed across the entire width of the back smoothly and evenly.

Since a small kidney can be well exposed through this wound,
the Edebohls incision is often best where stone is suspected.
The small kidney can be removed through this incision, but where
the organ is large, or a large abscess is present, or a graver condi-
tion exists, such as a suspected malignant growth, one of the other
incisions more ordinarily used for nephrectomy or nephrotomy
had better be employed. If, however, after making the Edebohls
incision as described it should prove insufficient, and a larger one
be required, one of the other kidney incisions may be employed;
or, as an adjunct to this, if necessary, the opening can be made
much larger than is ordinarily required.

This operation, or some modification of it, is the one recom-
mended by the writers for the use of those operators who do not
fear the after-effects of an adhesive inflammation that takes place
between the kidney surface, when it is denuded of its cortex, and
the muscles. It must be remembered, in this connection, that

262 THE SURGERY OF THE KIDNEY

it is the adhesive inflammation that holds the kidney in place.
At the present time, cases are being reported in which to anchor
the kidney the stitches are taken through the true capsule and kid-
ney tissue. As a result of passing ligatures through the kidney
tissue, Unes of scar tissue are formed, following the track in which
the ligatures are placed.

If it is desired to anchor both kidneys, the same procedure as
that outlined may be followed, anchoring one organ after the
other has been secured. Or, if it is desired, through the Edebohls
incisions made on each side of the erector spinae, both kidneys
may be brought through the wound and exposed, for purposes
of comparison.

Albarran* recommends, in anchoring a displaced kidney, if any
hydronephrosis is present, the kidney be retained in such a posi-
tion as to bring the ureteral opening at the most dependent part
of the sac.

NEPHROTOMY

This term is the one generally used to describe the operation of
opening the kidney; for example, when the kidney is opened for
the removal of calculi, nephrotomy is the term generally used to
describe the operation.

In performing this operation in the past it has been customary
to employ the loin incision previously described. If the operation
is done simply to open a pus cavity, the kidney should be
freed and brought as far up into the wound as possible, carefully
palpated, and an incision made into the most fluctuating portion
of the mass. After this has been done and the pus has been allowed
to escape, the cavity should be cleansed, a drainage-tube inserted
to the bottom of the wound, and the muscles and skin sutured on
each ^ide as far as the tube. After a few days the tube may be re-
moved and a smaller one introduced, or the wound be packed
with gauze, which should gradually be removed. By splitting
the capsule of the kidney, pushing it back a little on each side,
and then suturing the capsule to the walls of the wound a pocket
is formed at the bottom of the wound, which may be kept
open for observation as long as may seem desirable. The
French have applied the term nephrostomy to this procedure.
1 " Transactions Assoc. Fran^ais Urologie."

NEPHROTOMY

263

If this operation is performed for the purpose of releasing infected
urine from the kidney, rather than for simply effecting drainage

Fig. 97.— Method of attaching edges of kidney pocket to the abdominal wait (nephrostomy).

of a pus-cavity, Albarran advises that drainage be instituted
by the natural route in the following manner:

Fig. 98.— Kidney having been delivered through opetiing, assistant compressing pedicle; illus-
trating the so-called postmortem incision for exploration of kidney.

He catheterizes the ureter before the operation with a small
ureteral sound introduced into the ureter as far as it will penetrate.
After the kidney is opened, it is easy to make this sound penetrate

264

THE SURGERY OF THE KIDNEY

into the pelvis of the kidney ; then a larger sound may be attached
to this one and pulled down through until a No. 10 or 11 catheter
can be passed. The first sound that is passed by the aid of a
cystoscope is generally a No. 6. When the end of the large ureter

^^l

\:}y^

A

f

^

/^^^^El2i,

^

w

m

^

'^-'^^

-*-

Fig. 99. — Showing method of applying clamp to pedicle when impossible to deliver kidney
through opening (Bergerand Hartmann).

catheter has reached a suitable place in the kidney, it may be
fastened there by means of a ligature running out through the
lumbar opening, the other end of the sound, of course, protruding

Fig. 100. — Ureter ligated,^ separate ligation of blood-vessels (Berger and Hartmann).

from the urethra. To remove the catheter it is only necessary
to cut the thread and withdraw the catheter through the meatus.
Edebohls' incision may be used in performing nephrotomy when

NEPHROTOMY 265

the kidney is not too large and there is a large space between the
twelfth rib and the crest of the ilium.

When the operation of nephrotomy is performed for the removal
of stone, the kidney should be isolated as much as possible and
brought well up into the wound. A temporary ligature should be
placed around the portion of the kidney that joins the ureter,
thereby compressing the artery, or that portion of the kidney may
be compressed between the thumb and forefinger of the assistant.
If a stone can be outlined, it can be cut down upon and removed,
hemorrhage checked, and, if necessary, a few ligatures placed in
the kidney substance. If the presence of stone can be positively
diagnosed, the postmortem incision, or some modification of it,
should be made into the kidney, if the stone cannot be located by
other means. This incision, though very large, if carried to its full
extent, does not cut through a large number of blood-vessels, as
it runs nearly parallel to the urinary canal. It may not be necessary
to carry it the full length of the kidney — one or two centimeters
may be incised at a time, and the bottom of the wound exposed

Fig. loi. — Ligation of ureter, kidney delivered through opening (Berger and Hartmann).

until the pelvis has been reached. When the stone has been
found, it should be seized between forceps designed for the pur-
pose and removed; or, if closely incapsulated in the calices of
the kidney, it may be removed with a curet. If the stone is very
large and extends in various directions, the incision may be pro-

266 THE SURGERY OF THE KIDNEY

longed in the direction of the stone, which can be broken up with
forceps and the fragments removed. r

After a stone has been removed, others should be searched for
in the calices of the kidney. Retrograde catheterization of the
ureter with an elastic bougie should then be performed, in order
to determine that the ureteral canal is unobstructed. These
various procedures having been carried out, the wound in the
kidney should be sutured with two sets of sutures — a deep and a
superficial set; the compression of the pedicle of the kidney may
now be removed, the capsule of the kidney sutured, and the inci-
sion in the wall closed, with the exception of a short space in the
lower portion of the wound, where a small drain may be placed
for forty-eight hours. Some advocate, for the removal of stone,
opening the ureters just below the pelvis of the kidney — an opera-
tion known as pyelotomy. If this is done, the pelvis of the kidney,
easily accessible, may be examined through this opening by the
finger and the stone extracted; afterward the wound should be
sewed up and a drainage-tube inserted for a day or two, in case
urinary leakage should take place. If practicable, a still better
plan in these cases is to insert, in addition to the drainage-tube
left in the incision, a ureteral catheter, introduced through the
urethra.

NEPHRECTOMY

Nephrectomy is the operation by which the kidney is removed
entirely or in part. The ordinary loin incision, as described in
the operation of nephrotomy, is the one ordinarily employed for
this purpose, together with resection of a rib or a supplementary
incision, if necessary, to obtain the proper amount of room. This
procedure as generally carried out resembles nephrotomy, with
the exception that here it is more necessary to pull the kidney
well up into the wound so that the pedicle may be isolated and
properly ligated. Before undertaking nephrectomy, it is well to
ascertain positively that the other kidney is in a healthy condition ;
this is best done by ureter catheterization or by examination of the
organ through an exploratory incision. It is often very difficult,
as, for example, in suppurative diseases of the kidney, to bring
the kidney up into the wound, because of the adhesions. These

NEPHRECTOMY

267

must, therefore, be broken up, a proceeding that requires time and
patience on the part of the operator, who should not hesitate to
enlarge the incisions, where necessary, in the direction seemingly
most desired. He should have his assistant make counterpressure
and thus help to push the kidney through the opening.

The kidney having been well brought up into the wound, the
pedicle of the organ should be isolated. It is recommended that,
whenever possible, the blood-vessels and ureters be tied off sepa-
rately, and in tubercular cases it is wise to tie off the ureter
as low down as practicable, and also to cauterize the end of the
ureter left behind with a solution of carbolic acid, after which it
should be wiped off with alcohol. The passage of a bougie into
the ureter lends some aid in isolating it. If it is not practic-
able to separate the pedicle, so that the ureters and blood-vessels
can be tied off separately, a ligature can be placed about the entire
pedicle. In some cases it is so difficult to get at the pedicle that
it may be advisable to leave clamps in place in the wound for
twenty-four hours.
Ordinarily, after the
kidney has been re-
moved, the wound
may immediately be
closed if no pus has
been present. If the
condition is a sup-
purating one, more
or less inflammatory
infiltration taking
place into the sur-
rounding tissues, it
is advisable to leave
the wound open and
allow drainage to
take place from a
small opening at the

lower angle. In suturing the wound after nephrectomy, when-
ever practicable, three sets of sutures should be employed — a
deep set for the deeper muscles, a middle set, and a superficial set.

Fig. 102. — Showing curved line of incision in posterior
peritoneal wall to avoid injury to blood-supply of colon in
abdominal nephrectomy (Hartmann).

268 the surgery of the kidney

Abdominal or Transperitoneal Nephrectomy

The ordinary median incision, such as is used in making an
exploratory laparotomy, is also employed for effecting removal of
the kidney, or an incision may be made a little to the left or right of
and parallel to the median 'line, as the operator may see fit. Pro-
ceed as in the case of exploratory laparotomy, until it becomes
necessary to incise the dorsal reflection of the peritoneum. When
this has been done, the transversalis and fat should also be incised,
when the kidney will be reached; if any adhesions exist, they
should be broken up, the kidney delivered through the abdominal
opening, and the pedicle tied off as in extraperitoneal nephrec-
tomy. The opening in the posterior peritoneal wall should next
be closed, and then the corresponding opening in the anterior peri-
toneal wall should be sutured.

Much has been written, particularly in France, about the dan-
ger of injuring the blood-supply to the colon, and in order to
overcome this, some surgeons advocate the making of a curved
incision in the posterior peritoneal wall, outside and parallel to
the colon, as shown in the illustration (fig. 102). It is the practice
of some operators to establish counterdrainage of the postperitoneal
pocket, the place formerly occupied by the kidney, by making a
counteropening through the loin.

Partial Nephrectomy

The practice of removing portions of the kidney the seat of
traumatism or benign tumors is increasing. The operation is,
of course, essentially nephrectomy, except that only a portion
of the kidney tissue is removed. Hemorrhage must be carefully
checked, and the edges of the kidney wound then brought together
with one or two sets of Lembert sutures.

Although many of these operations are constantly being
reported, sufficient time has not elapsed to attest the value of this
procedure. Some compensatory kidney hypertrophy takes place,
and a considerable portion of the kidney may be removed, and
the remainder of the organ still continue to functionate, but in
tuberculosis, suppurative kidneys, and malignant disease, although
it often has been, and still is being attempted, the results of partial

NEPHRECTOMY

269

removal of the kidney are naturally not so good as in other con-
ditions that make the operation necessary or preferable.

It would be interesting to know just how much kidney tissue
can be removed, providing that left behind was in a healthy state,
and still have the organ functionate. As far as we can tell at
the present time, the amount is probably between one-half and
one-third ordinarily. Experiments on animals would tend to
show that still larger proportions can be removed, and such opera-
tions have occasionally been reported as having been success-
fully performed on human beings.

Ordinarily, in order to have a good union in performing par-
tial nephrectomy, a wedge-shaped or cuneiform piece should be

Fig. 103.

-Diagram illustrating method of resection of kidney (redrawn from Pierre
Duval).

removed from the kidney. When possible after a portion of the
kidney has been resected, the remaining parts should be brought
together by a double set of sutures — a deep and a superficial one
(fig. 103). Cases are commencing to be reported in which, for
an injury or wound to the kidney, partial nephrectomy is being
found to work successfully, and kidneys or portions of them
which would in the past have been removed, are at the present

270 THE SURGERY OF THE KIDNEY

time being saved. The operations for removing the kidney sac
are discussed under the heading of the Surgery of the Ureters.

Remarks on Nephrectomy. — There is, at the present time, no
one incision that may be considered as undeniably the best for
the purpose of cutting into or removing the kidney. The choice
of the incision to be used must depend largely on the particular
case in hand and on the personal equation and preference of the
operator. The somewhat brief description of the various opera-
tions on the kidney that has been given has reference to them as
they are ordinarily performed. The surgeon familiar with abdom-
inal work will be more likely to operate on the kidney through the
abdominal route than one unaccustomed to it. This method is
particularly valuable in those cases in which a large kidney is to be
removed, an extensive renal tumor excised, or when it is found
desirable to examine the appendix or other abdominal organs at
the same time. If the kidney is small and the space between the
border of the twelfth rib and the crest of the ilium is wide, Ede-
bohls' incision will permit examination of the kidney and probably
serve for its removal.

For general purposes, the Israel incision, as illustrated (fig. 87),
will be found satisfactory. This incision begins just below the bor-
der of the twelfth rib, about 3^ inches from the spine, runs down-
ward and outward to a point about an inch above the pelvic rim,
and then runs forward, keeping parallel with the rim of the pelvis
and about an inch above it. The incision should cut deeply through
the muscles of the back until the cavity in which the kidney lies
is reached ; it should then be carried onward slowly and carefully,
deep retractors being used, until it is large enough to permit re-
moval of the organ. Ordinarily, the peritoneum will be encoun-
tered at the junction of the incision with the anterior axillary
border. At this point, if it is desired to carry the incision further,
the peritoneum may be pushed ahead in front of the incision,
without being opened. The same course is followed if the long
transverse incision is selected. This incision is useful also in
removing a large kidney or one to which a large growth is attached.
Ordinarily, in performing nephrotomy or nephrectomy, the old-
fashioned loin incision, as illustrated in fig. 91, is a serviceable

NEPHRECTOMY 27 1

one. If the Edebohls incision is selected in any given operation
and it is found to be too small, the outer margin of the quadra tus
lumborum may be nicked near its insertion into the crest of the
ilium, as suggested by Edebohls. This method is especially
valuable when an examination of the appendix or other organs is
to be made, with a view to removal.

In operating for removal of the kidney, the chief danger lies in
hemorrhage, which is not ordinarily of the arterial type, but comes
from the veins or from the small vessels of the incised kidney.
Care should be used not to commence the incision too near the
spine, the wounding of an intercostal artery giving rise to profuse
hemorrhage.

Not infrequently, however, hemorrhage may seem more severe
than it really is, due to the fact that the cavity takes on
an exaggerated size, so that slight oozing may give the im-
pression of serious loss of blood. In such cases it is aston-
ishing to observe how quickly bleeding will cease when slight
pressure is made with gauze over the wounded surface of the
kidney; this, followed by careful sponging to remove the col-
lection of blood in the cavity, will leave a comparatively dry
operative field. If much difficulty is experienced in tying off the
ureter, the forceps may be allowed to remain in the wound for a
few hours after the kidney has been removed. It seems hardly
necessary to mention that a sufficient number of ligatures should
be placed around the ureter and the adjacent blood-vessels to
obviate secondary hemorrhage, and that after the kidney has
been removed, no attempt should be made to close the wound
unless it has been definitely ascertained that all bleeding has been
checked.

Sometimes the pleura descends lower in the back than usual and
may be wounded. If this accident occurs, it should be immediately
sutured and care taken that the patient is kept on his back for
several days.

The peritoneum is occasionally incised through inadvertence.
The incision should be immediately reunited with fine catgut.

The fatty capsule when met with should preferably be incised a
few inches on a director, as the finger can be more easily intro-
duced than if it is torn through. After the finger is introduced

272 THE SURGERY OF THE KIDNEY

it should be swept around over the surface of the kidney, patiently
freeing the organ from the adhesions between its surface and the
fatty capsule; then when it is well freed, if the fist of the assistant
makes firm counterpressure over the abdominal wall, it will aid
materially in delivering the kidney through the opening if the loin
incision has been employed. Sometimes the fatty capsule and
true capsule are almost grown together. It is easy to isolate the
ureter from the web-like tissue that surrounds the ureter and
blood-vessels if it is remembered that in the loin incision the ureter
is toward the lower end of the incision.

Under ordinary circumstances, after the removal of a kidney in
which no pus is found, the wound may be closed immediately
with three sets of sutures, two going through the muscles and one
through the skin. In performing nephrectomy in the presence of
an abscess cavity either in the kidney or in its immediate neigh-
borhood, a drainage-tube should be inserted following the opera-
tion, and the cavity treated as in the case of a pus-cavity existing
elsewhere in the body.

In the removal of a kidney, besides the difficulties that occur
because of the size of the organ and the presence of adhesions, in
very rare cases of renal or perirenal abscess the kidney itself is hard
to find, and sometimes, strange as it may seem, it cannot be dis-
covered at all, having been so extensively destroyed as practically
to have disappeared. In these cases, if a drainage-tube has been
inserted, all goes well while the tube is in position, but after its
removal recurrent abscesses or cysts are likely to form. In such pa-
tients the use of a permanent drainage-tube in the loin is indicated ;
this tube, while it may cause considerable inconvenience, will not
necessitate confining the patient to bed, nor will it hinder him
from performing his customary duties. Suppurating kidneys
that it is found difficult to remove at first may, after the pus-
cavity has been drained, be removed at a second operation with
more ease.

In removing the kidney it is advisable, under ordinary circum-
stances, to tie off the blood-vessels as the operation progresses,
instead of, as is often the custom in similar operations, to allow
the artery forceps to remain on any bleeding vessels until after
the operation is nearly completed. The operator will then not

NEPHRECTOMY 273

have the forceps in his way, as might otherwise prove the case.
Care should be used in making the sUght incision through the fatty
capsule before stripping it ofT from the capsule proper to avoid, if
possible, nicking the kidney surface. In dealing with a pus kidney
or a sac kidney the wall is apt to be very thin between the cavity
and the capsule of the kidney, and, therefore, easily punctured. It
is unwise to flood the field of operation with pus or other contents
of the sac if it can be avoided. It very rarely happens, but it may
occur, through the size of a tumor, through adhesions, or through
some malposition, that it is almost impossible to reach the ureter
and its accompanying blood-vessels so as to tie off the pedicle of
the kidney. In such a case either pole of the kidney may be
decapitated and large forceps put across the stump so as to arrest
the hemorrhage. This having been done, the pedicle of the kid-
ney can then be reached and tied off. The kidney will then only
be attached by the remaining pole, and can be easily removed.
Nephrectomy by morcellement is the name applied to this oper-
ation. In performing this, as in all operations on the kidney,
great care should be used in the selection of the clamps. Those
used should lock firmly, when no space should exist between the
blades. Clamps which tear through the structures should not be
used. Right-angled clamps will sometimes be found of use in
performing nephrectomy. In partial or complete nephrectomy,
at least a quarter of an inch of tissue should be left on the outer
side of the clamp, so that the pedicle or any portion of the kid-
ney held by the clamp may not slip out from under it when the
kidney is removed. We consider this advice important, as
failure to carry out this detail in an operation performed by one
of us was responsible for the severed pedicles sUpping from under
the clamp. When this unfortunate accident occurs, immediate
attempts should be made, through the means of long forceps, to
catch the bleeding vessels at the bottom of the cavity. This
done, difficulty may be experienced in ligating them beyond the
end of the clamp at the bottom of the cavity, but a series of
ligatures surrounding the clamp into the surrounding tissues,
each put a little lower than the other, will make it possible to
eventually ligate the vessel beyond the end of the clamp. Fol-
lowing nephrectomy, the cavity should be carefully examined
18

274 "^"^ SURGERY OF THE KIDNEY

with a portable electric light to see that no bleeding points
remain or tear in the peritoneum exists.

In removal of tumor of the kidney the operator should be
guided to a great extent by the conditions present in any given
case, and whether nephrotomy, nephrectomy, partial or complete,
or nephrectomy with ablation of the ureter as completely as pos-
sible, should be done will depend upon the circumstances surround-
ing any given case, such as the nature of the tumor, its get-at-
ability, and the condition of the other kidney.

Cysts of the kidney, when due to such conditions as hydatids,
should be removed entire without being opened, the kidney sewed
up, and preserved. In malignant tumors or tubercular growths
nephrectomy should be performed. Albarran states that when he
operates on both kidneys he always operates on the best one first
in order that he may know and have some idea as to how much
healthy kidney tissue there is in the body. Many surgeons prefer
the abdominal route for the excision of large tumors. It is
astonishing what little difference there is in the death-rate between
the abdominal route and the extraperitoneal route, as shown by
statistics in nephrectomy. It is recommended in operating for
malignant tumors that care should be used to remove the supra-
renal capsule and ganglia as much as possible ; this applies only to
one-sided growths.

Nephrectomy should be performed for tumors of the pelvis of
the kidney. These tumors are comparatively rare, and are most
often papillomata. When possible, it has been recommended, in
such cases, to remove the ureter completely, as papilloma of ureter
is apt to be present. Tumors of the capsule of the kidney, under
ordinary circumstances, if benign, should be removed without
removal of the kidney. Nephrectomy is the operation for tumors
of the kidney in children, which are almost invariably malignant,
and generally, even after successful removal, recur. In some
cases microscopic examination of the tumor at the time of oper-
ation may aid, but it is apt to be unsatisfactory.

Mayo, of Rochester, has recently invented a table, or an appro-
priate top for a table, on which to perform operations on the kid-
ney, of which there is an illustration in this work (fig. 89).

SURGICAL TREATMENT OF BRIGHT'S DISEASE 275

ABLATION OF KIDNEY
G. Gayget and P. Caraillon* report that they have carried on
a series of experiments on dogs in which the kidneys have been
ablated. They also report the results of autopsy on a patient on
whom this procedure was carried out. They performed ablation
simply by tying the ureter along its course, the kidney being thus
allowed to remain, but being prevented from performing its func-
tion. Judging from their experiments the result would seem to
be a distention of the ureter above the ligature, distention of the
pelvis of the kidney, gradual destruction of the kidney-cells, the
conversion of the kidney into a sac filled with fluid ; in other words,
hydronephrosis must inevitably. ensue. Curiously enough, their
experiments seem to show that after a considerable length of time
this fluid becomes absorbed and the kidney is transformed into a
very small dry sac. Hypertrophy of the other kidney takes place.

SURGICAL TREATMENT OF BRIGHT'S DISEASE

The treatment of interstitial nephritis and pyelonephritis by
means of contintwus catheterization of the bladder has been advo-
cated by Arthur T. Cabot, ^ who endeavors by this means to
secure rest for the inflamed and weakened kidneys. The method
is recommended in cases in which there is interstitial nephritis in
the aged, associated with a frequent desire to micturate and but
little inflammation of the bladder, or slight obstruction at its
neck. The writers have seen such cases cUnically, and believe
they are not infrequent, although postmortem evidence as to
just the anatomic condition at fault is lacking. Such a pro-
cedure may be of use in cases in which the weakened state or
other conditions render more active procedure impossible or in-
advisable.

Many surgeons have, for some time past, been advocating the
operative treatment of Bright's disease, but the results of these
operations thus far have not, in our opinion, been attended with
the desired success. By their efforts, however, the subject of
kidney surgery has been broadened, and they have, in addi-

1 "Etude exp^rimentale en Clinique de I'Exclusion Renale," "Journal de
Maladies des Organs Genito-Urinaire," vol. xxii, No. 5, 1904-

■' " On the Treatment of Interstitial Nephritis and Pyelonephritis by Con-
tinuous Catheterization of the Bladder." " Boston Medical and Surgical Jour-
nal," 1904.

276 THE SURGERY OF THE KIDNEY

tion, improved the operative technic and given a clearer concep
tion as to the extent of surgical interference that will be tolerated
by the kidney.

Decapsulation of the kidney, which has been recommended
from time to time for the relief of Bright's disease, is effected by
the same general methods of operating on the kidney as those
previously described. There is great diversity of opinion regard-
ing the good results to be attained from this operation, and the
death-rate is quite high. As illustrative of the extent of surgical
interference the kidney will tolerate is the fact that in some in-
stances patients survive after repeated decapsulation of the organ.
It is possible that more good follows the splitting of the capsule
than its removal. It has long been known that in certain cases
of persistent renal hemorrhage relief will follow an incision into
the kidney. This is probably due to the fact that tension is thus
relieved, and that the formation of cicatricial tissue, which appar-
ently follows decapsulation, does not take place after incision.
The operation is, therefore, to be recommended in certain cases of
nephritis attended with hemorrhage. For suspected nephritis
with persistent pain in and around the region of the kidney, it
may be advisable to make an exploratory operation. If no excit-
ing cause is found outside the kidney, splitting of the capsule of
the organ should ordinarily cause but slight damage, and may
give an insight into the true state of the kidney. In some cases
this procedure may give diagnostic aid; it should not be per-
formed too frequently, but reserved for those cases in which the
most exhaustive general measures have failed to lead to a correct
diagnosis, and in which careful, painstaking, and prolonged treat-
ment by nonsurgical methods has given no relief from hemor-
rhage or pain.

It is to be hoped that in the near future clearer views will be
had as to the proper procedures to adopt in the surgical treatment
of Bright's disease than at present exist. One reason why the
statistics on the operative results of the past are of so little value
is that the diagnosis of the disease and the amount of improve-
ment following the operation have been based on the results of
urinary examinations, which have been shown to be often
misleading.

While our experience has not been such as to convince us of

LAVAGE OF THE PELVIS OF THE KIDNEY 277

the great benefit to be derived from the operative procedures
advocated for the cure of Bright's disease itself, it has been such
as to lead us to believe that, through increased abihty on the part
of the profession to diagnose diseases of the kidneys, there will
be a corresponding increase in the number of diseased conditions
found that will be amenable to surgical treatment.

LAVAGE OF THE PELVIS OF THE KIDNEY
Lavage of the pelvis of the kidney through the ureteral catheter
is so easily carried out, once the physician becomes familiar with
ureteral catheterization, that the method is now being frequently
employed for the relief of pyelonephritis and its allied conditions.
The solutions generally employed are silver nitrate, not stronger
than 1 : 10,000, boric acid, argyrol, protargol, or albargin. Ordi-
narily, the irrigations should not be made oftener than once a
week. The ureteral catheter having been introduced, the con-
tents of a small syringe, containing from i to 4 ounces of the solu-
tion, are very slowly injected through the outer end of the cathe-
ter, the syringe is removed, and the injected fluid is allowed to
flow out through the catheter. The catheter is then removed, or
a small amount of fluid may be injected as the catheter is removed
with the object of distending the pelvis of the kidney and the
ureter. If too much or too strong a solution is used, renal colic
may ensue; the procedure is often followed by a sensation of
fullness in the kidney.

Judging from the carefully recorded histories of the cases of
Casper and Richter, the results following the use of this method
are not such as to encourage the belief that practical benefit will
accrue in any large number of cases. In certain cases it appar-
ently tends to hasten the disappearance of pus in the urine in cases
of pyelitis.

The chief difficulty that confronts us in estimating the true
value of the aforesaid procedure in the treatment of pyelonephritis
is that a correct diagnosis is not always possible, some observers
considering pyuria to be present when only a few leukocytes are
found in the urine. Repeated investigations will be necessary before
a correct estimation of the benefits to be derived from this pro-
cedure can be safely made ; the writers believe that it has but a
limited range of usefulness.

CHAPTER XVII

ANATOMY, PHYSIOLOGY, AND PATHOLOGIC ANATOMY
OF THE URETER

ANATOMY AND PHYSIOLCXJY OF THE URETER
The ureters are hollow tubes, from fourteen to sixteen inches
in length, that conduct the urine from the kidneys to the bladder.
Embryologically, as anatomically, they are direct continuations
of the pelvis of the kidney and they are formed from an offshoot
of the Wolffian duct. They lie behind the peritoneum, and enter
the bladder at its base in an oblique direction, in such a manner
than when the bladder is distended, the resulting pressure auto-
matically closes the ureteral orifice. They are made up of an
inner mucous membrane of transitional epithelium, laid down
upon a delicate supporting tissue, external to which is found a
coat of smooth muscle, consisting of an internal longitudinal
and an external circular layer. This is invested by a fibrous
connective-tissue sheath in which circular elastic fibrils are plenti-
ful. Normally, the walls of the ureter are collapsed and in contact.
Cross-sections show the collapsed lumen thrown into longitudinal
folds giving a stellate outline. The normal distended lumen
measures but from two to four miUimeters in diameter. Under
numerous conditions, as in hydronephrosis or pyonephrosis,
however, it may become considerably dilated, and may even per-
mit the passage of a stone 2 cm. or more in diameter. As a
rule, however, stones of this size are almost certain to lodge in
the renal pelvis, or if they enter the ureter, at the entrance to
the bladder.

The propulsion of the urine through the ureter is not a simple
matter of gravity, but takes place as a result of peristaltic waves,
originating in the pelvis of the kidney and passing downward.
These contractions occur every few seconds and force the urine
before them by a series of rhythmic spurts. This peristaltic mus-

278

PATHOLOGIC ANATOMY OF THE URETERS 279

cular action accounts in large measure for the facility with which
masses of necrotic tissue or calculi are forced through the lumen
of the ureters.

The ureter receives its nerve-supply from the inferior mesenteric,
spermatic, and hypogastric plexuses. Its contractions are, how-
ever, probably due largely to automatic muscular movements.

PATHOLOGIC ANATOMY OF THE URETERS

Malformations of the ureters are by no means uncommon, one
of the most frequent of these being an unusual point of entrance
into the bladder. At times both ureters discharge through the
same papilla, or occasionally only one ureter exists, associated
perhaps with horseshoe kidney or some other renal abnormality.
These variations should constantly be borne in mind in perform-
ing cystoscopic examination.

Most of the pathologic changes of the ureter are practically
identical with those of the renal pelvis or bladder. It is there-
fore chiefly concerned with various inflammatory diseases, and
with the results of and the passage of urinary calculi.

Tumors of the ureters are papillomatous, cystic, or carcinoma-
tous in type. They are almost invariably associated with, or a
part of, growths in one of the adjacent organs, especially in the
bladder or kidney. Primary growths of the ureter have been
reported, but are so rare as to be regarded in the light of surgical
curiosities. In the writers' experience but a single primary tumor
of the ureter has been found — that an epithelioma situated near
penetration of the bladder-wall.

Cysts of the ureter are occasionally reported; two such cases
were presented before the New York Pathological Society during
1907 (Bond Stow, Otto Schultze), and a considerable series of
these cases has been collected by Harris.' They are of relatively
small clinical importance, though most interesting from the pathol-
ogist's standpoint. They are probably inflammatory in origin.

Inflammation.- — The ureters are histologically a continuation of

the bladder structures and, to a considerable extent, of that of the

urethra; hence when subject to irritation, similar conditions as

occur in the bladder and urethra will naturally ensue after infection

' "American Medicine," vol. iii, p. 731.

28o ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF URETER

or irritation from any cause. Obstruction of the mouth of the
ureteral glands gives rise to an exudative inflammation with
ulceration or cyst formation, the ureters showing a particularly
strong tendency toward the development of these cysts. As a
final result of acute inflammatory processes there is a predisposi-
tion to the formation of scar tissue, resulting in stricture; never-
theless, in studying the literature on the subject of diseases of the
ureters it is somewhat astonishing to observe with how little
frequency strictures of the ureter have been reported. As the
result of the writers' observations, moreover, they believe that
stricture of the ureter is not so infrequent as is commonly supposed,
and that the subject is worthy of more attention than it has
received in the past. Attempts at catheterization of the ureters
have recently resulted in the finding of an increased number
of such strictures. As illustrative of a not uncommon class may
be cited a case that recently came under the care of one of the
writers. On attempting to catheterize the left ureter, renal
calculi being suspected, although the mouth of the ureter could
be made out and there was apparently no other obstruction,
still it was found impossible to pass a very small catheter — the
smallest available — because of contraction of the mouth of the
ureter. No history or clinical sign indicative of ureteral stricture
was manifest.

Stone. — A stone in the kidney, as it works its way down into
the ureter, gives rise to intense pain of a stabbing or burning char-
acter. This pain begins in the back, extends around to the side
and down the groin, in a manner characteristic of almost all forms
of renal colic. Not very infrequently a stone lodging in the ure-
ter will cause a distention of the tube and set up hydronephrosis.
These cases are generally differentiated easily from diseased
conditions of the cecum or appendix, by the usual clinical signs,
and examination of the urine either with or without cystoscopy
is a method of great assistance.

The ureters occasionally suffer from traumatism, although they
are so well protected and are placed so deeply that injuries are
comparatively rare. A few cases have been reported as the result
of knife and shot wounds.

The ureter is frequently diseased as the result of downward

PLATE IX

Dr. Bransford Lewis's case of three ureters, demonstrated during life by ureter
catheterization and radiograph. Gonorrheal infection of one of the three ureters.
Permanently relieved by ureteral lavage.

PATHOLOGIC ANATOMY OF THE URETERS

28l

extension of a lesion of the renal pelvis, or it may suffer from in-
vasion by way of the bladder. In some severe types of urethral
stricture with retention of urine dilation of the ureters occurs.
Fig. 104 illustrates such a condition. This principle is applied in
the treatment of calculi retained in the ureter, and it has been
suggested that the bladder be distended with some warm fluid ;

Fig. io4.^Showing dilation of the ureters and p)elvis, with excavation of the pyra-
mids, caused by long-standing stricture of the membranous urethra (one-third natural
size) (specimen from the Museum of Carnegie Laboratory).

the walls of the ureters might thus be increased in diameter,
permitting the stone to pass through more easily.

Tuberculosis may attack the ureter as the result of the exten-
sion downward of tuberculous disease of the kidney, or by
an upward extension from a similarlv diseased bladder. The

282 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF URETER

process is said occasionally to give rise to distention of the ureter
or to its obliteration by stricture formation.

Much has been written about kinks in the ureters, particu-
larly in connection with floating kidney. The so-called Dietl's
crisis, described elsewhere, is believed to be due to this cause,
a belief that is not fully borne out by postmortem findings. The
writers explain the occasional occurrence of this symptom-com-
plex as being due to spasmodic contraction of the ureter under
certain nervous stimulation similar in nature to like spasmodic
contractures of the urethra or esophagus. These contractions
are believed to be accelerated or inaugurated by any slight local
lesion that exists in the ureter. In some cases the gravid uterus
may press so severely on the ureter as to cause obstruction or
even serious damage to the tube.

Not infrequently the ureter is the seat of stricture or fistula,
the result of injury inflicted on the tube or adjacent tissues during
operation or from the passage of stone. The fistula due to injury
of the ureter following operative procedures manifests itself by
the presence of the perforation either at the site of the original
wound, or perhaps in some other structure of the body by the
discharge of urine. Wounding of the ureter during the course of
an operation is generally made apparent by the immediate pres-
ence of urine in the wound. The ureter is occasionally tied dur-
ing an operation, particularly on the uterus or its appendages.
If both ureters have been ligated, there is an immediate cessation
of the urinary flow. On attempting to pass a ureteral catheter
an obstruction will be encountered, which, together with the
total suppression of urine, will generally disclose the condition.
Fortunately, in such cases, when the wound is reopened and the
ureters are freed, they will ordinarily resume their function even
if the constriction has existed for several hours. If only one ureter
has been tied, and the condition remains unrecognized, hydro-
nephrosis ensues. If the ureters have been tied off but a little
distance from the kidney, this will probably manifest itself in a
few days by the occurrence of a swelling, owing to the distention
caused by the retained urine in the kidney ; or, on the other hand,
there may be marked distention of the ureter, giving rise to a
tumor that, on being opened, will be found filled with urine.

PATHOLOGIC ANATOMY OF THE URETERS 283

Wounds of the ureter discovered or inflicted during operation
may be immediately sutured, with or without the introduction of a
ureteral catheter. In suturing wounds of the ureter that have been
made for the removal of calculi, great care should be exercised
not to penetrate the mucosa of the tube. Fine silk ligatures,
which may afterward be buried in the tissues, or any very rapidly
absorbing catgut, may be used. In such cases it is well to leave
a drain at the angle of the wound for a few days lest leakage
occur. In such a case recently under the writers' care a ureteral
catheter was allowed to remain with its extremity in the pelvis
of the kidney for thirty-six hours, after which it was removed;
no further leakage occurred. The treatment of wounds is again
referred to in the chapter on Surgery of the Ureters.

When a stone in the ureter has become impacted and makes
no further progress toward the bladder, it may occasionally be
pushed up toward the kidney and thus easily reached through a
lumbar incision. The various operative procedures for the relief
of diseased conditions of the ureters will be described further on;
it remains to consider here briefly the methods of inspection of
the ureters as an aid to the diagnosis.

Diagnosis. — The value of the ^-ray and ureter catheterization
for diagnostic purposes is so well known as to require nothing but
mention here. Palpation of the ureters when carefully practised
is occasionally of considerable aid in diagnosis. In the chapter
on Diseases of the Kidney the valuable aid that may be obtained
from palpation and massage, along the course of the ureters in the
diagnosis of pyuria has been mentioned. Other things being
equal, it follows that a bimanual examination of the ureters may
be more easily made in a thin than in a stout subject. Continual
practice, however, will increase the skill of the examiner.

It has been claimed that, by the introduction of a finger into
the rectum above the prostate, diseased conditions of the ureters
can sometimes be detected. The writers have never been able
to determine to their satisfaction that a lesion of the ureter could
be thus accurately differentiated from an enlarged and diseased
seminal vesicle. This method of examination is, however, recom-
mended by some. In a woman it may be possible, with one hand
on the abdomen and a finger in the anterior vaginal culdesac, to out-

284 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF URETER

line a swollen ureter, but great care must be observed not to con-
found this condition with some diseased state of the ovary, tube,
appendix, or intestine.

As has been said, the two greatest aids that are at our command
in diagnosing diseased conditions of the ureters are ureter cathe-
terization and the :r-ray, or a combination of both.

The x-ray, in the hands of one skilled in its use, will sometimes
demonstrate the presence of a stone in the ureter very clearly.
Some admirable specimens of this work have been made, illus-
trating the passage of the stone down the ureter into the bladder.
The pictures were taken in frequent succession, and showed the
stone in many positions in the ureter as it proceeded on its journey.
A good illustration of the aid to be obtained from a combination
of the two methods was the taking of an x-ray picture of a sub-
ject in whom a metal ureteral catheter had been introduced from
the bladder into the kidney. The metal catheter was distinctly
seen in the picture, and outlined the course of the ureter very
clearly. It is doubtful, however, if the adoption of this proce-
dure as a routine practice for the determination of the movability
of a kidney, as recommended by some, will ultimately be of great
value. Metal catheters, after all, must be used with considerable
care in the ureters and are not to be employed in all cases, but,
as has been mentioned under the head of Floating Kidney, metal
catheters introduced through the ureter into the kidney, followed
by the taking of a radiograph, are very helpful in those cases in
which it is necessary to differentiate between a floating kidney
and a new-growth.

CHAPTER XVIII

SURGERY OF THE URETERS AND FOR THE RELIEF
OF HYDRONEPHROSIS

Much has been written in the text-books on surgery regarding
the various routes by which the ureters may be reached. For
practical purposes, the lumbar inguinal incision, as illustrated in
the cut (fig. 105), will enable one to find the ureter in most any
portion of its course. The incision may be begun just below the
twelfth rib, or further along toward the inguinal region, and may
be prolonged as far as necessary, the peritoneum, when met with,
being pushed ahead of it. The ureter may also be reached through
an abdominal incision, in much the same manner as the kidney
is reached; or by finding the posterior wall of the bladder, the
ureter may be followed along its course.

Statistics show that the best results are obtained if the ureter
can be reached by the extraperitoneal route. The increasing
facility with which ureter catheterization can be performed, being
often a comparatively simple procedure, will aid one in finding
the canal if a ureteral catheter has been introduced previous to
the operation. Gynecologists, in operating on ovarian tumors,
will undoubtedly find this of service, since by its use, in certain
cases, wounding of the ureter may be avoided.

For purposes of description operations on the ureter may be
divided into three principal classes: (i) Operations involving
the opening of the ureter into the kidney ; (2) operations concerned
with the portion of the ureter that opens into the bladder ; (3)
operations for wounds of the ureter or for the removal of stones
from, or for the relief of strictures of, the ureter.

ClAss I. — ^The operations coming in this class are most gener-
ally practised for the relief of renal retention of urine. Several of
the conditions in which these operations are indicated are shown
in the illustrations. In some cases the pelvis of the kidney
becomes so greatly distended as the result of hydronephrosis
that almost the entire length of the ureter has to be resected

285

286 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

and the kidney pelvis fastened directly to the bladder. When
the hydronephrotic kidney assumes the form of a pocket that
hangs down beside the ureter, a direct anastomosis may be made
between the lower portion of the sac and the ureter. In these
cases valves may form between the ureter and the pelvis of the
kidney; such valves may generally be destroyed by incision.
Israel and Albarran have advocated the suturing together of the
renal pockets that sometimes form, in cases of hydronephrosis,
behind the ureteral opening. The suturing together of the
pocket should be done in such a manner as to prevent the urine

mui(M(u|U||uu, il

Fig. 105. — Lumbar iliac incision for discovering the kidney and ureter in its whole
length (after Pierre Duval).

from accumulating in the back part of the pouch. In order that
these operations be successful it is necessary that the renal pocket
be shallow. When a thick pocket, containing some of the kidney
tissue, exists below the opening of the ureter, resection of the
portion of the kidney beneath the ureteral opening may be per-
formed.

The operation of Kiister* is only performed for very tight
stricture of the ureter. The ureter is cut off obliquely below the
stricture, an incision is made in the anterior surface of the ureter,
' Frisch and Zuckerkandl, 1904.

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 287

it is drawn into an opening in the anterior surface of the pelvis,
flattened out, and sewed in place. The primary wound in the
sac of pelvis is sewed up (fig. 106).

Fig. 106. — Ureteropyeloneostomy (Kiister): A — a, b. Sac-wall; C, incision through
ureter; B — b, c, anterior surface of split ureter, with sutures that draw up surfaces of
ureter to wall of pelvis; C — a, upper end of ureter; a, c, anterior incision of ureter;
D, ureter laid open after incision (redrawn from Frisch and Zuckerkandl).

Trendelenberg^ recommends the following operation for
hydronephrosis : A lumbar incision is made, the sac punctured
with a trocar and opened by incision. The redundant portion
of the sac and the included portion of the ureter are dissected off.
The stump of the ureter is then sewed into the lowest portion of
the remaining sac. The incision into the sac is then sutured. A
small drain is placed in the ureter and another in the pelvis, both
leading out through lumbar wounds.

^ " Deutsche Zeitschrift fur Chirurg.," 1904.

288 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

An illustration (fig. 107) is also furnished, showing the method
of destruction of the renal valves which so frequently form between
the pelvis of the kidney, and the ureteral opening, where a hydro-
nephrotic sac is present. It is easily seen how the anterior wall
of the valve is divided, being held between two forceps, and the
subsequent suturing which takes place. In this, as in several
other of the operations mentioned above, retrograde catheteriza-
tion by means of a ureteral catheter will be found useful.

Fig. 107. — Operation for incision and suture of renal valve (redrawn from Pierre Duval).

It should, of course, be borne in mind that in the past neph-
rotomy has often been the operation of choice for the relief of
hydronephrosis. When nephrotomy is performed, however, and
the sac opened, a urinary fistula results which may persist for
months. To a great extent the operation of nephrotomy is being
superseded for the relief of retained renal secretion by some of the
methods mentioned above. Referring to these operations more in
detail, a remark of Israel's may well be quoted here. He has well
stated that for the relief of hydronephrosis it is necessary to remove
the cause. In a large proportion of the operations for the relief
of hydronephrosis, anchorage of the kidne}' in a proper position

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 289

is required. Rarely, although occasionally, it alone may suffice,
but ordinarily it should be performed in connection wHh some
other operation. Albarran considers* that the three most useful
operations are those for the resection of the sac, of lateral anasto-
mosis of the ureter, and pyeloplication, which is the operation of
Israel.

In resection of the sac, the sac having been punctured and
emptied, the clamp is placed as shown in the illustration (fig. 108),

Fig. 108. — Operation for resection of hydronephrotic sac (redrawn from Pierre Duval).

the sac is amputated, lumbar drainage is instituted, and a ureter
catheter is allowed to remain. This operation was, we think,
first performed by Albarran. The operation of lateral anastomosis
is easily understood from the illustrations. The ureteral catheter
in No. 1 1 acts as a splint for the new ureteral orifice, and is tempo-
rarily fastened in place by a thread emerging through the nephrot-
omy wound. In suturing the orifice, the second set of sutures are
used to reinforce the first.

' " Transactions in Urology," 1904.

19

290 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

The operation of Israel is as follows':

The operation consists of the following steps:

(i) The occlusion of the pelvis of the kidney to such an extent
that the origin of the ureter lies in the most dependent portion of
the reservoir.

(2) The lessening of the volume of distended pelvic cavity of
the kidney.

(3) The forcing down of the upturned neck of the ureter.

An incision is made into the posterior wall of the pelvis for
exploration, and then sutured. Catgut sutures are then inserted
into pelvis of the kidney, 1.5 cm. from the sutured exploratory

Fig. 109. — Op)eration for lateral anastomosis of ureter (redrawn from Pierre Duval).

incision, each being separated 5 mm. from the rest. All sutures
pierce the walls of the pelvis of the kidney, diverging markedly.
The suture is brought out 5 mm. from the exploratory incision,
introduced again posterior to the exploratory incision 5 mm. away,
and finally brought out at a point at the widest distance between
the hilum of the kidney and outlet of pelvis. When these sutures
are tied, the distended wall of the pelvis is no longer present, and
the newly formed base of cavity is in a line from hilum of the kid-
ney to the mouth of the ureter. If the neck of the ureter is turned
upward, the following operation is done for its correction. A suture

* James Israel " Chirurgische Klinik der Nierenkrankheiten," May, 1901.

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 291

is introduced into the lower wall of the pelvis, i cm. above the
angle of ureter, is carried for 5 mm. into its substance ; it is rein-
serted below the point of angulation, and carried for several milli-
meters into the muscular wall, and then brought out. After

Fig. 110. — P}'eloplication and ureter correction. Posterior view of left kidney.
e. Exploratory incision; S, S, sutures for the pyeloplication of the sac ; U, suture to coi-
rect shape of ureter (redrawn from James Israel).

tying this suture the ureter is then brought down to its proper
position.

Class II. — The most frequent operations to be considered
under this head are those ordinarily performed for those cases
in which, as the result of injury, the lower opening of the ureter
is transplanted into another portion of the bladder than that into
which it originally opened. The ureter having been exposed by
whatever seems the most desirable route for the case in hand, may

292 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

be made to enter the bladder at a right angle or in an oblique di-
rection, as shown in the accompanying illustration (fig. iii). If
it is made to enter in an oblique direction, it should be firmly
fastened by sutures carried through the external bladder-wall, with-
out penetrating the inner coat of the bladder, for an inch, when
possible, before the mouth of the ureter enters the bladder-cavity

directly. The length
of the adherence
of the course of the
ureter to the blad-
der tends to make
the bladder act as a
splint to the ureter
and holds the latter
in place.

Operations have
occasionally been
made for the pur-
pose of transplant-
ing the mouth of the
ureter to the skin,
the vagina, rectum,
and the urethra.
Such operations are
sometimes per-
formed to give temporary relief after an operation for malignant
disease.

The most common operative procedures coming in this class
are those practised for the transplantation of the end of the ureter
into another portion of the bladder, as just described, and the
operation of transplanting the mouth of the ureter into the intes-
tinal canal. At the present time, the anastomosis is most gener-
ally made into the rectum. Such anastomosis is ordinarily per-
formed for the relief of exstrophy of the bladder. Carl Maydl
was the first to suggest that, in performing such anastomosis, if a
portion of the trigonum is removed with the mouth of the ureter,
the contractile power of the ureter might remain unimpaired.
This method has been modified somewhat by Carl Beck, of New

Fig. III.— Showing oblique insertion of transplanted ureter
into bladaer (after Biidinger).

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 293

York, and is described by him in an article entitled "Rectal
Anastomosis of the Ureters."^ He suggested that the flap assume
a rhomboid instead of an elliptic shape, which would permit it to
be more easily attached to the longitudinal opening in the intestine.
It occasionally happens that unilateral implantation of the

ureter into the rectum is
indicated for conditions
other than exstrophy of the
bladder, as for the relief of
destructive processes caused

Fig. 112.— Vesical trigonum exsected after intro-
ducing catheters into the ureters (Beck).

Fig. 113.— Lower end of ureter im-
planted into the bowel after being split
(Beck).

by malignant disease, such as carcinoma of the bladder or
ureteral fistula. In these cases, according to Beck, stenosis is
best avoided by splitting the lower end of the ureter before placing
it into the slit made in the bowel. The transplanting of the mouth
of the ureter by making a slit into the bowel and removing the
end of the ureter with a portion of the trigonum attached (fig.
112), or in unilateral cases by splitting the end of the ureter in the
manner just described, is the method by which the ureter is in-
i"New York Medical Journal," May 19, 1906.

294 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

vaginated into the wall of the bowel and sutured there (fig. 113),
and is probably preferable to any procedure that involves the in-
sertion of a mechanic appliance.

Inflammation of the kidney, the result of an upward extension
of infection, is often said to take place after anastomosis of the
lower end of the ureter, but this result does not necessarily follow

Fig. 114.— Various metliods of ureteral anastomosis : a, End-to-end anastomosis of severed
ureter : d, terminal lateral anastomosis ; c, the three steps in the operation of lateral anasto-
mosis (Pierre Duval).

in all cases. The statistics of Bouv^e showed that in 1903 the
operation of ureteral anastomosis was performed in in cases,
with 7 deaths.

A study of the histories of the cases on record lead to the con-
clusion that the various anastomoses on the upper end of the
ureter into some other portion of the pelvis of the kidney than it

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 295

originally occupied is often attended with failure. On the other
hand, anastomosing of the lower end of the ureter to a different
position in the bladder wall is very often successful, and the ureter
functionates in a natural manner.

Class III.^ — Operations for Wounds of the Ureter, for
Removal of Stone, and for the Relief of Strictures of the
Ureter. — Wounds of the ureter may involve either extremity,
but as they are made most often during gynecologic operations,
they are most likely to be inflicted along the mid course of the
ureter. Longitudinal wounds of the ureter have a tendency to heal
spontaneously. The ureter having been exposed, as previously
mentioned, a few sutures should be taken through the outer layers
of the ureter, or a catheter be allowed to remain in the pelvis of

Fig. 1 15.— Longitudinal section at mouth of ureter united by transverse suture (Berger and

Hartmann).

the kidney for a few days to act as a splint for the injured tube.
When the wounds run in a transverse direction and the ureter has
been completely severed, the procedure will be more difficult.

Various suggestions have been made by surgeons as to the best
means of effecting union of the severed ends. Generally speaking,
the same procedure is followed as in those cases in which the intes-
tine has been completely severed. The two severed ends may be
brought in apposition and sewed together, or one end be invag-
inated into the other. Incisions may be extended, made obUque,
or the two ends may be zigzaged into each other, as the surgeon
sees fit. The different methods of uniting the severed ends of the
ureter are well shown in the illustrations accompanying the article
(fig. 114).

296 SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS

For removing a stone from the ureter the longitudinal incision
is the preferable one. Occasionally, operating through the bladder,
a stone may be removed from the ureter by the finger or by the
use of long narrow forceps if the mouth is, as occasionally happens,
dilated.

In operating for the relief of stricture of the ureter, wherever

Fig. 116.— Method of incising and suturing stricture of ureter (Berger and Hartmann).

located, a longitudinal incision can be sewed up laterally, so as
to extend the diameter of the ureter, as illustrated in the cut
(fig. 116). This was suggested by Finger. Another method for
the relief of stricture of the ureter is its gradual distention by the
passage of sounds designed for that purpose.

Attempts have been made to remove the ureter completely
when the tube was found to be markedly diseased. The term
ureterotomy is applied to a simple incision in the ureter, whereas
ureterectomy refers to total ablation of the ureter. Resection of
the canal has been performed comparatively rarely. It is con-
sidered good practice, at the present time, in performing neph-
rectomy, to remove also large portions of the ureter when the
tube is apparently diseased.

Such a condition as tumor of the pelvis of the kidney, accord-
ing to Paul Wagner,^ not infrequently has a ureter diseased at
both ends, with healthy tissue between. When practical, in
performing an exploratory operation on the kidney, or a neph-
rectomy, the opening of the ureter should be examined and

^ Frisch and Zuckerkandl.

SURGERY OF THE URETERS AND RELIEF OF HYDRONEPHROSIS 297

some instrument passed through its canal into the bladder. The
lower end of it can, of course, be examined through the cystoscope,
and now that ureteral catheterization is being performed so fre-
quently, it is not only furnishing aid in the performance of many
operations on the kidney and the ureter for the purposes of drain-
age and for diagnosis, but also in furnishing knowledge as to the
condition of the ureter itself. The surgeon in performing ureterec-
tomy will necessarily have to be guided by the conditions surround-
ing any given case. It is seldom necessary, in performing ureter-
ectomy, to entirely remove the portion which enters the bladder.
If such should be the case, a straight median incision is made in
the posterior wall of the bladder, and a partial resection of the
bladder performed.

CHAPTER XIX

ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF THE

BLADDER

ANATOMY AND PHYSIOLOGY

The bladder is a hollow viscus, lying in the anterior portion of
the pelvis. It serves as a receptacle for the urine, which drains
downward through the ureters, and retains it until it is finally
voided through the urethra. The average bladder capacity is
about one pint, but this varies considerably in proportion to the
size of the body and according to the habits of the individual.
The viscus is so constructed as to permit of a considerable degree
of physiologic distention; and it may, under certain conditions,
become enormously distended. When empty, it lies posterior
to the pubic arch, its upper surface only being covered by the
peritoneum; but when distended, its cavity lies above the arch,
and the superior and posterior aspects become invested by peri-
toneum. Its summit is attached to the abdominal wall by a
fetal cord or filament, the urachus. The bladder is supported
by four true ligaments, all derived from the rectovesical pelvic
fascia.

The bladder is made up of four coats, a serous or serofibrous, a
muscular, a submucous, and a mucous.

The serous coat is derived from the peritoneum and is, as already
mentioned, incomplete. It is moderately well supplied with
blood-vessels and nerve-fibers. The muscular coat is made up
entirely of smooth involuntary muscle. Diagrammatically it is
divided into an external longitudinal, a middle circular, and an
internal longitudinal layer; anatomically no distinction can be
made between these layers, which are blended into one another
and associated with numerous oblique fibers so that contraction of
the bladder takes place in every direction. In the lower part of
the circular layer, however, the fibers thicken distinctly around
the urethral opening, just posterior to the prostate gland, where

298

PLATE X

Cross-section through normal male pelvis.

PATHOLOGY OF THE BLADDER 299

they form a distinct muscle — the sphincter vesicae. The submu-
cous coat is made up of a dense layer of areolar connective tissue
in which yellow elastic fibers occur in great abundance. This
coat is highly vascular and contains many nerve trunks. The
mucous coat of the bladder is made up of a thick layer of transi-
tional epithelium, so arranged that when the bladder is collapsed,
the cells pile up together; when distended, they gUde over one
another so that the entire surface is still invested by epithelium;
in a greatly distended organ, therefore, the mucosa may be cov-
ered only by a layer of simple squamous epithelium.

The blood-supply of the bladder is derived from the superior
and inferior vesical arteries and from branches of the hypogastric.

The nerve-supply of the bladder comes from the third and
fourth lumbar and the second sacral spinal nerves and from
branches of the hypogastric sympathetic plexus.

The function of the bladder is largely that of a passive reservoir
into which the urine is ejected by the ureters. Its muscular
contractions are, to a greater or less degree, under voluntary
control, although dependent largely on the smooth muscle coat,
which is innervated by the sympathetic nervous system. These
movements are inaugurated and intensified by the voluntary
contraction of the abdominal muscles. The external sphincter
of the bladder seems also to be, at least to a considerable degree,
under voluntary control. The contraction of the bladder is, how-
ever, undoubtedly inaugurated as a reflex act following stimula-
tion of the sensory nerves of the urethra by the escape of a few
drops of urine into it. The spinal center that controls the con-
tractions of the bladder is probably situated between the second
and fifth lumbar segments.

PATHOLOGY OF THE BLADDER
Congenital Malformations.— The most important of these abnor-
mities assumes the form of aplasia or exstrophy. In this condi-
tion the anterior wall of the bladder and of the abdomen is defec-
tive and the posterior wall of the bladder, usually showing the
urethral orifices, is exposed to the air. The condition is generally
associated with epispadias, or with other congenital defects of
development in this region. Cases of permeable urachus, in which

300 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF BLADDER

the urine may be discharged through the umbilicus, are occasion-
ally seen. The condition occurs most frequently when more or
less atresia of the urethra exists. Abnormities in the shape and
size of the bladder are not infrequently seen, usually at autopsy;
they are anatomic curiosities and have but little clinical impor-
tance.

Acquired Malformations. — The most frequent acquired malfor-
mation of the bladder is a chronic dilatation that follows habitual
overdistention of the viscus. This occurs, as a rule, as a result
of obstruction to the urinary outflow, as from urethral stricture
or hypertrophy of the middle lobe of the prostate. The condi-
tion is frequently associated with more or less ulceration of the
mucous membrane, and with alkaline fermentation of the
urine when infection has taken place. Dilatation of the
bladder, when of long standing, is generally associated with thin-
ning and atrophy of the muscular coat, and with more or less
interstitial hyperplasia. In the early stages of the disease con-
siderable hypertrophy of the muscular coats may take place, but
this commonly terminates in muscular atrophy and fibrous re-
placement, with a greater or less degree of inflammatory change.

Vesical diverticula may form as a result of localized areas of
muscular atrophy, such as may follow embolism of the nutrient
vessels or fibrous proliferation occurring in inflammatory dis-
ease associated with overdistention.

Considerable distortion of the bladder may take place in the female
in cases of vaginal cystocele or in either sex when the bladder is
included in a hernial protrusion, or where foreign bodies are found
in it.

Rupture of the bladder may occur as the result of either acute
or chronic overdistention. It may arise spontaneously or follow
infliction of a traumatism, oftentimes of very slight degree. It
not uncommonly takes place in certain comatose conditions, as
in alcoholism, in which overdistention of the bladder is associated
with some injury. The writers have seen a case of vesical rupture
follow the simple fall of an intoxicated man. The accident is
much more likely to occur when ulceration or some other disease
process has brought about a lowering of the resistance of the
bladder- wall.

PATHOLOGY OF THE BLADDER 30I

Perforations of the bladder permit the more or less rapid extrava-
sation of urine into the surrounding tissues. They mav be caused
by stab or gunshot wounds, by direct or indirect traumatism, as
in fracture of the pelvis, or as a result of ulceration or neoplasm
of the bladder or adjacent viscera. A perforation into the peri-
toneal cavity is usually followed by a rapid and often fatal peri-
tonitis, and when the puncture occurs in the lower quadrant,
urinary extravasation into the pelvic structures and fascia takes
place. This often results in the production of gangrenous in-
flammations or in the formation of vesicorectal or vaginal
fistulae.

Atony of the Bladder. — Weakness of the muscles of the
bladder-wall is usually due to overdistention. It may be due to
a natural atrophy of the muscular tissues, which normally occurs
in old people, and which has been so carefully investigated by
Chiencanowski, in a work already referred to by us, who found
in old people only about two-thirds of the normal amount of mus-
cular tissue was apt to be present. It may be due to a disease
of the nervous system, such as neurasthenia, and it may follow
conditions giving rise to exhaustion, such as various forms of
fevers. It is frequently found allied with such conditions as
urinary obstruction or cystitis. It is more often seen in women
than in men, not infrequently following such a condition as preg-
nancy. It is occasionally seen after influenza as a sequela to this
disease. It is characterized generally by overdistention and very
much diminished expulsive power in the passage of the urine.

Diagnosis. — A history of the case, the slowness of passage of
urine, even if bladder is catheterized, and the presence of overdis-
tention. Patients generally pass little urine with this condition,
and that voided is apparently an overflow, and is liable to mis-
lead the medical attendant as to the condition present unless the
catheter is used. When percussion and palpation of the abdo-
men show fullness over the bladder region, it is generally advis-
able to use a catheter to aid in the diagnosis rather than to be
misled through trusting too much to the history of any given
case.

Treatment. — The treatment necessarily, to a considerable ex-
tent, consists in treatment of the underlying causative factors,

302 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF BLADDER

such as of any cystitis that may be present, or that directed toward
the relief of the urinary obstruction. The internal administration
of certain nerve tonics, unless their use is otherwise counterindi-
cated, is beneficial. The following prescription is useful:

Tincture of nux vomica 2 drams

Tincture of cantharides i dram

Compound tincture of cinchona to make 4 ounces.
SiG. — One dram three times daily, in water, before meals.

As regards local measures, the most useful is vibratory massage
applied by the hand on the abdomen over the bladder region. The
use of static electricity, both to the spine and over the abdomen,
may be attended with good results. In these cases the utmost
regularity should be observed as to emptying the bladder at cer-
tain specified times.

Incontinence of Urine in Children. — Incontinence of urine
in children generally occurs at night. It is often associated with
organic disease of the urinary tract, but it is usually due to insuffi-
cient innervation of the compressor urethrae muscle. The treat-
ment of this condition is both general and local. Internally,
belladonna and strychnin are the two most popular remedies; the
administration of these drugs, however, is not always followed
by relief. Locally, faradization of the suprapubic region and
the perineum has often been recommended. Massage, similar to
massage of the prostate in the region of the seminal vesicles, has
been highly lauded by a German specialist. It is recommended
also that care be used to avoid pressure of the bed-clothing on the
bladder region, and habits of emptying the bladder at regular
intervals should be formed. In every case the child should fully
empty the bladder before going to bed, and the amount of fluid
taken during the afternoon and evening should be restricted. Men-
tal control should be inculcated, and all local irritations, as from
vulvitis or proctitis, relieved.

The writers' experience with this class of cases seems to show
that, if examined carefully, some abnormal condition of the gen-
eral system will be found, which, if cured, will usually result in
relief of the incontinence. Thus a considerable number of cases
are relieved or cured by circumcision or by successful treatment
of a urethritis. An examination of the blood will frequently

PATHOLOGY OF THE BLADDER 3O3

reveal the presence of anemia or malaria, which may act as pre-
disposing causes.

These or similar existing conditions should receive appropriate
treatment, associated with measures that tend to improve the
general health, such as cold sponge-baths. The internal adminis-
tration of nerve tonics, such as the phosphates, has, in the writers'
experience, given excellent results. Raising the foot of the bed
so as to keep the urine away as much as possible from the neck of
the bladder is generally of benefit.

Cystitis. — Inflammation of the bladder, or cystitis, may be a
limited, localized process, affecting only a small area of the blad-
der surface, or it may be a generalized process that involves
the entire mucous membrane. Cystitis is most frequently caused
by the presence of infectious micro-organisms, although traumatic
cystitis is by no means unknown; even in the latter instance, bac-
teria that subsequently enter usually play an important role.
The disease generally arises as the result of infection extending
inward from the urethra; when, alkaline decomposition of the
urine occurs, it acts as an additional etiologic factor. Cystitis
is frequently induced by careless instrumentation, as a result of
which bacteria are directly introduced into the bladder cavity,
or some injury inflicted on its mucous membrane that may first
cause a mechanic and not an infectious process to manifest
itself.

Following injuries to the mucous membrane of the bladder
it should be remembered that bacteria, often of a pathogenic
variety, are excreted normally in the urine. Under healthy
conditions these give rise to no disturbance ; but in the presence
of an abraded mucous membrane, infection and cystitis are very
likely to develop.

A certain number of cases of cystitis occur in consequence of
infection extending downward from the kidney. This is partic-
ularly true of certain instances of renal tuberculosis and pyoneph-
rosis.

The disease occurs very commonly as a result of the presence of
foreign bodies in the bladder. These may be particles introduced
from without, or, in many cases, are stones formed either in the
kidney or in the bladder itself. Infection with more or less urinary

304 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OK BLADDER

decomposition is practically certain to develop in nearly all such
cases.

Simple catarrhal inflammation of the bladder is a much more
prevalent condition than is generally supposed. It most com-
monly arises as the result of inflammation set up by a urine that
possesses irritating chemic or physical characteristics. This
occurs in such conditions as oxaluria, in high concentration of
the urine, or when acid phosphates are present in excessive
amounts. Catarrhal cystitis is also an uncommon accompani-
ment of the acute exanthemata.

The pathologic lesions present in cystitis vary more in degree
than in character according to the etiologic factor in each partic-
ular instance. The simple catarrhal condition is manifested by
congestion of the blood-vessels, swelling of the mucous membrane,
and usually more or less desquamation of the epithelium. Leuko-
cytes and pus-cells appear in small numbers, and unless the con-
dition is of long standing, the other coats of the bladder present
little, if any, change.

Purulent cystitis may follow as a direct result of the catarrhal
disease or it may develop independently. In this form of cystitis
marked erosion of the bladder epithelium takes place ; the blood-
vessels of the submucosa become intensely hyperemic, and there
is an abundant exudation of pus-cells, extending not only through
the mucosa into the cavity of the bladder, but also into the sub-
mucous and muscular coats. Ulceration develops sooner or later,
and is generally associated with alkaUne fermentation of the urine,
so that a precipitate of triple phosphates and other urinary salts
is deposited on the inflamed and eroded mucous surface. In long-
standing or active cases the ulceration may extend from the
submucosa into the muscle-walls ; hyperplasia of connective tissue
almost invariably follows, and results in muscular atrophy and
marked fibrous thickening of the bladder- wall. This thickening is
directly associated with greatly impaired muscular force and
diminished elasticity of the bladder-walls. Even when healing
takes place and the mucous membrane is completely covered
with newly formed epithelium, the interstitial hyperplasia in the
muscle coat may have been so great as to preclude the restoration
of <» proper muscular control of the bladder.

PATHOLOGY OP THE BLADDER 305

Phlegmonous cystitis occurs in very active and virulent infec-
tions, or in those cases in which trophic disorders are associated
with overdistention, as is well exemplified in many spinal lesions.
Usually when active gangrenous destruction of the bladder-wall
takes place, if the patient survives long enough perforation
results.

Tuherctdar cystitis is by no means a rare condition. As a rule,
it is secondary to tubercular disease of the seminal vesicles, pros-
tate, or urethra or to renal tuberculosis. It must be remembered,
however, that purely tubercular infections of the kidney do not
tend to set up tubercular cystitis unless mixed infection occurs,
or some mechanic factor, as overdistention or instrumentation,
acts as a predisposing cause.

The pathologic changes in tubercular cystitis differ but little
from those seen in the other forms of cystitis, except that tuber-
cles occur. The tubercular ulcerations are usually not sufficiently
characteristic to justify an absolute diagnosis from their gross
appearance alone. This is doubtless due to the fact that mixed
infection almost invariably takes place and the lesions no longer
remain of a characteristically specific type. Inspection with the
cystoscope is, however, of great diagnostic assistance, and at times
may be conclusively final. Where tubercular cystitis is suspected,
one should carefully search for other tubercular lesions elsewhere
and a bacteriologic examination of the urine should be always made.

Acute syphilitic disease of the bladder is infrequent. When it
exists, it is so closely associated with mixed infections as to ren-
der its diagnosis in local lesions impossible, but the contracted
bladder common in old cases of syphilis is a frequent and impor-
tant condition.

Timiors of the Bladder. — The study of this subject has received
a new impetus on account of the greater facility with which the
condition may now be diagnosticated while still in a stage afford-
ing some hope for favorable results of treatment. At the same
time the use of the operating cystoscope, and of other modern
surgical methods, has placed in the operable class many neoplastic
lesions of the bladder which up to very recent times were con-
sidered absolutely hopeless. The recent publications of Watson,
Mandelbaum, and others in America, and those of Albarran,

3o6 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF BLADDER

Frisch, Zuckerkandl, and Stoerk abroad have reopened the entire
question in an entirely new Hght.

Growths of the bladder have, nevertheless, been found as a rare
condition in our personal experience, both clinical and post-
mortem, but the growing importance of the subject is now such
as to demand more than passing attention.

Neoplasms of the bladder may, for clinical purposes, be best
discussed as innocent and malignant and as primary or secondary.
True metastatic tumors, as pointed out by Mandelbaum,' are
unusual.

Innocent Tumors. — Innocent tumors of the bladder, of course,
occur only as primary growths, except where virtual invasion
of the bladder may result from the extension of an adjacent
tumor so that compression of the bladder follows. As an example,
one might cite osteomata or chondroma springing from the pelvic
girdle.

Papilloma is unquestionably the most frequent and most
important innocent tumor of the bladder. It is composed of
an elementary villus of connective tissue which originates from
the submucosa of the viscus, growing inward and investing itself
with a sheet of epithelium which in most cases retains the general
character of the transitional epithelium of the cystic mucosa.
In some cases, however, the epithelial coat is made up of simple
or stratified columnar epithelium. As a rule, these growths are
pediculated, though occasionally one finds sessile masses of this
variety. They are generally highly vascular, the blood-vessels
being supported by the scanty connective-tissue framework;
they, therefore, bleed readily when injured. The tumor commonly
originates as a small and slowly growing excrescence, generally
situated near the trigone, but if not promptly removed, they are
very prone to extend rapidly and may eventually involve the
entire surface of the bladder, as shown in Plate XI. As a result
of the villous nature of the growth, crystals and deposits of urinary
salts are very likely to take place about them and may so cause
relatively early disturbance of a recognizable nature. Undoubt-
edly, bits of these tumors so detached oftentimes form the nucleus
of stone formation.

' "Surgery, Gynecology, and Obstetrics," Sept., 1907, p. 315.

PLATE XI

■"^■^is^srr^T

PATHOLOGY OF THE BLADDER 307

Papillomata show a well-recognized tendency to return, even
after apparently complete removal, and for this reason we advo-
cate the more active methods of surgical treatment, even in the
early stages, for this variety of tumor. Furthermore, there is
ijo question but that they may eventually become the seat of
malignant alterations which form the nidus of cancer formation.
The diagnosis is usually easy, fortunately, because of the charac-
teristic gross appearance with the cystoscope and also since the
growth ordinarily causes a good deal of irritation, which attracts
the patient's attention to the bladder. Occasionally bits of the
villi may become detached and swept off in the urine, appearing
in such condition as to permit of microscopic examination and
absolute diagnosis.

Fibroma. — This tumor is found but very rarely, and is seen
mostly in the neighborhood of the trigone. It is found develop-
ing in the submucosa or from the muscle coats, and ordinarily is
covered over by the mucous membrane, which does not become
attached to the growth except as a result of secondary inflamma-
tion. The tumors are generally of small size, and the only cases
which have appeared in the experience of the authors have been
associated with general fibromatosis.

Myxomata of the bladder are also infrequent, and develop in
much the same location and way as the fibroma. They are more
apt to grow to tumors of considerable size, and in most cases are
closely allied to myxosarcoma.

Myomata of the bladder have been observed, but the authors
have never seen a case. They are reported as of the smooth muscle
variety, and develop within the muscular or fibrous coats of the
organ.

The malignant tvunors of the bladder are reported with
greatly variable frequency by various observers, largely since
some include among the malignant growths most, if not all, the
papillomata and some the myxomata as well. As we have pointed
out, the papillomata are no more to be considered as primarily ma-
lignant in the bladder cavity than they are when they occur as
primary growths, for example, on the skin or genital mucosa.
None the less the frequency with which papillomata become malig-
nant should be alwavs borne in mind.

308 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF BLADDER

In our experience by far the larger number of primary malignant
tumors of the bladder have been secondary and not primary in
the bladder. As stated by some authors, metastatic tumors of
the bladder are relatively infrequent, but the organ is especially
prone to become involved by extension from tumors of the uterus,
Fallopian tubes, ovary, vagina, and notably from primary tumors
of the prostate gland, a fact to which we have called especial
attention in a previous publication. The importance of this
observation is self-evident since, where the growth is but an exten-
sion from tumors primary in other tissues, but little more than
temporary and palliative results are to be expected as a result
of treatment of the bladder growth alone.

In regard to the primary malignant growths of the bladder,
Mandelbaum makes the important statement that, as a rule, they
remain more or less localized for comparatively long periods,
and, therefore, operative measures of a vigorous nature are more
justified than in instances where early general metastasis is prone
to follow.

Cancer. — Carcinoma is undoubtedly the most frequent of the
malignant new-growths of the bladder. As we have already
indicated, the tumor is, in our experience, usually secondary and
not primary, and this is especially so where a primary focus is
located in the prostate. Primary cancer of the bladder, in our
opinion, originates most frequently as a result of malignant trans-
formation of a papilloma, hence the histologic variety, in a con-
siderable percentage of the cases, is that of a papillary carcinoma.
Adenocarcinoma also appears, and is found*most commonly about
the trigone, where a possible genetic relationship to the elementary
glands located here seems probable. Epithelioma springing from
the vesical mucosa is also found : it is usually of a somewhat less
active course than the papillary and adenomatous types of cancer,
which are found to be the most actively malignant. A relation-
ship between the development of epithelioma and the irritation
of a cystic calculus seems to be definitely established in some
cases. Epithelioma and scirrhous carcinoma as well are found to
develop in the edges of old ulcerations of the bladder. In such
instances, unless the ulcer is kept under frequent inspection, the
malignant transformation is apt to be insidious and unexpected.

PATHOLOGY OF THE) BLADDER 309

This affords a good argument for radical treatment, particularly
in resistant cases of chronic ulcerative cystitis, especially those
occurring after the fortieth year.

Perforation of the bladder-wall and extension of the growth
to adjacent structures are frequent in bladder cancer — rather less
so in certain special forms, as in the scirrhous type, than in others,
notably with the adenomatous and papillomatous forms. In
practically all cases, oftentimes in the early stages of malignant
neoplasm of the bladder, a cystitis develops, and this possible
relationship to malignant disease should be considered in all cases
where an idiopathic cystitis has developed. Where metastases
take place, they are seen first in the pelvic lymph-nodes, as a rule.

Sarcoma. — This form of malignant tumor is seen rarely except
as a result of extension of growth from the surrounding structures.
No case of primary sarcoma has appeared in the writers' personal
experience, and where metastatic sarcoma is present, it is most
difficult to determine anatomically if the primary site be in the
bladder or elsewhere. Except where material for microscopic
diagnosis can be obtained, or where the growth is secondary in
nature, differential diagnosis from cancer is very difficult and is
relatively unimportant, since the methods of treatment are the
same in both instances and the prognosis does not differ materially.

The more rare malignant tumors of the bladder, such as endo-
thelioma, teratoma, and hypernephroma, do not demand spe-
cial attention here, both because of their great infrequency and
because the methods of management are identical with those
in the conditions already considered. It is very probable that
metastatic hypernephroma is not so very infrequent (two cases
have been seen by the writers), on account of the marked tend-
ency of this tumor to metastacize in the genito-urinary organs.

CHAPTER XX

DIAGNOSIS AND TREATMENT OF DISEASES OF THE

BLADDER .

The necessity of first making a correct diagnosis in the treat-
ment of bladder diseases cannot be too strongly dwelt upon.
Clinical experience has served but to strengthen the opinion that
carelessness in this regard is all too common, mistakes as to the
nature of the existing condition, as well as to the causative factors,
being frequently made. Not alone isolated, but whole series of
cases are constantly being brought to our attention in which the
seat of the trouble is primarily in the spinal cord, and the cystitis
followed as the result of some nervous disorder and was confounded
with primary cystitis. This mistake often occurs from an inability
on the part of the practitioner to recognize and properly diagnose
lesions of the nervous system. Locomotor ataxia, myelitis, and
various other degenerative changes in the spinal cord are impor-
tant and frequent factors in causing bladder disturbance. Then,
too, there are seen cases of bladder disease due to muscular weak-
ness— either weakness of the abdominal muscles or, in the aged,
a weakness due to atrophy of the muscles in the bladder-wall
itself, as was shown by the very interesting work of Cienchanowski.
It is evident, in these conditions, that beyond local treatment,
which should ordinarily, in these cases, be of the piildest char-
acter, the indications are to conserve and increase, so far as possi-
ble, the activity of the muscle. At the same time, by the use of
baths, massage, a well-selected diet, and suitable internal medica-
tion, pathologic conditions of the spinal cord or of other portions
of the nervous system may be improved or held in abeyance.

Another factor that is very often concerned as a cause of chronic
inflammatory conditions of the bladder is late syphilis. The
conditions to which we refer to are more often found in old syphi-
litics.

310

CYSTITIS

3"

CYSTITIS

Acute Cystitis. — For clinical purposes cystitis may be classified
as acute and chronic. Acute cystitis is rarely found existing alone
or as a primary condition, being almost always secondary to or
accompanied by acute inflammatory affections of other portions
of the urinary tract.

Symptoms. — The most prominent symptom in acute cystitis is
painful urination, accompanied by pain and distress referred to
the lower portion of the abdomen. The urine is highly colored,
occasionally tinged with blood, and contains pus, mucus, des-
quamated cells, and occasionally necrotic tissue from the super-
ficial layers of the bladder. Rigors or chilly sensations generally
occur, and there is usually a rise in temperature.

Diagnosis. — As referred to in the section on Examination of
Patients, in making the diagnosis it is necessary to exclude acute
urethritis, stricture- of the urethra, prostatic obstructions from
below and attacks of gravel from above, or disease of the nervous
system when these conditions do not accompany the disorder.
After carefully washing out the urethra as far as the compressor
urethrse muscle, if, on urination into two glases, the fluid in both
glasses is found to contain pus, it is very positive proof that cystitis
or some inflammation further up the canal is present. From
stricture of the urethra it may be differentiated by the appro-
priate methods, which will be described in the diagnosis of stric-
ture, and it may be differentiated from prostatic obstructions
by a careful rectal and bimanual examination of the prostate.
It is apparently an easy matter to make a diagnosis between cys-
titis and difficult urination due to urinary obstruction caused by
an enlarged prostate; mistakes are, however, frequently made,
and in doubtful cases a very careful examination is often neces-
sary. In many cases of simple cystitis the ability to empty the
bladder completely or in part still remains.

Gonorrheal cystitis in its clinical symptoms is similar to other
forms of the acute variety, except that it is, as a rule, more severe
in degree and more frequently attended with difficulty in micturi-
tion.

Treatment of Acute Cystitis. — ^The indications in acute cystitis

312 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

are to render the urine as unirritating as possible to the inflamed
bladder-wall, to relieve spasms and pain, and to administer such
remedies as tend to allay irritation of the mucous membrane.
Rest in bed and a diet consisting largely or entirely of milk in
some form is to be prescribed. For the relief of spasm warm
applications to the lower part of the abdomen, hot sitz-baths, or,
better still, when possible, partial immersion in a bath-tub above
the waist, and urination under the water, will be found of benefit.
Internally, small doses of spiritus aetheris nitrosi and salol, repeated
four or five times during the day, are advisable. The old-fashioned
infusions of buchu and uva ursi still have their advocates. The
writers occasionally prescribe an infusion consisting of equal
parts of flaxseed and elder flower flavored with licorice root; a
small handful of the mixture is steeped for five minutes in a pint
of water, and this is taken two or three times during the day. The
infusion of dried violet flowers, as recommended in the treatment
of Bright's disease, by stimulating the activity of the skin and
thus relieving the kidney, indirectly benefits the bladder. Very
rarely is the use of an opiate required in cystitis to relieve pain.
When this is demanded, a rectal suppository of opium should be
preferably given.

In the local treatment of acute cystitis, when not due to or
associated with an enlarged prostate or with stricture of the ure-
thra, the use of the catheter is but rarely required, but its employ-
ment may be followed by relief, and in certain cases, especially
those of gonorrheal origin, when the patient is unable to urinate,
its use may be imperative. Even in severe cases, however, hot sitz-
baths may relieve the congestion at the neck of the bladder, and
the power to urinate, which was temporarily lost, be regained
after an hour or two. In cases of acute cystitis the smallest cathe-
ter practicable should be employed ; and in lavage of the bladder,
which is often done in conjunction with catheterization, only
unirritating preparations should be used. Solutions of boric acid
or of mercury bichlorid, i : 10,000, with a drop of phenol to the
ounce, or mercury and phenol combined in a saturated solution of
boric acid make a useful fluid for the purpose, or mercury oxy-
cyanid, i : 4000, may be employed. Later, as the patient im-
proves, daily or triweekly lavage with silver nitrate, i : 10,000,

CYSTITIS 313

may be used. Internally, as the acute symptoms subside, oil
of sandalwood may be administered. Fluidextract of kava-kava,
in dram doses, repeated three or four times a day, or sandal-
wood oil and kava-kava combined, may be prescribed. Small
doses of quinin are frequently needed from the onset, but very large
doses of quinin tend to increase the congestion in inflammatory
-conditions of the bladder. The use of the salol, if introduced,
should be continued for some time.

Chronic Cystitis. — Diagnosis. — In the diagnosis of chronic cys-
titis the same steps are to be followed as are taken in mak-
ing the diagnosis of acute cystitis, which it often follows. The
cystoscope is coming more and more to be recognized as useful
for this purpose. In a large proportion of the cases of chronic
cystitis the inflammation will be found, on cystoscopic examina-
tion, to be confined to the lower portion of the bladder — very
rarely, indeed, is the vault of the viscus invaded. A varicose con-
dition of the veins at the base is often found, and the general
appearance described in the section on the Pathology of Cystitis
is seen. Attention must be called, however, to the difficulties
that mav be encountered in making an accurate diagnosis from
cystoscopic observation unless the examiner is familiar with the
appearance of the normal bladder.

Treatment of Chronic Cystitis. — Patients suffering from chronic
cystitis are generally able to be up and about, and in some cases
are benefited by exercise in the open air. For those of a robust
constitution, such exercises as swimming are sometimes of value
in hastening the convalescence from all chronic inflammatory
conditions of the bladder and urinary tract. A careful but not
necessarily a restricted diet, avoiding especially asparagus, cab-
bage, cauliflower, rhubarb, or highly seasoned foods and all irri-
tating condiments, is to be advised. The general health of the
patient should receive attention, and suitable tonics should be
prescribed. If blood examination shows the presence of malarial
Plasmodia or the existence of anemia, proper corrective measures
should be instituted.

The internal treatment of chronic cystitis differs somewhat
from that of the acute type. Iron in an unirritating form,
arsenic, and quinin may be advantageously administered. The

314 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

various balsamics may be employed with benefit, either alone
or in combination, and used in conjunction with the infusions
previously suggested as serviceable in the treatment of acute
cystitis. Fluidextract of kava kava in dram doses, several times
a day, may be used with benefit.

Local Treatment. — The local treatment is of great importance
in this condition. Silver nitrate is the most useful of the local
applications. The bladder should be filled with from four to
eight ounces of a very weak solution of silver nitrate — not stronger
than 1 : 10,000 to begin with. If this is well borne, the strength
may gradually be increased to i : 5000. Silver nitrate is very
commonly prescribed in solutions of too great strength. These
irrigations of the bladder should be made from two to four times
a week. The silver nitrate irrigation should not be followed by
one of boric acid, as a chemic change will take place between the
two solutions, rendering both inert. If the bladder does not react
well to silver nitrate, the solution next in favor with the writers is
the old Ultzmann mixture of zinc sulphate, phenol, and alum, of each
from 1 : 1000 to i : 500. A few applications of this will frequently so
far improve the condition as to permit the silver nitrate irrigation,
which previously proved too irritating, to be used. Of the newer
remedies, probably albargin, in the strength of i : 5000, or mercury
oxycyanid solution, i : 5000 or i : 2000, will give good results.

In certain cases of chronic cystitis the following combination
has been recommended for bladder irrigations: Tincture of iodin,
one part, potassium iodid, one part, extract of belladonna, one
part, water, 300 parts; or, if preferred, the belladonna may be
omitted, and the amount of tincture of iodin be increased up to
two or three parts.

Potassium permanganate in very weak solutions is also useful.

A large number of cases of cystitis of the chronic type may be
divided into two classes: (i) those with overdistended bladder;
(2) those with contracted bladder. Overdistention is the most
common cause of bladder disease. In such cases, if the mucous
membrane is, in addition, chronically inflamed, a large quantity
of fluid may be used in irrigation without giving rise to pain.
These cases of overdistention with cystitis are often associated
with enlarged prostate or urethral stricture. The other class.

CYSTITIS

315

those with a contracted bladder, are usually cases of pure cys-
titis. In these, there may be no urethral lesion or prostatic
obstruction. When irrigations are used in such cases care must
be observed that too large an amount of fluid is not used. Some-
times the bladders of such patients retain with comfort only
from two to four ounces of either urine or any irrigating fluid.
Although not to be recommended for routine procedure, good
results have been obtained in such cases by irrigations, say,
of from two to four ounces of weak silver nitrate solution, in-
creasing the amount of each irrigation by 60 to 90 drops over
the preceding one. The frequency with which syphilis is the
cause of chronic cystitis of the second type — that with a contracted
bladder — should be borne in mind, and it is not amiss in these
cases to try the effects of mixed treatment.

In non-tubercular cases, when other measures fail to bring
relief, a perineal section may be made, a tube introduced, and the
bladder allowed to drain for a week; thus affording rest to the
bladder-wall and diminishing the congestion of the mucous mem-
brane.

Tubercular Cystitis. — ^Tubercular cystitis almost never occurs
as a primary disease, but results as an extension downward of the
infection from a tuberculosis of the kidney, or it occurs as an as-
cending infection from portions of the tract lower down, such
as from the urethra or prostate {vide supra). In its late stages
it is diagnosed with comparative ease, and is accompanied by
such symptoms as painful and frequent micturition, pus in
the urine, and more or less pain over the bladder region. In
the earlier stages the diagnosis is made with more difficulty,
for there may be only a slight amount of burning on urination,
and the urine may show so little pus as to appear only on micro-
scopic examination. In patients with pulmonary tuberculosis,
however, even such mild urinary symptoms should lead to a
suspicion of tubercular cystitis, particularly if there has been
no history of previous urethral infection. Occasionally a his-
tory of repeated urethral infections and of many forms of treat-
ment having been tried will be given, extending over a period
of many months or years, with a gradually decreasing reac-

3l6 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

tion to treatment, either local or general. These symptoms,
if associated with marked physical depression, even if there
is no evidence of pulmonary tuberculosis, should arouse a suspi-
cion in the mind of the observer of beginning tuberculosis, either
primarily or secondarily associated with the bladder. Those cases
of cystitis that react poorly to almost all ordinary forms of treat-
ment, either general or local, have not infrequently a tuberculous
element, either pure or mingled with some other infection, such
as gonorrhea. Statistical investigation tends to show that gonor-
rheal infection is one of the most frequent predisposing causes of
tubercular infection.

By means of an air cystoscope ulcerations may be painted;
one of the writers' associates recently applied phenol and iodin
through an air cystosocpe to vesical ulcers of a tubercular char-
acter, but with negative results. It is to be hoped that in the
future increased experience of surgeons with the effect of the
direct application of local remedies will be productive of good
results.

Even in cases of contracted bladder, if the bladder will hold 1 50
c.c, which is not enough, ordinarily, to permit ureter catheteriza-
tion, cystoscopy may still be employed.

A rough but sometimes helpful method of diagnosing tubercu-
losis of the bladder is that of observing whether or not the bladder
is intolerant to irrigations of silver nitrate of the weakest character
even of a strength of i : 10,000. Many observers have noticed
that in tubercular cystitis silver nitrate applications are badly
borne. This intolerance to silver nitrate, to be sure, is not found
wholly in the tubercular; those patients of neurotic tendencies
sometimes show marked intolerance to the drug, and occasionally
a constitutional idiosyncrasy against it exists. Many foreign as
well as American writers have recommended irrigations of silver
nitrate in strengths of from i : 500 to i : 50; this is too strong.
For irrigating either the bladder or the deep urethra in tubercular
or non-tubercular cases it is seldom advisable to use stronger
irrigations than i : 5000. Locally, for irrigating purposes, solu-
tions of mercury bichlorid i : 10,000, may be used. Iodoform
also seems to be most popular among the local applications

CYSTITIS 317

for the relief of the condition. It is generally used suspended in
oil or liquid vaselin.

In many cases of tubercular cystitis, general treatment, con-
sisting of life in the open air, together with the internal adminis-
tration of appropriate remedies, such as creasote, can best be
relied upon to relieve the bladder condition.

One of the great difficulties that confronts the practitioner in
treating tuberculosis of the bladder is to decide whether a given
tubercular ulceration is due to a tubercular kidney or not, as
the existence of the latter may often be suspected in these
cases when it cannot be clearly demonstrated to be present.
As the investigations of the whole matter of tuberculosis of
the genito-urinary system are carried on with more thorough-
ness, tuberculosis of the kidney is found with increasing fre-
quency.

Tubercle bacilli are found, according to Joseph Walsh, in
75 per cent, of the urines of fatal cases of pulmonary tuber-
culosis.

Since tuberculosis of the kidney is present in the vast majority
of cases of tuberculosis of the bladder, and since in most cases of
renal tuberculosis of kidney the infection is most marked in one
kidney, the question arises, should the most diseased kidney be
enucleated in the hope that this step will aid in the cure of the
cystic tuberculosis. Apparently removal of the kidney aids
in the cure of the cystitis in quite a proportion of cases, par-
ticularly if associated with the usual methods of general tuber-
cular treatment. In all cases the general system, as a whole,
should be fortified as much as possible by a large food-supply
and the greatest amount of fresh air obtainable. Urinary anti-
septics, such as urotropin and salol, may be used, nor in spite
of the fact that the kidney is known to be diseased should local
treatment of the bladder be entirely neglected, but, reaUzing that
the bladder is ulcerated, greater care than ever should be taken
in the introduction of all instruments. All local measures used
should first be tentatively essayed, and modified as circumstances
seem to indicate. In irrigation small quantities of fluid should
be used, as the bladder is frequently contracted — one should
commence with not over four ounces. We have found irrigations

31 8 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

with ichthyol, looo to 2000 or 4000 parts of water, apparently
beneficial when used two or three times weekly.

Bazy advocates that, in cases where some mild preliminary
local irrigation has been used, the bladder be emptied and the fol-
lowing remedy injected:

Iodoform (pulverized) 1 gram

Vaselin (liquid sterilized) 20 grams.

He recommends that the patient refrain from micturating as
long as possible after the injection, and that urination be sus-
pended on the first appearance of oil in the urine. In other words,
the patient should not completely empty the bladder. His theory
is that the iodoform will sink to the bottom of the bladder, where
ulcers are most likely to be located, will serve as a coating for
them, and, if the bladder is not completely emptied on urination,
such a coating may remain for several days. Some patients
retain a portion of the vaselin for from three to fifteen days, at
the end of which time another similar application may be made.
Iodoform may also be administered in the following combination :

Iodoform 1 gram

Liquid guaiacol 5 grams

Sterilized liquid, vaselin 100 grams.

If desired, the quantity of iodoform in such solutions may be
increased four or five times. The guaiacoL may be used alone —
5 parts dissolved in 100 parts of oil. Gomerol, a substance some-
what resembling guaiacol, and obtainable either pure or in a 10
per cent, oil mixture, has been recommended in the treatment of
tuberculosis; it is given either internally or 'applied locally by
means of 10 per cent, instillations of the drug suspended in oil;
it has also been used in the form of irrigations (i : 500) for the
relief of tubercular cystitis. From experiments carried on by
the writers they conclude that the drug is comparatively harm-
less, and although they are not enthusiastic over its use, they
consider it worthy of further investigation.

STONE IN THE BLADDER
The frequency with which stones occur in the bladder apparently
depends to a great extent on climate. In the writers' experience,

STONE IN THE BLADDER 319

cases of vesical calculi are not numerous in New York city or its
immediate vicinity. In some European countries, especially in
England, and in India they are quite prevalent.

The symptoms of stone in the bladder resemble closely those
of chronic cystitis, with or without enlargement of the prostate,
a condition that is often associated with the presence of vesical
calculi. The patients generally complain of some disturbance of
micturition, which is more noticeable during the day than at night,

Fig. 1 17. — Cystic calculi (from the B. Farquhar Curtis collection in the Museum of Carnegie
Laboratory): a, Calculus mostly composed of ammonio-magnesiuni phosphate, weight 20 Gm.
(reduced one-half); *, stone largely composed of calcium oxalate. vveig;ht 4.8 Gm. (reduced
one-half); c, fragments of calculi formed about a silk suture (c') left ni the bladder after a
suprapubic cystotomy ; d, uric acid calculus (natural size); e, mixed calculus, largely phos-
phatic, weight 30 Gm. (reduced one-half); f, small, hard oxalate calculus (natural size); g,
mixed calculus, largely alkaline phosphates, weight 13 Gm. (one-half natural size).

and is apt to be augmented by exercise. Riding over a rough
road or any act that tends to cause congestion at the base of the
bladder aggravates this symptom. The urine is generally turbid,
and indications of catarrhal or purulent cystitis are present.
A useful diagnostic point is that occasionally, while the stream
of urine is quite strong, it is suddenly completely checked, with-
out any dribbling taking place, as generally occurs when the
urinary volume is diminished owing to prostatic hypertrophy.
After a time the patients are again able to urinate as freely as ever.

320 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

This interference with urination is due to the stone falling up
against the opening of the urethra into the bladder.

In examining for suspected stone, and also to get an insight
as to the size and condition of the bladder, and to learn the
general feel of the bladder (the bladders of old persons, as is
well known, often present ridges that are easily distinguish-
able), the Thompson searcher (Fig. 12) is the instrument gen-
erally used. In the absence of a Thompson searcher a medium-
sized steel sound may be employed. Dr. Chismore has modi-
fied the Thompson searcher so that it represents an instrument
of the same curve and length as his lithotrite.

After the bladder has been emptied, several ounces of fluid are
injected into it through a catheter ; or, the searcher being hollow,
the fluid may, if it is preferred, be injected through the nozle of
the syringe placed in the opening at its upper end; the searcher
is introduced into the bladder, and pushed to the back wall, care-
fully avoiding inflicting injury, its beak pointing upward; then,
by means of its handle, the searcher is revolved a little from one
side to the other, and is gradually withdrawn until it reaches the
urethral opening into the bladder. Now, the searcher being
revolved a little on its passage from the back to the front wall
of the bladder, it will strike the bladder- wall first on one side,
and then on the other, at the urethral orifice. The searcher is
divided off into inches and their fractions, and there is a small
sliding scale that moves up and down on the shaft of the searcher.
It should be noticed, as it strikes the anterior wall of the bladder,
being revolved from side to side, whether it meets with an obstruc-
tion on one side sooner than it does on the other. If it does, this
indicates generally a lateral enlargement of the prostate on the
side that shows the obstruction first. After this procedure has
been completed, the searcher may be pushed to the back wall of
the bladder again and completely rotated, so that its beak points
downward toward the base of the bladder. It may then be
brought forward and rotated from side to side, as was previously
done, except that this time the beak points downward. When
it approaches the urethral orifice, it will naturally meet with an
obstruction to its entire removal, for the reason that its beak is
lower than the urethral orifice; if, however, there is much third

STONE IM THE BLADDER 321

lobe enlargement of the prostate, a practised hand may be able
to detect this from the angle that the searcher assumes or from
the feel of the obstruction as the searcher strikes it. If a stone in
the bladder is present, it will very likely be encountered with the
end of the searcher on its journeys back and forth, as described.
If the searcher strikes a stone, a characteristic feel will be im-
parted to the hand and sometimes a click will be heard. When
this is noticed, the angle should be carefully observed, and
also, by means of the measuring scale, the distance should be
carefully gaged, and the searcher withdrawn and a Chismore
Uthotrite introduced, when, if it is placed at exactly the same*
angle and at the same distance as shown by the measuring scale,
the stone should be reached. In using the searcher for detect-
ing the presence of prostatic enlargement it is a good plan, after
the obstruction has been encountered, to introduce a finger
of one hand into the rectum, the other hand holding the searcher
in the bladder ; the distance between the searcher and the finger
may then be estimated. The same procedure may be followed
when the searcher strikes a stone, but care should be observed
not to move the stone too much if it is to be crushed immediately,
or it will get out of position. It would hardly be necessary to
describe this simple procedure in such detail were it not for the
fact that it lends valuable aid and is a method that, the writers
find, is very often neglected by the general practitioner and by
the members of house-staffs in hospitals. If there is any doubt in
the mind of the surgeon as to the condition of the bladder and as
to the presence or absence of stone (further than is furnished by
the searcher), a small exploring cystoscope should be introduced
and the bladder-walls examined with the aid of electric light.

As is well known, in cases of third lobe prostatic enlargements
a pocket-like sacculation is formed at the base of the bladder,
beneath the projecting third lobe; this pocket is often a favorite
site for the lodgment of a calculus. Once a stone has become
lodged here, it is somewhat harder to reach with the lithotrite,
and, if the instrument is reversed, it is possible for a careless
operator to grasp the third lobe between the two jaws of the
instrument and, by crushing, do an immense amount of damage.
Even if an enlarged third lobe is not present, the rectovesical

322

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

fold may project up into the bladder at the base,
making an apparent sacculation that may also, if
care is not used, be grasped between the jaws of
the reversed lithotrite and damaged. It is better
in these cases first to ascertain the effect of throw-
ing a current of fluid into the bladder, for by this
means the stone may be thrown into the jaws of
the lithotrite, and careless manipulation with the
beak of the instrument reversed thus be obviated.

Bige-

ow's lithotrite.

Fig. 1 19. — Bigelow's evacuator.
LiTHOLAPAXY

The operation of litholapaxy, or that of crush-
ing and evacuating stones in the bladder by
means of instruments devised for the purpose,
has been employed since the early part of the
nineteenth century. A great many modifications,
both in technic and in the instruments themselves,
have been made from time to time. Space will
not permit of a detailed historic account of the
development of this interesting operation. It
may be briefly stated, however, that the original
instruments for crushing stone were devised by
French surgeons. An important modification
was the invention, by the late Dr. John Bigelow,
of Boston, of an evacuator, which, by aspiration.

STONE IN THE BLADDER

323

removes the fragment of the stone. I,ater on an important ad-
vance was made by Dr. Joseph D. Bryant, of New York, who
devised' an instrument that served both as a crusher and an
evacuator. In this the female blade of the
crusher encircled a catheter, so that the
bulb of the evacuator could be attached
to the handle of the crusher, and fluid re-
moved from the bladder through a hole
in the female blade, or forced into the
bladder by means of the aspirating bulb
through the same blade, thereby creating
a current in the bladder that washed the
stone or fragments of stone in between the
jaws of the crusher. The late Dr. George
Chismore, of San Francisco, a recognized
authority on operations for the removal
of vesical calculi, performed this crushing
operation on 154 cases of stone in the
bladder. He kindly placed at the writers'
disposal not only his detailed description
of the valuable modifications of the opera-
tion as devised by him, but also his history
book and the manuscript of a forthcoming
treatise on the subject, written by him and
his associate, Dr. Edward Giles McCormick,
of the same city. From personal experi-
ence in the past the writers prefer to effect
removal of a stone through a suprapubic
opening rather than to attempt to crush it ;
Dr. Chismore's modifications of previous
instruments seem so ingenious, however,
and his results, which are fairly stated,
have been so good, that it has convinced
us that there may still be a fruitful field
for the operation of litholapaxy.

Dr. Chismore's first modification consisted in the making of a
catheter in the male blade. This catheter has a large eye, so that

Fig. 120. — Chismore's evacuat-
ing lithotrite.

324 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

good-sized fragments can be sucked through when the evacuator
bulb is attached to the handle of the crusher; the second advan-
tage of this modification is that a stream of water can be forced
through the catheter in the male blade, thus sending a current
of water into the bladder, which loosens up stones, and, through
the force and direction of the current, brings them into the jaws

Fig. 1 2 1.— The Chismore bladder evacuator and obturator.

of the crusher and so sometimes prevents the necessity of turning
the crusher around with its beak pointing toward the base of the
bladder. Dr. Chismore has also invented a hammer for use when
hard fragments of stone are caught between the blades of the
crusher, and cannot be crushed by the hand-screw on the end of the
instrument or by an assistant using
a ratchet and pinion on the side of
the instrument. This hammer is
attached to the crusher while in
position, and works on the prin-
ciple of a pneumatic drill. It re-
sembles in action a hammer such
as dentists use in filling teeth.

Technic. — The Chismore Utho-
trite is prepared for use by lubri-
cating the male blade freely with
a stiff ointment of lanolin to which
ten grains to the ounce of boric
acid has been added, working it
back and forth until the lubricant is thoroughly distributed be-

Fig. 122. — Curved and straight evacu-
ating tubes for removing fragments of
crushed stone.

STONE IN THE BLADDER 325

tween the male and female shafts. This serves as a packing to
prevent the ingress of air and the egress of fluid while aspirating.
This point is important and must not be neglected, for if it is,
fluid will escape freely from the bladder between the shafts of the
male and female blade when the aspirator is compressed, and
air will rush in when the bulb is relaxed, thus rendering the pro-
cedure a partial or even a total failure. Two aspirators should be
on hand, from which the air should be withdrawn by a syringe.
(When seeking a stone with a searcher, if the stone is found, an
attempt should be made to find its farthest border, and, having
found it, the index on the searcher at the meatus should be set,
and an effort made to approximate its size by withdrawing the
searcher until its nearest border is felt. Note the angle that the
shaft of the searcher makes with the axis of the body. The stones
are generally found, according to Chismore, in the region of the
base of the bladder, to one side of the median line — most fre-
quently the right.)

The stone having been discovered and located, ordinarily an
attempt should be made to crush it immediately.

One and one-half to three ounces of a warm 4 per cent, solution
of cocain should be injected into the bladder through the searcher
or through a catheter. Chismore recommends that the opera-
tion be done with the bladder as nearly empty as is convenient,
and considers that nothing but harm follows the strenuous use of
antiseptic solutions employed for the purpose of rendering the
bladder-wall as clean as possible.

In about five minutes the bladder should be anesthetized;
then the lithotrite may be introduced, great care being taken
to overcome spasm and to proceed with gentleness in pass-
ing the triangular ligament. Carry the instrument to the further
end of the stone, and then go still a Uttle further. Open the shaft
to a width that will accommodate the stone if the size is known.
Deflect the beak in the direction in which the stone is known
to be, seeing that the angle is the same as was the angle of the
searcher, and close the jaws of the instrument. If the stone is not
grasped the first time, another effort should be made. If this
does not succeed, gently push the bladder up with the female

326 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

blade and depress the jaws by elevating the handle of the instru-
ment, thus giving the bladder a V shape with the instrument in
the angle of the V. Squeeze in an ounce or two of fluid by coup-
ling on the aspirator, then sharply relax the aspirator bulb so
that the fluid will be drawn out again, for it is possible that in
this way the stone will be drawn into the jaws. It may be neces-
sary to repeat this maneuver over and over, varying the angle of
the shaft, or perhaps reversing the jaws, which should be very
frequently closed in order to determine whether the stone has
been seized. When the stone has been secured, manipulate it
slightly, so as to ascertain that the bladder-walls have not been
grasped as well.

There are three methods of crushing a stone: One is by the
use of the hand-cap; another is by means of the ratchet and
pinion; and a third is accomplished by the aid of the hammer.
The line of procedure is as follows: First try the hand-
cap; when that fails, let an assistant use the pinion; this fail-
ing, let the assistant hold the stone as firmly as possible with
the pinion while the operator fixes the hammer; holding this
in his right hand, he makes firm pressure on a line with the
shaft of the lithotrite — this pushes the piston slightly inward and
sets it. Then, with the first and second fingers of the same hand,
he brings the lugs sharply home-; this releases the hammer and
delivers the stroke; the left hand, in the meantime, holding the
female blade of the lithotrite, controls the position of the jaws
within the bladder and also furnishes the counterresistance to
the force of the hand-cap, pinion, or hammer. The stone being
crushed, the aspirator may be used again to remove the fragments,
or a larger tube, to which the aspirator may be attached, may be
introduced for evacuating the material.

If there is much pain, the cocain solution may be released and a
fresh one injected. When the operation is over, the cocain
solution should be washed out with a small quantity of boric acid.
The after-treatment is simple. The small fragments that remain
after thorough aspiration will generally pass out of the urethra
spontaneously, but if there are indications that large fragments
remain, after a few days a litholapaxy tube may be introduced
to remove them.

STONE IN the; bladder 327

In elderly and feeble patients and in those with enlarged pros-
tate, particularly enlargement of the third lobe, even greater care
and gentleness are necessary, and several attempts may be needed
before the stone is finally reached. In such cases the stones are
generally lodged in the pocket behind the third lobe, and if the
jaws of the instrument are reversed in order to reach them, care
must be used, as was previously directed, lest the third lobe be
grasped between the jaws of the instrument or a fold of the
rectovesical membrane be crushed. It is a good plan, after
the stone has been seized by the lithotrite, to rotate the instru-
ment slightly to be certain that no mucous membrane has been
seized.

After the stone has been crushed, if fragments get in behind
the third lobe, they are very often, after a few days, washed out.
Here, as in many conditions of the genito- urinary tract of similar
nature, when the patients are so much enfeebled that heroic meas-
ures cannot safely be undertaken, time is an important factor.
As regards the results that may be expected from the removal of
vesical calculi, these are dependent on the individual case. It is
not to be expected that in an old man with a large prostate, chronic'
cystitis and incontinence of urine would entirely disappear after
the removal of a stone, although a large measure of relief will
generally follow. When, however, no complications exist, a
complete cure will naturally be expected to follow. It is the
writers' belief that in New York and its vicinity the treatment
of stone in the bladder by litholapaxy has not received sufficient
attention in the past, the tendency, in almost all cases of vesical
calculi, to perform suprapubic cystotomy being on the increase.
It is difficult, however, to formulate a series of rules that will be
applicable to all cases. Suprapubic cystotomy, when good after-
nursing can be assured and the patient is in a fair degree of health,
will probably, with many surgeons, be the operation of choice,
since under such circumstances the danger of a suprapubic fistula
forming is reduced to a minimum, and the operator can be certain
that the stone has been entirely removed. On the other hand,
in dealing with patients with stone in the bladder who are unwill-
ing to submit to a cutting operation, who are aged or very infirm,

328 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

or when it is not possible to obtain good after-treatment, litho-
lapaxy is to be preferred.

Remarks on the Removal of Vesical Calculi. — In cases of stric-
ture of the urethra that will not easily permit of the introduction
of the lithotrite, the stricture should be well dilated before any
attempt is made to do litholapaxy. In elderly persons a stone in
the bladder will often be found associated with enlarged prostate,
and it is well, therefore, when doing a prostatectomy, to examine
the bladder for stone, and if one is found, to remove it through the
opening used for prostatic enucleation. In two cases seen by the
writers it was found difficult to remove the stone through the
opening made for a perineal prostatectomy, and a suprapubic
opening was also required.

Encysted stones may frequently be detected by the searcher,
or may be seen by the cystoscope, but the surgeon will find that
he is unable to remove them. In attempting their removal a
suprapubic cystotomy is the operation to be preferred. Chis-
more has found that oxalate of lime stones are those most fre-
quently encountered; next in frequency come the phosphatic
calculi, whereas the uric-acid formations are least likely to occur.
Occasionally stones form very rapidly, large quantities of gravel
coming down from the kidney acting as a nucleus. Sometimes
the crushing must be repeated every two or three months, or the
stones may not reform for several years. Dr. Chismore operated
fifteen times on one man. The bladder should be inspected very
carefully about a month after a stone has been removed, and, if
possible, the patient should be kept under observation and be
seen several times a year.

In using gomerol it is advisable that a very small quantity
of the oil — from ten to twenty drops — be used in the commence-
ment of the treatment. If beneficial results ensue, the amount
can be increased ordinarily until one -half to one ounce is applied.

Bladder Puncture.— This is occasionally done for temporary
emptying of the bladder, by means of an aspirating needle or a
trocar. It is generally used as an expedient for temporary relief
of distention preceding some operation which may have to be
temporarily delayed. The puncture should be made as near the

SUPRAPUBIC CYSTOTOMY

329

pubes as possible, so as to avoid wounding the peritoneum. It
should be made as exactly as possible in the median line of the
abdomen, so as to avoid wounding the veins on the outer surface
of the bladder. Every possible precaution should be taken as
to the sterilization of instrument and cleanliness of the field of
operation. In doing retrograde catheterization, occasional success-
ful attempts have been made, through the use of a trocar, to per-
form retrograde catheterization. The operation, however, is
not one that ordinarily commends itself to the surgeon. In the
past this operation was most often performed for retention of
urine due to obstruction, such as that caused by an enlarged
prostate. The trocar, or aspirating needle, should be made to
penetrate for a distance of one and one-half to two and one-half
inches from the surface of the abdomen, according to the amount
of fat present in the abdominal walls. It is safer, in order to avoid
wounding the peritoneum, to make a very small preliminary inci-
sion immediately above the pubes down to the bladder-wall before
making puncture. When obtainable, a curved instrument should
be used with its concavity pointing toward the pubes.

Suprapubic Cystotomy
This operation of opening the bladder through the abdom-
inal wall has come into more general use within the past twenty
years, and, the writers believe, its present popularity is well
merited. It is now to a great extent the operation chosen for
the surgical relief of stone in the bladder, and it is very fre-
quently employed when the prostate is to be also attacked. The
difficulties attending the performance of this operation have been
somewhat exaggerated. There are, however, certain practical
objections to its indiscriminate use. One of these is that the
peritoneum may be wounded ; this objection is overcome in large
measure, however, if proper small catgut sutures are kept at hand,
and if the wound is immediately sutured, for but little harm will
result. The greatest practical objection to its performance is the
difficulty with which the suprapubic wound heals after the opera-
tion. Much depends on keeping the edges of the wound clean;
these are soiled by the urine that is continually flowing through

330

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

the suprapubic opening. In any given case, therefore, in which
the surgeon feels assured that the patient will receive the proper
attention after the operation, it is often the operation of choice.
When doubt exists as to the efficiency of the nurse, or when it is
questionable whether or not the wound will receive the proper

attention, some other
method of entering
the bladder should,
when possible, be at-
tempted. This opera-
tion is almost never
performed on the fe-
male. The technic of
the operation is as fol-
lows:

The pubes and
scrotum having been
shaved and the opera-
tive toilet having been •
carefully made, the
bladder should be
washed out, and as
much of a saturated
solution of boric acid
should be injected through a catheter into the bladder as the
organ will comfortably hold — usually about one pint.

After the bladder has been filled, a catheter should be tied around
the root of the penis, to prevent escape of the fluid. It not infre-
quently happens that during an operation through the perineum for
the relief of prostatic hypertrophy, it is decided to open the bladder
from above. When this step is determined upon, it will not be
necessary to inject fluid into the bladder, but if there is sufficient
room in the urethra, an ordinary steel sound may be passed into
the bladder, and the tip of the sound be cut down upon supra-
pubically. If for other reasons it is found desirable to open up
the bladder without filling it, the same measures may here be
adopted. By the latter method of performing the operation,

Fig. 123. — Suprapubic cystotomy (Lejars).

SUPRAPUBIC CYSTOTOMY

331

however, the danger of wounding the peritoneum is somewhat
increased.

Having placed the patient in the proper position, a straight
incision, about six inches long, beginning just below the upper
border of the pubic bones and passing directly upward in the
median line, should be made. The skin is cut through, and then
the white line of the
muscle-fibers is in-
cised. At the lower
part of the wound the
small fibers of the
pyramidal muscles
may be cut through
or pushed to one side,
and the muscular
aponeurosis of the
underlying muscle cut
through, when the
yellow prevesical fat
will appear. When
this is seen, the blad-
der-wall is near at
hand; it is well then,
with the finger or the
handle of the knife,
to press the fat as

far as possible out of the way. In cutting through the tissues
just mentioned as being surrounded by the fat, a few small
vessels may be severed ; there being no large ones in this region
or very close to it. Such vessels as are cut through should be
immediately ligated, thus keeping the approach to the bladder
as clean as possible. When the bladder wall is approached or
when it can be outlined with the finger, it is well to pass a sharp
hook through what appears to be the wall, keeping as near as
possible to the superior border of the pubes, the wound through
the skin and muscles having been held open by retractors. Hav-
ing hooked the bladder-wall, a very small puncture should be

Fig. 1 24. —Suprapubic cystotomy (Lejars).

332

DIAGNOSIS AND TREATMENT <3F BLADDER DISEASES

made to one side of the hook, as near the pubes as possible ; the
escaping fluid will indicate that the bladder has been punctured.
Before proceeding further, examine carefully to see if the perito-
neum has been wounded. If this has been done, one or two sutures

Fig. 125 .—Suprapubic cystotomy. Right hand incising bladder, left hand holding hook

(Lejars).

should be passed through the wound, and the peritoneum pushed
as far as possible out of the way. Having punctured the bladder,
a ligature may be passed through the bladder-wall on one side,
and a corresponding ligature on the other; the hook should then
be removed, the wound in the bladder- wall being held open by an
assistant pulling on the ligature on each side ; the incision should
be extended upward as far as may be required, or far enough to

SUPRAPUBIC CYSTOTOMY 333

allow the introduction of one or two fingers into the opening in
order thoroughly to examine the inner bladder-wall. In perform-
ing operations on the bladder the writers find it most convenient
to have at hand a small portable electric light, about the size of a
pea, on a flexible wire; this they drop into the bladder in order
that the existing conditions may be seen as well as felt. In
operations done for the simple extraction of a stone, this procedure
is unnecessary, for the stone can be grasped at once. If desired
the bladder wound may be enlarged by placing a retractor in each
side of the wound and a third retractor in the upper end of the
incision, the ligatures preventing the bladder from sinking back
into the pelvis.

A great objection to the performance of suprapubic cystotomy
is that, so far as the writers are aware, no satisfactory method of
effecting after-drainage of the bladder has yet been discovered.
The tubes that have been allowed to remain in the bladder-walls
for the purpose of effecting drainage have been found so useless
that it is deemed almost as well immediately to sew up the blad-
der-wall partially and allow the urine to drain through the open-
ing left behind, trusting to the care of the nurse to keep the wound
clean, and so prevent the formation of a suprapubic fistula. This
difficulty has been overcome to a certain extent by a method
originally advocated by Kahler, in performing gastro-enteros-
tomy, and which has been strongly advocated by C. L. Gibson, of
New York, for use in bladder operations. It consists in invagi-
nating the bladder-wall around the tube introduced through it.
Having examined the interior of the bladder and performed
whatever operation may be required, — the removal of a pros-
tatic overgrowth, a stone, or a bladder tumor, — the wound should
be closed in the following manner: A tube about the size of the
largest sized catheter is fastened in the bladder by two deep liga-
tures; then, by means of Lembert's sutures, the wound in the
bladder-wall is sewed up on each side in such a manner that the
pressure of these superficial ligatures tends to invaginate the super-
ficial layers of the wound in the bladder-wall around the catheter,
and to push the inner layer of the bladder carrying the catheter
down into the bladder a little distance, forming a dimple. When
the tube is removed, a part of the exterior bladder-wall will be

334 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

brought against the corresponding part on the opposite side, and
union will take place more quickly between these two than if a
simple incision is made through the bladder-wall and the opening
is allowed to close by granulation. After inserting the tube in
the manner described, the bladder should be allowed to fall back
into the pelvis and the skin wounds should be sewed up on each
side as far as the tube will permit; proper dressings should be
applied, the nurse must be instructed as to the necessity of chang-
ing the dressings as often as may be demanded. Under ordinary
circumstances the tube may be removed from the bladder in four
or five days, and if the dressings are frequently changed, the fistula
left behind should close in a few days without giving rise to further
trouble.

In Europe the custom is somewhat more prevalent than in this
country to immediately sew up the wound in the bladder-wall by
means of a double row of sutures, deep and superficial, going to,
but not penetrating, the bladder- wall ; thus the edges are approxi-
mated as closely as possible, and the escape of urine is prevented;
the skin wound is then sewed up, leaving a small opening at its
base for drainage. Under these conditions either of two measures
may be adopted: the one is to make a perineal incision and drain
through the perineum by means of a tube, and the other is to
introduce a retention catheter and to make no perineal incision.
The writers' experience with retention catheters has not been
altogether a fortunate one. If it is desired to close the bladder
wound immediately, a retention catheter having a small neck
around its base may be introduced into the urethra by means of
retrograde catheterization from the bladder. This last proce-
dure is advisable only in those cases in which the patient is in
good general condition and the bladder-wall is healthy.

It is hardly necessary to state that the prospect of rapid union,
after the bladder-wall is immediately sewed up after suprapubic
cystotomy, and a drainage catheter passed through the urethra,
is better if the case is one in which infection of the bladder has
not taken place and the urine is clear. It has recently been sug-
gested by a French surgeon^ that if for the space of about an inch

' " Suture Hermitique de la Vessie," Paul Delbet, " Ann. de Malad. Genito-
urinare," 1907.

SUPRAPUBIC CYSTOTOMY

335

the mucous layer is dissected off from the muscular layer of the
bladder around the margin of the suprapubic wound, and then
stitches inserted through the muscular layer at about an inch
from the margin of the wound at each side of the wound, and the
sutures tied. The raw surfaces of the mucous layer will thereby
be placed together, and a water-tight union will soon take place.
Superficial sutures can also be introduced into the muscular layer
of the bladder immediately over the wound.

In Russia, where we understand stone in the bladder is very
frequent, Koppuloff, after suprapubic cystotomy in cases where

Fig. 126.— Guyon's tube. Fig. 127.— Freyer's tube.

urinary infection has not taken place, and where lesions of the
bladder-wall do not exist, sews up the opening in the bladder
controlling the abdominal muscles with a silver wire. He starts
his sutures in the skin a centimeter from the center of the wound,
traverses the abdominal wound, passes his Lembert suture to
within a half centimeter of the vesical wound without going through
the mucous layer, and then emerging a centimeter higher, the same
thread is repassed in an inverse manner so as to make it come out
at the side of its own orifice or entrance. Two to five points are
enough when they are tied, the skin being protected by a little
pad of gauze. The wires are removed eight days afterward, and

336 DIAGNOSIS AND TREATMENT OK BLADDER DISEASES

a complete cure is obtained in fourteen days* He drains through
a urethral retention catheter.

As far as drainage-tubes are concerned, we believe, at the present
time, the Freyer's tube or the Guyon tubes will be found most
serviceable.*

When a tube is allowed to remain in the bladder for the purpose
of effecting drainage, the bladder may be irrigated with a solution
of boric acid through the tube, or through the retention catheter
if one is used, several times a day. The older operative methods
of opening the bladder, such as by lateral lithotomy, have become
almost obsolete, and their description is, therefore, unnecessary.
The removal of stones from the bladder, when any cutting opera-
tion is performed, is generally accomplished through a suprapubic
incision.

Lateral Incision. — It is the custom of some surgeons, in-
stead of making a longitudinal incision in the bladder in the
performance of a suprapubic cystotomy, to make a lateral cut,
keeping as close to the pubic symphysis as possible, and at right
angles to it, the contention being that thus more room is obtained
and the danger of wounding the peritoneum is diminished. The
writers have seen one or two cases operated on in this manner,
and although the method seems practicable, it does not appear to
offer any great advantages. Some surgeons advocate that, during
the performance of a suprapubic cystotomy, when the prevesical
fat is encountered, the operator should introduce a finger just
under the edge of the pubes and press upward. In this manner
the fat may be pushed up out of the way, and will carry with
it the fold of peritoneum, which has a tendency to drop down
over the front of the bladder. By this means also, it is claimed,
the bladder-walls may be distinctly made out, both by their
appearance and by the presence of the veins adhering to their
outside surface. Theoretically, this may be true, but prac-
tically, under ordinary circumstances, and if the operation is
one in which haste is required, too much time cannot be wasted
on very fine dissections, but it is well to find the juncture of the
peritoneum with the bladder.

' Method of Rosumorffsky Kopulloff " Metallic Soutre de la Vessie," " Annal.
de Mai. des Organs Genito-urinaire," 1907.

CYSTOSTOMY 337

An interesting case of suprapubic fistula came under the writers'
observation some years ago. The patient suffered from paralysis
of the compressor urethrae muscles following a perineal incision,
and also from an operative suprapubic fistula. When he stood
erect, the urine ran out through the urethra; but when he lay flat
on his back, it escaped through the suprapubic opening. Since
seeing this case the writers recommend that, in bladder operations,
the head of the bed be slightly elevated to permit of thorough
drainage downward. In making permanent suprapubic fistulas
sutures not easily absorbable should be used to attach the blad-
der to the abdominal wall, or a long retention catheter may be
employed when such attachment is undesirable.

CYSTOSTOMY

Cystostomy. — Cystostomy is the term applied to the operation
of making a permanent suprapubic fistula. It is particularly
useful as a palliative operation for inoperable tumors. The open-
ing should be made in the bladder-wall well down to the pubes.
Various modifications of this simple operation have been suggested,
some of them with the idea that the permanent suprapubic opening
can be made to act like a sphincter over which the patients will
have control to a considerable extent.

A practical way is to sew the bladder-wall around a cath-
eter and drop the bladder to its original position, and until the
healing occurs to pack gauze between catheter and symphysis.
If a catheter is not used, it is necessary to fasten the mucous
lining of the bladder to the skin. If the catheter is not used,
the dressings should be changed frequently and the stitching
of the mucous layer to the skin should be prepared very care-
fully to prevent infiltration into the space of Retzius. After
good union has taken place between the mucous membrane
and the skin, a certain proportion of patients will have some
voluntary control over the fistula, and may be able to refrain
from soiling the dressing for several hours at a time. Our per-
sonal experience with the retention catheter through the supra-
pubic opening has been good where the patient has been confined
to a recumbent position, but if the patients are to be allowed to
walk about, the permanent fistula without the catheter is the most

338

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

desirable. In our experience young patients with good muscular
tissue have the best control over the suprapubic sphincter. The
two illustrations show a very good way of making the fistula.
The operation can be divided into two sections, as shown in
the illustration. The first part consists in the fixation of the
muscular portion of the bladder-wall to the abdominal muscle.
On each side a stitch is run through the muscular wall of the
bladder and through the inner surface of the abdominal muscle.

Fig. 128. — Operation of cystostomy. Fig. 129. — Operation of cystostomy.

Sewing of muscular layer of bladder to Sewing of mucous layer to skin (redrawn

abdominal muscles (reclrawn from Pierre from Pierre Duval).
Duval).

not penetrating the skin. Then a stitch is run one above and one
below these side stitches, which penetrates the muscular layer of
the bladder, and each of the two abdominal muscles some inches
from their border. Above and below the abdominal wall is
sutured to the skin. All this is shown in the first illustration.
Then the bladder is opened in the median line and the second part
of the operation is proceeded with, which is shown in the second
illustration. This consists in the suture of the mucous lining
of the bladder to the skin. Two lateral sutures take in the skin
and the mucous lining of the bladder. Then a stitch above and

CYSTOSTOMY

339

a stitch below penetrate the skin on two sides and in two places
the vesical mucous membrane. The vesical orifice ought to be
situated as near as possible to the bladder.

Suprapubic fistulas resulting from operations frequently become
a source of much annoyance. They are more often encountered
in hospital than in private practice, and usually heal with diffi-
culty. In treating a case of suprapubic fistula following a pre-
vious operation it is well, when possible, not only to enlarge
the opening and freshen the edges of the wound, as advised in
most works on surgery, but also carefully to examine the bladder
for the purpose of detecting any foreign substance that may have
been left behind after the operation or which may have subse-
quently formed. The writers have seen one case in which non-
absorbable ligatures were found in the bladder and were the appar-
ent cause of the fistula ; in another case a piece of gauze was found
that was responsible for the non-union of the bladder wound.

In the case of a medical friend, who had been operated upon for
papilloma of the bladder, the cause for the suprapubic fistula
was found to be a piece of gauze, one yard long and two inches
wide, that, through carelessness, was left behind after the opera-
tion. The urethra and meatus being large, the gauze eventually
showed itself through the urethra to such an extent as to make its
presence known to the attending physician, who extracted it
through the urethral canal.

If the interior of the bladder has been examined and nothing
has been found to account for the presence of the fistula, the edges
of the wound may be freshened and sutured with a deep and a
superficial layer of sutures, a retention catheter being introduced
through the urethra or a perineal opening for drainage made.
It has been our experience that some of these cases have a
tendency to fistula formation. It is wise to try the e£Fect of a
retention catheter before doing perineal section, for sometimes
in the latter event the suprapubic fistula will heal but a perineal
fistula will develop. Some suprapubic fistulas do well with occa-
sional applications of nitric acid or the cautery. Often in such
cases, particularly if there is any tubercular tendency, change of
air or residence in the country will have a curative effect. Other
methods failing, plastic operations must be resorted to.

340 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

TREATMENT OF BLADDER TUMORS

The symptoms of bladder tumor are painful micturition, changes
in the urine, generally the presence of blood in the urine, and not
infrequently pain in the neighborhood of the bladder. Tumor
of the bladder may, however, exist for years without causing any
symptoms at all. Such tumors are non-malignant and generally
small in size. One quite common characteristic of most bladder
tumors, and even of cancer, is the fact that they are very slow in
their progress, even after the symptoms have shown themselves.
Fatal results most frequently occur not from them, but from the
invasion of other organs.

The diagnosis is generally comparatively easy on account of
the history of the case, and can ordinarily be settled positively
by a cystoscopic examination performed by one familiar with such
work. It sometimes happens, in our own experience, as in that
of other observers, that the contraction of the bladder and the
easy bleeding of the bladder surface connected with a cancer or
other tumor of the bladder renders it very difficult to make a
satisfactory cystoscopic examination, viz., on account of the
inability of the bladder to hold sufficient fluid and the impos-
sibility of having the fluid in the bladder clear enough to
obtain a proper view. In such cases a careful examination
by means of a Thompson searcher may make the diagnosis
very clear. The use of this instrument has been described in a
previous portion of the book. The tumor should be investigated
by a similar method to that employed in searching for stone, and
in measuring for the purpose of obtaining an accurate idea of the
size of the prostate. Particularly in searching for tumor is it
important to turn the instrument so that the beak will point
toward each side of the bladder, then withdraw it as far as possible,
and measure the distance. Diagnosis by this method can be made
in certain cases, as has recently been demonstrated by one of us.

The tumor of the bladder having been located, various proced-
ures may be instituted for its removal.

The suprapubic route is the most popular. After the bladder
has been opened in the classical manner, a careful inspection of
the tumor and of the urethral and the ureteral orifices should
be made. If it is desired, one of the bladder specula so frequently

TREATMENT OF BLADDER TUMORS

34?

used by the French surgeons may be employed to distend the
wound and hold it open. It is our custom to use, in operating
on the bladder, the very small electric light attached to a flexible
cord, called by electricians a pea-light, which is let down into the
bladder and which well illuminates its surface. It will probably
not be necessary in the small pediculated growths of the bladder
to do more than to nip off the growth from the pedicle and cau-
terize the base lightly. Except in cases of very small growths

Fig. 131.

Fig. 130. — Showing method of making cone and line of incision. Cone is com-
posed of the mucous layer and superficial muscular layer. The mucous layer is incised
in a circular manner and the muscular layer resected as a cone from its submucous couch.

Fig. 131. — Scheme showing how, in extirpation of a tumor as in preceding illus-
tration, there is a superficial removal of the muscular layer underneath the tumor, cone
shaped (redrawn from Pierre Duval).

they should be removed by an incision into the mucous membrane
of the bladder, the growth removed, and, whenever possible, the
wound in the mucous membrane left by the removal of the tumor
brought together by sutures. This manner of removing turgors
of the bladder is shown in figs. 130, 131, 132. Great care should
be used to gain as much union as is possible of the mucous mem-
brane wound. Growths of larger extent, if deep, may require
a deep incision, sometimes into the perivesicular tissues for their

342

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

removal. If the neoplasm involves the orifice of the ureter, the
ureteral orifice should be made in another portion of the bladder.
The manner of removing a grgwth attached to the extremity of
the ureter is illustrated in figs. 135 and 136.

If an infiltrating growth be present, which is also extensive,
and such growths are generally malignant, a more difficult situ-

Fig. 132.

-Method of closing cavity in bladder from which tumor has been removed
(redrawn from Pierre Duval).

ation is presented. It is, of course, well recognized that some of the
bladder tumors which are not malignant are associated with
similar tumors in adjacent organs. Papilloma of the bladder
and papilloma of the kidney are liable to exist together, while

Fig. 133. — Showing how, in some implanted bladder tumors, a pedicle can be made
\>y exerting traction on two transfixion needles introduced at right angles to each other.
•a, b. Transfixion needles (redrawn from Pierre Duval).

malignant growths of the bladder are very apt to be associated
with the involvement of other organs, like the prostate. It has
seemed to us, from our clinical experience, where a growth in the
bladder is malignant from a transformation of a previous benign
bladder tumor, it is less liable to be associated with maUgnant
^owth elsewhere.

TREATMENT OF BLADDER TUMORS

343

Malignant tumors of the bladder should be treated on the same
lines as those laid down for benign tumor, except that, when practi-
cal, it is wise to remove the prostate at the same operation, and some
have advocated the removal of the adjacent lymph-nodes. Lymph-
node hypertrophy may be largely inflammatory, and true metasta-

Fig. 134. — Illustrating the placing of the forceps at base of cone formed by the trans-
fixion needles (redrawn from Pierre Duval).

sis of the cancer not have taken place. If the cancer is extensive,
and has involved the base of the bladder, a palliative operation,
such as cystostomy, should ordinarily be the method of choice,
or the bladder may be ablated, the ureters transposed to the

Fig. 135. — Illustrating line of incision for removal of bladder tumor involving orifice of
ureter (redrawn from Pierre Duval).

intestine or the skin, or nephrotomy may be performed. If there
is considerable involvement of the surrounding tissues, and the
patient is not suffering much pain, in our experience cystostomy
renders them quite comfortable, and the disease may go on for
some time without causing marked changes in their physical

344

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

well-being. If the cancer is more toward the fundus of the bladder,
partial resection of the bladder may be attempted, with or without
the transplantation of the ureters. Partial resection of the bladder
is sometimes quite successful; it is necessary, however, to leave
about one-half of the bladder to carry on its functions. At the
present time it seems doubtful if a quick microscopic examination
will be able to tell the precise nature of the growth and indicate
whether a given cancer is primary or secondary.

The question of drainage after the removal of a growth in the
bladder is quite an important one. Where very small non-malig-

Fig. 136. — Illustrating further removal of tumor with end of ureter. Showing insertion
of ligatures and ligation of accompanying venous pedicle (redrawn from Pierre Duval).

nant growths exist which have been simply tied off without
incising the mucous membrane to any extent, the bladder wound
should be sewn up immediately and the bladder allowed to drain
through a retention catheter through the urethra. In cases where
the bladder has not been infected and the growth has been of
moderate size and it has been possible to bring the mucous mem-
brane opening from which the growth was removed into good
apposition, the same procedure may be tried. Where the growth
has been large, and where it has been impossible to close accurately
the mucous membrane incision, suprapubic drainage should be
instituted through a Freyer's tube. No tube should be allowed

TREATMENT OF BI^ADDER TUMORS 345

to penetrate to the bottom of the bladder, and irrigation should
be made most gently for the first four or five days, so as not to
disturb any clot which may form at the place from which the
growth has been removed.

The Nitze operating cystoscope, previously described, is an
ingenious apparatus through the aid of which a galvanic cautery
snare can in some cases be placed about the pedicle of the tumor,
and so be snared and cauterized off without necessitating opening
of the bladder. The various attachments are so arranged that
the snare can be thrown out at different angles. Up to the present
time comparatively little work has been done with these instru-

Fig. 137. — Suture of the resected ureter in the superior border of the bladder wound;
suture of the bladder (redrawn from Pierre Duval).

ments by American surgeons, although one or more of them have
designed operating cystoscopes. This method will undoubtedly
come into more general favor as we become more familiar with
the use of the cystoscope, mainly for the following reason: It is
well known by all who have had occasion to operate on bladder
tumors through the suprapubic route that they tend to recur,
and it can easily be seen that any measure that will obviate the
necessity for frequently reopening the bladder- wall will be regarded
with satisfaction by both patient and surgeon.

Foreign Bodies in the Bladder. — These may or may not present
symptoms. Cystoscopic examination, however, will generally

346

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

reveal their presence, if the searcher has not already done so.
In doubtful cases an x-ray picture may be taken. When found,
they can often be removed with the lithotrite, with long forceps,

Fig. 138. — Apparatus used after Sonnenberg's operation for exstrophy of the bladder.

the forceps being in a tube containing a cystoscope, — an instru-
ment devised by Casper, — or by making an opening into the blad-
der. It is the writers' experience that when fistula follows bladder
operations or the removal of stone, the condition is often due to

EXSTROPHY OF THE BLADDER

347

material left behind, such as dressings or unabsorbed ligatures;
they therefore recommend that a thorough search be made for
foreign bodies at the time any procedure for the closing of fistula is
inaugurated.

EXSTROPHY OF THE BLADDER
This dreadful condition is a congenital one, and, fortunately,
of very rare occurrence. It is due to non-closure of the abdominal
cleft. It may be partial, so that only a slight fissure is left near

-■- ■'-''>i^ ----^^^^V' ' -■-* -"i^-- •.•-■■.■••-••••■.■■•:-.■-■:■.•

Fig- 1 39- — Scar on abdomen after Sonnenberg's operation for exstrophy of the bladder.

the urachus or at the lower angle of the cleft. If slight, stimula-
tion of the edges or a slight plastic operation may result in closure.
When complete in children so afflicted the anterior bladder-wall
is absent, so that the posterior bladder- wall presents itself in the
front of the abdomen. In males hypospadias coexists; hence
such subjects, if they live to attain adult life, are so malformed
that their genital organs are useless.

A great variety of operations have been performed for the at-

348

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

tempted cure or relief of this distressing condition. So far as cure
is concerned, these operations have all proved unsuccessful. The
results so far as relief is concerned are, however, somewhat better.
Only an outline of the operations for the relief of this condition
will be given here. In a general way the operations that have
been attempted may be divided into three classes :

Fig. 140-— Maydl's method for exstrophy of the bladder. The abdomen is opened by an
incision around the upper part of the bladder, using one or two fingers introduced into the
abdominal cavity as a guide ; the sides of the bladder are then separated. The peri-ureteral
portion to be incised is shown by the dotted line.

Class i. — This consists in separating the symphysis pubis in
an attempt to fold and unite the two sides of the bladder- wall so as
to make a complete bladder, an operation being performed at
the same time for the relief of the hypospadias — in other words,
to unite the borders of the bladder. There are several different
modifications of this method.

EXSTROPHY OF THE BLADDER

349

Class 2. — This consists of various methods of grafting skin
from a neighboring part or from the intestinal region, transplant-
ing also a portion of mucous membrane, with the idea of making
a cavity that will act as a bladder.

Class 3. — Measures that consist in excising the bladder entirely
and transplanting the ureters into the intestinal canal — generally

Fig. 141.— Maydl's method of operation for exstrophy of the bladder. The sigmoid
flexure is incised along its free border, and is then fastened to the peri-ureteral portion of the
bladder with catgut sutures.

into the rectum. The writers have never had the opportunity of
operating on a case of this kind, but one has been brought under
their observation that was operated on according to the last-des-
cribed method by Dr. Frank Hartley, of New York. The patient
was alive several years subsequent to the operation, and the
rectum seemed very tolerant to the urinary flow. This is the opera-

350

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

tion of Maydl. The illustrations (figs. 140, 141, 142) furnish a clear
idea of its nature. In this class also may be considered a series
of operations that consist in transplanting the ureters into the penal
gutter — ^the method of Sonnenberg, of which two illustrations are
given (figs. 138, 139). The bladder is entirely removed in this
method and it necessitates the constant wearing of a urinal.

Fig. 142-— Maydl's method of operation for exstrophy of the bladder. The periureteral
portion of the bladder is inserted into the opening in the sigmoid and the edges sutured
together.

(These operations are described in considerable detail by Berger
and Hartmann in their "Text-book of Surgery," vol. ix; they also
commend the article of Katz, "Traitemente Chirurgical de I'Ex-
trophie de Vessie," " Th^se de Paris," 1902-03, No. 535, G. Stein-
heil, editor.)

Also should be considered in this class the method of Segond,

EXSTROPHY OF THE BLADDER

351

illustrated in figs. 143, 144, 145. This method consists in
dissecting out the wall of the bladder pretty well down to the
attachment of the ureters; then doubUng it over and attaching
it to the penal gutter; then making a hole in the underlying
prepuce and pushing the gutter through so that the prepuce
makes a hood. The bladder flap should be trimmed to fit as

Fig. 143 — Segond's operation for exstrophy of tfie bladder. The under surface of the
bladder-wall is pushed up and dissected along the dotted lines ; it is then brought down upon
the penal gutter.

the dotted lines in Fig. 143 show. The edges of the penal gutter
should be freshened to unite them with the bladder flap. As
much vesical tissue as possible should be left around the ureters
when the flap is turned over. The upper border of the preputial
hood can be united to and will help cover the opening in the

352

DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

abdominal wall left by the removal of the bladder; if necessary,
side flaps can be made to help cover in this latter.

We have very recently received from Dr, John T. Bottomley,
of Boston, Mass., the report of a case of exstrophy of the bladder
treated by what seems to us a very practical method, and that is

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f utter and of the adjacent skin are freshened, the dissected portion of the bladder-wall is
rought down upon the penal gutter, and the two first sutures (i) are put in each side. The
adherent border of the prepuce is then punctured transversely and turned inside out, and is
spread apart by the retractor to show the extent of the raw surface which is to be brought up
over the portion of bladder-wall.

the removal of the bladder which is preceded by the transplan-
tation a few days earlier of the ureters to the skin of the loins.
He has recently operated on a patient by this method, the report
of the operation, as kindly furnished us by him, is as follows:
"Through an incision on either side of the abdomen about

EXSTROPHY OF THE BLADDER

353

parallel with the crest of the iHum go to the peritoneum; the
latter structure is pushed forward, the ureter on either side is
found, freed, cut across at the point where it crosses the iliac
vessels, and through a small stab wound in the loin the end is

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Fig. 145. — Segond's operation for exstrophy of the bladder. The dissected portion of the
bladder has been folded down and fastened on each side with the sutures (i, 1), and the
preputial hood has been raised over the penis and the raw surface of the dissected portion of
the bladder. The sutures (2, 2) fix the shape of the meatus. The sutures (1, i) have been
passed through the prepuce so as to be removed after\\'ard. The prepuce is lifted aside to
show the course of the suture (i) on the right side. The suture (3) reunites the skin of the
penis, the freshened border of the penal gutter, the dissected portion of the bladder, and the
preputial hood. The suture (4) closes carefully the vesical fold near the ureter. The suture
(5) will lift up the prepuce and fasten it to the skin of the abdomen.

carried out on to the skin of the loin and held there by sutures
to the skin, about one-eighth inch of the ureter being allowed to
project. Ten days after the preliminary operation the ectopic
bladder is removed; the denuded area is covered in by grafting

354 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

and by skin flaps. The patient wears an apparatus for collecting
the mine, is really very comfortable, there is no urinous odor,
and the apparatus keeps the patient dry." Mr. Reginald Harri-
son,^ in 1896, treated a case by removing one kidney and then
transplanting the ureter of the remaining kidney to the skin of
the corresponding loin. Dr. Bottomley in performing his opera-
tion attached the ureter of each kidney to the loin on the corre-
sponding side.

INJURIES OF THE BLADDER

Injuries of the urinary bladder occur in the form of wounds,
contusions, and rupture of the organ. In dealing with an injury
of the bladder it is important to determine whether the lesion is
an extraperitoneal or an intraperitoneal one. Now that such
great advances are being made in general surgery and explora-
tory incisions for the purpose of ascertaining the extent of an
injury have become so common, together with the fact that skil-
ful operators are becoming so numerous, it hardly seems neces-
sary to divide injuries and rupture of the bladder into many
different classes, each to be considered under a separate head.
The most exhaustive work that has been done on this subject,
according to the writers' knowledge, is recorded by Duplay
and Reclus, "Traite de Chirurgie," vol. vii.

The bladder is rarely wounded in its anterior aspect, unless the
organ is very much distended, for the reason that, when empty
or only partially full, it is protected in front by the pubic bone.
It is more often wounded as the result of a penetrating injury
through the perineum, as from falling on a sharp substance;
through the rectum or through the back, following the infliction
of a stab wound, and occasionally from the toss of a bull. It is
also not infrequently wounded during the performance of some
abdominal operation, particularly during hysterectomy. Quite a
large portion of the bladder-wall may be torn off either from the
inside or as the result of injury outside of the bladder, the organ
continuing to functionate and repair of the wound following.

Wounds of the bladder are very seldom uncomplicated, being al-
most always associated with wounds of some other organ. Exper-
iments and observations on both experimental animals and on
'Harrison, Reginald: "Lancet," 1897.

RUPTURE OF THE BLADDER 355

man tend to show that nature very quickly attempts the repair of
an injury to the bladder.

If the wound is situated intraperitoneally, adhesions from the
peritoneum form very rapidly and tend to close it in. If extra-
peritoneally, it closes almost as rapidly. A considerable portion
of the bladder substance may be removed and cicatrization and
repair still go on. The folds of the wounded bladder tend to shut
down on themselves and keep the urine from escaping through
the wound.

Painful micturition, bloody urine, and shock are more or less
constant symptoms of bladder injuries. Later, if the wound has
been an intraperitoneal one, these symptoms may be followed by
peritonitis or by symptoms of purulent cystitis. A fistula may
subsequently be established. If the bladder is wounded during
an operation and the wound is immediately sutured, ordinarily
but little trouble follows. Infiltration of urine into the surround-
ing tissues may, however, follow infliction of the wound, and can
generally be diagnosed by the swelling caused by such infiltration
if the wound has been an extraperitoneal one.

The treatment of wounds of the bladder is as follows :

The hemorrhage should be checked, foreign bodies removed,
and proper care observed, by the use of antiseptic measures and
drainage, to prevent the after-formation of fistula. This can be
accomplished by the introduction of a retention catheter or by
making a perineal or suprapubic incision. In all doubtful cases
of penetrating wounds of the lower portion of the abdomen an
exploratory laparotomy is indicated.

RUPTURE OF THE BLADDER
Rupture of the bladder is probably somewhat more common
than are wounds of the bladder. It may be the result of injury
or of overdistention of a diseased bladder. Rupture has been
known 'to follow overdistention due to the employment of too
large a quantity of an irrigating fluid by the surgeon. It would
be interesting to observe how many cases of rupture of the bladder
occur in drunkards either from overdistention or from injury.
Rupture of the bladder may occur either extraperitoneally or
intraperitoneally, the latter being by far the most common. The

356 DIAGNOSIS AND TREATMENT OF BI^ADDER DISEASES

site of the rupture is generally at the back or at the bottom of the
bladder. The rupture that occurs in fractures of the pelvis is
more likely to be extraperitoneal. The rent is generally a vertical
or an oblique one.

The symptoms of rupture of the bladder, like those of wounds
of the bladder, consist of shock, which is particularly marked
in those cases in which the rupture is due to some abdominal
injury. In other cases the shock is not so marked. Tenesmus
and hemorrhage are generally associated. If sought for care-
fully shortly after rupture a prevesical swelling will generally be
detected — symmetric if it is intraperitoneal, asymmetric if it is
extraperitoneal. A searcher introduced into the bladder may
locate the rupture, as evidenced by the pressure made by the
searcher against the hand on the abdomen. In intraperitoneal
rupture very little urine can be obtained, the jet is diminished in
volume, with feeble pressure under the movements of inspiration
and expiration. Rupture of the bladder, particularly of the intra-
peritoneal type, if allowed to go untreated, is likely to be followed
in four or five days by symptoms of general peritonitis. One
hundred and seven cases of intraperitoneal rupture have been
reported, of whom 82 died during the first five days. In those
cases in which the rupture takes place extraperitoneally the
symptoms of urinary infiltration are more numerous, and its
increase is manifested by the extension of the prevesical swelling
and the tendency of the infiltration to extend in other directions.
More or less pain in the region of the buttocks is generally present.

Rectal examination may be an aid in diagnosing urinary infil-
tration. It is necessary to differentiate this condition from injury
of the kidney, as the latter may also give rise to tenesmus and
bloody urine. The searcher, associated with the rectal and abdom-
inal touch, should be of considerable aid in making the differen-
tiation. The prognosis will depend upon many different factors —
the nature of the injury to other organs, the age of the patient,
and many accompanying circumstances. As a rule, the prognosis
is grave.

Treatment. — The treatment must necessarily be modified to
suit the individual case. When doubt exists concerning rupture
or injury of the bladder within twenty-four hours of the time of

TOTAL EXTIRPATION OF THE BLADDER 357

the injury, an abdominal incision should be made and the bladder-
wall examined. If an intraperitoneal rupture has occurred, it
should be sewed up with catgut. The peritoneum should also
be united with fine catgut or silk, the latter being used in preference
to the catgut when there is fear that the former may be too rapidly
absorbed before the opening has united. An ununited opening
may give rise to peritonitis. The serous and muscular surfaces
only should be sutured. The opening should then be closed,
and a perineal section made for drainage purposes or a retention
catheter should be put in place. If an extraperitoneal rupture
exists, a suprapubic incision may be made, the condition of the
walls of the bladder examined, and such after-treatment pre-
scribed as the needs of the case may seem to indicate. If infil-
tration has taken place, this is manifested by the swelling about
the gluteal region, thighs, perineum, and lower part of the abdo-
men. In such infiltrations incisions should be made through
the skin and cellular tissue, and as many drainage-tubes,
running in various directions, introduced as the character and
number of such infiltrations require, in order that the skin and
cellular tissue be drained as well as possible, otherwise trouble-
some sloughing will result ; some is, nevertheless, bound to occur
in any case.

There is one point to which attention must again be drawn,
and that is as to the urgent need of performing early catheteriza-
tion in persons found in an unconscious state from injury, drunk-
enness, or apoplexy. In a large series of these cases studied by
the writers, overdistention was found to be the principal pre-
disposing cause of cystitis. This series included some cases of
unrecognized rupture of the bladder. Early catheterization, then,
if sometimes performed on the unconscious, would reduce the
number of cases of cystitis due to overdistention, and would
occasionally permit an earlier diagnosis of rupture of the bladder
to be made, thereby increasing the prospects of a favorable after-
result.

TOTAL EXTIRPATION OF THE BLADDER

This operation is occasionally performed for extrophy of the
bladder, as previously mentioned, or for the relief of patients
suffering from malignant diseases of the bladder. It necessitates

35*5 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

the performance of a double nephrotomy, or that the ureters be
transplanted into the intestine or the loin. In transplanting the
ureters care must be used to see that the course of the ureter
is not interfered with, and that no kinking results. The method
of transplanting or making an anastomosis with the intestine
has already been referred to. The operation of excision con-
sists in making a long incision in the median line from the
pubes to the umbilicus; at right angles to this incision, just
above the pubes, an incision is made across each side as far as
the external border of the recti muscle, so that the general shape
of the incision is that of the letter T. The skin, muscles, and peri-
toneum are incised; then the bladder should be freed from the
deep layer of the peritoneum on each side, in the following manner;
the intestine having previously been pushed upward, a pair of
forceps is put on the top of the bladder to pull it above the pubes ;
the peritoneum is then cut along the sides of the bladder, as far
as the base of the bladder ; a transverse incision then divides the
peritoneum, just back of the posterior superior border of the
prostate ; the peritoneum is then stripped off the bottom of Douglas'
cul-de-sac and the posterior aspect of the prostate. With the
peritoneum are detached the seminal vesicles and the extremities
of the vas. The bladder is now pulled forward on to the pubes,
and the pelvic peritoneum is brought together by a vertical suture
from the bottom of Douglas' cul-de-sac to the upper border of
the abdominal incision ; the remainder of the operation is extra-
peritoneal. The various ligaments are tied off, and the ureters
are cut through. If the bladder be lifted up with considerable
tension, the incision of the ligaments is rendered easier. The
urethra is then incised in front of the neck of the bladder, the
organ being pulled toward the umbilicus for this purpose. The
bladder is then removed as a complete sac, the cavity is then
drained and, if necessary, packed.

HERNIA OF THE BLADDER

Vesical hernia is generally associated with inguinal hernia, and
manifests itself, as does the latter, by swelling in the groin. Very
rarely it happens that a hernia of the bladder descends with
intestinal hernia into the scrotum. The condition often remains

HERNIA OF THE BLADDER

359

unrecognized until operation for the relief of hernia is performed.
Occasionally it is very manifest, as is shown in the illustrations
taken from Frisch and Zuckerkandl. If marked diminution in
the size of the tumor is found to take place on urination, a diag-
nosis of bladder hernia can be made.

In operating for the relief of inguinal hernia, if protrusion of
the bladder is also encountered, it should be freed from adhesions
and returned to its place and the wound sutured. An attempt
should be made to restore it to its former position even if all the
adhesions cannot be freed. If a vesical hernia becomes strangu-
lated, it may be necessary to open and drain. If the bladder
hernia has formed a pouch so that urine that collects in it cannot
be released from the bladder, it may be necessary to also open the
pouch and drain. If the bladder is wounded during the opera-
tion for hernia, the incision should be sutured, the hernia of the

Fig. 146. — Hernia of bladder (Frisch and Zuckerkandl).

bladder replaced, and drainage instituted through the suprapubic
incision by the perineal route or by a retention catheter.

The treatment of the case will depend to a great extent on the
individual circumstances surrounding each case ; it may, however,
be summed up as follows : the return of the hernial pouch ; when
possible, the opening and draining of the bladder pouch, which
will hasten the expulsion of retained secretions that cannot other-
wise be voided, together with drainage of the bladder, when

360 DIAGNOSIS AND TREATMENT OF BLADDER DISEASES

necessary, by suprapubic or perineal incision. Resection of the
bladder for hernia followed by suture of the organ has not as yet
been demonstrated to be a successful operation.

DIVERTICULA OF THE BLADDER

These may not in themselves give rise to any characteristic
symptoms, whether they are of the congenital or the acquired
variety. The use of the cystoscope and instrumentation will
generally render their diagnosis comparatively simple. Concern-
ing their treatment, if there is no cystitis present, they can be
allowed to remain as they are. If the bladder becomes infected,
the effect of irrigations should be observed; if such irrigations
are not sufiicient to restore the bladder to a normal condition, it
may become necessary to operate on the diverticula. The form of
operation required will be indicated by the nature of the diver-
ticula. A simple wall existing between the diverticula and the
bladder can be removed by incision, and the whole cavity thrown
into one. Other forms of diverticula will require complete removal
and suturing of the bladder-wall.

Patent Urachus. — A patent urachus may be the seat of abscess
and sometimes the point of origin of tumors and cysts. The
cysts are generally retention in origin, according to Vaughan,^ who
has thade a careful study of the matter. The different forms of
patent urachus are discussed under the four headings:

(i) The complete, in which the duct is open all the way, forming
a continuous communication between the bladder and the out-
side of the body at the navel.

(2) The blind internal, in which the navel remains closed, but
the duct communicates with the bladder.

(3) The blind external, in which the communication with the
bladder is closed, but the navel end of the duct remains open.

(4) The blind, in which both ends are closed, but the duct re-
mains open in the middle.

Thirty-two out of fifty congenital cases were in men, the lesion
appearing at birth or soon after the stump of the cord separated.
The acquired cases, that is, those in which patent urachus subse-

' " Patent Urachus," " Transactions of the American Surgical Assoc," 1905,
vol. xxiii.

DIVERTICULA OF THE BLADDER 36I

quently develops, may be of any age, the oldest reported, accord-
ing to Vaughan, being seventy-nine. Symptoms vary according
to the condition present ; they may consist in having urine appear
at the umbilicus, or pus, or the indication of formation of cysts.
Patent urachus can be diagnosed with comparative ease if there
is an exudation of ous or blood from the umbilicus; if a cystic

Fig. 147. — Patent urachus: N, Navel; U, urachus (dilated); B, bladder (after Vaughan).

formation exists, it may be mistaken for cysts due to other causes.
If the umbilicus opening is closed, it may be diagnosed from cysts
due to other causes by instrumental or cystoscopic examination
of the bladder. Treatment, when possible, consists of extirpa-
tion, closure of the bladder opening with sutures and drainage,
or in some cases the slitting up of the cavity and packing it.

4

CHAPTER XXI

THE ANATOMY OF THE PENIS AND HALE URETHRA

The penis is made up of four elemental structures. These are
the corpora cavernosa, the corpus spongiosum, and the glans
penis. Of these, the corpora cavernosa form the principal part.
They are two cylindric bodies, placed side by side, flattened at
their median aspect, and partly blended together in the median
line in the anterior portion, but separated posteriorly, where they
branch out into first bulging and then tapering masses ; these are
attached to the rami of the pubic bones, and are known as the
crura of the penis.

Each corpus cavemosum is surrounded by a thick and very
dense layer of fibrous connective tissue known as the tunica albu-
ginea. The tunics of the corpora blend more or less in the median
line, to form the septum pectiniforme, which is, however, not a com-
plete septum, since in the anterior portion of the penis its con-
tinuity is broken, so that the substance of the corpora blends,
to a greater or less extent, in the anterior portions. From the
interior of the fibrous envelops and from the septum numerous
lamellae, bands, and cords composed of mingled fibrous and
elastic connective tissue and of smooth muscle pass inward and
run through and across the cavity in every direction, thus sub-
dividing the corpora cavernosa into many interstices. The
trabeculae are larger and stronger near the periphery, and, con-
versely, the spaces are larger, and have thinner walls near the center.
In general, the long diameter of these spaces is parallel to the long
axis of the penis. These connecting spaces are lined by a layer of
endothelial cells, and are directly continuous with the veins, so
that they are in reality dilated, anastomosing venous spaces.

The corpora cavernosa receive their principal arterial blood-
supply from the profunda penis arteries, the dorsal artery of the
penis contributing a smaller amount. Inside the corpora caver-
nosa numerous arteries are carried within the trabeculae; they

362

ANATOMY OF THE PENIS AND MALE URETHRA 36;^

terminate in branches of capillary minuteness, which open directly
into the intratrabecular spaces or the venous sinuses. Some of
the arteries project into the spaces, where they present a peculiar
contorted or curling aspect, and are therefore called the helicine
arteries. The purpose of these loops or coils is probably to pre-
vent the vessels from being torn when the organ becomes erect.
Directly continuous with the venous spaces are the veins which
convey the blood from them, emptying it into two sets of return
trunks — those of the dorsal vein of the penis and those of the
prostatic plexus.

The inferior portion of the united surface of the corpora caver-
nosa is marked by a longitudinal groove in which is lodged the
corpus spongiosum, a cylindric mass beginning at the triangular
ligament of the perineum, where it is placed midway between the
crura. The posterior portion is enlarged into a bulbous dilation
and extends forward as a somewhat tapering cylinder, until it
reaches the anterior extremity of the corpora cavernosa, over
which it expands into a large, conic mass, the glans penis.

Throughout its entire course the corpus spongiosum incloses
and invests the male urethra and its special coats. The structure
of the corpus spongiosum is essentially the same as that of the
corpora cavernosa, but the fibrous framework is much less dense
and the venous spaces are much smaller. These become congested
in the erect state of the organ, but never to so marked a degree
as do the sinuses of the corpora cavernosa. The blood-supply of
the corpus spongiosum is derived from the two lateral branches
of the internal pubic, which enters the body at the bulb and ex-
tends as far forward as the glans.

The glans penis is a conic enlargement of the corpus spongiosum
which covers over the ends of the cavernosa and forms the anterior
portion or cap of the penis. It is made up of a still more dense
form of erectile tissue than is the corpus spongiosum, and is covered
in by a thick mucous membrane of stratified squamous epithelium
which is reflected over very numerous small papillae of the connec-
tive tissue, beneath which are contained the special sense nerve-
endings, the genital corpuscles. The glans receives its arterial
supply from the dorsal artery of the penis, and returns its venous
blood into the great dorsal vein.

364 ANATOMY OF THE PENIS AND MALE URETHRA

The three cylindric bodies of the penis are united by somewhat
dense encircling fibers of areolar connective tissue, which support
the vessels, nerves, and lymphatics of the organ. Outside the
encircling sheet of connective tissue there is a loose areolar layer
of connective tissue, devoid of fat and uniting the skin to the penis.

The skin covering the penis is characterized by its thinness, its
freedom from fat, and its large venous and lymphatic supply.
Its anterior portion is devoid of hair, and is prolonged over the
glans as the foreskin, or prepuce, the internal surface of which is
lined with a mucous membrane uniting the back of the corona
with that which covers the glans. About the corona is situated
a ring of large modified sebaceous glands called the glands of
Tyson. These give rise to an odoriferous waxy secretion, which,
mixed with the desquamated epithehal cells, forms the smegma.

The blood-supply of the penis has been sufficiently described
elsewhere. The lymphatics form a dense network on the glans
and foreskin, and also surround the urethra in the corpus spongio-
sum; they empty chiefly into the inguinal lymph-nodes, but
some of the deeper trunks that supply the corpora join with the
lymph tracts of the pelvis.

The male urethra presents a structure of considerable com-
plexity, and to the physician who makes a specialty of diseases of
the male genital organs its microscopic structure is of the greatest
possible importance. It extends from the bladder to the end of
the penis, a distance of about eight inches, varying according to
the length of the penis and the condition of that organ. Its inner
tube is lined by a continuous epithelial covering and normally
its walls are collapsed and in contact, except during the passage
of the seminal or urinary fluids. Anatomically the urethra may
be divided, for purposes of description, into three portions — pros-
tatic, membranous, and penile.

The prostatic urethra is that portion inclosed in the prostate
gland. It is about i| inches in length, and is wider than either
of the other two portions. At about its center it presents a dilata-
tion known as the prostatic sinus. The lining membrane is thrown
into longitudinal folds, and is covered by a transitional epithehum
continuous with that of the bladder, A few millimeters from the
opening into the bladder there is a small triangular elevation of

PLATE XII

Ischiocavcrnosus

riilve of navicular fosia'

external orijin of uretbrn

a, Tlie corpora cavernosa of the penis: The glans penis and the anterior
part of the corpus cavernosum of the urethra have been drawn aside. * =
Points which are in contact when the parts are in their natural position. /;,
The male urethra with the corpora cavernosa of the penis, the ])ulbourethra 1
glands and the prostate: The corpus cavernosum of the urethra has been
opened by a longitudinal incisicjn in its mid-ventral line. ** = Sounds in the
orifices of the bulbourethral glands (Sobotta and McMurrich).

ANATOMY OF THE PENIS AND MALE URETHRA 365

the mucous membrane known as the verumontanum; this acts as
a valve that closes the entrance into the bladder and so serves to
prevent return flow of the semen during ejaculation. On each
side of the verumontanum the floor of the urethra is slightly
depressed and perforated by numerous foramina, which are the
ducts of the prostate gland ; these discharge their viscid secretion
into the urethra at this point. Just anterior to the verumonta-
num is the orifice of a blind pouch, the sinus pocularis, on whose
edges are the slit-like openings of the common seminal or ejacu-
latory ducts. Into this pouch, as it extends backward for about
half an inch, numerous tiny glands open. It is lined by columnar
epithelium, and discharges its contents into the urethra. When
this pocket is involved in inflammatory disease of the urethra,
the condition does not respond readily to treatment on account
of this anatomic structure. The walls of the prostatic urethra
are made up of the firm tissue of the prostate gland, but at the
point where the urethra unites with the bladder there is a well-
developed circular band of smooth muscle — the so-called "cut
off muscle."

The membranous urethra is that portion situated between the
prostate gland and the bulb of the corpus spongiosum. It is
about three-fourths of an inch long, and its anterior part is covered
by the bulb of the corpus spongiosum ; it is the narrowest portion
of the urethra and is lined by stratified columnar epithelium. Its
wall is made up of a vascular erectile areolar connective tissue,
and of encircling fibers of smooth muscle that are continuous
with those fibers that make up the muscular walls of the bladder.
These are further augmented by the compressor urethrae muscle,
which externally surrounds the membranous portion of the ure-
thra. Into the anterior portion of the membranous urethra enter
the ducts of Cowper's glands. These are two racemose glands,
situated on each side of the membranous urethra, just back of the
bulb. They are lined by clear columnar epithelial cells, and their
basement membrane is made up of smooth muscle and areolar
connective tissue. They secrete a clear viscid substance which is
discharged into the membranous urethra.

The penile or spongy portion of the urethra is entirely inclosed by
the erectile tissue of the corpus spongiosum; it is the longest

366

ANATOMY OF THE PENIS AND MALE URETHRA

portion of the canal. In cross-section it is seen as a transverse
slit running up to the glans, where it dilates into a spindle-shaped

chamber called the jossa nav-
icularis. This opens on the
surface of the glans by a
vertical slit, the meatus urin-
arius, which is normally the
narrowest part of the entire
urethral canal. The penile
portion of the urethra is lined
by simple columnar epithe-
lium up to the fossa navicu-
laris; there the lining con-
sists of stratified squamous
epithelium, which is a con-
tinuation of that of the sur-
face of the glans. Numerous
small tubular glands whose
ducts open out into the
epithelial surface are found
throughout the entire course
of the penile urethra — these
are the glands of Littre
and the lacunae of Morgagni.
They secrete a substance
that keeps the mucosa of
this portion of the urethra
moist. The walls of the
penile portion of the urethra
contain no muscle tissue, but
are made up of the epithelium and of a continuation of the con-
nective tissue of the corpus spongiosum.

Fig. 148. — Longitudinal section through the
urethra, showing the large lacunae of Morgagni
and the small glaTids of Littr6 (after H. Frantz).

CHAPTER XXII

DISEASES OF THE MALE URETHRA

URETHRITIS

Pathology. — Urethritis may, for descriptive purposes, be
divided into two forms — the acute and the chronic; this division
is capable of further subdivision, and of these the catarrhal and
the purulent forms are most important. The condition is most
frequently due to infection by the gonococcus, and hence it is
the gonorrheal form with which we are chiefly concerned. In the
clinical consideration of this disease the term urethritis is used
somewhat generally to describe various forms of inflammation of
the urethral canal, the term being applied to both those cases in
which the gonococcus can and those in which it cannot be de-
monstrated.

Acute catarrhal urethritis results, as a rule, from the irritation
set up by chemic substances excreted in the urine. The changes
produced by this condition consist of a hyperemia of the blood-
vessels of the mucosa, usually with more or less desquamation
of the urethral epithelium, and a greater or less degree of leuko-
cytic exudation and infiltration. When the condition is due to
bacterial activity, it is usually succeeded by the development of
acute purulent urethritis, under which heading these more impor-
tant changes will be discussed. Owing to the stimulation of the
irritant that produced the inflammation hypersecretion of mucus
from the urethral glands takes place, giving to the exudate a char
acteristic glairy and mucoid character. When infection follows
catarrhal urethritis, particularly when such organisms as mem-
bers of the proteus or colon group are present, chronic inflamma-
tion may follow.

Chronic catarrhal urethritis may occur as a sequel to prolonged
acute catarrhal urethritis, but, as a rule, it more frequently fol-
lows suppurative and particularly gonorrheal urethritis. In these
cases it is usually associated with stricture and with chronic

367

368 DISEASES OF THE MALE URETHRA

inflammation of the mucus-secreting glands. These changes will
be discussed at greater length under the sequels of purulent ure-
thritis.

Acute Purulent Urethritis. — Acute purulent urethritis may de-
velop as the result of infection of the urethra by any virulent
organism, or it may follow the application of an irritant to the
urethra for medicinal purposes or the voiding of irritating sub-
stances in the urine. The gonococcus is by far the most frequent
cailse of urethritis, however, as seen by the practitioner. In the
discussion of the pathology of urethritis, therefore, the aim will
be to adhere to the changes that occur in this most frequent
specific type of the disease, it being understood that the anatomic
changes that take place in all the infectious forms are practically
alike, varying in intensity according to the virulence of the infect-
ing organisms.

Bacteriology. — For a proper understanding of the changes that
take place in gonorrheal urethritis it is necessary first to consider
briefly the biologic characteristics of the gonococcus, for it is by
certain of these qualities that the virulence of the disease and its
treatment are considerably modified. Perhaps the most impor-
tant of the biologic characteristics of the gonococcus is its almost
strictly parasitic nature, as a result of which the organism cannot
live for any considerable length of time except in living animal
tissues or in carefully prepared artificial media that closely simu-
late them. As a further result of this parasitic character, which
is further confined to man and the higher apes, gonorrhea is trans-
mitted almost always directly from subject to subject. The
organism soon dies when out of the body even when present in
moist discharges on infected clothing, so that cases of secondary
infection by this means are probably rare. Nevertheless this
mode of infection may be sometimes held responsible for the
epidemics of gonorrhea seen in children's hospitals. A further
characteristic of the organism is its predilection for the mucous
and serous surfaces, although hemic infection, as in gonorrheal
endocarditis or septicemia, occasionally takes place. No toxins
or antitoxic bodies are formed by the gonococcus ; and immunity,
either natural or acquired, in man is a most unusual condition.
This statement must, however, be somewhat modified by the fact

URETHRITIS 369

that, under certain circumstances, prolonged exposure to a defi-
nite strain or culture of the organism confers a degree of resistance
toward it, as is well shown in certain cases of gleet. This pecu-
liarity is noticeable in cases in which, infection having taken place,
continued exposure does not result in the breaking out of the
infection in one or the other, although either subject would be
capable of transmitting it to a third person; if, however, a fresh
infection is introduced, active acute inflammatory changes develop.

A predisposition to gonorrheal infection undoubtedly exists
in many cases, but, in most instances, this is a direct result of
conditions facilitating primary inoculation, such as, for example,
abrasion or fissure of the exposed epithelial surfaces; simple
inflammatory conditions induced by a highly acid urine or by the
excretion of alcohol and other chemic irritants.

Mode of Infection. — Under normal conditions the epithelium
of the fossa navicularis, so capable of obviating bacterial infec-
tion, does not permit infection with the gonococcus to take place
in this portion of the urethra. If, however, from any cause this
surface is eroded or fissured, infection quickly follows. Close
clinical observation apparently demonstrates that in many cases
the gonococcus may remain in the fossa navicularis for a consid-
erable period of time, and may even reproduce in this portion of
the tract, without exciting marked infiammatory reaction. If,
however, the organism gains access to the pendulous portion of
the urethra, either by direct extension from the fossa navicularis
or by being drawn backward by the aspiratory action said to fol-
low relaxation of the bladder or of the extrusor muscle, acute
inflammatory reaction almost immediately takes place. These
facts have been amply proved by the experimental inoculations of
Finger, who showed that gonococci will not penetrate the healthy
squamous epithelium of the fossa navicularis under normal con-
ditions, although infection quickly follows the implantation of
infectious material on the columnar epithelium of the pendulous
portion.

Pathologic Anatomy. — Finger found that three days after

infection the mucous membrane was covered with a copious

purulent secretion and that the epithelial layer was extensively

infiltrated with pus-cells, which, on examination, showed that

24

370

DISEASES OF THE MALE URETHRA

abundant gonococci were present. The lumen of the urethra
contained quantities of mucus rich in gonococci. The inflamma-
tory reaction had extended into the tissues of the corpus spongio-
sum, which showed also purulent infiltration and round-celled
proliferation, although gonococci were but rarely found in the
deeper layers.

The glands of Littre become extensively involved, the infection
apparently traversing the duct of the gland down to the deep-
lying acini, where local inflammation, often terminating in abscess
formation, takes place. Later marked desquamation of the
urethral epithelium occurs, and the mucous membrane, as seen

through the urethral coat,
'^ ^ appears studded with

.... ^V'"';-.:.-,»:? .- minute ulcerations, usu-

ally situated about the
openings of the urethral
glands. Thrombosis of
many of the submucous
blood-vessels takes place,
and may extend into the
erectile sinuses of the cor-
pus spongiosum or even
into those of the corpora
cavernosa, giving rise to
chordee, which is due to the
irregular distention of the
erectile spaces when the
penis becomes engorged.
In a certain number of cases of acute urethritis the infection
may not extend to a point back of the pendulous urethra, although
from anatomic researches, the writers are convinced that, as a
rule, the entire channel finally becomes more or less involved.
In favorable cases healing may take place by an absorption of the
inflammatory exudate, the epithelium reforming, covering the
excoriated areas with a layer of new epithelial cells that are no
longer columnar, but of the simple squamous type. Inevitably,
cicatrices of greater or less degree are formed in the submucous
connective tissues following the absorption of the inflammatory

I'i.i;. 14'!.— Ai,\iu- Kuii(inln.-al iiri.-llii itis iinolving
the pendulous urethra ; eight days after infection : A,
Urethra ; B, desquamated epithelial cells ; C, body of
a gland of Littr6; D, inflammatory infiltration of tis-
sues about urethra.

URETHRITIS 371

exudate, resulting in conditions that will be discussed further on
under the head of Stricture.

One of the most frequent sequels of acute specific urethritis is
abscess formation in one or more of the glands of Littre. The
duct may become occluded, thus tending to localize the process,
whereas the exudate in other portions of the urethra may entirely
disappear. Acute reinfection may follow the rupture of such an
abscess, or, in a certain number of cases, rupture through the
capsule of the corpus spongiosum and external drainage, with
the formation of urinary fistula, may follow. There can be no
question but that many cases of reinfection follow this autoinocu-
lation in what are apparently cured cases of gonorrhea.

Fig. 150. — Chronic stricture of the posterior urethra showing gramiloniatons masses pro-
jecting into the channel and explaining the persistence of urethral discharge in these cases.
A, Urethra; B, granulomatous masses projecting into urethra; C, scar tissue formed about
urethra as a result of chronic inflammation.

When the infection extends into the posterior urethra, an
extension may occur from the membranous portion into the glands
of Cowper and into the prostatic urethra, through the ducts of
the prostate gland into the acini, where suppurative prostatitis
may be set up. Similarly, the infection may involve the sinus
pocularis, and, through the ejaculatory ducts, the vas and seminal
vesicles, in this way often reaching the epididymis and testicle.
Diffuse abscess formation may follow this extensive area of in-
fected mucous membrane, and occasionally terminate in gangrene
involving the entire penis. It should be remembered that the
extension and character of the later anatomic changes are largely
dependent on secondary infection, and in long-standing cases

372 DISEASES OP THE MALE URETHRA

the gonococcus may even disappear entirely, having apparently
been superseded by secondary organisms, chiefly of the proteus
and colon varieties.

Strictures of the urethra are among the more frequent compli-
cations of gonorrheal urethritis. They may occur in any portion
of the tract, although in the writers' experience they have been
found to occur most often in the membranous urethra. They result
from the hyperplasia of the submucous connective tissue that
follows the acute inflammatory changes, or that ensues as the
result of physiologic attempts at repair where loss of tissue, as
from abscess formation or thrombosis with necrosis, has taken
place. If this occurs about or near the urethra, more or less
obstruction inevitably follows, the extent of which depends entirely
on the degree and location of the scar tissue. The epithelium
covering the urethral surface may be entirely absent, or, if present,
is of the simple squamous and atypical variety.

When these obstructions to the urethra exist, proper drainage
is no longer possible, and chronic inflammatory exudation almost
always follows, giving rise to the discharge of a thin, watery
secretion that contains a few pus-cells, desquamated epithelium,
and, in an acute exacerbation of the inflammation, blood-cells and
pus in larger quantities. This exudate is usually rich in bacterial
growth, and is more or less highly infectious, although the gonococ-
cus itself may be absent from it. It may be remembered that
cicatrization of greater or less extent occurs in all cases where
loss of tissue has taken place or inflammation of long standing
existed ; but the degree of urethral strictur that results is depen-
dent not so much on the extent of this process as on its location.
]Bxtension of the inflammatory process to the bladder has been
discussed under the head of Cystitis.

Symptoms of Urethritis
It is customary at the present time to make a classification of
the disease according to whether the inflammatory condition
extends beyond the bulbomembranous juncture or remains en-
tirely within the pendulous urethra, two varieties being named —
anterior and posterior urethritis. Such inflammatory conditions
may be either acute or chronic. Thus we have acute anterior and

URETHRITIS 373

acute posterior urethritis, and chronic anterior and chronic pos-
terior urethritis.

When acute inflammation exists in the posterior urethra, the
anterior urethra, as a rule, is also involved; therefore when acute
posterior urethritis is present, a general urethritis may ordinarily
be said to exist. It may easily be demonstrated that in a large
majority of cases — probably in all — urethritis involves the pos-
terior urethra. It is the custom with many, however, to consider
clinically as either acute or chronic anterior urethritis those cases
in which the symptoms are not urgent enough to indicate much
involvement of the posterior urethra.

Symptoms and Course of Acute Anterior Urethritis. — The period
of incubation after infection has taken place and before any
marked discharge occurs from the anterior urethra is from one to
six days. During this period no clinical symptoms of which the
individual is cognizant may be manifest, or there is a slight
burning sensation, an itching, or a feeling of moisture. The first
discharge that appears is mucous in character; later it becomes
mucopurulent, in a few days more frankly purulent, and occa-
sionally bloody. Ordinarily there will be considerable pain and
burning on micturition; the mucous membrane and the meatus
become swollen; micturition increases in frequency, and painful
erections occur, particularly at night; attacks of chordee are
usually frequent and extremely painful, and the acute stage of
urethritis, generally of gonorrheal origin, may now be said to be
fully established.

After a period whose length depends, among other things, on
the constitution of the individual and on the treatment instituted,
the discharge diminishes. It is, as a rule, more profuse in the
morning than at night, and subsequently becomes mucopurulent in
character. Ordinarily, in untreated cases, the change from the
markedly purulent to the mucopurulent character takes place in
from the third to the fourth week. After the discharge has be-
come mucopurulent it gradually diminishes in quantity and
eventually disappears; usually, in cases that do well, this oc-
curs in from four to eight weeks. Relapses, however, are very
likely to occur, and a subacute condition may be brought about
in which a somewhat profuse mucopurulent discharge that may

374 DISEASES OF THE MALE URETHRA

remain for weeks and months may be present. Or, what is still
more frequent, a single drop of discharge may be emitted in the
morning; this is indicative of that condition of the mucous mem-
brane of the urethra that it has been the custom, in the past, to
designate as gleet — in other words, a chronic inflammatory con-
dition exists.

Symptoms of Chronic Anterior Urethritis. — The general symp-
tom, then, of chronic anterior urethritis is the persistence, for
many weeks and months after the acute inflammatory condition
has passed away, of a mucopurulent discharge of the morning-
drop variety previously mentioned, or of the appearance of a
large number of shreds from the anterior urethra. This inflam-
matory state may depend on several causes, combined or indi-
vidual, such as unhealed erosions, granulomata (so-called softs
strictures), or infection of some of the urethral glands.

Sjrmptoms of Acute Posterior Urethritis.— The clinical symp-
toms believed to be diagnostic of acute posterior urethritis are
frequent micturition at night, severe tenesmus, often a marked
diminution of the discharge from the anterior urethra, bloody
urine, occasional drops of blood exuding from the meatus, pain
at the end of the penis, more or less uneasiness in the perineum or
rectum, and generally some rise in temperature.

Symptoms of Chronic Posterior Urethritis. — This condition is
frequently associated with . chronic anterior urethritis and also
with chronic prostatitis, in either of which conditions the symp-
toms indicative of the complicating disease would naturally be
expected to be present. When not associated with the conditions
mentioned, its most frequent symptoms are increased frequency
of micturition at night, uneasy sensations at the end of the penis,
in the perineum, or in the rectum, a feeling of moisture, a burning
sensation after urination, pain in coitus, or indications of sexual
neurasthenia.

Diagnosis

Recently much exhaustive work has been done to devise vari-
ous methods for the more accurate diagnosis of the conditioHS
previously mentioned. Hugh Young,' under the title of the

' " Johns Hopkins Hospital Report," 1906.

URETHRITIS 375

"Seven-glass Test," has made an investigation of the various
glass tests that are in vogue, and has a modification of his own,
which is as follows : He uses in this test a urethral irrigation tube
made of glass, with a rubber cup made from half a small ball at a
point about ten centimeters from the urethral end. "The patient
is instructed to compress the urethra between the thumb and
finger far back at the root of the penis (at the suspensory liga-
ment) ; the irrigating tube is then slowly inserted, with the water
running, up to the point of compression (suspensory ligament),
and the fluid escaping is caught in two glasses, the first containing
shreds, if any be present, and the second is clear (showing through
cleansing). Then the patient's fingers are removed, and the tube
carried back as far as the deeper part of the bulbous urethra, the
urine again being caught in two glasses, the first containing shreds
from the bulbous urethra and the second is clear as before.

"The patient then voids his urine in three glasses, as in Koll-
mann's test.

" Besides being far simpler, owing to the use of the lavage tube
and cup in place of a catheter, the differentiation of the pendulous
and bulbous portions of the urethra afforded has proved not only
of considerable interest, but often of great imp)ortance in locating
the lesion, and directing the character and extent of treatment
necessary."

The Kollmann test referred to consists in collecting the urine in
three glasses after the anterior urethra has been irrigated and the
washings caught in two glasses.

We have already, in the chapter on the General Examination
of the Patient (page 30), referred to some of the glass tests now
commonly used for the purpose of diagnosing what part of the
urethral canal is involved by the inflammatory process. When
the urethra is in a state of very acute inflammation, with a very
profuse yellowish discharge from the meatus, it is unwise to wash
out the anterior urethra for the purpose of diagnosis through any
instrument whatever, whether the instrument be so long that it
will extend to the region of the bulb, or whether a short nozzle
alone is used. For any degree of discharge less than the very acute
one just mentioned we have found the very small olive-pointed
gum catheter the most useful. It should be so small that it

376 DISEASES OF THE MALE URETHRA

will not occlude the meatus to such an extent, but there will
be a free flow of the fluid out from the meatus along the side of
the catheter. It should be introduced with the utmost gentleness
as far as the region of the bulb, and four to six ounces of normal
salt solution should be injected through it with as little force as
possible. The water should be allowed to run as the instrument
is removed from the urethra. The washings can be collected in
glasses, as in the method of Kollmann or Young. The patient
should then be allowed to urinate in three separate glasses. If
the urine is clear in all three, it will be fairly good evidence
that no acute inflammatory process at least exists beyond the
compressor urethrse muscle. If the lirine is cloudy in the first
glass, or contains shreds in the first glass, it will indicate that the
posterior urethra is affected, and that an acute posterior urethritis,
with or without a prostatitis, exists. If all three glasses are c)oudy,
it will indicate that a cystitis or some inflammatory lesion beyond
the compressor urethrae muscle exists. If the first glass is cloudy,
the second glass is clear, and some slight cloudiness is present
in the third glass, it will probably indicate some inflammatory
condition of the prostate, the discharge from which is squeezed
out by the contraction of the muscular fibers at the end of urina-
tion.

Concerning the diagnosis of chronic urethritis, if the patient
complains of a morning drop, or that he has shreds in the urine,
the anterior urethra should be washed out in one of the ways
suggested, and if no shreds are found in the three glasses passed,
it is very good evidence that the shreds do not come from the
posterior urethra or the prostate. If, after washing out the
anterior urethra, shreds are found in the first glass, it indicates
that they come from the posterior urethra or the prostate. If the
second glass is clear and shreds arc found in the third glass, it
would indicate that they came from the prostate. The character
of the shreds also is somewhat of an indication as to the place
from which they originate. The long fluffy shreds are ordinarily
from the anterior urethra; the small hammer-shaped shreds from
the prostate.

The diagnosis of chronic anterior urethritis, as previously
mentioned, and its nature can be made out by direct inspection

URETHRITIS 377

through an endoscope, by the use of the bougie a boule of varying
sizes, by the sensation to the touch through the passage of an oHve-
pointed bougie. It generally depends upon a granuloma, that
is, an inflammatory infiltration, or the involvement of some of the
glands of Littre or the crypts of Morgagni. Almost all cases of
chronic anterior urethritis are associated with chronic posterior
urethritis to a greater or less extent.

The diagnosis of chronic posterior urethritis, in addition to the
information furnished by the various glass tests mentioned, can
be aided by the passage into the bladder of an olive-pointed bougie
for the purpose of observing whether a stricture may be present
or not. The posterior urethra may also be observed under direct
inspection through a long endoscopic tube, and the appearance of
the colliculus should be particularly noted. In addition to this,
information is afforded by examination with a steel instrument
in the bladder and the finger in the rectum. The diagnosis of
prostatitis, which almost always accompanies posterior urethritis,
is referred to in the chapter dealing with Diseases of the Pros-
tate. It is hardly necessary to state in detail here the various
causes besides the gonococcus which may give rise to the urethral
discharge. It may be associated with, or follow, fevers, it may
be due to stricture, calculi, the presence of parasites, and various
other organisms, such as the pneumococcus, it may be traumatic,
or associated with gout or rheumatism. The secretions should be
examined microscopically before any positive diagnosis can be
made. The Gram stain will demonstrate the gonococcus if present
in the secretion in the vast majority of cases. Culture tests for
the gonococcus we have found to be too uncertain for routine
use.

For further information concerning details of diagnosis the
reader is referred to the chapter on Examination of Patients and
Examination of Exudates.

Treatment of Non-gonorrheal Urethritis

The treatment of the various forms of non-gonorrheal urethritis
necessarily is the treatment of the condition which is the causa-
tive factor of the case. If a slight discharge is due to a stricture,
dilatation of the stricture and the proper treatment will cure the

378 DISEASES OF THE MALE URETHRA

discharge. If due to irregularities in the diet, proper hygienic
measures should be executed. A discharge occasionally seen,
in which no gonococci can be found by the microscope, but which
is due to infection with simple pus micro-organisms, should be
differentiated from a discharge of similar general appearance due
to irritation of some previous existing chronic lesion of the urethra.
If the latter is not present and the discharge persists, local treat-
ment by irrigation with the Ultzmann injection, or nitrate of sil-
ver I : 10,000, used three times weekly, should be instituted. Such
discharges ordinarily quickly stop under the appropriate treatment.

The Abortive Treatment of Urethritis
Before entering into a discussion as to the proper treatment of
acute anterior urethritis, the methods now in use for aborting a
threatened attack of the disease must be considered. Various
lines of treatment intended to serve this purpose have been sug-
gested and tried for many years past, but too many factors had
to be considered to render statistics as to the benefit to be derived
from certain procedures of any value.

The following method has for many years past been occasion-
ally used by the writers. Recently we have learned of a method
that is somewhat popular in Germany; for the description of
this we are indebted to Dr. Henry H. Morton, of Brooklyn, N. Y.
Authors' Method. — If possible, before the gonococci have in-
vaded the urethra and before the discharge has become frankly
purulent, it is the writers' custom, in certain cases, to inject as
large a quantity of glycerin as possible into the anterior urethra,
compressing the meatus; the latter is then allowed to open, and
a small pledget of cotton wrapped about the end of a wooden
applicator, and moistened with silver nitrate solution of the
strength of ten grains to the ounce, is introduced through the
meatus and the outer two or three inches of the urethra
painted. This application should not be made through an
endoscope, for, in the writers' experience, the endoscopic
tube proves irritating to the urethra. Under ordinary circum-
stances, the application should not extend beyond the first two
or three inches of the urethra. The active inflammation set
up by the silver nitrate should be counteracted externally by

URETHRITIS 379

applying cloths wrung out of hot water, and internally by the
administration of potassium bicarbonate and hyoscyamus, which
will render the urine unirritating. Not more than one appUca-
tion should be made daily, and if, after three applications, no
beneficial results ensue, the treatment should be discontinued. If
good results are apparent, the treatment should be continued at
gradually increasing intervals until six or eight applications in
all have been made. Clinically, in the writers' experience, this
method seems most useful in cases of relapsing acute urethritis in
which a chronic inflammatory condition has previously existed.

German Method. — If the patient is seen in the first three days
before the discharge is active, and the microscope shows the pres-
ence of epithelial cells and leukocytes together with the gonococci,
most of the latter being extracellular, the following procedure
may be adopted in an effort to abort the disease. If, however,
the gonococci are very abundant and intracellular, the method is
contraindicated.

A microscopic examination of the secretion from the meatus
will demonstrate whether or not an attempt at aborting the
disease should be made by this method. When the effort is to
be made, this is best done by irrigating the entire anterior urethra
with a freshly made solution of albargin, i : looo. Occasionally,
in such cases, the patient is also directed to repeat the injection
himself three or four times daily. Each time that the albargin
is used a fresh solution should be made ; for this purpose the albar-
gin tablets are most convenient. If, after five or six days, a cure
seems to be established, a provocative injection of silver nitrate
may be used and any discharge that appears afterward examined
to see if gonococci are still present. If they are found to persist,
the abortive treatment may be considered to have been a failure.
If, as the result of the abortive treatment, pus still appears and
the gonococci have disappeared after five or six days, the albargin
irrigation should be discontinued and irrigations of potassium
permanganate substituted.

In addition to the local abortive treatment, the originator of
the foregoing method also prescribes gonosan internally. There
is danger, in almost all forms of abortive treatment, of giving rise
to epididymitis, and also to other complications of urethritis.

380 DISEASES OF THE MALE URETHRA

From a study of fig. 149, which portrays a patient who died of
pneumonia while suffering at the same time from an acute ure-
thritis, it will be seen that the inflammatory condition extended
into the foUicles of the urethra and the glands of Littre. From a
pathologic point of view, therefore, it would be impossible to
cure a urethritis by means alone of local injections and irrigations
confined to the anterior urethra; nevertheless this early local
treatment, unaccompanied by the use of any other remedial meas-
ure, is still very popular.

As the result of the writers' pathologic investigations and clini-
cal experience, amply substantiated by some of their associates,
they are convinced that it is better to postpone the active local
treatment of urethritis until after the acute stage has passed and
the discharge first becomes mucopurulent ; this is generally about
the fourth to the sixth week after the onset of the disease. It
may be said, however, that many conscientious and able surgeons
hold a different view as regards the treatment of acute anterior
urethritis; in acute posterior urethritis, on the other hand, almost
all agree that active local measures should not be undertaken.
Those who favor the early local treatment do not directly dispute
the fact that most, if not all, cases of anterior urethritis are ac-
companied by coincident posterior urethritis; nevertheless they
differentiate clinically, more than pathologically, between the
two conditions, diagnosing as acute anterior urethritis those cases
in which painful and increased frequency of micturition at night,
and various other symptoms that are characteristic of acute
posterior urethritis, are absent. In outlining any early local
treatment to be pursued for acute urethritis, therefore, that
method of local treatment that appeals most strongly to the
writers has been described, although, as previously stated, they
consider is wiser to postpone all local treatment until after the
acute stage has passed.

Treatment of Acute Anterior Urethritis
The medicinal treatment of acute urethritis has been so exten-
sively dealt with that most physicians are familiar with it. If
no attempt is made to abort the disease and the patient is seen at
the beginning of the attack or when the acute stage is at its height,

URETHRITIS . 381

he should be induced, when possible, to remain in bed, and a
diet consisting largely of milk should be prescribed. He should
be instructed as to the great necessity for observing cleanliness,
and should be informed of the serious danger to vision that fol-
lows infection of the eyes with the discharge. The necessity for
observing personal cleanliness, particularly in respect to the
parts that are concerned in the trouble, should be pointed out to
the patient. This is best accomplished by means of bits of cotton,
or, better still, pieces of gauze, through which a hole has been
cut for the insertion of the glans, and the foreskin being pulled
down over it, a new piece being applied after every urination.
Coitus should be interdicted, and he should be warned against
the excessive use of tobacco. All alcoholic, malt liquors, and
wine should be forbidden. Strawberries and particularly aspa-
ragus should be avoided. If the patient cannot be prevented
from moving about, a diet as light as is consistent with his condi-
tion and occupation should be recommended. A suspensory
bandage should be worn. If possible, the patient's blood should
be examined, for the presence or absence of various forms of
anemia or of the malarial plasmodia. The nature of the disease
and the pathologic condition that exists should be carefully ex-
plained to the patient, even at the expenditure of considerable
time on the part of the surgeon. At times a simple pencil sketch
of the anatomy of the neck of the bladder will help to make mat-
ters clear to the patient. The writers have almost invariably
found that when the patient's condition is fully and patiently
described to him, he becomes more submissive and more amenable
to treatment. Once persuaded that it is the desire of the surgeon,
after the acute symptoms have subsided, to restore the urethral
canal to complete health, patients are, as a rule, wilUng to forego
any desire they may previously have had for quick and powerful
local treatment. It has been the writers' experience that if such
explanations are made, the fear entertained by many practitioners
that unless they do not immediately adopt local measures their
patients will leave them, is groundless. As a general rule, the
small minority who do seek the advice of another practitioner
are very likely to return later on with ope of the complications of
urethritis, which renders them much more ready to resume treat-
ment.

382 DISEASES OF THE MALE URETHRA

For the relief of the painful micturition the following well-
known prescription will be found beneficial :

I^. Tinct. hyoscyami 5ss.

Potassi bicarb 5 j.

Aquae ad Sviij.

Sig. — Tablespoonful in water three or four times daily.

For the relief of chordee or painful erections camphor or the
various preparations of the bromids may be prescribed. Cloths
wrung out of cold water may also be applied with benefit. Cold
sitz-baths have been advocated, but great caution should be exer-
cised in their use, particularly by those who are feeble or infirm,
for they are not infrequently followed by attacks of neuralgia.

Casper advocates the use of fluidextract of pichi, and prescribes
it mixed with equal parts of balsam of copaiba and oil of sandal-
wood, flavored with oil of peppermint. This mixture is given in
doses of 20 drops three times a day. He believes that pichi is
useful for the relief of tenesmus. While this may be so, in a series
of experiments carried on some years ago for the purpose of ob-
serving the effects of pichi in diminishing the discharge, the writers
found no particular effect follow its use. Casper also recommends
that tea be taken frequently during the day, presumably for the
astringent effect of the tannin.

In the declining stages of acute anterior urethritis good results
follow the internal administration of dram doses of fluidextract of
hydrastis (golden-seal). Benefit may also be obtained from the
following capsule :

Urotropin gr. ij.

Oil of sandalwood,

Oleoresin of cubebs,

Copaiba,

Oil of nutmeg, of each, Tijiij.

One of these capsules should be given three times a day. Gonosan
capsules, which have been advocated in this disease, consist of
kava-kava and oil of sandalwood, of each, 3 decigrams; two of
these capsules are to be taken three times a day. A tea made of
uva ursi is useful for relieving the irritation at the neck of the
bladder. Triticum repens may also be of service. The fluid-
extracts of staphisagria and of thuja, of each a half teaspoonful
two or three times a day, may be of benefit. When possible,

URETHRITIS 383

patients should be seen at least once weekly, and oftener if the
indications of the case demand it. If no local treatment has been
given, at the end of about from four to six weeks the discharge
begins to decrease in volume or lose its yellow tinge, or both, the
process tending to become subacute or chronic. If the surgeon
was not decided as to the best time to begin earlier local treatment,
it may now, if deemed advisable, be instituted in a tentative man-
ner, or the patient may be kept under close observation, and if he
does well, the discharge gradually subsiding and finally ceasing
altogether, the urine becoming clear, and if there are no other
indications pointing toward any continuation, of the disease, the
patient may be discharged without receiving local treatment.
It is well, however, to inform him that his condition was a serious
one, the results of which may become manifest in after-life, and
he should, therefore, be advised to visit the physician occasion-
ally so that any after-efifects may be detected.

In acute anterior urethritis in those cases in which most of the
effects of the disease are evident in the anterior urethra, some
advocate the passage of a sound into this portion of the urethra,
the discharge diminishing very considerably at the end of about
the fifth week. This may be repeated at intervals of from once a
week to once in five days, the amount of secretion being the guide
as to the frequency with which the instrument should be passed.
Instead of a sound, a Kollmann anterior dilator may be used.
This procedure is to be followed in three days by irrigation with
silver nitrate, i : 10,000, or ichthargin, i : 4000. Patients may at
the same time use an injection of zinc and resorcin.

Early Local Treatment of Acute Anterior Urethritis. — As has
previously been stated, the writers deem it advisable, certainly
in the majority of cases, to postpone the local treatment of
the urethra by means of irrigations or injections until the dis-
charge begins to assume a mucorpurulent character, relying for
the time entirely upon proper hygiene, the alkalis, balsams, or
herb teas, as previously mentioned. For those who desire, how-
ever, to begin local treatment earlier, the following methods are
suggested.

One or two grains of albargin to 5 ounces of water may be used
as an injection by the patient four times a day ; it is to be retained

384 DISEASES OF THE MALE URETHRA

for five minutes. Protargol one per cent, may be used in the
same manner. If, in the course of about three weeks, the micro-
scope demonstrates the presence of epitheUum but the absence of
gonococci, a different injection should be prescribed. The micro-
scopic findings at this time should determine the changes to be
made in the injection. If gonococci disappear, an injection, as
mentioned above, may be used twice a day, alternating with the
following: zinc sulphate one gram, resorcin two grams, water
150 grams. The patient should then receive an injection of this
liquid twice a day, and the albargin injections should be limited
to two a day. Gradually the albargin is dispensed with and only
the zinc and resorcin mixture is used. After the discharge has
ceased and threads from the anterior urethra alone remain, the
patient may use silver nitrate injections, i : 10,000, or injections
of ichthargin, i : 5000.

It should be remembered that in the ascending stage astringent
injections will only tend to further seal up the gonococci which
have already deeply invaded the tissues. The theory is that
through the use of non-astringent germicidals, such as the various
albuminate of silver salts, — albargin, protargol, or argyrol, — if not
used in too irritating a form, the gonococcus is destroyed. In
properly selected cases, under such treatment as outlined above,
at the end of three weeks, the gonococci should have disappeared,
or to have commenced to disappear from the secretion. Then
the astringent substances mentioned should gradually come to
be used until the discharge has almost entirely ceased. The
gonococci having disappeared from the discharge, the various
astringents having then been used and the discharge still persist-
ing, the injections should be changed, and one of oxycyanid of
mercury i : 4000 substituted. Then if the discharge still persists
to any considerable extent, the patient is probably suffering from
overtreatment and all local measures should be stopped, while
the patient is still kept under observation, or posterior urethritis
may be present to such an extent as to prevent the cure of the
anterior urethritis. A certain amount of posterior urethritis
is not considered by the originators of the above form of treat-
ment to counterindicate it as a method for the treatment of acute
anterior urethritis. They do not refrain from instituting this

URETHRITIS 385

form of treatment if the various glass tests show the posterior
urethra to be only slightly involved, if no other clinical evidence
of the involvement of the posterior urethra exists, such as fever,
pain in the perineum, blood in the urine, or excessive tenesmus
is present. They claim that through this method they diminish
to a considerable extent the proportion of cases which become
attacked by severe posterior urethritis. In carrying out this
early local treatment the prostate should be frequently examined,
and if it becomes swollen or tender, all local treatment should be
stopped. The microscope should be regularly brought into use
for the purpose of examining the secretions, and the injections
should be modified according to the findings in the manner sug-
gested above. The above method has been presented, in an ampli-
fied form, in a recent edition of a work by our friend, Dr. Henry
H. Morton.'

Treatment of Chronic Anterior Urethritis
Chronic anterior urethritis only may be said to be present when
the diagnostic methods described show that the posterior urethra
is in a healthy condition, but a slight amount of purulent discharge,
generally of the morning-drop variety, persists at the meatus or
there is an abundance of threads or slightly purulent urine.

Treatment consists of injecting, as far as the bulbomembranous
junction, a weak solution of silver nitrate, i : 10,000, or the Ultz-
mann injection, of phenol, alum, and zinc sulphate. If the con-
dition still persists, an endoscopic examination should be made,
for the chronic inflammatory state is, as a rule, due to the presence
of some granulomatous infiltration about one or several of the
urethral glands or to commencing stricture. If conditions per-
mit, the inflamed area should be painted through the endo-
scope with silver nitrate solution or with some other suitable
astringent; or the treatment may consist of destruction of the
diseased glands by electricity, or of dilatation of the anterior
urethra. These conditions are almost invariably associated with
more or less chronic posterior urethritis, the proper treatment of
which will, at the same time, tend to heal the inflamed area in the
anterior urethra.

1 " Genito-Urinary Diseases and Syphilis," 1906.
25

386

DISEASES OF THE MALE URETHRA

There seems to be marked agreement among those who have
observed the effect of the silver salts that they are most useful in
hastening elimination when gonococci are present if applied in
dilute form; and that for a purulent discharge when gonococci
are absent, or present only in small numbers, solutions of potas-
sium permanganate, of resorcin, or of zinc sulphate are of benefit;

for cleaning and disinfecting
purposes, salt and water, boric
acid, and solutions of the mer-
cury oxycyanid, i : 4000, are
efficacious. The writers firmly
believe in the efficacy of the
old-time injections of phenol,
zinc sulphate, and alum, of
each, I : 1000 to i : 500, as the
exigencies of the case may de-
mand, particularly when doubt
exists as to whether the proper
time for instituting local treat-
ment has arrived. The local
treatment just outlined for
chronic anterior urethritis, if
injections or irrigations are
used, may be carried out once
daily or oftener at the sur-
geon's office, using an irrigator,
if desired, that does not pene-
trate far beyond the meatus;
of these there are many forms
on the market. The patient
may also use a hand injection,
if this is deemed advisable.

It is a common practice in
making irrigations of the ante-
rior urethra to increase the force with which the fluid is thrown
into the urethra by elevating the reservoir, in order to overcome
the resistance of the constrictor urethrae muscle and thus allow
the fluid to enter the bladder The writers are opposed to this

Fig. 151. — F. C. Valentine's irrigating outfit.

URETHRITIS 387

method of bladder washing, for they beheve that the danger of
infecting the prostate or of increasing the virulence of any infec-
tion that may exist is thus enhanced. They recommend, when
it is desired to wash the bladder, that this be done through a
small, flexible tipped, bulb-pointed, French silk catheter, or
through the small-sized, soft-rubber, velvet -eyed catheter, to the
end of which a hand syringe or an irrigator may be attached, as
the surgeon sees fit.

We are equally opposed to the routine method of forcing fluids
into the bladder beyond the compressor urethrae muscle by one
of the glass hand-syringes to which is attached a rubber tip for
the purpose of thoroughly occluding the meatus. It is com-
paratively easy, by the use of one of these hand-syringes, such as
the Janet, to force fluid back of the compressor urethrae muscle,
and it is a procedure frequently carried out as a routine method
by which irrigations are made along the course of the posterior
urethra, especially in some of the dispensaries. When such
procedure is carried out, if the irrigating apparatus is used,
it should not have an elevation above five feet above the
urethra. If the hand-syringe with a rubber tip is used, as much
gentleness as possible should be employed in making enough
pressure to force the fluid used into the bladder. From clinical
observation of cases of urethritis, which have been treated by
others, and have afterward come under our care, we believe the
tendency of irrigations which overcome the contractile power of
the compressor urethrae muscle by pressure is to cause more of
an infiltration of the prostate than would otherwise exist. Under
our observation such prostates, through a rectal examination,
appear to be more swollen than in those cases of posterior urethritis
in which irrigations have been made through a small olive-pointed
catheter, as advised by us. Herasco, of Bucharest, in a recent
communication to the Association Fran9aise Urology,^ in dis-
cussing abscess of the prostate, states that he has operated forty
times on abscess of the prostate, and that in most of his cases the
abscess was caused by lavage of the vesical urethra without the
use of the catheter. On the other hand, it is hardly necessary
to state, when irrigating the deep urethra through a catheter, in
^ " Ann. de Mai. Genito-urinaire," 1907.

388 DISEASES OF THE MALE URETHRA

addition to the necessary precautions as regards asepsis, great
gentleness must be exercised; if any violence is used, it too will
be liable to cause infection, and abscess of the prostate may
ensue.

Treatment of Acute Posterior Urethritis
The pathologic changes that take place in acute posterior
urethritis have been considered. As the result of the exam-
ination when the clinical symptoms show that the posterior
urethra becomes acutely involved, all local treatment, if it has
previously been administered, should cease. The patient should
be put to bed, and proper hygienic measures instituted. The
writers have previously expressed the belief that almost all cases
of urethritis involve the posterior urethra; for this reason they
advocate that all cases be treated from the beginning as if pos-
terior urethritis were already established. In severe cases of
posterior urethritis quinin in small doses is useful, and for the
relief of urgent symptoms salol, sweet spirits of niter, infusions of
uva ursi or triticum repens, or hyoscyamus and opium to relieve
pain. Alkalis, if there are indications for their use, and hot sitz-
baths make up, with the above, the treatment.

Treatment of Chronic Posterior Urethritis
This ordinarily is best treated by irrigations of silver nitrate,
I to 10,000, or irrigations of the Ultzmann solution of phenol boric
acid and zinc sulphate two or more times weekly, or by dilation
with a KoUmann dilator for the deep urethra or by a combination
of the above methods.

In cases of chronic posterior urethritis many practitioners
believe in the efficacy of instillations, that is, the application of a
few drops of such a solution as silver nitrate — 2 to 10 grains to
the ounce — by means of a soft catheter or through syringes, such
as the Ultzmann, designed for the purpose. Instillations are not
as efficacious as irrigations for inflammations of the posterior
urethra that are at all diffuse in character ; in those that are local-
ized they may be of benefit. Instillations are useful, however, and
the employment of them is sometimes attended with remarkably
good results, so far as improvement in sensation of those who
suffer from neurasthenia accompanied by slight inflammatory

URETHRITIS

389

lesions in the posterior urethra is concerned. Instillations are also
of value as an adjunct to other measures employed in the treat-
ment of lost or enfeebled sexual power as a result of this condition.
Ointments have been recommended by many writers for the
treatment of chronic posterior urethritis, and exhaustive refer-
ence to them may be found in text-books on the subject. The
writers' experience with them has been limited, the methods just
mentioned having been found adequate and preferable. When
threads alone are present, zinc sulphate ointment may be of use.
A 10 per cent, aristol ointment is serviceable in hyperesthesia of

Fig. 152. — Hutchinson's catheter for applying ointments to the urethra.

the deep urethra. Other ointments useful in the treatment of
chronic posterior urethritis are :

Argent, nitrat 15 grains

Olive oil 1 J drams

Lanolin 3 ounces

or:

Potassium iodid H drams

lodin, pure 15 grains

Lanolin 3 ounces

Olive oil 1 J drams.

The application should be made by means of a steel sound de-
vised for the purpose, having grooves on the outside to hold the
ointment. Dr. Young, of Baltimore, has just invented an inge-
nious applicator. The Hutchinson syringe may be used if a
Young's applicator or the grooved sound described is not available.
This treatment may find more favor in future when it has been
decided which is the best ointment base to use, and when the
applicator best suited for the pvupose has been made.

Various insufflators have been devised for the purpose of intro-
ducing powders into the urethral canal; however, they have been
almost entirely discarded. Bismuth was the base of most of

390 DISEASES OF THE MALE URETHRA

the powders intended for this purpose, an antiseptic, such as
phenol, often being added. Medicated bougies that melt at the
body temperature have been widely vaunted as a remedy in this
disease. In these cacao-butter generally forms the base, some
antiseptic substance, such as phenol or iodoform, or an astringent,
such as zinc sulphate, alum, or copper, generally being added.
These do not, apparently, fulfil the indications so well as the
other methods described.

In relapsing cases of chronic general urethritis hard infiltration
is likely to be present, particularly when there is a history of
previous infections. In these cases it may be found that quite a
tight stricture exists in the urethra at the bulbomembranous
junction. Dilation of the stricture at proper intervals rapidly
cures the discharge; irrigations temporarily relieve it, but it is
likely to return. The recurrent form of this disease occurs in
patients who have had repeated attacks of gonorrhea extending
over a series of several years.

Occasionally the discharge persists in the form of a drop or
two, and does not respond to treatment. An examination of the
anterior urethra by means of the endoscope will show that glan-
dular infection has taken place and that glandular urethritis is
present. In such cases the glands may be destroyed by electro-
lysis, instruments being devised for that purpose.

A condition that is quite frequently seen is that of peri-ure-
thral urethritis, in which the glands are infected just inside the
meatus. Such glands may be divided by a small knife or treated
by electrolysis.

R6sum6 of the Treatment of Urethritis
The writers recommend the occasional adoption of abortive
measures. They regard all cases of urethritis as involving the
posterior as well as the anterior urethra, and treat them accord-
ingly, i. e., they advise that no intra-urethral local measures be
adopted until after the acute symptoms have subsided and the
discharge has become mucopurulent, such measures being then
adopted as are indicated for posterior as well as anterior urethritis,
and that the posterior as well as the anterior urethra be treated
locally, when any local treatment is required, generally by irriga-

COMPLICATIONS 39 1

tion of very weak solutions of silver nitrate or after some tenta-
tive irrigations of the Ultzmann solution have been used or by
dilation.

Relapsing cases are generally due either to the too early insti-
tution of local treatment or to the presence of stricture. The
treatment for this, together with the treatment of prostatitis,
which in so large a proportion of cases accompanies chronic ure-
thritis, will be dealt with in a later portion of this work.

COMPLICATIONS

The complications of gonorrheal urethritis are very numerous,
but no attempt will be made to discuss any save the more impor-
tant and frequent of these complicating conditions. In order
to obtain a clearer view of the complications resulting from
gonorrhea, it may be well to review briefly, in the light of our
present knowledge of pathology, the relations that exist between
the reaction of the tissues and the gonococcus when the body is
invaded.

An acute gonorrhea follows the same course pursued by other
infectious conditions in other portions of the body, modified some-
what by the shape and the function of the part attacked. As
was previously shown, all the symptoms of an acute exudative
inflammation appear. The exudation of pus, which is so terri-
fying to the patient, is not a disease in itself, but a symptom
of the battle that is being fought between the infecting micro-
organism and the forces of the body — the effort of nature to
conquer the infecting hosts. The fluid of pus is made up of serum
from the blood, which in itself is a bactericide, and washes away
with it organisms that have attacked the body, as well as the dead
tissues resulting from the conflict that is going on. Swelling of
the membranes is due to the surrounding protective walls of
phagocytes or similar elements thrown out by nature to prevent
the further invasion of the body, for nature always makes an
effort to protect the whole as much as possible. The body having
thus been protected at the expense of the urethra, after the acute
exudative inflammation has passed off, excoriations, granulations,
and beginning formation of cicatricial tissue occur. The system
has to a considerable extent been saved, but at the expense of

392 DISEASES OF THE MALE URETHRA

the part; hence as the result, generally, of constitutional condi-
tions or of unwise treatment complications of urethritis often
occur. Among these are phimosis, paraphimosis, balanitis, lymph-
angitis, invasion of the parietal glands with resulting parietal
abscesses, and invasion of the follicular glands of the urethra
with resulting follicular abscesses. The prostate and the seminal
vesicles often become involved, cystitis may ensue, and inva-
sion of the kidney and pyelonephritis may result. The nervous
system is occasionally attacked, and myelitis and meningitis of
gonorrheal origin may occur. Involvement of the testicles mani-
fests itself by the onset of epididymitis and orchitis, which may
lead to stenosis of the vas deferens, producing sterility. Osteomye-
litis, phlebitis, pulmonary infarct, pleuritis, and endocarditis may
occur.

Gonorrhea of the mouth and of the rectum is extremely rare,
but cases are occasionally reported, and, according to Caspar,
gonorrheal stomatitis of the newborn is found now and then. Cas-
par quotes Jaddeson as saying that gonorrhea of the rectum has
been known to result from rupture of a prostatic abscess, as well
as from direct inoculation.

Gonorrhea of the eye and gonorrheal rheumatism are such
frequent complications that they merit detailed description here.
For the following article on "Gonorrhea of the Eye" we are in-
debted to Dr. Richard Kalish, of New York.

Gonorrhea of the Eye. — Specific urethritis may cause both
extra-ocular and intra-ocular disease, the most frequent mani-
festation of the former being acute blennorrhea of adults, and of
the latter, iritis.

Acute blennorrhea, called also purulent or gonorrheal conjunc-
tivitis or ophthalmia, is due to contamination from urethral
discharges, usually carried by the fingers of the patient; one eye
is first affected, and it is generally possible to tell from this whether
the sufferer is right or left handed. Other means of infection are
the hands of nurses and soiled dressings. In four cases seen in
the writer's practice the source of infection was traced to the
towels used in the offices where patients were employed. From
an extensive clinical experience, the writers cannot concur in the

COMPLICATIONS 393

opinion that the toxins of the gonococcus circulating in the sys-
tem may produce gonorrheal conjunctivitis.

Symptoms. — In every case of this disease the gonococcus of
Neisser is present. The symptoms appear very soon after inocu-
lation,— usually within forty-eight hours, — and at first, on casual
inspection, resemble those of acute catarrhal conjunctivitis; a
closer examination, however, discloses the fact that the ocular
conjunctiva presents a more brawny and turgid aspect. Great
swelling rapidly supervenes, with intense congestion of the con-
junctiva, and a marked chemosis forms an elevated ring surround-
ing the cornea which appears as if sunken to the bottom of a pit.
The slight opalescent excretion quickly gives way to a very profuse,
greenish yellow discharge, presenting the physical characters of that
of gonorrhea. Unless modified by active and unremitting treat-
ment, all these symptoms rapidly become aggravated. Ulcers
appear on the cornea and may perforate it, or, as has occurred
in the writer's hospital service, the entire cornea may slough,
extrusion of the ocular contents and collapse of the globe follow-
ing. In other cases, after a small perforation has taken place,
prolapse of the iris occurs, which is succeeded by infection of all
the deeper structures, setting up a general inflammation or pan-
ophthalmitis.

Prognosis. — With the modem treatment of this disease recovery
may usually be expected and the dangerous sequelae of the past —
leucomata, partial or complete staphyloma, incarceration or
synechia of the iris, and panophthalmitis — do not often follow,
provided the patient is seen early in the attack and before there
has been any interference with the nutrition of the cornea.

Treatm,ent. — One eye being usually first affected, the other
should be protected from infection by covering it with a Buller's
shield; this is made of a watch-crystal of large size (the writer
uses a lens from the so-called driving glasses), fitted in an oval
piece of rubber adhesive plaster. This is carefulh" applied to
brow, nose, and cheek, but not to the temple, for if hermetically
sealed, the insensible perspiration within the shield, condensing
on the inside of the lens, would smear it and thus prevent the
early recognition of infection of this eye, if this unfortunately
occurs. The rubber plaster easily becomes loosened; the edge

394 DISEASES OF THE MALE URETHRA

and the contiguous skin should, therefore, be painted with flexible
collodion into which a few shreds of absorbent cotton should be
incorporated before the collodion hardens ; the union of protector
and skin will then be complete.

Unremitting care is the key to the successful treatment of this
disease. Ice-cold compresses must be applied continuously as
long as the cornea remains unclouded. They are best used in the
form of two-inch squares of patent lint which should be placed on
a block of ice. These compresses must be changed often enough
to keep the lids chilled — about from every fifteen to thirty seconds
at first; later at longer intervals. Before applying them to the
eyelids the integument should be anointed with an ointment
consisting of equal parts of cosmolin and simple cerate. Vaselin
is too quickly washed away to prevent the dermatitis caused by
the cold apphcation. Every three hours a small lump of white
vaselin should be placed under the lids by means of a probe.

The discharge must be removed as rapidly as it forms, for the
integrity of the globe is threatened not only by the swelling of
the lids and ocular conjunctiva, causing nutritional interference,
but also by the acridity of the secretion. Success is impossible
unless absolute cleanliness is maintained; therefore the advice
to clean the eyes every twenty minutes cannot be too severely
censured. The discharge must be wiped away as soon as it
forms — at first every time a cold pad is applied. Irrigations of a
warm saturated solution of boric acid should be employed at least
every fifteen minutes. Solutions of mercuric bichlorid, biniodid,
or cyanid cannot be used in germicidal strength and are, even in
these weak solutions, too irritating. The irrigator should not
be placed at a height of more than i8 inches above the head of
the patient, and the solution should flow over, and not strike,
the eyeball. As soon as the cornea assumes a steamy appear-
ance the use of the cold pad must be discontinued and heat, as
strong as the eye can bear, must be substituted. If hot com-
presses are employed, the water should be heated at the bedside.
The best method of applying heat is to fill a glass to the brim
with hot water and let the patient hold this to the eyelids, open-
ing and closing the eye under the water. Irrigation should be
practised as often as the discharge accumulates, even if required

COMPLICATIONS 395

at five-minute intervals. Alum should never be used, as it dissolves
the cement holding the corneal plates, and thus favors the entrance
of micro-organisms, to the subsequent danger of the eyeball.
For similar reasons cocain should not be used, except early in the
attack. To arrest the discharge and to destroy the gonococcus
protargol or argyrol should be thoroughly applied to the conjunc-
tiva in from lo to 25 per cent, solutions. These applications
should be made from every three to six hours, depending upon
the quantity of the discharge and the rapidity of its production.
These remedies are much superior to the argentic nitrate, since
they may be used from the very inception of the trouble, whereas
the nitrate must never be used until the stage of secretion is fully
established; the latter, furthermore, does not penetrate the in-
fected tissues as do both protargol and argyrol.

The writer does not favor scarification to relieve the turgid
conjunctiva, as it is likely to permit infection of the deeper seated
structures. Marked benefit may be obtained by the application
of three or four leeches to the temple, the bleeding being favored
by hot fomentations. Leeching may advantageously be repeated
in selected cases every third or fourth day.

Whenever swelling of the lids produces injurious pressure on
the globe, a canthotomy should be performed. Corneal ulceration
when centrally located calls for atropin; if situated peripherally
for eserin or pilocarpin. Abscission should never be performed
for prolapse of the iris, for this opens up a channel for infection of
the deep structure of the eye, and subsequently panophthalmitis
will occur. The eyelids sometimes recover completely, but in
other cases there follows a true trachomatous process, which
demonstrates that trachoma is a hypertrophy of the subconjunc-
tival adenoid tissue, resulting from inflammation, etc., instead
of being caused by a special micro-organism. For this sequel
scarification, followed by the application of tannic acid in glycerin,
will usually effect complete recovery.

Ophthalmia Neonatorum. — Ophthalmia of the new-bom is due
to infection contracted during the passage of the child's head
through the mother's vagina. Other modes of infection are those
mentioned as occasionally operative in the causation of gonorrheal
conjunctivitis in adults. There are two types of this disease — a

396 DISEASES OF THE MALE URETHRA

mild one, which yields readily to the ordinary treatment for acute
catarrhal conjunctivitis, and a virulent one, in which the gono-
coccus is always present. As a rule, with proper precautions,
this is a preventable disease ; and as reliable statistics have shown
that from 30 to 55 per cent, of all cases of blindness are due to
this condition, neglect to observe such precautions is criminal.
In all suspected cases the Crede preventive method should be
adopted, i. e., as soon as the child is born or, better, as soon as the
head emerges from the vulva, the face should be cleaned, the
eyelids separated, and one drop of a 2 per cent, solution of silver
nitrate should be instilled in each eye. In extremely rare instances
conjunctivitis follows this treatment, demanding the use of cold
compresses, cocain, and irrigations with warm boric acid solution;
as a rule, however, there is no reaction to the silver application.
When ophthalmia neonatorum does occur, the treatment should
be as active and energetic as that recommended for purulent
ophthalmia in the adult.

Iritis. — This is the most frequently observed form of intra-
ocular disease due to systemic involvement. Not infrequently
the attack cannot be differentiated from rheumatic iritis. Usu-
ally a knee-joint is first affected, then the eye, and in some cases
these alternate. The iritis is often bilateral, attacking the eyes
simultaneously or in succession. The symptoms and course are
identical with those of rheumatic iritis, and as these attacks occur
so often in patients who are the subjects of rheumatism at other
times, the gonorrheic implication is, to say the least, a doubtful
one.

There is, however, one form of iritis that seems to depend on
metabolism of the gonococcus. It occurs early in the course of
the gonorrhea, none of the avascular structures of the joint being
affected. It usually attacks but one eye, although both may be
affected, and severe inflammation is the rule. The pupil is often
occluded by a grayish lymph, and there may be an abundant
exudation in the anterior chamber. If seen early in the attack, a
cure is confidently to be expected. A striking case of this kind
was seen in the summer of 1905. The patient's first attack of
gonorrhea was accompanied by a severe iritis. A similar condi-
tion occurred with his second attack, and also with the third — for

COMPLICATIONS 397

which the writer was consulted. Only one eye — the right one —
was affected. He had never had rheumatic attacks, and had
suffered but these three attacks of gonorrhea, in each of which
iritis supervened within ten days after the urethral discharge
had been established.

Among other intra-ocular diseases attributed to the toxins
generated by the gonococcus are cyclitis, iridocyclitis, and chorio-
retinitis. In the course of a gonorrheal attack of long standing
amblyopia has been observed to occur. In these cases the dis-
tinctive symptoms are a sluggish and slightly dilated pupil, with
hazy vision, scintillating scotomata, and an inability to read or
write for more than a few minutes at a time. In a case seen in
the writer's private practice there was likewise a restriction of the
field of vision for both eyes, at the nasal side. When the gonor-
rhea was cured, complete visual restoration followed.

Gonorrheal Rhetunatism. — This term is most unfortunately
chosen, and is unquestionably responsible in part for the misunder-
standing so prevalent in regard to the disease. It is to be classed
in no way with any variety of rheumatism except in point of
differential diagnosis. It is due to a specific and well-accepted
etiologic factor, affecting the synovial sacs, the tendinous sheaths,
and in rare cases the investment of the nerve-trunks as a simple
inflammatory process. It is an infectious synovitis, and is due
in all instances to infection with the gonococcus, though in some
instances the infection may be mixed. In a sufficient number of
, cases the gonococcus has been recovered from joints involved,
though on account of the elusive nature of this organism to ordinary
methods of bacterial investigation, it may not be always possible
to demonstrate it. There is some evidence to indicate that the
organism itself may not invariably be present in the involved
areas, but that the symptoms are due to the production of some
toxic body, specific in nature, which is elaborated by or in the
presence of gonococci. This toxic theory is largely substantiated
by the fact that very frequently, when the original nidus of infec-
tion be healed, the disease disappears spontaneously without local
treatment of the inflamed tissues of the joint or general measures.

In the opinion of the writers, however, subjects especially sus-
ceptible to rheumatic diseases are rather more liable to develop

398 DISEASES OF THE MALE URETHRA

gonorrheal synovitis rather than those not so incUned. We
explain this fact by the theory of lowered tissue resistance. The
disease is not a very frequent one, fortunately, but occurs in the
experience of every general practitioner, internist, surgeon, and
urologist with quite sufficient frequency. Various writers esti-
mate the proportion of occurrence at from 2 to lo per cent, of
the total number of cases of gonorrhea. It undoubtedly occurs
more commonly in male than in female patients. This is prob-
ably largely explained by the fact that in the male gonorrhea is
more apt to be a persistent disease in which hidden foci of possible
infection exist for a longer period than is common in women, except
in instances of uterine or tubal infection.

Course. — Gonorrheal synovitis rarely appears during the acute
stages of an active infection, but is most common in the later
stages, and is seen rarely in cases which are free from complicating
lesions, such as a serious posterior urethritis, epididymitis, or
gonorrheal vesiculitis. It may arise, however, during the early
acute stages, particularly in secondary or recurrent cases, or it
may occur months after the original infection has subsided. In
practically all the instances which have fallen under the observ^a-
tion of the writers some focus of persistent infection could be
demonstrated after sufficient search. The most frequent seats
for such foci in our experience have been the posterior urethra,
and especially prostatic abscess and vesiculitis. In many cases
the local symptoms are so slight as to fail to attract the attention
of either the patient or the careless clinician. The frequency
with which the disease arises after forceful instrumentation in
cases of gleet or posterior urethritis should be held as very sig-
nificant.

The onset of the disease is rarely acute and active, but is more
apt to be relatively slow and to be preceded by several hours,
days, or weeks of mild pains in the region of the infected joint.
With the onset there is commonly a moderate rise in temperature,
with proportionate quickening of the pulse, pains in the back, and
the general symptoms of infection. Occasionally the disease is
violently inaugurated, with rigor, high temperature, and profuse
sweating. Ordinarily, but a single joint is at first involved, though
subsequently others may become invaded. The joint most fre-

COMPLICATIONS 399

quently attacked is the knee, the tendons of the foot, such as the
tendon at the plantar aponeurosis or the calcaneus, often being
likewise affected. It may attack other portions of the feet, may
give rise to periosteitis of the calcaneus, and may cause myositis
and various forms of synovitis. Next to the knee and the foot,
it shows a predilection for the elbow. Occasionally the attack ter-
minates in suppuration, which possibly breaks through the joint,
with the usual accompaniments of abscess formation, such as
fever and chills. It is stated, and we believe correctly, that with
the onset of the synovitis an increase or reappearance of the ureth-
ral discharge is likely to develop.

The involved joint swells, oftentimes to a considerable degree,
but it rarely takes on the deep-red color seen in the average case
of acute articular rheumatism. Movement of the articulation
is productive of exquisite pain, but when the joint is immobolized
and kept at absolute rest, the pain is generally not so great as in
articular rheumatism. The disease may be accompanied by severe
sweating, but this is never so pronounced as in true rheumatism,
nor is the sweat of so striking and acrid an odor. Prostration
is generally not marked, except in those cases complicated by
bacteriemia and endocarditis. Endocarditis is occasionally seen
as an accompanying lesion, but it never occurs with the frequency
with which it is seen in rheumatism.

Diagnosis. — The disease must be differentiated from acute
articular rheumatism, from simple synovitis, rheumatic gout, and
acute cases of tubercular arthritis, and from occasional instances
of acute syphilitic synovitis. One of the most important steps
in the diagnosis is the history of a relatively recent attack of gonor-
rhea, and in a large percentage of cases the detection of foci in
which gonococci may still be demonstrated. The less prostration
and sweat, the less tendency to migrate from joint to joint, and
the less frequent occurrence of endocarditis are important points
in the differentiation from acute articular rheumatism. Where
endocarditis is present, blood cultures may show the presence of
the gonococcus, on the one hand, or of the streptococcus or staphy-
lococci, on the other. Similarly, in cases of simple arthritis, in
cases of septic nature, the demonstration of the nature of the hemic
infection is a point of very conclusive value. lycukocytosis, which

400 DISEASES OF THE MALE URETHRA

is absent in the gonorrheal condition, is also a helpful diagnostic
sign in general septic states.

The differentiation from rheumatic gout is, in our opinion, most
difficult in many instances, and in some cases must rest on the
results of treatment if gonococci cannot be found in any of the
usual tracts. From acute tubercular arthritis, the less active
natare of the infection, the detection of tubercular foci elsewhere,
or the presence of a Calmette or vaccination tubercular reaction
are points of importance. Within a few days' time the differ-
entiation from acute syphilitic synovitis is a matter of ease, owing
to the appearance of other manifestations of this general infection.

Prognosis. — The prognosis as regards life is good. Gonorrheal
rheumatism shows a tendency to go on to recovery, in the majority
of cases, in from three to four weeks, without receiving any treat-
ment whatever; some cases have, however, been known to per-
sist for months in previously healthy individuals.

Owing, probably, to continued absorption of the virus of gonor-
rhea from the urethral wall, in a small proportion of cases a very
obstinate form of arthritis is set up — knee- or elbow-joints, syno-
vial tendon-sheaths of wrist or foot, etc., may be affected by an
inflammatory process secondary to the gonorrhea. This generally
takes the form of a hydrops of synovia, which is very slow to
clear up and appears about three or four weeks after the infec-
tion has taken place. Very rarely suppuration occurs in all the
involved joints, with the attendant dangers of pyemia. The
disease may in such cases terminate in more or less stiffened joints,
and ankylosis is not unknown.

Treatment. — This primarily consists in the treatment of any
inflammatory conditions of the urethral canal that may exist.
Most commonly a posterior urethritis is present in conjunction with
the rheumatic symptoms, and this must receive the proper treat-
ment, such as occasional deep irrigations with weak solutions of sil-
ver nitrate. The resultsof the employment of very heroic measures
in the treatment of inflammatory conditions of the urethral canal,
such as opening the seminal vesicles for the cure of gonorrheal
rheumatism, are difficult to estimate properly. If skilfully car-
ried out, these measures may produce excellent results, and in
some of our cases great benefit has followed. The method is

COMPLICATIONS 40I

not one, however, for general use, and probably has a very limited
field of application. The fact, however, that gonorrheal syno-
vitis shows a tendency to recover is one of the reasons why
it is so difficult to estimate the amount of benefit actually derived
from the use of any therapeutic measure, medical or surgical.
The affected joints should be immobilized. Applications, either
of heat or cold, as the patient may find most soothing, should
be made. Cloths wrung out of hot lead-and-opium solution
and reapplied as frequently as they become cool will be found
useful when the pain is severe. In a few cases we have found
the application of ice-bags or cloths soaked with ice water
to give great relief. Vasogen iodin may be well rubbed into
the affected joints two or three times a day; this has been
especially efficient in chronic and persistent cases. This same
local treatment will also be found beneficial in other conditions,
such as involvement of the synovial she3,ths. An ointment com-
posed of ichthyol and oil of wintergreen has acted well in some
cases. Various other stimulating applications, such as chloroform
liniment or one of the menthol preparations, may be employed.

Internally, the treatment should be that of septicemia; tonics
of iron, quinin, and manganese, sulphur compounds, and prepara-
tions of phosphorus may all be employed advantageously. It
is the custom to recommend salol, asparin, and various other
forms of the coal-tar products, which have a decided analgesic
action and also serve as urinary antiseptics. We have found
asparin the most efficient of this class. Urotropin sometimes
acts well, probably for the same reason. In some cases the use
of powerful hypnotics, as codein, veronal, and morphin, may
become imperative. It has been our custom, for many years
past, to employ oil of wintergreen, five to twenty drops, three
times a day. In a good many cases this relieves the pain, but we
do not feel that it materially shortens the course of the disease.

In some chronic cases the alternating hot and cold spray acts
well, and in one persistent case we have used the Bier hyperemic
treatment with signal success; in one other instance, however, we
must note that the disease appeared to become much worse after
this method. The use of dry heat and the x-ray both have their
advocates, but our experience does not lead us to favor either.
26

402 . DISEASES OF THE MALE URETHRA

Massage and passive movements are also to be used only with
great care, and alone in quiescent cases. The general tone of the
body should be improved, and for this purpose glycerophosphates
and various other constructive tonics in large doses will be found
beneficial.

In our experience we have not found it necessary to restrict
the diet, as in rheumatism, and for most largely afebrile cases we
recommend a full and nourishing though readily digestible diet.

The antitoxin and vaccine treatments of general gonorrheal
infections are now receiving a great deal of attention, especially in
certain New York clinics, but our experience is as yet too limited
to permit us to generalize in regard to the methods, although they
seem to promise much for the future management of these trying
conditions.

When complications, such as ankylosis, persist after recovery
from the acute condition has taken place, these should be treated
according to the rules laid down in the text-books on ortho|)edic
surgery.

Gonorrheal Endocarditis.^ — Gonorrheal involvement of the
endocardium is probably a much more frequent disease than is
generally recognized. Since it may occur in mild form with no
more septic reaction, in the way of fever, chills, or prostration,
than might be accounted for by the urethral condition, it is highly
probable that cases have slipped the notice of all of us. The
lesion is, of course, most apt to arise in the course of gonorrheal bac-
teremia or synovitis, but may be seen in apparently simple cases.

As a rule, the symptoms are quite pronounced, and are mani-
fested by night temperature, with morning fall, chill at onset, and
a typical septic course. As with ordinary acute endocarditis,
the temperature-curve may strongly suggest malarial infection.
As just mentioned, clinical manifestations may, however, be slight
and pass unrecognized until the heart examination shows the
presence of an acute murmur. As a rule, the mitral segments
are mostly involved, and next to these the aortic- flaps. These are
the only two valves which we personally have found so diseased.

Diagnosis must rest on the detection of the murmur, with the
usual symptoms of endocarditis, associated with gonorrheal
infection, but absolute diagnosis is only possible when the gonococ-

COMPLICATIONS 403

cus can be isolated from blood-cultures. By no means all cases
of endocardial infection arising in the course of gonorrhea are of
this specific nature, for other organisms may enter through the
disease focus. A case of gonorrheal synovitis recently seen in
the service of one of the writers showed the development of an
acute endocarditis, with classic signs and symptoms. The case
was naturally supposed to be one of gonorrheal endocarditis,
but blood-cultures showed the gonococcus absent and a strepto-
coccus present.

In the few cases which have fallen under our clinical observation
the general course of the disease has been less violent than in ordi-
nary endocarditis. No detectable infarctions have appeared, and
all save one of our cases recovered. Other observers record quite
contrary findings, and it seems probable that our fortunate results
were entirely a matter of chance.

The treatment consists of the usual measures employed in acute
ulcerative endocarditis, plus active treatment of the local gonor-
rhea. Rest in bed and the ice-bag to the precordium are the most
important of the measures specifically directed to the cardiac
disease.

Stricture of the Meatus

In the male this is quite common ; less so in the female. Gen-
erally it is hereditary, although it may be the result of disease.
The meatus occasionally being only pin-hole in size, admitting
only a small instrument, conditions similar to the above' may
cause no trouble, except that if infection of the urethra has once
taken place, the size of the meatus may interfere with drainage
and may retard recovery, which would be materially hastened
by incision of the opening. It is frequently necessary to enlarge
the meatus by incision to obtain room for the introduction of
such an instrument as a cystoscope. Meatotomy is performed as
follows: Soak a pledget of cotton wrapped around the end of an
applicator or probe in a 4 per cent, solution of cocain; insert it
into the urethra for an inch; apply over the frenum another
pledget of cotton soaked in cocain and have the patient make
pressure over the two for ten minutes; then remove the cotton
from the frenum and the cotton plug from the urethra and with
a straight blunt-pointed knife or a meatotome (fig. 153) incise

404 DISEASES OF THE MALE URETHRA

the meatus and about half an inch down the urethra until a
No. 30 French sound can be easily passed. It is well to remem-
ber that after healing the size of the meatus will be two or
three numbers smaller than what it was originally cut to. To
stop the bleeding after the incision the same urethral plug can
be introduced that was used before the incision and counter-
pressure made on it over the frenum. The patient should be

Fig. 153.— Otis' meatotome.

loaned a short straight sound made for the one purpose, with
instructions to introduce it three times daily for three or four
days to keep the cut open, or otherwise it may grow together
again. The incision, it is hardly necessary to remark, should be
made on the floor of the urethra toward the frenum. Instead of
using the cotton plug with cocain a few drops of the latter can
be injected into the frenum.

Stricture of the Urethra
Symptoms. — A stricture of quite small caliber may sometimes
be present without exhibiting any manifestations of its existence.
Such patients may complain of pain on urination and frequency,
particularly during the day. Prostatic cases, on the other hand,
are likely to be troubled by frequency of micturition occurring at
night or toward morning. A slight discharge from the meatus
often accompanies stricture, and it is often the cause of a relapsing
urethritis. It is frequently associated with some disturbance of the
sexual function. In stricture the caliber of the stream is influenced
to a greater or less degree by the extent of the stricture. Thus it
may be but little diminished or may be forked; there may be
dribbling after urination, and in a stricture of very small caliber
the patient will pass a thread-like stream, not infrequently tinged
with blood; in strictures that cause almost complete occlusion
only a few drops at a time can be passed, the effort being attended

PLATE XUl

Stricture of posterior portion of pendulous urethra following chronic gonorrhea
and showing secondary distention of the prostatic urethra.

COMPLICATIONS 4O5

with much pain and difficulty. The form of the stricture can be
perfectly shown only by practising intra-urethral instrumentation.

Location. — The majority of strictures occur in the membra-
nous urethra, and practically all that need operative interference
are found there; those occurring in the anterior urethra, with
but few exceptions, are capable of being dilated.

Treatment. — The treatment of stricture, like the treatment of
hypertrophy of the prostate, will, in the future, be largely of the
preventive form. In the section on the pathology of this con-
dition it was shown that true stricture is the formation of scar
tissue at the base of a granulomatous lesion. It may be assumed
that if urethritis were so treated that no granulation tissue
formed, true stricture, which is made up of resulting scar tissue,
would not occur. Unfortunately, through either unwise treat-
ment or neglect, scar tissue does follow urethritis in a very
large proportion of cases. Quite often, however, these scars
are so small that they never give rise to any apparent symp-
toms.

For diagnostic purposes, when the stricture is not a very tight
one, an ordinary olive-pointed bougie having a circumference of
No. 16 or 18 French, will prove a useful instrument. If the
bougie passes into the bladder easily, and then shows a tendency
to pop out, because of the good contractile power of the com-
pressor urethrae muscle, the probabilities are that no stricture
of particular consequence exists, either in the anterior or in the
posterior urethra. Often small masses will be encountered in
the anterior urethra as the olive point slides down the surface.
These are very likely to be granulomata, particularly if chronic
urethritis is present; they are commonly known as soft stric-
tures, and have been mentioned and illustrated elsewhere. If a
more definite examination of the anterior urethra is to be made,
a rubber bougie a boule may be used. The largest one possible
should be made to slip by the obstruction; when the next one
larger fails to pass, the caliber of the stricture may be estimated.
A very useful instrument for the purpose of measuring the di-
ameter of the anterior urethra is the urethrometer of the late Dr.
Fessenden D. Otis, previously illustrated. If it is desired, the
anterior urethra may be inspected with the endoscope in order to
observe whether granuloma or true stricture is present. The gran-

406 DISEASES OF THE MALE URETHRA

ulomatous infiltrations are benefited by any measure that stimu-
lates circulation through the parts without unduly irritating them,
such as pressure by means of bougies or steel sounds or by the use
of the straight KoUmann dilator; if the infiltrations are situated
at the bulbomembranous junction, the curved Kollmann dilator
should be used. These cases of stricture should, when possible, be
kept under observation for some time, and dilation should be per-
formed about once a week. The granulomatous infiltrations will
also disappear under stimulating irrigations, such as silver nitrate,
without pressure being used. The foregoing remarks have refer-
ence only to the treatment of strictures of a caliber that will admit
a No. 12 sound or one of large diameter. These strictures are
rarely seen without some accompanying chronic inflammatory
condition of the urethra, and are best treated not only by dis-
tention, but by irrigations as well. As a rule, several processes
are going on at one time in the same urethra. Divulsion should
never be performed; this method of tearing a stricture apart by
means of special instruments devised for the purpose has been
productive of much harm. The old-fashioned instruments used
for this purpose served as a model from which the Kollmann
dilator was evolved, an instrument that, when properly used,
will be found of great value. Kollmann dilators are procurable
in three forms: The straight, which are used for the anterior
urethra; the curved, with the prostatic curve, for the deep
urethra, and covered with rubber; and curved for the deep
urethra, which are intended for irrigation at the same time, and
that are not covered with rubber. The writers prefer the curved
that are covered with rubber. Irrigations can be performed
through a small silk catheter immediately after passing the Koll-
mann dilator or at a subsequent visit. In individuals with sensi-
tive urethras it is better to postpone irrigation after dilation to a
subsequent visit. Undoubtedly in the past many of the masses
of granulations mentioned have been incised under the classifica-
tion of "urethrotomy for strictures of large caliber," an opera-
tion which has to a great extent passed out of use. While in
very exceptional cases it may have been productive of good
results, it often caused harm, generally by causing after-deformi-
ties of the penis. Dilation is as useful for true stricture as it is

COMPLICATIONS

407

for the granulomatous masses; only true scar formation yields
less readily to treatment. When the true strictures
are not too tight, the same general rules should
apply as in the
dilation of the
softer variety.
A stricture

Fig. 154.— Koll-
mann's straight di-
lator.

F's:- iss--k:o1I-

maiin's dilator for
posterior urethra,
with irrigating at-
tachment.

Fig 156.— K0II-
tnann's double
curved dilator for
posterior urethra.

Fig- 157-- KoU-
mann's curved artic-
ulated dilator with
Beniques curve for
posterior urethra.

that has been so widely dilated that it will admit a KoUmann
dilator, of the caliber of No. 20 French, may be stretched until a
sense of resistance is felt and the patient complains of pain,
or until the index has been screwed up ordinarily two or three

408 DISEASES OF THE MALE URETHRA

points from the caliber which it had reached on a previous
visit. Under any one of these conditions distention should not
be carried further. The dilator should not be allowed to re-
main in the urethra for more than ten minutes. Strictures of the
anterior urethra proper rarely produce harm in themselves, and
they can, as a rule, be very rapidly dilated. After the urethra has
been dilated to No. 40 or 42 French by the Kollmann dilator, or
so widely that it will admit a No. 32 or 33 French sound with com-
parative ease, the stricture may be considered cured so far as
distention is concerned. The chronic urethritis accompanying
the condition may, however, require further treatment in the
form of irrigations. In any case the patient should be advised to
report three or four times a year in order that any tendency to
further stricture formation may be detected.

In using the Kollmann dilator for the deep urethra when it is
desired to dilate the bulbous more than the posterior urethra,
the handle of the instrument should be somewhat elevated. To
dilate the bulb while stricture exists, the instrument, still expanded
to the extent that will not cause too much inconvenience to the
patient, should be slowly withdrawn from the urethra. True
cicatricial strictures are probably not much benefited until dilated
beyond 30. Once the Kollmann instrument has been introduced
by the surgeon, the patient may, if desirable, perform the dilation
himself. The procedure may consume ten minutes, the instru-
ment remaining in place a few minutes at full dilation. Irrigations
may be used after or between the dilations. The treatment
should extend over a period of at least three months, dilation
being performed at intervals of a week in the case of old persons ;
young and middle-aged patients with true stricture may allow
longer intervals to elapse between dilations without giving any
evidence of recon traction. After a certain stage of the treatment
has been reached, especially with the latter class of patients, the
urethra will generally remain well dilated for months or a year
without requiring further instrumentation. It is a good plan,
in dilating for stricture, occasionally to observe, by means of
the endoscope, the effects of the instrumentation on the urethra.
A change from a whitish or grayish to a pinkish color is a good
indication.

For performing thorough dilation a silk bougie, the steel

COMPLICATIONS 409

sound, or the Kollmann dilator may be used. For dilation up
to No. 20 F. the best instrument to use is the silk bougie ; be-
yond that the steel sound or the Kollmann dilator should be
employed. During the last few years the writers have used the
Kollmann dilator more and more in private practice, and have
almost entirely discarded the steel sound. In using steel sounds
above No. 20 F. care should be observed to choose conically
pointed sounds rather than the blunt ones so often placed on the
market. It is not advisable, ordinarily, to pass more than two
or three sounds at one sitting. Such sounds may gradually
increase one to three numbers in diameter.

Treatment for Retention of Urine and of Tight, Im-
passable Stricture

In examining a patient who is unable to urinate or who voids a
very small stream with much difficulty, it should be remembered,
before making any examination, that if the patient is old and gives
a history of gradually increasing urinary difficulties, the retention
is very probably due to enlargement of the prostate. If the man is
of middle age or younger, particularly if he has been very careless
or dissipated, the probabilities of the urinary difficulties being due
to stricture are much stronger. When retention occurs as a com-
plication of acute urethritis, it is due to intense swelling of the
walls of the urethra, and true stricture is often absent.

Hot sitz-baths and efforts to urinate under hot water in a bath-
tub, the water covering almost the entire body, will generally
faciUtate the flow of urine. Such measures should be given a
fair trial in the effort to overcome a recent attack of retention
before instruments are made use of.

Whatever be the conditions suspected, it is well, in making an
examination, first to attempt to pass an ordinary olive-pointed,
very flexible tipped, French silk catheter of a caliber of about No.
16 or 18. If it meets with an obstruction, as it very often will,
at the bulbomembranous junction, three points are to be con-
sidered— whether we are dealing with stricture, with an enlarged
prostate, or with spasmodic stricture due to nervousness. Spas-
modic strictures are generally quite easily recognized by any one
who has considerable clinical experience in the treatment of
urethral disorders, but the inexperienced practitioner will some-

4IO DISEASES OF THE MALE URETHRA

times find them quite confusing. If it is suspected that the
inability to enter the bladder and the obstruction at the bulbo-
membranous junction of the urethra are due to a spasm of the
compressor urethrae muscle, a steel sound, a few sizes larger than
the catheter previously mentioned, may be inserted, remembering
that by making slight gentle pressure at the bulbomembranous
junction spasm may almost always be overcome. This failing,
an attempt should be made to overcome the spasm by injecting
a considerable quantity of warm water through a soft catheter
carried as far as the seat of the occlusion. If this irrigation
through the catheter is continued for some time, — ten or fifteen
minutes, — it will generally be possible, then, after the catheter

Fig.158.— Mercier's elbowed metal catheter.

has been removed, to pass an instrument into the bladder if the
constriction was really due to spasm. If an obstruction is present
that hinders the passage of a small olive-pointed bougie and not
due to spasmodic occlusion, this is due to one of two conditions —
stricture or retention caused by an inflamed hypertrophied pros-
tate. If due to hypertrophy of the prostate, this is generally made
clear by the history of the case, the age of the patient, and the
marked rectal enlargement of the prostate that is to be felt. In
such cases, which are comparatively rare, but which do occasion-
ally occur, the urethra takes a different curve from the normal,
and it is for this reason that the ordinary catheter will often not
enter the bladder, necessitating the use of a catheter of a particular
curve. The Mercier curve, which is to be had in steel or rubber cath-
eters, will generally prove effective. This failing, a steel catheter
"with a large prostatic curve may be used ; if this too prOves unsuc-
cessful, a bicoude curved catheter may be used. It is the writers'
custom to keep on hand a series of these three catheters. They
are extremely useful at times if the retention is due to enlarged
prostate. After the catheter has entered the bladder, that organ
may be emptied and washed out. The advisability of an imme-

COMPLICATIONS

411

diate operation should now be considered, or another catheter
may be passed in a few hours' time. These
cases have been more fully dealt with in the
chapter on Diseases of the Prostate.

If the retention is not due to prostatic obstruc-
tion, stricture exists. An effort should first be
made to pass the stricture with some instrument
and later to dilate it. For passing the stricture
the following procedure may be adopted: The
urethra is filled with warm oil and bougies of
gradually decreasing caliber are inserted until the
filiform bougies are reached. By the exercise of
much care and patience on the part of the sur-
geon the vast majority of ,cases of stricture of
small caliber may be passed by a filiform bougie.
When one bougie has been passed, an attempt
may be made to introduce another one alongside
of it. If the ordinary whalebone bougies fail to
pass, catgut bougies, which are still finer, may be
tried. Some urethras are so long that a bougie
of double the ordinary length may be required to
reach the bladder. After the filiform has entered
the bladder, in cases where the retention is not
complete and the patient able to urinate a little,
it may, if desired, be tied there for a few hours,
at the end of which time a very small bougie —
one larger than the filiform, however — can usually
be substituted. Not infrequently the attempt
is made to enter the bladder by inserting a tun-
neled steel sound of the smallest caliber over the
filiform.

If this steel sound can be passed into the bladder over the fili-
form acting as a guide, the problem, so far as retention is concerned,
is generally solved. The stricture may be so much distended by
the passing of larger and larger tunneled sounds over the filiform
that after a short time a catheter may be forced in and the bladder
emptied.

The after-treatment will consist of rest in bed, the use of uri-
nary antiseptics internally, and gradual distention by means of

/

Fig. 159. — Gou-
ley'stunneled sound
and guide.

^

412 DISEASES OF THE MALE URETHRA

steel sounds, larger and larger ones being passed at intervals of
every four or five days. If it is found impossible, by any of the
means described, to get the best of the stricture, the situation
becomes somewhat more perplexing; in similar cases the writers
have found the use of a certain instrument to be of great value.
This is a modification of the long, whip-like fiUform known ar
the Banks bougie. This bougie is extremely small at one end, —
the size of the smallest filiform, — and gradually grows larger so
that toward the upper end it has a diameter of a No. 10 French.

The objection to Banks'

bougie is that, being made

of whalebone, is it some-

_^!^' what rigid; to overcome

- ^=^" -"^^^ this, one of the writers had

'^~ a bougie of similar shape

■- ~^ made of vulcanized rubber.

-^ 'I^:^^ ' ^ This is much more flexible

^. . o ■ . tr- ^ ■ K 1 K -A than the original form, and

Fig. 100. — Points of Gouley s whalebone guides. ° '

has repeatedly proved suc-
cessful where other instruments have failed; for, if the end
will pass the stricture, it is only necessary to continue pushing.
The lower portions of the shaft will double up as it enters the
bladder, without doing any harm, so it may be pushed on until
the full diameter of the shaft is engaged in the stricture. After
withdrawal, it is comparatively easy to pass a small ordinary silk
bougie and so continue distention. It is always well to attempt
to pass this instrument before resorting to filiforms.

In our experience, almost invariably if a fihform has once been
passed and tied in for several hours, this whip bougie can be passed
and the following treatment of the case much simplified. Very
rarely, since this instrument was manufactured, at our suggestion,
about ten years ago, have we found it necessary to use the tunnel
sound. In our experience, when in possession of the former, the
latter instrument is practically no longer required for the purpose
of distention of stricture.

In cases in which the stricture proves impermeable, it is well
to administer an anesthetic and then repeat the attempt. If
this also proves unsuccessful, an operation is necessary. It is
rarely necessary to operate for the relief of stricture when filiforms

COMPLICATIONS

413

can be passed. This is a rule to which there are a considerable
number of exceptions, generally due to a dense formation of cica-
tricial tissue, or to the fact that time enough cannot be taken to
dilate the stricture in a proper manner. We have purposely not
attempted to classify these exceptions, as has often been the cus-
tom in the past. We do not wish to encourage the unneccessary
performance of operations, and
the better the surgeon, the more
often can strictures be overcome
without incision.

It is not considered desirable
or necessary to give here a re-
view of all the various methods
of operating for the relief of
stricture. They consist, for the
most part, of the performance
of either internal or external
urethrotomy.

Internal urethrotomy is to
be performed only when the
stricture is at the bulbomem-
branous junction and when a
small silk bougie that acts as a
guide, and later on doubles up
in the bladder, the end of the in-
strument being attached at the
upper end of the bougie, can get
past the obstruction. The in-
strument ordinarily used for the
purpose is called the Maison-
neuve, after the French surgeon
who invented it. The portion
of the instrument above the at-
tachment to the filiform consists
of a curved steel sound of a very
small caliber, running along the anterior surface of which is a
groove; along this groove runs a knife-blade with a very long
handle, which projects above the upper border of the instru-

Fig. 161.— Greene's whip vulcanized rub-
ber bougie.

414

DISEASES OF THE MALE URETHRA

ment. The filiform guide, followed by the instrument without
the knife, having been pushed into the bladder, the penis
being firmly held by an assistant in such a manner that the
urethra is on the stretch, the knife-blade is introduced at the
meatus in the groove of the instrument, pushed rapidly down
in the groove beyond the bulbomembranous junction, and as
rapidly withdrawn. The instrument is now removed and a some-
what stiff, olive-pointed silk catheter of
No. lo or 12 caliber is passed into the
bladder; the bladder is washed out through
this, and the instrument is then tied in
place by means of tape passed around
the meatus, being allowed to remain thus
for six or eight hours, in order that, by
the pressure it exerts, it may tend to
prevent hemorrhage. At the end of this
time the bladder should again.be washed
out and the catheter removed. At intervals
of every three or four days the stricture may
gradually be dilated by the insertion of
sounds — either rubber bougie or steel sounds
of larger and larger diameter. It is best to
use the silk bougies at first, and, when larger-
sized instruments are required, the steel
sounds, or the after-dilation may be made
by the Kollmann dilator. In performing
this operation it is wiser to use the smallest
of the Maisonneuve knives.

Internal urethrotomy may be performed
by means of the Maisonneuve instrument,
without the employment of general anes-
thesia, a 2 per cent, solution of cocain be-
ing instilled two or three times and allowed
to trickle down the posterior urethra into
the bladder and remain there. The Maison-
neuve instrument is a fairly good one, and
has in the past served a useful purpose. At the present time it
is rarely, if ever, required in the performance of an internal ure-

Fig. 162. — Maisonneuve's
urethrotome.

COMPLICATIONS

415

throtomy, for if a stricture will admit the introduction of a filiform
bougie into the bladder, it can almost invariably, by means of
tunneled sounds or otherwise, be so distended that no cutting
operation will be required. If these operations — either external
or internal — for the relief of stricture at the bulbomembranous
junction can be avoided, it should be done.
Although the death-rate following these opera-
tions is comparatively low, and is probably
growing still lower each year, there is always
some danger, which should be considered, of
so wounding the floor of the prostatic urethra
as to render a hitherto virile man impotent.
It was often the custom in the past to
incise strictures of the anterior urethra,
some of which permitted the passage of
large instruments — the so-called strictures
of large caliber. Many thousands of such
operations were performed. In quite a large
proportion of cases deformities of the penis
follow the making of too deep incisions in the
anterior urethra. Such operations are now
performed much less frequently than formerly.
Many ingenious instruments were devised for
the purpose. That of the late Dr. Fessenden
S. Otis is useful for this operation, which is
mentioned here not because it is practised by
the writers as a routine procedure, but because
they consider it an adjunct to external urethro-
tomy. Dr. Otis' urethrotome carries a sheathed
straight knife in a groove cut in the upper end
of the instrument. A dial-plate registers the
amount of separation effected by means of a
screw apparatus. The instrument is introduced
and passed by the stricture closed; then dis-
tended. When the desired caliber is reached,
the knife-handle is lifted, which releases the Fig. 163.-0115' dilating

urethrotome.

knife from the sheath, when it can be brought

up across as much of the urethra as it is desired to incise, and

4l6 DISEASES OF THE MALE URETHRA

then pushed back into the sheath and the instrument removed
from the urethra.

External urethrotomy is the operation generally used when
one is required for the rehef of stricture. It may also be used for
other purposes, such as bladder drainage, prostatectomy, and the
like. This operation was performed more often in the past than it
is at present, and undoubtedly much more often than was neces-
sary in the attempt to overcome tight stricture of the urethra.
When performed with a guide — that is, when the operation is
done for the relief of a stricture that is not entirely impassable — it
consists of cutting down through the perineum just behind the
scrotum, exactly in the median line, upon an instrument, ordinarily
a small grooved steel sound, which has been pushed into the bladder
or a filiform bougie.

The patient being anesthetized and the operative toilet having
been made, the legs are elevated, the testicles pulled up out of
the way, and the bulbomembranous region, with the aid of an
assistant holding a guide, being rendered as tense as possible
over the instrument in the bladder, the incision is made in the
manner previously directed, directly over the curve of the instru-
ment in the bladder, which can be felt; it should be kept exactly
in the median line and parallel to the shaft of the penis, and should
be about two inches long. The dissection should then be carried
carefully down until the urethra is met. By keeping the thumb
and finger of the free hand on each side of the cut hemorrhage
will be largely prevented. Any bleeding points encountered
may be tied off as the operation progresses.

The urethra, it must be remembered, if dissected out from the
body of the penis, closely resembles in appearance a piece of half-
cooked macaroni; being densely surrounded by tissue in the
perineum, it does not, however, at first assume this appearance
when cut down upon with the knife, but if the dissection proceeds
slowly and carefully and the knife-handle is frequently used to
push the other tissue out of the way, it is generally fairly easy,
even for an inexperienced surgeon, to determine when the urethra
is reached. Having been encountered, the urethra should be
carefully incised for an inch or two from above downward, a liga-

COMPLICATIONS 417

ture being placed on each side and given to an assistant to hold,
so as to keep the incision in the urethra open ; an attempt may-
then be made to examine the urethra further. When a stric-
ture is present, this cannot be done, as the guide that has been
placed in the bladder will become tightly engaged in the stricture.
This being the case, Arnott's grooved probe director should be
pushed along the bottom of the guide, which may be seen running
into the bladder, the groove of the instrument pointing downward ;
then a small, narrow-bladed knife or a Gouley's beaked bistoury
should be run along the groove in the director until the constrict-
ing bands have been severed. If a grooved sound has been used
for a guide, the knife may be run along the groove in the sound.
In cutting the constricting band it is possible for an inexperienced
operator to wound the rectum. It is well, at this point of the
operation, to introduce a finger in the rectum in order to learn if
the knife is approaching too closely. The incision having been
made, the knife should be withdrawn, followed by the director;
then the guide, which has been run down the urethra into the
bladder, should be removed, and the forefinger of the operator
introduced through the perineal wound into the bladder. As a
rule, when the bladder is reached, this will be made manifest by the
urine that will flow out of the wound after the incision is made in
the urethra through the stricture, and urethra depressed. Before
or after the guide has been withdrawn, and after the incision has

Fig. 164.— Teale's probe-pointed gorget.

been made in the urethra along the director and the director re-
moved, a Teale probe-pointed gorget may be run along the ure-
thra until the bulbous-pointed end reaches the bladder. Although

27

41 8 DISEASES OF THE MALE URETHRA

this is not, of necessity, the instrument to use, ordinarily it makes
a good tunnel along which the bladder may be reached. Medical
students and surgeons in general will find it an advantage to
familiarize themselves with the fe^l of the prostatic urethra as
imparted to the examining finger. So far as this is concerned,
when the urethra enters the prostate, the finger running along the
canal feels as if it had entered the neck of a bottle or as if it were
entering the slightly distended cervix uteri. From the fact that
many of the cases that require an external urethrotomy are riddled,
as it were, with scar tissue along the bulb and pendulous urethra,
it is good practice, the writers believe, when the bladder has been
reached and the stricture incised, etc., to insert in such cases an
Otis urethrotome, previously described, pushing it down closed
through the urethra from the meatus until its end projects
through the perineal wound; then, opening it until the index
points to the desired diameter, — 32 or 33, — in the manner pre-
viously described, withdrawing it along the anterior urethra
as far as may seem desiriable — possibly all the way out. A
No. 30 French sound should now be introduced from the meatus
downward and allowed to emerge through the perineal opening.
If it passes easily, the strictures have probably been incised
far enough. If the gorget was used, it should be withdrawn
from the perineal wound and a soft-rubber catheter of large
caliber introduced into the wound and run along into the
bladder. Care should be taken that this does not press too hard
against the posterior wall of the bladder, and also that its
farthest end is so far to the front as to prevent urine or any
fluid injected through it into the bladder from escaping. It
can be fastened in by means of tapes tied about it, run around
the body in an over-and-under fashion, or two or three catgut
ligatures may be inserted through the skin of the perineum and
piercing the wall of the drainage-tube. Before the tube is fastened
in place, — and this cannot be insisted upon too strongly, whether
or not there is hemorrhage, — narrow gauze should be packed
around the tube — that portion of it which is in the urethra.
The packing may be removed and not replaced in twenty-four
or forty-eight hours, and the tube at the end of four days ; if de-

COMPLICATIONS 419

sired, it may again be inserted and allowed to remain for three or
four days longer. The bladder should be washed out daily through
the tube, and before and after the tube is removed considerable
attention should be paid to keeping the dressing and the borders
of the perineal wound clean. By means of a little glass tube a
small piece of rubber tubing can be attached to the perineal tube
and the urine allowed to drain ofT into some convenient recep-
tacle. At the end of four days, when the tube is removed, a No.
30 sound should be gently passed into the bladder. If its end
engages in the perineal wound, a finger introduced in the
wound will guide its beak onward into the bladder. A cath-
eter should be reintroduced about every four days, and, ordi-
narily, within a few days after the removal of the tube the
patient will gradually become able to urinate through the
meatus.

It sometimes happens that a filiform can be introduced into
the bladder, but that, on account of the density of the cicatricial
tissues, a steel guide or tunneled sound cannot be passed. In
such a case pass a small tunneled sound over the filiform as far
down the urethra as it will pass; it will generally go pretty well
down to the bulb; make an incision in the median line just over
its extremity or just below it until the filiform is reached; then,
using care not to disturb the end of the filiform that is in the
bladder, pull the other end out through the perineal wound ; then
take a Rand tunneled knife, run the end of the filiform through
the opening in it, and push the knife through the constricting
bands. After the stricture has been cut and the knife and filiform
removed, a Teale gorget can be passed into the bladder. In

making the incisions use care to avoid

::0^r^'^i' - cutting the filiform. This is Rand's

^^^S^^^^^E'' modification of Gouley's operation. We

^

Fig. 165.— Rand's tunneled knife for incision of stricture.

consider the Rand tunneled knife a good modification, from the
fact that in a very tight stricture we have found the stricture hug

420 DISEASES OF THE MALE URETHRA

the filiform so tightly that after the perineal incision it was diffi-
cult to pass anything between the filiform and the stricture.

When it is impossible to pass any instrument as a guide, through
a stricture, it becomes necessary to do an external urethrotomy
without a guide. This is a somewhat more difficult procedure,
and one that has been widely discussed in the past. It is not
always easily and rapidly performed, even by experienced opera-
tors. It should be remembered, however, that the surgery of
the urethra is a much more familiar subject than it was ten or
twenty years ago. Nothing is to be gained by undue haste;
on the other hand, however, more serious consequences are likely
to result from a too prolonged retention of urine than from the
operator making a few unnecessary nicks. It is also well to
remember that a suprapubic cystotomy is a comparatively simple
operation to perform; that, the bladder being opened, a catheter
or guide may be introduced from the bladder along the urethra
forward, the perineum being incised to meet it, and in this way
the stricture be overcome.

Urethrotomy is performed as follows: A Wheelhouse staflf
should be passed
along the urethra
as far as it will go,

the crook in its Fig.i66.—Wheelhouse's staff.

bulbous end point-
ing outward. The perineal incision should be made over this, and
a ligature passed through the urethra on each side, these being held
by an assistant; the Wheelhouse staff should then be turned
around and hooked into the upper angle of the wound. A tri-
angular opening is thus made close to the site of the stricture.

The Wheelhouse staff
%^f^yy,,y,'^.r^- should form the apex,

Fig.i67.—Arnotfs grooved probe. HgaturCS holding the

wound apart at the cor-
ners of the other angles. Now, with a small probe, or, better
still, an Arnott's probe-pointed director, push gently along into
the wound, when, in a large proportion of the cases, a urethral
opening will be found. If this is the case, an incision should be

COMPLICATIONS 421

made with a small, narrow-bladed knife along the probe or director
that has found the opening, and the stricture incised. The re-
maining steps of the op-
eration are the same as ^====:^^fe^

those ordinarily pursued " "^'X^^S^^''^^^... ^t^r-'r .=»

in performing external ^. ,„ '' . , , „

Fig. 108.— Gouley s beaked bistoury.

urethrotomy.

A surgeon not familiar with the field, on operating for stricture
without a guide, will be surprised at the small size of the opening
of the stricture ordinarily present in cases requiring the above
©{Deration. The urethra having been incised, held up at its apex,
and pulled apart by the sutures on the side in the manner suggested
above, will present a lozenge-shaped surface to the eye of the
observer, some one or two inches long, according to the length of
the incision which has been made in it. In the face of this, the
opening of the stricture must be looked for very carefully. In
our experience it is more apt to be found toward the upper angle
of the wound, and when perceptible to the naked eye, exactly
resembles the opening of one of Morgagni's crypts, as seen in the
anterior urethra. This explanation is made for the benefit of
those who have not had experience in this of>eration, and who,
without such experience, might naturally be looking for an opening
with a larger mouth than is apt to be present.

If, after patient effort, the operator does not succeed in finding
the urethral opening, he should not become discouraged. He
must remember that he is searching for the end or some other por-
tion of a white, macaroni-like tube, which issues from a structure
resembling the neck of a bottle, runs toward him, and the end of
which is very close to the wound. If he so desires, by placing
his hand on the abdomen and pushing down, or by having an
assistant do so, the neck of the bladder may be brought a little
nearer to him. A dissection should then be made, always keeping
in the median line, and being careful not to wound the rectum.
The perineal wound should be extended and the incision be made
deeper and deeper and a little farther down toward the back.
If no deflection is made from the median line, the urethra is very
certain to be reached by this procedure. A small trocar may be

422 DISEASES OF THE MALE URETHRA

introduced to reach just back of the stricture. If urine escapes
after the stilet has been withdrawn, the perineal incision may
be extended to it. Dr. C. L. Gibson, of New York, has suggested
that a hook be introduced into the rectum, the prostate hooked,
and that then, by exerting traction downward and backward,
the urethra will be stretched and more easily made out and
reached through the perineum. With one finger in the rectum,
a stab-like puncture may be made through the perineum over
the seat of the stricture, and the knife-blade pushed forward
toward the region of the neck of the bladder, the finger in the
rectum being kept at the apex of the prostate to act as a guide.
The stricture may be incised anteriorly later.

Other methods failing, two procedures yet remain to be tried:
suprapubic cystotomy with retrograde catheterization and the
exposure of the urethra through the Senn incision, described
further on as a method for reaching the prostate and the seminal
vesicles. In order to make this incision it is only necessary to
extend the perineal wound a little nearer to the rectum, and then
make an incision from the end of the perineal wound running off
from each side of the rectum at an angle. The rectum being
pulled out of the way as the muscles are incised, the deep urethra
and neck of the bladder will be brought into view ; it will then be
possible to incise the urethra at the desired point.

RUPTURE OF THE URETHRA
Rupture of the urethra is the result of accident or follows a
neglected stricture ; in the writers' experience it is most frequently-
due to the latter cause in the hospitals, and is seen in old alco-
holics with neglected strictures in whom infiltration into the
surrounding tissues has already taken place, forming a brawny
swelling behind the ruptured portion, in the perineum, along the
inner surface of the thighs, and possibly on the abdomen, over
the pubic region. When urinary infiltration has taken place,
sloughing is, of course, eventually to be expected. It is astonish-
ing to observe how extensive an amount of infiltration of urine
into the surrounding tissues may take place and recovery still
follow.

RUPTURE OF THE URETHRA 423

The diagnosis in these cases is comparatively easy; the swelling,
with the history of, or the presence of, stricture, pointing to rup-
ture. These cases should be treated as certain other forms of
stricture — i. e., by external urethrotomy; for although the ure-
thra is ruptured, the rupture is not often complete, and it will
generally be possible to pass a guide into the bladder ; free drain-
age of the infiltrated surfaces should be instituted. It is some-
times necessary to make a large number of incisions. A case of
rupture of the urethra coming under the care of one of the writers
recovered after drainage-tubes had been inserted in the inner
surface of the thigh, lower portion of the abdomen and groin,
the tubes running in many directions. Recovery may follow
even in those cases in which the after-sloughing is so extensive
as to demand a plastic operation for the purpose of covering the
denuded surfaces. One of the secrets of success in treating
this class of ruptured urethras consists in the careful establishing
of free drainage by means of the introduction of tubes through
multiple incisions into the infiltrated portions of the tissues.

Rupture of the urethra from injury may be complete or incom-
plete. If incomplete, as shown by the patient's ability to urinate
and painful micturition, or pain in the perineum with hematuria
is all that is complained of, nothing should be done but to keep
the patient under close observation. Not even a urethral instru-
ment should be passed. If slight perineal swelling takes place
but does not increase, it may eventually be incised and clots let
out. If well-marked increasing infiltration appears, it should
be incised, the urethral opening, if possible, found, and a retention
catheter placed in the bladder for a few days. Complete rupture
would be indicated by the appearance of infiltration, inability
to urinate, and probably severe shock. In such cases it is neces-
sary to operate, find the distal end of the urethra, and unite the
two ends over a retention catheter, not letting the stitches pene-
trate the inner walls of the urethra. It may be difficult to find
the distal end of the urethra; but, the proximal end being found,
the distal end may be searched for in the tissues ordinarily through
a longitudinal perineal incision. A drop of blood or a drop of
urine may indicate its presence. When not found by longitudi-

424

DISEASES OF THE MALE URETHRA

nal perineal incision, it may be necessary to find it by exposing
the prostatic urethra through the curved perineal incision or some
modification of it, as when operating for a prostatic abscess.
Severe stricture is likely to result and a guarded prognosis should
be given in such a case.

ABSCESS OF COWPER'S GLANDS
These two glands, lying outside the urethra at each side of the
bulb, occasionally, but rarely, suppurate. When they do, a one-

Fig. 169. — Line of incision for abscess containing extravasated urine.

sided swelling develops in the perineum in the immediate vicin-
ity of the bulb, manifesting a tendency to extend backward
toward the anus. Unless both glands are involved, a general
brawny swelling of the perineum does not occur. It is commonly
believed, at the present time, that abscess of Cowper's glands is
almost invariably of tubercular origin, which infection may be,
and in such cases generally is, associated with urethritis. If these
cases are not seen until some time has elapsed, they resemble
the urinary infiltrations that occur as the result of rupture of the
urethra. They are also at times easily confused with the effects
of injury or with a simple periurethral abscess. We have oper-
ated on one case in which no swelling of the perineum could be

RESECTION OF THE URETHRA 425

made out, the main indication being the pain in the perineum
suffered by the patient, which was, of course, immediately re-
lieved by the evacuation of the pus.

Treatment consists of opening the abscesses at the most promi-
nent protuberance, evacuating the pus, and cleaning out the
cavity very thoroughly. If the abscess is really one of Cowper's
gland, the hole in which the finger is placed will probably feel

Fig. 170.— Line of incision for abscess of Cowper's gland.

more circumscribed than if some other form of abscess in that
locality is present. Urinary tubercular fistula or extra-urethral
fistula may result, and the case prove quite annoying. These
factors are to be borne in mind in giving a prognosis before opera-
tion. They are also to be guarded against by observing the
utmost care in cleaning out the cavity. A finger in the rectum
may be of aid in indicating the point at which the incision is to
be made or curetage performed.

RESECTION OF THE URETHRA

Resection of the urethra is occasionally performed for the relief

of stricture, particularly in those cases in which there is a large

amount of cicatricial tissue in and around the floor of the posterior

urethra. It is rarely that resection is performed for stricture in

426

DISEASES OP THE MALE URETHRA

the anterior urethra. Resection is, in the majority of cases, a
partial resection. The portion of the urethra removed being
situated in the floor of the urethra, a band of connecting mem-
brane is left on the roof of the urethra. An inch or more of the

Fig. 17 1.— Rupture of the urethra ; uniting of the two ends (Lejars).

floor of the urethra may be removed if the roof is left intact, and
satisfactory union yet take place. The object to be attained in
performing resection ordinarily is to get rid of old cicatricial
masses and nodules, in the hope that the scar that will necessarily
result from the reunion of the severed portions will be softer and
more uniform. After resection of a portion of the urethra, the
severed ends may be brought together; if desired, slight longi-

OPERATIONS FOR RELIEF OF URETHRAL FISTULA

427

tudinal incisions may be made in the floor, so that the resulting
cicatrix will not be too annular and the severed ends made to fit into
each other in triangles. It is more generally the custom to make
the floor of the perineum serv^e as the floor of the urethra; one
median and an external set or the mattress form of sutures which
does not include the skin, may be employed and the skin wound
allowed to heal by granulation. To obtain the best results it is
necessary to remove the cicatricial tissue very completely.

Fig. 172. — Urethral fistula; skin freed by
transverse incision.

Fig. 173. — Skin freed by transverse incis-
ion and fistula closed by sutures.

OPERATIONS FOR THE RELIEF OF URETHRAL FISTULA
These operations may be considered under three heads: (i)
Operations for fistula in pendulous urethra. (2) Operation for
perineal urethral fistula. (3) Operation for urethral rectal fistula.
Of these, the last is the most important variety.

I. Urethral fistula in a pendulous urethra may be operated upon
by a method similar to those pursued when the fistula is in the
perineum, or by the methods recommended for the relief of hypo-
spadias. If it is deemed advisable, a plastic operation may be

428

DISEASES OF THE MALE URETHRA

performed. The illustrations (Figs. 172 to 177) give an idea of
the methods most in vogue. Diffenbach, to avoid pressure on the
line of suture, makes two lateral incisions, one on each side of
and one parallel to the wound, thus permitting the borders of
the cut to unite without too much strain.

Several other methods of operating for the relief of this condi-
tion have been devised. They consist of the making of various
forms of flaps. The persistence of erections increases the diffi-
culty of uniting wounds, and may necessitate a perineal incision

in order to anchor the urethra at the

fistulous portion.

2. Operations for Perineal Urethral

Fistula. — Resection of the urethra,

Fig. 174.— Urethral fistula j
edges freshened and fistula cov-
ered by scrotal flap.

F'g-i75- — Repair of urethral fistula; edges fresh-
ened, side incisions to overcome retraction of skin.
Sutures placed but not tied (Berger and Hartniann).

together with removal of any cicatricial tissue remaining in
the perineum, is a method that may be employed for the relief
of perineal urethral fistula. Resection of the urethra may be
performed in the same manner as is done for the relief of stric-
ture. Another method of operating for perineal urethral fistula
is to place a guide in the bladder, incise the fistulous portion on
the guide, carefully remove any cicatricial tissue in the region
of the fistula, sew up the incision in the urethra with fine catgut,
not permitting the stitches to go through the inner coat of the

OPERATIONS FOR RELIEF OF URETHRAL FISTULA

429

Fig. 176.— Urethral
fistula; edges freshened,
side incisions, sutures
tied (Berger and Hart-
niann).

urethra, and either allow the patient to urinate naturally or per-
mit a retention catheter to remain in the blad-
der for a few days. Another set of stitches
is taken, as desired, through the exterior
perineal tissue. This is the simplest method
of operating for the relief of these fistulas.

In the writer^' experience, however, this op-
eration has not been so satisfactory as could be
desired. They have seen these fistulas most
often in hospital patients, and particularly in
tuberculous subjects. Such patients have poor
reactive powers and do not retain retention
catheters well, as their mucous membranes are
very easily irritated. The most practicable
method, the writers believe, of operating on a
perineal urethral fistula, as it ordinarily presents
itself, was devised by Dr. Fraser, of Brooklyn,
an associate of Dr. Henry H. Morton, of the same city, to whom
we are indebted for the suggestion. The procedure consists in
clearing away the cicatricial tissue surrounding
the fistula, introducing a sound into the blad-
der, and then, a retention catheter having been
placed in position, sewing up the perineal tissues
with deep silver wire sutures which reach to, but
do not go through the urethra. These sutures
are allowed to remain in position for a week or
ten days, and are useful for holding freshened
edges of the perineal tissue together so that com-
plete union, to a very great extent, may take
place ; the slight oozing remaining after the re-
moval of the sutures generally disappears in a
few days.

3. Operations for the Relief of Urethrorectal
Fistulas. — These fistulas have, until recently,
been rarely reported. Ordinarily, they are due
to injury from within the urethra, owing to
improper instrumentation, or they may be due
to accident from without. In a case recently under the writers,

Fig. 177. — Ureth-
ral fistula ; liberation
of skin by the aid of
two transverse in-
cisions, method of
N^laton (Berger and
Hartmann).

430

DISEASES OF THE MALE URETHRA

care, it was caused by injuries sustained during an explosion
of dynamite. Within the last few years, i. e., since operations
through the perineal roof for the relief of prostatic hypertrophy
have become so common, urethorectal fistulas have increased
largely in number, mostly following this operation.

Diagnosis. — This is easily made from the fact that, generally,
a portion of the urine is voided through the rectum, flatus and
occasionally liquid feces being passed through the penis. With
a sound in the bladder and a finger in the rectum, the latter may
be pressed on the surface of the sound, which presents itself with-

Fig. 178. — First step of Tuttle's operation for repair of recto-urethral fistula.

out offering any impediment to the finger, and the size of the
fistulous opening may thus be made out.

Prognosis. — If, immediately after an injury, the fistulous open-
ing in the rectum is found to be no larger than a ten-cent piece or
a copper cent, the prognosis is good, complete recovery ordinarily
following the adoption of simple measures. If the urethrorectal
opening is large, the prognosis is doubtful.

Treatment. — There are three methods of treatment: palliative,
local, and operative. The palliative treatment consists in the

OPERATIOxNS FOR RELIEF OF URETHRAL FISTULA

431

patient using the greatest care in regard to his diet, guarding
against constipation, and, above all, against diarrhea.

He must also observe the utmost cleanliness of that portion
of the rectum that may extend from the anus to the fistulous
rectal opening. The best means of securing this is by ordering
rectal injections of some mild cleansing wash, such as a weak
solution of some mild antiseptic.

Local measures consist in the introduction of a Kollmann
dilator into the bladder through the urethra at the meatus at
intervals of four or five days, and the gradual overdistention of

Fig. 179. — Second step of Tuttle's operation for repair of recto-urethral fistula.

the prostatic and membranous urethra. If possible, the dilata-
tion should be continued until a caliber equaling that of No. 45 F.
has been reached. If a Kollmann dilator is not available for
this purpose, steel sounds may be used. In passing either the
sound or the dilator, however, great care must be observed to see
that the beak of the instrument does not enter the rectal opening
through the urethra instead of entering the bladder. The patient
himself will generally be aware of it when this occurs. To obviate
this it is best to proceed slowly, to hug the roof of the urethra
closely, and, while passing the instrument, to insert a forefinger

432

DISEASES OF THE MALE URETHRA

into the rectum in order to learn when the beak of the instrument
enters this, and to help to guide it upward and outward on its way
to the bladder. Such remedial measures as cauterizing the edges
of the fistula, either in the rectum or the perineum, have proved
useless in the writers' hands.

Operative Treatment. — Although a number of operations have
been devised for the relief of this condition, one that, in the writers'
experience, has been followed by good results, is that of Dr. James
P. Tuttle, of New York city. This is performed as follows :

Fig. i8o. — Third step of Tuttle's operation for repair of recto-urethral fistula.

Tuttle's Operation for Closure of Recto-urethral Fistula. —
First: The operation should not be undertaken until suppuration
in the bladder, the urethra, and the fistulous tract has completely
disappeared.

Second: All strictures of the pendulous urethra should first be
thoroughly dilated.

Third: The operation should be preceded by a week's course
of urotropin and intestinal antiseptics.

The Operation. — With the patient in the Sims posture, the hips
being well elevated, the urethra is laid open from the scrotum
back to the fistula; the incision is then carried through into the

OPERATIONS FOR RELIEF OF URETHRAL FISTULA

433

rectum, thus making an opening that reaches to the fistula. The
latter is then dissected up from the rectal side and left attached
to the urethra. The rectum and urethra are next separated
transversely well above the fistula, so that the anterior rectal
wall can be dragged down over the fistula to the anal margin.
The mucous membrane is then dissected from the anal margin
on each side of the wound and trimmed off, so as to form a crescent
with the edge of the gut that has been separated from the urethra
above the fistula. A soft rubber No. 22 F. catheter is now passed
from the meatus into the bladder. The edges of the fistula are

Fig. 181.— Fourth step of Tuttle's operation for repair of recto-urethral fistula.

then inverted, and their freshened surfaces sutured together
with No. I ten-day chromicized gut, the continuous Lembert
suture being employed. The urethra is thus closed down to
one half inch below the level of the external sphincter ani. The
remainder of the perineal wound and urethra are left open. Rein-
forcing flaps are then cut from the perineal tissues on each side of
the sutured area, and brought together over the first line of
sutures by a continuous chromicized suture. A silkworm-gut
suture is then passed through the skin from one side of the anus
up through the perineal tissues to the apex of the wound, through
28

434 DISEASES OF THE MALE URETHRA

the muscular wall of the gut at this point, and back through the
perineal tissues and skin on the opposite side, the ends being left
untied. The anterior wall of the rectum is then brought down
and sutured to the margin of the anus, from which the mucous
membrane was dissected, thus forming an impervious layer be-
tween the sutured urethra and the rectal canal. Finally, the
silkworm -gut suture, which acts as an anchor to the rectal wall,
dragging it down and preventing tension on the marginal sutures,
is tied firmly over a small roll of gauze, so that it will not cut into
the skin. The perineal wound is then packed, and the catheter
fastened at the meatus, so that it cannot slip out. The catheter
is left in situ ten days or more. When it is taken out, a perineal
fistula remains that usually heals in about three weeks.

CHAPTER XXIII

THE FEMALE URETHRA

ANATOMY

The female urethra is considerably shorter than that of the
male and it virtually represents but the posterior portion of the
male passage. It is about one and one-half inches in length, but
varies considerably in this respect in different subjects. Its walls
are ordinarily in immediate apposition, but when its longitudinal
corrugations are distended the passage is about one-fourth inch
in diameter. The tube can be greatly dilated, however, suffi-
ciently so as to permit the introduction of a palpating finger.

The organ lies embedded in the anterior vaginal wall and its
external orifice is found about one inch posterior to the glans
clitoris. It passes upward and backward, joining with the walls
of the bladder and draining this cavity at its most pendent por-
tion, the trigone. The internal or cystic orifice is stellate in the
resting condition and the external orifice or meatus presents itself
between the nymphae as a vertical slit with slightly raised margins.
The urethra penetrates the triangular ligament and is attached
to the pubic arch by the pubovesical ligaments. The body of
the tube is inclosed by the compressor urethrae muscle. The
ducts of Skene enter the urethra just within the meatus. These
gland tubules are of considerable importance, since in infectious
diseases of the female urethra they afford lodgment for micro-
organisms which may later infect the bodies of the glands and
excite a persistent inflammatory disease with sporadic outbreaks
of adjacent infection.

The walls of the urethra are made up, beginning from within,
of a thick layer of transitional epithelium, continuous with that
lining the bladder and like it in its appearance; at the external
meatus this epithelium becomes transformed into a form like
that making up the external genital mucosa. At the vesical

435

436 THE FEMALE URETHRA

extremity of the channel many mucous glands are found, the ducts
of which enter the urethra at this point. The mucous membrane
of the urethra is laid down on a delicate basement membrane
which is in turn applied to a thick and very highly vascular con-
nective-tissue coat which is further characterized by the presence
of many elastic connective-tissue fibrils. The connective-tissue
layer is inclosed by an inner longitudinal and an outer circular
layer of smooth involuntary muscle which acts as and receives
the name of the compressor urethrae muscle. The muscular coat
is united to the surrounding structures by a layer of connective
tissue which blends with the surrounding stroma.

The lymphatics of the upper portion of the urethra drain into
the internal iliac nodes, but the lower ones enter into the channels
of the external genitals and so pass to the inguinal nodes. The
blood-vessels and nerves are very abundant and are derived from
the same sources as those supplied to the vagina.

CONGENITAL MALFORMATIONS
Congenital malformations of the female urethra are more rare
than in the male. They are usually found associated with accom-
panying malformations of the genitals. Atresia is the most fre-
quent congenital malformation with which the obstetrician and
general practitioner meets. Its treatment is obvious and the
severity of measures necessary depends on the degree of the
atresia. Occasionally the urethral meatus is indicated and the
septum separating it from the bladder can be perforated by a probe
or sound. When no such landmarks exist and where the tube
cannot be felt, it may be necessary to open the bladder suprapu-
bically or through the vagina, following later with a reparative
or constructive plastic operation such as is indicated by the asso-
ciated lesions of the particular case under question. Hypospa-
dias and epispadias are very rare and exstrophy of the bladder is
also less frequent than in the male. The treatment of these con-
ditions has been sufficiently discussed under the like conditions
in the male.

Traimiatisms of the urethra are much less common in the
female than in the male on account of the protected location of
the canal. As a rule, they result from direct violence, and the

EXAMINATION OF THE FEMALE URETHRA 437

chief difficulties presented in their treatment follow from their
close proximity to the genital tract and the rectum, from which
infections are likely to arise.

Treatment is directed mainly toward surgical repair, when neces-
sary, and toward the prevention of septic infection. On account
of the great vascularity healing generally takes place rapidly.

EXAMINATION OF THE FEMALE URETHRA
On account of the short length of the channel, its dilatabiUty,
and its accessible position, examination of the female urethra is a
much more simple matter than that of the male. Palpation of
practically the entire length of the passage can be usually satis-
factorily performed through the anterior vaginal wall, the index
or examining finger being introduced for that purpose into the
vagina. In this manner, calculi lodged in the lumen may be read-
ily detected, and in most cases the location and extent of stric-
tures or new-growth formations can be ascertained.

Examination of the mucous membrane can be best accomplished
by the introduction of a small sized Kelly cystoscope, and as the
instrument is slowly withdrawn the walls of the canal fall together
over the open end of the instrument, when they can be closely
inspected bit by bit as the tube is slowly withdrawn. A strong
light is necessary and the best results are obtained when light
reflected by means of a head mirror is employed. Where Kelly's
instrument is not available examination can be quite satisfactorily
accomplished with an ordinary urethral endoscope of large size.
In the withdrawal of the tube one must particularly inspect the
openings of the gland tubules, which appear normally as minute,
yellowish, slightly pink spots. Inflammatory and ulcerative
processes are especially apt to be seen at these points. The
entrance of the ducts of Skene's glands appears just as the instru-
ment is about to escape from the urethra. Where infection of
these glands is suspected, massage along their course may force a
droplet of discharge into the urethra, from which it may be
collected for examination by means of an applicator. Abso-
lute asepsis is, of course, requisite in every step of the examina-
tion.

438 THE FEMALE URETHRA

STRICTURE OF THE FEMALE URETHRA

Strictures of the female urethra are rare as compared to the
like change in the male canal, still they are present much more
commonly than is generally thought to be the case. A stricture
of considerable degree may exist without attracting the especial
attention of the casual observer, since unless it be very marked
or accompanied by acute inflammatory changes, the symptoms
complained of are few and considerable retention of residual urine
may sometimes exist for a long time in women without attracting
the attention of the patient.

Strictures most commonly follow previous inflammatory disease
of the urethra, in the cause of which, as in the male, gonorrhea
leads in frequency. Tubercular or syphilitic ulcerations are, how-
ever, by no means unknown, and strictures following traumatism
in child-birth are relatively common. They are very apt to occur
with new-growths of the urethra or in the course of neoplasms of
adjacent parts, also from inflammatory or ulcerative disease of
the vagina or vulva.

Diagnosis. — Diagnosis is usually readily effected, by digital
examination through the vagina, when a thickened node of infil-
tration or fibrosis may be detected; quite frequently it is first
discovered through attempting to pass a catheter. The use of
the ordinary male sound is not satisfactory for the detection of
the stricture, for in nearly all cases the lumen can be so readily
dilated as to permit the passage of such an instrument. The
olive-tipped sound should be used, and unless very slight the
passage of a stricture by one of these instruments can be very
easily detected by the practised hand.

Treatment. — Treatment follows along the same lines as employed
in the male. The most efficient is the use of graduated sounds or
bougies. Dilation can be well effected under cocain anesthesia,
or in less marked cases without any anesthetic whatever. Rapid
dilation must not be practised, and of course rigid asepsis is to
guard every step. Where extensive ulceration, as in new-growths
of the parts, or where a large amount of cicatricial tissue causes
a stricture near the external meatus, it may be found better to
form an artificial meatus in the anterior vaginal wall. The

DILATION OF THE URETHRA 439

portion of the tube posterior to the stricture should be brought
down into a vaginal incision and its mucosa stitched to that
of the vagina. A catheter must be left in position until union
has taken place.

These strictures sometimes show a marked tendency to recur,
and it is frequently necessary to redilate from time to time.
In every case injury to the tissues must be carefully avoided or
inflammation and subsequent formation of more cicatricial tissue
may follow.

DILATION OF THE URETHRA

Relaxed or patulous urethra is not uncommonly seen in women.
As a rule, incontinence of urine does not follow, but in some cases
the relaxation may be so marked as to prevent normal retention
and operative relief may be imperative. In some cases prolapse
of the mucous membrane may take place and a condition simulat-
ing hemorrhoids in a small way may appear.

Dilation of the urethra most commonly follows overstretching
of the tube, perhaps in unskilful endoscopy, in the extraction
of a cystic calculus or occasionally where the entire tissues of the
parts are relaxed as a result of some general or local disease. Dila-
tion of the urethra, often to great size, is occasionally seen in cases
where, owing to malformation or agenesis of the vagina or exter-
nal genitals, persistent attempts have finally dilated the urethra
up so that coitus through this channel is possible. The authors
have seen two such cases; in neither, however, did the patient
experience any resulting difficulty, nor were they aware of any-
thing abnormal in their condition. Kelly states that, as a rule,
these cases do not complain of incontinence, and he advises let-
ting the condition alone except where the normal genital channel
can be established, when the urethra commonly contracts down
considerably.

Treatment. — As just mentioned, certain cases demand no treat-
ment. Where prolapse of the mucosa has taken place, the pro-
tuberant tissues are to be cut away and the edges of the wound
carefully sutured to the normal mucosa. Where the condition
is due to relaxation of the surrounding parts or to traumatism,
interference may be necessary and the surplus tissue may be
removed surgically. A properly fitted hard-rubber or glass vagi-

440 THE FEMALE URETHRA

nal pessary may in some cases sufficiently replace the tissues so
tliat operative procedure may be obviated or at least delayed.

URETHRAL FISSURE
This is a condition of rather frequent occurrence. It consists in
a fissure or crack in the mucous membrane which usually extends
longitudinally to the lumen. It may be caused by rapid dilation,
or more frequently it follows mild or catarrhal types of urethritis.
The condition is often very painful and may cause considerable
irritation. It is readily detected from the history and on exami-
nation of the urethra. It may be treated by the application of
silver nitrate in from 3 to 7 per cent, strength ; in certain aggra-
vated cases careful dilation of the urethra must precede the
treatment. Occasionally we have found it necessary to repeat
the treatment for a considerable time before complete relief was
afforded. As a general thing these fissures are associated with
more or less urethritis and sometimes with cystitis.

PERI-URETHRAL ABSCESS
Abscess formation occasionally occurs about the female urethra.
As a rule, it follows urethritis with infection of the urethral glands,
and it is commonly gonorrheal in origin. Sometimes these ab-
scesses occur as a result of tubercular or syphilitic ulcerations
of the urethra. They may point into the urethra, or may appear
as a bulging sac on the anterior wall of the vagina. Their treat-
ment is naturally incision and drainage.

URETHRITIS

Urethritis is probably as frequent in the female as in the male,
but in most cases its course is so mild that it appears but as an
incident in the course of a vaginitis or vulvitis, and often escapes
the observation of the physician. It is caused most commonly
by the gonococcus, but may follow infection with any of the va-
rious infectious agents or it may result from traumatism. In
the last mentioned cases, unless complicated by subsequent in-
fection or by stricture, the progress is toward recovery and the
course of the disease is short.

Some cases of urethritis, especially some cases of gonorrheal

URETHRITIS 44 1

infection, are very resistant to treatment and are often most
distressing to the patient. The appearance of the mucous mem-
brane varies from bright pink to deep purple in color. Eversion
and swelling of the mucosa at the meatus may be seen and an
abundant discharge is usually present. Where infection of the
ducts of Skene's glands is, as is most commonly the case, present
pus can be expressed from them by massage through the vagina.
Microscopic examination of the exudate is always advisable in
these cases in order that the definite etiologic agents may be
demonstrated.

Ulceration of the urethra is very prone to occur in acute ure-
thritis, and, as in the male, stricture is apt to take place with heal-
ing of the ulcer.

In chronic urethritis, as a rule, the entire surface of the mem-
brane is not involved and the parts are not so tender but that
they may be satisfactorily examined and treated through the
endoscope. Patches of redness, of superficial ulceration, or of
edema are seen and direct applications to the diseased surface
are often possible.

Treatment. — The treatment in general follows closely along
the lines outHned for the treatment of the like condition in the
male; the disease as a general thing, however, responds much
more readily to treatment. In many cases, owing to the short-
ness of the canal and the less complicated nature of the mucous
membrane, the disease is self -limited. Many cases take place and
become cured without even the knowledge of the physician or
particular complaint on the part of the patient. This is especi-
ally frequent when the adjacent parts are the seat of a more
active inflammatory process, as in gonorrheal vaginitis and vul-
vitis.

One of the first steps in the treatment is the rendering of the
urine bland by the use of large amounts of water and perhaps
by administering alkalis. Beyond question a certain number of
cases are set up by an intensely acid urine. Warm sitz-baths
are often of great benefit, not only in the cure of the disease but
also in relief of its most annoying symptoms. Where severe pain
occurs on passing the urine, it may often be voided with com-
paratively little distress while in the warm bath. Local applica-

442 THE FEMALE URETHRA

tions of various sedative and astringent lotions to the external
meatus are often beneficial, and of such the familiar "lead and
opium wash" is one of the best.

As a rule, we have not found local irrigation of the membrane
advantageous in acute cases. Irrigation in this stage of the
disease is very apt to cause infection of the bladder and cystitis.
General measures suffice in most cases at least until the exquisite
tenderness has subsided, when direct applications of silver nitrate
in a strength varying from 3 to 10 per cent, may be made to the
mucous membrane. Protargol acts better in the more acute
cases, especially where marked edema is present. In some pa-
tients where the inflammation has extended from the urethra
into the bladder, where it is frequently located just at the tri-
gone or about the urethral orifice, it is good practice to first irri-
gate the urethra with a mild solution of potassium permanganate,
protargol, or silver nitrate, and then to inject a small quantity
into the bladder, where the patient should retain the fluid for
a few moments before it is voided.

Chronic cases are to be treated very much along the same lines,
but here, as a general thing, direct applications to the diseased
portions of the mucous membrane are possible through the endo-
scope and stronger solutions are necessary.

Throughout the entire treatment of both acute and chronic
urethritis attention must be paid to the general condition of the
patient and the administration of tonics and a properly adjusted
diet are often essential for rapid recovery.

TUMORS OF THE FEMALE URETHRA
Tumors of the female urethra are not common except where
secondary invasion of the urethra has taken place from neo-
plasms of the vulva, vagina, or uterus. Primary neoplasms appear
most commonly about the external meatus, where diagnosis is
easy, and as a rule the nature of the growth is sufficiently evident
on mere gross inspection, though postoperative microscopic ex-
amination is necessary for certainty and for proper postoperative
treatment. The tumors are conveniently divided for discussion
into malignant and innocent.

Malignant Tumors. — Carcinoma is the most frequent malignant

TUMORS OF THE FEMALE URETHRA 443

tumor of the urethra ; it is, however, rare as a primary growth.
It is seen most often as an epithelioma of the squamous celled
type, originating, when primary, from the mucosa of the meatus,
as a rule. The malignant character of the growth may be recog-
nized by its tendency to infiltrate, by superficial necrosis, and by
the pain which accompanies it, though the parts are generally
not very sensitive locally. As a general thing the gross appear-
ance of the growth is such as to leave little doubt as to its nature.
Carcinoma of the urethra is in our experience most commonly
confused with syphilitic ulcerations. Differential diagnosis must
rest on response to syphilitic treatment and on microscopic ex-
amination.

Sarcoma of the urethra is very rare except in general or local
sarcomatosis.

Treatment. — The treatment in malignant tumors of the urethra
is early extirpation in all cases whenever this is possible. The
incision should include as much of the surrounding tissues as
practicable, and we strongly advise the application of the rr-ray
after the surgical removal of these growths. Care must be taken
in the use of this agent, however, and it should not be employed
about these delicate mucous membranes except in the hands of an
expert.

Innocent Tumors. — The most frequent innocent tumors of the
female urethra are condylomata. They appear as more or less
pediculated papillomatous masses, generally in groups and more
or less symmetrically arranged, for they are autoinoculable.
They probably bear a direct relationship to uncleanliness and
in many instances are the result of venereal inoculation. They
are ordinarily painless except in secondary inflammation; they
grow rapidly, particularly under conditions of moisture and filth,
and may develop to tumors of considerable size. The treatment
consists in removal, and the surgeon should be particular to
fully excise the base of the growth, and the wound should then be
cauterized with strong silver nitrate solution.

Urethral caruncles are tumors developing from the lips of the
external meatus. They are deep purple in color, due to the large
number of blood-vessels which enter into their structure. They
may be either pediculated or sessile. They are covered over by a

444 "THE FEMALE URETHRA

delicate reflection of the mucous membrane, bleed readily, and
are exquisitely tender. They cause great distress, especially on
urination or from chafing or pressure. They may further become
intensely inflamed. Microscopically they are made up of a deli-
cate connective-tissue stroma which supports a very abundant
number of large, thin-walled blood-vessels. The tumors are prob-
ably inflammatory in origin; they do not recur on removal and
never grow to be of large size.

The treatment consists in removal, which must be done under
efficient local or general anesthesia. In nearly all cases removal
by the knife is to be greatly preferred to cauterization, both be-
cause the pain during and after the operation is less and also
because the resulting scar after excision is much smaller and better
placed than when removed by cautery.

Polypoid fibroma are occasionally found attached to the ure-
thral lips or projecting from the tissues immediately internal
to the meatus. The mass of the tumors is made up of myxo-
matous or embryonal connective tissue and they are covered in
by a reflection of the urethral mucosa. Blood-vessels are not
numerous. The tumors may cause considerable obstruction of
the urethra at times, but unless they become much inflamed
they are generally painless. Treatment consists in removal by
cutting them away at the pedicle or by twisting them off at this
place. They do not recur.

CHAPTER XXIV

THE PENIS

INJURIES OF THE PENIS
Treatment. — Generally speaking, injuries or wounds of the
penis have a tendency to heal rapidly. It is not deemed neces-
sary to enumerate here the various injuries or wounds of this organ
that have been recorded from time to time. The organ may be
completely or incompletely severed or portions of it may be torn
away. When completely
severed, the ordinary sur-
gical measures for arrest-
ing hemorrhage should
be adopted and a good
stump made. When in-
completely severed, the
aim should be to pre-
serve the integrity of the
urethra as much as pos-
sible by means of deep
and superficial sutures,
placing the organ on a
splint, and establishing
either perineal or supra-
pubic drainage and
adopting such other
measures as will give the
injured organ a chance to

heal. An astonishing amount of the outside skin may be torn
away and repair still take place. If much of the skin surrounding
the penis has been destroyed, autoplastic measures may be at-
tempted. These may be divided into two classes: .First, when
a large portion of the skin has been lost and scrotal tissue can be
used, and, second, when a large portion of the skin has been lost

445

Fig. 182.— Operation of Bessel-Hagen for the plastic
repair of denudations of skin of tlie penis where a scro-
tal flap cannot be obtained. First step, bridge is taken
from the abdominal wall and penis inserted through
it (redrawn from Berger and Hartmann).

446

THE PENIS

and scrotal tissue cannot be used.

T>

When the skin on the inferior
surface of the penis, ex-
tending to the scrotum,
is lost, the foreskin, if in-
tact, may be split, and a
portion of this may be
used, Reich's method,
shown in fig. 184, con-
sists of making a bridge
from the scrotal tissue.
Twenty days afterward
the bridge is freed by
making an incision on
each side. When pos-
sible, the skin from the
scrotum is used.

Bessel-Hagen'smethod
is illustrated by figs. 182,
183. When skin from
the scrotum is lacking,
the penis is made to pass under a bridge cut from the belly.

Fi^. 183. — The second step in the Bessel-Hagen
operation. Eleven days after tirst operation the line
a b and a' b' is cut through to recover the denuded
penis. Then a flap L is made following on lines
a a' c with which the denudation at the base of the
penis is covered (Berger and Hartmann).

Fig. 184.— Operation of Reich for the plastic repair of denudations of the skin of the penis
by means of a bridge of scrotal tissue, a ana a', dancl/!'' representing the upper and lower borders
of the incision; lower, about 9 centimeters, slightly the longer. The flap having been freed, the
surface of denuded shaft of the penis having been freshened is slipped through as though a ring
and fastened with a few sutures through top and bottom to the flap. After about twenty days
the ring is freed by incising line c b (redrawn from Berger and Hartmann).

Eleven days after he cuts each side line, a b and a' b\ He uses
the sides of the bridge and recovers with it the shaft of the penis;

1

GROWTHS AND ULCERATIONS OP THE PENIS 447

then he takes another flap and recovers with that, Hne a a' c, the
base of the penis.

Fracture of the organ may take place; this is in reaHty a frac-
ture of the corpora cavernosa. The injury is accompanied by
pain and sometimes by fainting; the organ becomes flaccid and
enormously swollen. Occasionally this is complicated by a rup-
ture of the urethra. As a rule the injury is followed by distur-
bance of the sexual functions, as after healing the posterior por-
tion of the organ may become rigid at times, the anterior generally
remaining flaccid.

Probably the best treatment, if the case is seen early enough,
is to cut down on the organ, remove any clots, and, by means of
fine sutures, sew the
fractured portions
well together, apply-
ing splints, and pre-
venting, so far as pos-
sible in the after-treat-
ment, the formation
of cicatricial tissue.

GROWTHS AND UL-
CERATIONS OF THE
PENIS

Saddle-shaped nod-

ijI^q npofldnnnllv fnrm ^'^- 185— Epithelioma of the foreskin. (Natural size.)
ttteo \j\^\^a.sL\jiiciii\ njnn From a specimen in the museum of Carnegie Laboratory.

in the corpora caver-
nosa and spongiosum, and interfere with the proper performance
of the sexual function. They generally occur in men past middle
life, and there is much diversity of opinion regarding their origin.
They may be syphilitic, gouty, or possibly, in certain cases, malig-
nant. If syphiUs is suspected, internal and local external treat-
ment should be tried; antiphlogistic treatment of various kinds
may also be effective. If these fail to effect their removal, sur-
gical measures should be undertaken, but a guarded prognosis
should be given as regards recovery of the lost sexual function.
Tumors of the organ, with the exception of carcinoma, are rare.
Horny excrescences and cysts of varying size occasionally form.

448

THE PENIS

and are treated as successfully as are cystic formations occurring
elsewhere in the body. Cancer of the penis originates from the
epithelium of the glans in most cases ; it occurs almost exclusively
as a primary growth of the epitheliomatous variety, and is seen
only rarely as a metastatic process. The treatment is early and
complete surgical removal, and temporizing measures should be
adopted only in inoperable cases. Ulcerations on the glans penis
are quite common, generally being either chancre or chancroid,
for a detailed description of which the reader is referred to any

of the text-books on sy-
philis. Gumma also oc-
curs, usually as an ulcera-
tive process, and where
diagnosis is in question,
antisyphilitic treatment is
always advisable in cases
of ulcerated neoplasms
of the penis. Tubercular
ulcerations may occur,
but are very rare. They
should be treated by
appropriate destructive
agents, such as carbolic
acid, followed by as-
tringent dusting-powders.
Ordinarily chancre and
chancroid, except of the
phagedenic type, yield
readily to local treatment, such as applications of carbolic acid
or dusting-powders like aristol, together with the appropriate
internal treatment. Chancroid is the principal cause of sup-
purating inguinal glands, or bubo, which may be mentioned
here. Btiho is the term applied to an inguinal gland which has
suppurated. The treatment of this condition is preventive and
operative. The preventive treatment consists in the applica-
tion of vasogen-iodin or mild mercurial ointment or applications
of alcohol on gauze covered with rubber tissue, together with
rest in bed. If suppuration takes place the gland should be

Fig. I J

-Tuberculosis of the glans penis (Frisch and
Zuckerkandl).

FOREIGN BODIES IN THE URETHRA

449

opened by means of as small an incision, half an inch or more,
as is practicable, pus evacuated, and iodoform, lo per cent, in
glycerin, injected three times into the cavity, injection to be
repeated on following day and again in four or five days if re-
quired. A wet dressing is to be kept applied. In obstinate cases
it may be necessary to make a large opening and curet the cavity.

Fig. 187. — Cancer of penis and scrotum (author's collection).

FOREIGN BODIES IN THE URETHRA
The literature bearing on foreign bodies and urethral calculi
in the urethra is very extensive, and the methods recommended

Fig. 188. — Thompson's urethral forceps.

for their removal are numerous. If nature fails to remove an
obstruction and simple measures — ^such as distention of the canal
anterior to the obstruction — fail, an effort should be made to
grasp the body by means of long, very narrow dressing forceps
29

450

THE PENIS

designed for the purpose. Occasionally small
substances may be removed by means of a small
curet with a long handle. If these measures do
not accomplish the desired results, an incision
should be made over the shaft of the organ and
the obstruction removed; this is not a very
serious operation. Or, if desired, the ordinary
perineal incision may be made and the sub-
stance pushed back through the perineal wound.

HYPOSPADIAS
Hypospadias, or fissure of the inferior ure-
thra, is ordinarily a congenital condition, and
is generally divided for purposes of description into three classes,
of which the first is the most common: (i) Hypospadias of the

Fig. i8g. — Beck's op)-
eration for hypospadias.
The urethra freed.

Fig. 190.— Fastening hypospadiac orifice to the catheter.

HYPOSPADIAS

451

Fig. 19 1.— Dissecting the urethra while stretching it with catheter.

Fig. 192. — Beck's operation for hypospa-
dias. Tunneling the glans.

Fig. 193- — Beck's operation for hypo-
spadias. The freed urethra brought through
tne tunneled canal in glans.

452

THE PENIS

Fig. 194.— Catheter with urethra drawn through glans; insertion of suture.

Fig. 195.— Beck's operation for hypospa-
dias. Suturing the skin. Glans trenched
instead of tunneled.

Fig. 196. — Beck's operation for hypo-
spadias. Suture finished; urethra fastened
in tunneled glans.

HYPOSPADIAS

453

glans of the penis. (2) Hypospadias of the body of the penis.
(3) Perineal or scrotal hypospadias.

Fig. I07-— Beck's operation for hypospadias showing relaxation sutures, to allow for tension:
A, Relaxation suture introduced over simple suture; B, relaxation suture complete.

Fig. 198.— Beck's operation for scrotal hypo-
spadias. Showing line of incisions.

Fig. IQ9.— Beck's operation forscrotal hypo-
spadias. Showing new formed urethra.

Operations for the relief of this condition are extremely interest-
ing and deserving of more consideration than can be given them

454

THE PENIS

here. When the penis is curved downward and bound
scrotum by adhesions, it should be cut free and the lateral
sewed longitudinally by the method of Duplay.

The operation of Dr. Carl Beck,
of New York, is the one advocated
by the writers for the relief of hypo-
spadias of the glans. It is divided
into three parts, which are well
shown in the illustrations (figs.
189 to 197 inclusive).

Make a longitudinal and two lat-
eral incisions on each side of the
urethra, and dissect from the sur-
rounding tissue for an inch or
two, if desired aided by catheter

to the
wound

Fig. 200.— Beck's operation for scrotal hypo-
■spadias. Showing flap taken from scrotal tissue
•twisted on itself covering new-formed urethra.

Fig. 201.— Instruments used in
Beck's operation for hypospadias, a.
Toothed retractor ; 6, toothed adjust-
able holding forceps.

in urethra. With a trocar make a hole through the top of the
glans to the urethra, draw the urethra through, fasten with a
iew stitches, and support and keep open for a few days with a

EPISPADIAS

455

retention catheter, thus holding it in place until it unites. Sew
up the skin wounds at the base of the glans. Relaxation sutures
assist to overcome tension. Instead of tunneling the glans may
be trenched.

Operations for the relief of hypospadias occurring high in the
shaft of the organ are of the same character as those performed
for hypospadias occurring in the glans. When situated at or
near the scrotal junction, they are similar to those performed for
perineal hypospadias.

Operations for the Relief of Perineal or Scrotal Hypospadias. —
The Beck operation is here probably the
best. It consists of making several flaps
(figs. 198, 199, 200) :

Beck makes, on each side of the gutter

Fi^. 202. — T h i e r s c h
operation for epispadias.
Narrow lines for refresh-
ing the canal in the glans.
Two incisions are made
which if prolonged would
meet one another. First
step.

Fig. 203.— Thiersch opera-
tion for epispadias. Refreshing
the canal, showing lines after
the suture, the segment hav-
ing been taken away and the
side walls thus refreshed liga-
tured together over a sound.
First step.

Fi^. 204. — T h i e r s c h
operation for epispadias.
Illustrating lines for side
flaps. Second step.

and parallel to it, an incision sufficiently long to reach the point
of the new urethral orifice. The penis being lifted, he unites
these two incisions by a third, and forms a flap (separated from
the penis by dissection) which he folds around a sound, sutures
its two edges together, and thus makes a new urethra ; the second
flap he bends back on itself to form a surface over the new
channel; this flap is cut from scrotal portion in the form of a
tongue with its base superior, and is used to cover the denuded
portion.

EPISPADIAS
This condition is the opposite of hypospadias — the opening
being on the superior aspect of the organ. It is also an accom-

456

THE PENIS

paniment of exstrophy of the bladder. The opening being high,
the urethra can be dissected out, brought into proper position
and replaced, and, if necessary, a small flap may be utilized to
cover the open space. Epispadias in which the opening occurs
at the base of the shaft of the organ is sometimes met, and is a
much more difficult condition to treat. Probably the operation
of Thiersch is as good as any. It demonstrates what may be and
has been occasionally successfully done in the way of performing
a plastic operation. First refresh and unite canal in glans (figs.
202, 203).

In fig. 204 two flaps are shown, taken from each side of the

Fig'. 205. — Thiersch operation for epi-
spadias. The right flap is brought over
onto the raw surface of the turned over
left flap. Second step.

Fig. 206. — Thiersch operation for epi-
spadias. The prepuce is incised and pulled
over glans, covering freshened edges of
corona fistula. Third step.

median line on the superior surface of the organ. They are so
united that they come in contact, raw surface to raw surface, in
the ordinary way, thus covering over the open canal with a dura-
ble roof. The next step in this interesting operation is the making
of a foreskin. This Thiersch does, as is shown in the illustration
(fig. 206), by making a button-hole incision in the redundant
skin hanging down like an apron underneath the glans, and pulling
the glans through the opening, just as the glans penis is pulled
through an opening in a piece of gauze often used as a dressing in
cases of urethritis; the skin is then sutured to cover coronal
fistula. The opening of the canal has now been closed over, the
foreskin made and sewed in place, but the lower end of the ure-

AMPUTATION OF THE PENIS

4.57

thral opening at the base of the organ has not been closed. This
the operator accompUshes, as will be seen from the cuts (figs.
207, 208), by taking two winged-shaped flaps from the pubic
region, bringing them over the opening in a manner analogous

Fig. 207.— Thiersch operation for epi-
spadias. Showing two flaps, left triangular,
right rectangular; left turned over orifice
and base of penis. Fourth step.

Fig. 208. — Thiersch operation for epi-
spadias. The rectangular right flap has
been brought over on to the top of left flap.
Wounds caused by flap removal will close
by granulation. Fourth step.

to the flap operation on the shaft of the penis, and securing them
according to the method shown in the illustration.

Almost all operations for the relief of epispadias and hypospa-
dias of any extent require a perineal section in order that the
parts may be kept at rest while healing is taking place.

AMPUTATION OF THE PENIS

This operation is not infrequently performed for cancer, and
may be made necessary by injury or gangrene. In the main
there are two operations for the relief of cancer of the penis or
allied conditions. Both are comparatively easy to perform.
One consists of entire removal of the organ, and the other of the
performance of amputation in continuity. The writers recom-
mend the latter operation for cancer, as the operation of complete
removal of the gland is open to serious objection.

The operation for entire removal is performed as follows : The

458

THE PENIS

legs of the patient being elevated and the proper operative toilet
having been made, an incision is made splitting the scrotum down
to and exposing the urethra; then, with careful dissection, the
corpora cavernosa are dissected away from the urethra, this canal
being allowed to hang down like a piece of tape. The corpora
cavernosa are now severed at their connection to the crest of
the pubes; this is likely to cause severe hemorrhage, and Dr.
Henry H. Morton recommends burning off the corpora cavernosa
from the pubes by means of the thermocautery to avoid hemor-
rhage. After the corpora cavernosa have been removed, the
urethra is pulled through the perineal opening and stitched to

Fig. 209. — Amputation of penis : A, A, Method of making: dorsal flap ; B, /?, line of amputa-
tion ; C, projection of urethra.

its edges. Any part of the urethra that proves too long for the
purpose required can now be snipped off. As has been observed
by Dr. Morton and others, with whose observations the writers,
from their limited experience, are in accord, the objections to this
operation, which is a comparatively simple one to perform, and is,
in its way, brilliant, are that where the cancerous process has ad-
vanced so far as to demand this procedure, death from extension
of the process or from infection of the wound rapidly ensues.
The operation of choice, then, for cancer of the penis is to amputate
as soon as a positive diagnosis has been made.

AMPUTATION OF THE PENIS 459

A word as to the diagnosis between gumma and cancer of the
penis. It is, in certain cases at least, impossible to differentiate
from the appearance of the ulceration alone. In a case seen
in the service of one of the writers at the City Hospital the
absence of a syphilitic history and the clinical appearance of
the ulceration seemed to point conclusively to cancer. A sec-
tion examined microscopically failed to show the presence of
cancerous tissue. The pathologist, however, was convinced,
from the appearance of the lesion, that the specimen was can-
cerous, although, as said, microscopic examination failed to
prove this. An active course of antisyphilitic treatment was
instituted, but the ulceration continued to spread. Contrary
to the judgment of the house staff, and in spite of the increas-
ing ulceration, operation was postponed, and the antisyphilitic
treatment was continued. At the end of about a month, when
it seemed utterly injudicious to delay longer, operation was
decided on. Before the day of operation arrived, however, the
ulceration had begun to improve under the same treatment that
it had so long withstood. Healing continued with astonishing
rapidity, and in a period of about two weeks complete recovery
ensued. Although there was no evidence to substantiate this
view, it is possible that the method of administration of the
antisyphilitic treatment in this case was faulty. vSince this time
it is the writers' practice, despite the clinical appearance and the
history of the case, to advise against amputation of the penis
for the relief of cancer until thorough antisyphilitic treatment has
been carried out for several weeks, in order that an absolute
diagnosis may be arrived at before operating.

Amputation of the penis in continuity is a simple operation to
perform, and, under ordinary circumstances, gives good results.
It is performed as follows: Run any sharp, pointed instrument
through the body of the penis — hat-pins have been popular in
the past. It is not necessary, as was formerly done, to run two
instruments through, nor is this done, as was stated by some of
the earlier writers, for the purpose of preventing the urethra from
slipping back. The pin is run through merely to serve as a point
of anchorage for the ligature. Pass a small soft-rubber catheter
around the penis, and under and over the projecting ends of the

460

THE PENIS

instrument that has been run transversely through the body of
the organ, tying it tightly or compressing it with forceps in order
to prevent hemorrhage. Mark the point at which it is desired to
amputate; then make another mark on the body of the penis,
an inch or so in advance of the first mark on the superior
aspect, which is the point for making the preliminary incision.
This incision should go only through the skin, and is made for
the purpose of procuring a flap for the corpora cavernosa. Dis-
sect the skin back until the mark on the superior surface of the
organ is reached — the point at which the actual amputation is
to be done. Next cut through the corpora cavernosa down to,

Fig. 210.— Amputation of penis. Method of sewing together the sheath of the corpora caver-
nosa and the splitting of the urethra.

but not through, the urethra. This will leave the urethra pro-
truding, with the glans of the penis hanging to the end of the ure-
thra. It will then be seen that each of the corpora cavernosa is
surrounded with a sheath. With fine ligatures sew the sheath
of each over the end of the respective corpus to prevent hemor-
rhage. Before this is done tie off any bleeding points that may
be left. After the sheaths have been carefully stitched over the
corpora, attend to any further hemorrhage that may exist. Then
cut off the glans from the end of the urethra, leaving the urethra
protruding about a half -inch from the wound, like the nozzle of a
spout; split the urethra at the bottom, take one stitch through

AMPUTATION OF THE PENIS

461

the comer angle of the urethra, and run it up through the corre-
sponding flap; take the next stitch through the other corner of
the urethra, and run it through its corresponding flap; place a
few sutures in between, and two or three below. It is a matter
of little importance, apparently, if these sutures are not placed
precisely in the proper manner and if the urethra should have a
slight twist at the point of the amputation. Remove the hat-pin
or other instrument that was first used, and also the ligature.
Pass a large sound a short distance so as to be certain that the
urethral opening is large enough ; introduce a catheter k demure,

Fig. 2 1 1 .—Amputation of the penis. Stitching the urethra to dorsal flap and final appearance

of stump.

and apply a suitable dressing to the wound. Pay particular
attention to the dressing of the wound for the first three or four
days after the operation, at the end of which time the catheter
may be removed, or it may be allowed to remain for a few days
longer. After the catheter has been removed, under ordinary
circumstances, a good stump will have been obtained, and the
patient will be able to urinate with a comparative degree of com-
fort. In performing this operation, some surgeons are accus-
tomed to remove, at the same time, some of the glands from the
groin. This seems to the writers a useless procedure unless these
nodes are known to be involved. The illustrations (figs. 209,
210, 211) show this operation in detail. They are made from

462 THE PENIS

sketches made while one of the writers was amputating for reUef
of a phagedenic chancroid.

PHIMOSIS

Phimosis is a condition in which it is impossible to retract the
foreskin back of the glans, because of adhesions or inflammatory
processes. This condition is familiar to most practitioners. It
occurs most frequently as the result of urethritis or of uncleanli-
ness ; in the latter case the smegma which has been allowed to col-
lect between the inner surface of the foreskin and the corona of the
glans becomes infected, and may give rise to a discharge that
simulates urethritis, although urethritis may not be present.
This latter condition is commonly known as balanitis praeputialis.
It may be differentiated from true urethritis by inserting the nozzle
of a small syringe under the foreskin, between it and the glans,
washing out carefully, and then, by examining the meatus
closely, observing whether or not any discharge issues from its
orifice. Balanitis may exist alone, but is frequently associated
with urethritis. Another common cause of this condition is
chancre or chancroid. Phimosis may exist for a considerable
length of time, and, if there is no other active process going on, is
comparatively harmless.

The treatment for the relief of this condition consists of frequent
injections of a simple lotion, such as lead and opium wash, between
the inner surface of the foreskin and the glans ; this solution may
also be applied by means of a cotton swab wound on the end of a
small stick. Absolute cleanliness should be observed, the dis-
charge and decomposing smegma being removed two or three
times a day.

Operative procedures for the relief of this condition may be
instituted at any time, but unless there are urgent indications,
as when chancroid is present, it may be postponed so long as
an acute process is going on. If the phimosis is due to syphilis,
mercurial plasters may be strapped over the foreskin, mercurial
washes may be used locally, and constitutional antisyphilitic
treatment instituted; these measures, by causing absorption of
the chancre, will in time permit the foreskin to be retracted.
If operative treatment is decided upon, this is best carried out

PARAPHIMOSIS

463

under cocain or general anesthesia: By means of strong scissors
make a longitudinal incision down the foreskin on each side of the
penis, as far as the corona of the glans. This will make a lid
of the upper part of the foreskin, which may be lifted up and
then cut across transversely. This eflfects a partial circumcision.
Another lid will be left by this operation at the lower surface of
the penis. This lid may be removed at the time, or, better,
amputated a week or two later.

After phimosis has once been relieved, as it ordinarily can be,
by the use of cleansing lotions, the patient should be told that one

Fig. 212.— Method of reducing paraphimosis.

attack is likely to predispose to another, and that after any acute
process that may be present has been cured, circumcision should
be performed. If this is refused,' he should be instructed to
observe great care to prevent, by daily washing, the accumula-
tion of secretions between the foreskin and the glans.

PARAPHIMOSIS
Paraphimosis is a condition just opposed to phimosis. It is
the result of a tight foreskin having been pulled back of the glans,

464 THE PENIS

some inflammatory condition producing a contraction that makes
it impossible to bring it forward by means of ordinary measures.
Edema and temporary deformity of the organ are generally asso-
ciated with the condition, and tend to make it appear more serious
than it really is.

Treatment. — Marked edema may be relieved by making multi-
ple punctures with a needle, squeezing out the serum, and apply-
ing hot cloths. By holding the glans of the penis between the
first two fingers of each hand and placing the thumb of each hand
over the meatus, an attempt may be made, by making gentle
traction with the fingers, to push back the glans underneath the
foreskin. The procedure is generally successful. If the condi-
tion is allowed to go untreated, ulceration of the constricting
band may take place. If gentle measures fail, an incision one
or two inches long may be made over, down, and through the
constricting band, which can be felt just back of the corona.

aRCXJMasioN

The removal of an excessively long foreskin as a hygienic meas-
ure is one of the oldest operations known to surgery. There are
several methods of performing circumcision, the choice of these
depending on the demands of the individual case. For an acute
phimosis associated with chancroid, circumcision by means of
lateral incisions made on each side of the foreskin, as described
previously for the relief of phimosis, is the operation of choice.
The best method for performing circumcision in children and
infants is to make a straight incision in the median line on the
superior aspect of the penis through the foreskin as far as the
corona, one being also made through the membrane to the same
extent. Retract the mucous membrane and the skin, and with
the thumb break down any adhesions, being sure that the corona
of the glans is entirely free. Insert one suture in each upper cor-
ner of the incision, in order to hasten the adhesion of the skin and
the mucous membrane, A little, if desired, may be clipped off
each corner before the stitch is inserted. Dress the wound with
a wet dressing, such as lead and opium wash, keeping compresses
soaked in this solution over the wound for several days. This

CIRCUMCISION

465

method of operating consumes but a few minutes, and is by far the
one of choice with children. The tabs or ears that, in the adult,
tend to form underneath when this method of circumcision is per-
formed, become, in time, absorbed in the child. In tuberculous
children or in those in poor general condition a severe balanitis is
likely to follow this simple operation. Rest in bed and the con-
stant application of a soothing dressing will cause this complica-
tion, in which the glans may become very much excoriated, to
disappear in a few days.

Fig.2i3^-Circumcision with clamp. Removing- the foreskin.

The ordinary method of performing circumcision on an adult
is as follows :

An encircling mark should be made on the foreskin, parallel
to the corona glandis, one-fourth of an inch in front of the margin
of the corona on top, and underneath the glans toward the frenum,
one-half to three-quarters of an inch above the sulcus of the corona.
It is best, as a rule, to perform this operation under general anes-
30

466

THE PENIS

thesia — if desired, nitrous oxid gas may be used for this purpose;
not infrequently, however, local anesthesia is employed. In such
cases cocain — 2 per cent. — should be used freely. A few drops
should be injected into the tissues of the foreskin in the neigh-
borhood of the mark that was made to act as a guide for the
incision. This should be followed by the application of a clanip.
Many varieties of clamps have been devised for this purpose,
but for one familiar with the operation, almost any large one
will answer. The foreskin having been pulled over the glans

Fig. 214. — Circumcision with clamp. Splitting of the membrane.

and clamped, at the indicated place, by a quick stroke of a very
sharp knife, the foreskin should be severed, the clamp removed,
and any bleeding points caught up with artery forceps. The
mucous membrane then presents itself for removal ; this is gene-
rally the most painful part of the operation. A small quantity of
cocain solution should be injected into several portions of the
mucous membrane, and then, with a pair of sharp scissors, it
should be incised on its superior border down to within a quarter
of an inch of the severed skin ; next, with the scissors, cut off the

CIRCUMCISION

467

Fig. 215.— Circumcision with clamp. Trimming the membrane and sewing membrane and

skin together.

Fig.216.— Showing method of performing circumcision without a clamp: A, Incision i
skin ; £, skin turned back like a cuf! and membrane incised.

in the

468

THE PENIS

corners of the membrane, running along parallel to the cut surface
of the skin and ending at the frenum in front. The skin and
mucous membrane should be sutured together, a sufficient num-
ber of fine catgut ligatures being employed. It is better to insert

Fig. 217.— Showing method of performing circumcision without a clamp: C, Skin pulled
forward and incised on superior aspect to meet other incisions ; D, skin and membrane dis-
sected off.

Flg.aiS.— Circumcision without a clamp: E, Appearance after dissection of skin and mem-
brane ; /", insertion of stitches.

too many sutures than too few. The penis should next be care-
fully cleansed and the sutured surfaces dusted with iodoformogen.
A narrow strip of gauze bandage should be wrapped about the

CIRCUMCISION 469

wound at the site of the suture. This should be covered with a
strip of zinc oxid plaster of the same width. The elaborate
bandaging occasionally employed is unnecessary. The patient
should be instructed to hold a small pad of gauze immediately
under the meatus when he urinates, so that no urine will enter
the wound. After the operation the patient should be put to bed,
and, if cocain has been used, he should be told that within two
hours he will probably feel worse than he did immediately after
the operation. The longer the patient can be kept quiet, the
better, as the irritation produced by walking tends to retard heal-
ing. The bandage should be changed frequently and great clean-
liness observed. Under proper antiseptic precautions, serious com-
plications rarely, if ever, follow this operation. The tendency in
performing circumcision is to remove too much rather than too
little of the foreskin. If too much is removed, quite a long period
of time will be required for the necessary granulation to take place.
Our illustrations (figs. 213, 214, 215) show the ordinary procedure
clearly. Another method, and a good one, is shown in the illus-
trations made from sketches (figs. 216, 217, 218), by which the
foreskin may be removed without the aid of a clamp.

CHAPTEll XXV

THE SEMINAL VESICLES

At the base and on each side of the bladder are found tubular
sacs that unite with the corresponding vas deferens just at the
ampulla. They are lined with a mucous membrane of columnar
epithelium, resting on an areolar connective-tissue basement
membrane. Outside of this layer is a smooth muscular coat
that is united by strands of connective tissue to an external
fibrosa. The seminal vesicles secrete a fluid that mingles with
spermatozoa, forming the seminal fluid; they may also serve as
reservoirs for the storage of semen just prior to ejaculation.

Diseases of the Seminal Vesicles. — The diseases of the seminal
vesicles have of late years received a considerable amount of
attention from specialists. Undoubtedly there is pathologic evi-
dence to support the views of many who have written concerning
the diseased conditions of the seminal vesicles. The most fre-
quent form of seminal vesiculitis is due to an extension of a
gonorrheal process from the posterior urethra. The vesicles may
also be involved in tuberculous processes, or may be the seat of
invasion of malignant growths. The inflammatory condition may
be of a catarrhal nature, or, more rarely, abscesses of considerable
size are seen. Clinically, from the writers' experience, diseases of
the seminal vesicles are, nevertheless, of comparatively rare occur-
rence. Several years ago the writers studied a series of 1 1 6 cases
of urethritis, in every one of which the prostate and the region
of the vesicles were examined carefully through the rectum ; in
thirty the secretions obtained by means of prostatic massage,
were examined microscopically by an expert pathologist. In not
one of these cases was there any evidence pointing toward an
involvement of the seminal vesicles. As to the question of

470

PLATE XIV

body of bladder

ampulla of
vas deferens

prostate gland.'
(posterior surface)

right vas
deferens

^ ejaculatory duct

The urinary bladder with the seminal vesicles, the ampulla of the vasa
deferentia, and the ])rostate seen from behind and below. The prostate is
partly divided lonjijitudinally (Sobotta and McMurrich).

THE SEMINAI. VESICLES 471

involvement of the seminal vesicles in tuberculosis, it is interest-
ing to observe the frequency with which tuberculous testicles
having a thickened and indurated cord are removed. In other
words, there is a route leading directly to the vesicles, but there
is rarely evidence of vesicular involvement after the testicle is
removed. From a clinical standpoint, the vesicle would thus
appear to be an organ that, while open to infection, is only excep-
tionally involved in inflammatory conditions that so frequently
attack neighboring structures.

Vesiculitis is commonly differentiated from chronic posterior
urethritis and chronic inflammatory conditions of the prostate by
the finding, by means of careful rectal examination, of a small
swelling, of the shape of the tip of a glove-finger, just above the
prostate, on each side of the median line. If the swelling is slight
and situated quite high up, and if the individual to be examined
is inclined to be corpulent, a long finger may be required in order
properly to reach the mass. As an aid to the diagnosis, the find-
ing of pus and spermatozoa in the secretion massaged from the
region of the vesicle by a finger in the rectum is useful.

Th^ clinical symptoms of a catarrhal vesiculitis of a chronic
form resemble very closely those of a chronic posterior urethritis
or prostatitis; an acute seminal vesiculitis or presence of a large
abscess so closely resembles an acute prostatitis or a prostatic
abscess that they can be distinguished only with difficulty.

The treatment of vesiculitis is very similar to that of diseased
conditions of the prostate, with which it is so closely allied.
Irrigations of the bladder, measures tending to improve the gen-
eral tone of the patient, and, in cases where it is indicated,
massage of the prostate and of the vesicles are useful. When
large abscesses form that do not break into the posterior urethra
and the contents of which cannot be expelled by massage, oper-
ative measures may, in certain cases, be required. The writers
would hardly go so far, however, at the present time at least, as
to advise the performance of an incision through the perineum
and opening and drainage of the vesicles for the relief of such a
condition as gonorrheal rheumatism, unless a well-marked, definite
abscess could be made out ; in the latter case it is subject to the
same surgical laws as govern the treatment of an abscess occurring

472

THE SEMINAL VESICLES

in any other portion of the body, modified by knowledge of the
function and the position of the vesicles. If an operation for the
release of pus in this location is followed by relief from pain
involving various other portions of the body, it is what is naturally

Fig. 219.— Kraske's incision.

to be expected to follow the opening of an abscess and the release
of pus as in other portions of the body.

There are several incisions that may be used for the purpose
of opening or for effecting removal of the seminal vesicles. These
incisions are described in detail here, as they will be found useful

Fig. 220.— Rydygier's modification of Kraske's incision.

not only for opening an abscess in, or for the removal of, a seminal
vesicle, but also for opening an abscess in the prostate, for general
diagnostic purposes where it is desired to explore the perirectal
tissue, and for the relief of stricture in performing external ure-

THE SEMINAL VESICLES 473

throtomy without a guide. It is to be remembered, however,

Fig. 221.— Van Dittel's incision.

Fig. 222.— Kocher's incision.

Fig. 223.-Zuckerkandl's incision.

that the writers do not advocate their use ordinarilv for the

474 THE SEMINAL VESICUES

removal of an enlarged prostate, preferring other routes. The

Fig. 224.— Senn's incision, No. i.

Fig.225.— Senn's incision, No. 2.

Fig. 226.— Fuller's incision.

number of incisions that have been named for their originators

THE SEMINAL VESICLES

475

is so large that it would be very difficult, if not impossible, to decide
which one was best suited for the purpose. The Kraske, the
Rydygier, and the Van Dittel, being one-sided incisions, are per-
haps more useful to the rectal surgeon. The Zuckerkandl and
the Kocher are so similar that they should be considered together.
The Senn and the Fuller differ somewhat from the other incisions
mentioned and from each other.

In the Senn operation "a median perineal incision is made, as

Fig. 227. — Opening periprostatic space; showing curved line of cleavage between the
urethra and the rectum; recto-urethral muscle and triangular ligament just being incised.
Sketched at operation.

in an external urethrotomy, and the urethra is laid bare, but not
opened; from the lower angle of the median incision on each side
lateral incisions are then carried to a point , half-way between
the anal margin and the tuberosity of the ischium, and, chiefly
by means of blunt instruments, the rectum is dissected out of
the way. This is a comparatively bloodless operation, and there
is not much . danger of wounding the rectum. The wound is
-opened as extensively as possible with deep retractors, and, if

476

THE SEMINAL VESICLES

considered necessary, an incision is made in the urethra and a
finger introduced through it into the bladder, acting Uke a blunt
hook, will help to push the prostate and vesicles up into a position
within reach of the operators."

In the operation devised by Dr. Eugene Fuller, of New York, the
incision, as will be seen from the cut (fig. 226), begins considerably
further back than where the Senn incisions terminate. "From a
point a little above the upper border of the coccyx, and just inside the

Fig. 228. — Removal of seminal vesicle through a perineal incision. At the apex of the
exposed field under the retractor is situated the membranous urethra, below it lies the pros-
tate, and below the prostate the seminal vesicles. Hugging the rectum, the capsule is incised.
The incision is made over the entire length of the vesicle up to the prostate (Pierre Duval).

body of the right ischium, two converging longitudinal cuts are made
which extend downward and slightly inward, keeping just within
the borders, of that bone, passing the tuber ischii, and ending a
short distance below the tuberosity at a point laterally, and about
three-fourths of an inch anteriorly, to the anterior margin of the
anus; the incision on the left and that on the right correspond
exactly to each other. The transverse incision is then made,,
which connects the converging ends, dividing the perineum trans-

THE SEMINAL VESICLES

477

versely about three-fourths of an inch anterior to the anterior
margin of the anus ; then the longitudinal incisions and after this
the transverse one are deepened, being careful to keep far enough
away from the anus to avoid wounding the sphincter muscle.
With the thumb and finger of the left hand, in the rectum and
out, the flap containing the rectum is then pulled up out of the
way, the cutting being done with the right hand, the fingers in
the rectum serving as a guide; the object is to incise along the

Fig. 229. — Removal of seminal vesicles. The capsule is opened. Exposure of the vesicle.
The vesicle is seen to the right, the vas deferens with its ampulla to the left, on the external
border of which is the group of vessels (Pierre Duval).

rectal walls as closely as possible without wounding them. Blunt
dissection will enlarge the incision sufficiently to permit the pros-
tate or vesicles to be attacked. A plentiful number of sutures
should be introduced, a space for gauze packing being left in the
middle of the transverse cut."

It should be borne in mind that a very large abscess in close
proximity to the urethra has a tendency to bulge toward the
perineum. This being the case, almost any semilunar "incision
will suffice for drainage.

478

THE SEMINAL VESICLES

The various incisions into, as well as the anatomy of, the peri-
neum have been recently exhaustively considered in one of the
best works on the prostate yet written, " Enlargement of the
Prostate, its Diagnosis and Treatment," by John B. Deaver,
Philadelphia, 1905.

A word of our own concerning the incision, anatomy of the
perineorectal region, and appearance of the space between the
rectum, bladder, and prostate: If as an aid in performing pros-
tatectomy by means of some form of prostatic depressor the

prostate is pulled down,
a straight or some other
form of incision may
answer that purpose ; but
if it is desired to open up
the space mentioned, only
one form of incision can
be used after the skin
and superficial muscles
have been incised, and
that is well shown in
our illustration (fig. 227),
the dark crescentic line
to the left of the knife
representing the natural
line of cleavage between
the rectum and urethra.
This illustration is made
from a sketch drawn
while one of us was
recently operating for a prostatic abscess. The line, it will
be noticed, resembles closely the Zuckerkandl incision. Incis-
ing at the point shown in any other direction would wound
either the urethra or rectum or strike bone. It is difficult,
in operating to open up this space, to get the picture as shown
in anatomies. It is well to remember that the muscles to be
cut through seem to be bunched, the thickest at the bulb.
After they have been incised the space opens up. In performing
the operation it is well to hug the rectal wall very closely, follow-

Fig. 2 -^o.— Scheme of vascular pedicle of vas deferens
and the seminal vesicle. To the right is the ureter, open-
ing into the bladder. Behind the ureter lie the arteries
and veins running to the external border of the vesicle,
the artery of the vas lying on the front of the canal
(Pierre Duval).

THE SEMINAL VESICLES

479

in'g the general directions as laid down in the description of the
Fuller incision. The appearance of the opened up space is as
shown in the illustration made from a sketch (fig. 248, p. 522).
If the seminal vesicles are to be incised, a long, narrow-bladed knife
will be found convenient. We prefer, when practicable* to obtain
it, to have the patient in the knee-chest position. It is difficult to
keep the field of operation clean, but there seems to be a tendency

Fig. 23 1 .—Removal of seminal vesicles. The vas deferens with its artery is ligated, cut
across, and turned inward. A forceps is placed over the group of vessels. The vessels are
ligated, and the vas deferens and vesicle are removed en masse with curved scissors.
Galvanocautery applied to base (Pierre Duval).

for rapid healing following these incisions. Illustrations are also
exhibited (figs. 228, 229, 230, 231) to show the method by which
the vesicles may be entirely removed, an operation not often
necessary.

CHAPTER XXVI

ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF THE
PROSTATE GLAND

ANATOMY

The prostate is a glandular and muscular organ, surrounding
and enclosing the posterior urethra and situated immediately be-
yond the neck of the bladder. It is made up of three lobes — two
lateral and one median. It measures, according to Quain, about
one and one-half inches transversely, one and one-fourth inches
vertically, and three-fourths of an inch longitudinally. Its size,
however, varies greatly in different individuals, and under both
physiologic and pathologic conditions. It completely invests the
prostatic urethra, in the floor of which is found the sinus pocularis.
Just posterior to this is an erectile mass of tissue, the caput gall-
inaginis. The prostate is invested by a dense connective-tissue
capsule that is closely united to the supporting structure or
interstitium of the gland. The parenchymatous tissue is made up
of a large number of simple and compound tubular glands, which
empty through fourteen or fifteen ducts, arranged equally on each
side of the median ridge of the posterior urethra. The supporting
stroma of the organ is composed of connective tissue in which
are found abundant masses of smooth muscle, which render the
organ contractile. The glandular acini are lined by simple, some-
times stratified, columnar epithelial cells, which produce a mucoid
secretion. Corpora amylacea are frequently found in these acini
under physiologic conditions, but are present in greater number
in many pathologic states, particularly such as cause retention of
secretion.

Embryologically, the organ develops from structures analo-
gous to those from which the uterus of the female develops, and
the organ is sometimes known as the uterus masculinus. This
fetal relationship to the uterus is further exemplified by the
glandular and muscular arrangement of the prostate, and also,

480

PLATE XV

middle umbilical ligament

mucous folds

muscular coat
mucous coat

orifice of ureter
trigonum vesicae

uvula vesicae

orifices of prostatic ducts
prostatic portion of urethra

ejaculatory duct

ureteric fold
colliculus seminalis

prostate gland
urethral crest

The urinary liladder and prostate seen from in front. The structures
have been laid open by a longitudinal section, and the interior of the bladder
further exposed by a horizontal slit (Sobotta and McMurrich).

CONGENITAL DEFECTS 48 1

to a certain extent, by its physiologic activities and pathologic
manifestations.

The vascular supply of the gland is derived from the vesical,
hemorrhoidal, and pudic arteries. The veins connect with those
of the penis anteriorly, and posteriorly with the ramifications
of the internal iliac vein. The nerves are derived from the hypo-
gastric plexus, and are made up of both meduUated and non-
meduUated fibers.

PHYSIOLOGY

The prostate secretes a tenacious and slightly turbid mucoid
fluid, which is discharged into the urethra, where it mingles with
the spermatozoa and other secretions of the male genital glands.
Its addition increases the viability and activity of the sperma-
tozoa, and it unquestionably forms an essential element of the
male genital secretion.

The organ develops rapidly in size at the time of puberty, and
in old age ordinarily undergoes more or less atrophy. Its activi-
ties are dependent to a considerable degree on those of the tes-
ticle, and castration causes atrophy in a great number of cases.
Although the organ is essentially an accessory genital gland, it
is also definitely associated physiologically as well as anatomi-
cally with the urinary organs, and assists materially in the function
of active urination.

CONGENITAL DEFECTS
Errors in development are not frequent in the prostate gland.
They occur most commonly associated with generalized anomalies
of development or in cases of marked sexual aberration. Under-
development of the gland has usually been found present in cases
of retarded sexual development; and on several occasions the
writers have seen almost absolute agenesis of the gland attending
absence of sexual instinct and function; in less marked cases the
size and number of glandular acini is greatly diminished. As
a general rule, the growth of the prostate corresponds quite closely
to that of the testicles in the same individual, and in cases where
this organ has been removed in early life, the prostate usually
remains undeveloped and its tissue is differentiated from the
bladder-wall only by microscopic examination.
31

482 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

Occasionally one finds congenital variations in the posterior
urethra; it may be unusually narrowed, .very tortuous, and in
some instances traversed by strands of connective tissue. Marked
abnormalities may also exist in the verumontanum. The writers
have recently seen a case in which this appendage was congeni-
tally elongated and of such size that, when congested, the entire
lumen of the urethra was occluded. Great variation in its size
exists normally, and in some cases almost no traces of it are to be
seen.

INJURIES OF THE PROSTATE

On account of the anatomic situation of the prostate gland,
which is deeply placed between the rami of the pubes, direct
traumatisms but seldom reach it. Furthermore, it is covered
over by a thick layer of subcutaneous and perineal fat, so that
traumatisms directly applied rarely cause injury to the gland,
even though they may damage the membranous urethra. In
the writers' experience falls are the most frequent cause of injury
to the prostate, the patient having fallen astride certain sharp
objects. Some forms of saddles, particularly the older type of
cavalry saddle, gave rise to relatively conmion injuries to the
prostate as a result of contusions. Even with the admirably
constructed cavalry and cowboy saddles now in use in this country
injuries occasionally result in riding unruly or frightened horses.
In the early days of bicycling injuries to the prostate were not
uncommon, and were usually due to blows received from the
unduly prominent saddle prong employed in the earlier models
of this machine.

Injuries through careless instrumentation are, unfortunately,
still so common that every clinic affords numerous examples of
them.

Traumatisms to the prostate gland are oftentimes of a very
serious nature, because of its situation, its high vascularity, the
difficulty of establishing drainage when the wound is infected,
and the close relationship which it bears to the urethra ; even rela-
tively trifling injuries to the prostate may cause cellulitis, with
urinary extravasation and extensive pelvic gangrene, or, as the
histories of cases show, be followed later on by malignant disease.

PROSTATITIS 483

HYPEREMIA OF THE PROSTATE

This condition usually follows excessive physiologic stimulation.
It may occur, however, as the result of obstruction to the circu-
lation, as in thrombosis of the hemorrhoidal veins, which is seen in
inflammatory conditions of the rectum or in hemorrhoids, and in
some cases of atrophic cirrhosis of the liver. The importance of
the condition lies chiefly in the fact that, as a result of this pro-
longed congestion, true inflammatory lesions, perhaps with inter-
stitial hyperplasia, may follow. There can be but little doubt
that at least a few cases of prostatic hypertrophy may result from
conditions of this nature; although, as will be discussed further
on, the writers believe that, in by far the larger number of cases,
prostatic hypertrophy is due to other and more specific causes.

Anemia of the prostate may result from generalized anemia,
but it is seen physiologically in youth and in old age, where it is
associated with underdevelopment or atrophy.

PROSTATITIS

Acute prostatitis may result from metastatic infection or from
urethral infections extending from the urethra through the ducts
and into the bodies of the prostatic follicles. The process may
then become disseminated throughout the entire gland, although,
as a rule, it is more or less localized — often to a single lobe or
perhaps to only a few acini. Acute prostatitis may be set up
also as the result of extensions of inflammatory, and particularly
suppurative, processes of the surrounding ischiorectal structures.
The disease may be anatomically divided into simple inflammatory
and suppurative, according to the degree and type of the inflamma-
tion present. It is needless to say that by far the larger number
of cases of acute prostatitis follow posterior urethritis of gonorrheal
origin. There can be little doubt, however, but that a certain
number of cases follow prostatic hyperemia, either from over-
stimulation or as the result of the use of irritant drugs or condi-
ments. It is possible that a small number of cases also develop
in the course of rheumatic and gouty dyscrasiae.

The changes present in the prostate necessarily depend chiefly
upon the origin and nature of the etiologic factor, and especially

484 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

on its location. Suppurative processes are particularly prolonged
on account of the difficulty of drainage and because of more or
less urinary infiltration and fermentation, which add in all cases
to the exciting inflammatory agents. As a rule, urethral infection
results in abscess formation of greater or less extent, depending
on the number of acini infected and, to a considerable degree,
on the virulence of the infecting organisms. On account of the

Fig. 232.— Miciopholograph. Acute suppurative prostatitis following gonorrheal urethritis,
a, Broken-down acini ; ^, purulent exudate.

dense nature of the capsule of the prostate, most abscesses drain
into the urethra, which they naturally penetrate along the ducts
of the diseased gland. Not infrequently, however, the pus may
point and rupture into the perineal tissues or even, in certain cases,
into the bladder or rectum.

When the acute prostatitis is diffuse and nonsuppurative, it is
more likely to become subacute or chronic and finally to result
in an interstitial hyperplasia with eventual sclerosis and atrophy;
or, in a certain number of cases, hypertrophy of the organ.

HYPERTROPHY OF THE PROSTATE 485

Chronic Prostatitis. — Chronic prostatitis is unquestionably a
much more frequent disease than it is usually believed to be. Its
etiologic factors may be almost exclusively grouped under the
head of acute prostatitis, long continued, and of chronic hyperemia
conditions due to any cause. Its anatomic changes may be classi-
fied as diffuse and localized. The former occur most often as a
result of hyperemia or of acute diffuse prostatitis; the localized
forms usually follow abscess formation or traumatic conditions.
The pathologic anatomy of chronic diffuse prostatitis consists
essentially of a diffuse hyperplasia of the connective-tissue frame-
work of the organ, sometimes, it is true, associated with glandular
hyperplasia, but, as a rule, chronic diffuse prostatitis resulting
from interstitial hyperplasia causes atrophy of the glandular
elements, with subsequent fibrous replacement.

Chronic localized prostatitis usually consists of long-standing sup-
purative processes, conmionly encapsulated by dense connective-
tissue formation, and ordinarily limited to a single lobe or lobule,
although in a considerable number of cases diffuse necrosis or
gangrene takes place, so that the entire gland may become con-
verted into an abscess cavity, limited, perhaps, by the greatly
thickened capsule.

When the chronic localized prostatitis follows healing of a sup-
purative process or is a result of traumatic disease, localized
hyperplasia takes place, with the production of masses of scar
tissue, at first highly vascular and then avascular.

HYPERTROPHY OF THE PROSTATE

Hypertrophy is by far the most important and one of the most
frequent affections of the prostate gland. The condition undoubt-
edly occurs most commonly in old age, but the more careful ex-
aminations that are now made in genito-urinary practice tend to
establish the fact that the condition is much more prevalent
among middle-aged and young men than was formerly believed.
Occurring in the young, the most insistent symptoms do not, as
a rule, become obvious on account of the physiologic activity
and possibilities of the tissues at this age. Thus, for example,
although there may be some obstruction to the flow of urine,
on account of the greater resiliency of the tissues, and particularly

486 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

because in youth the contractions of the bladder are more forci-
ble, the symptoms of obstructed urination may remain for a long
time unobserved. Furthermore, the writers find that in a very
considerable number of senile cases a careful review of the history
will serve to establish the fact that the condition has developed
gradually, originating probably in comparative youth.

The chief symptoms of the disease are those resulting from ob-

r~ -^WTTj ^

Fig. 233.— Microphotocraph showing histologic changes in nrostatic hypertrophy of the
fibroid type. The glandular elements are completely replaced by hyperplastic connective
tissue.

struction to the flow of the urine, generally associated later with
infections of the prostatic tissue or of the bladder ; and it is only
when this urethral obstruction develops that the clinician's atten-
tion is drawn to the disease. An examination reveals the presence
of an enlarged prostate. It is, therefore, to be expected that
marked prostatic hypertrophy is often discovered postmortem,
when, owing to the fact that the urethra was not encroached upon
by the enlarging gland, no symptoms nor clinical signs were

HYPERTROPHY OF THE PROSTATE 487

found detailed in the history of the case. The truth of this state-
ment has been confirmed by an extensive postmortem experience.

When the enlargement is most pronounced in the middle lobe,
clinical signs develop soonest, on account of the peculiar situa-
tion of this portion of the prostate body, as a result of which
enlargement causes earlier obstruction.

Before discussing minutely the etiology of prostatic hyper-
trophy, it seems essential, for its proper understanding, that we
first acquaint ourselves with the pathologic anatomy of the con-
dition.

V- ,

Fig. 234. — Acini in hypertropliied prostate filled by desquamated cells simulating cancer for-
mation.

Pathology. — Prostatic hypertrophy of old age may involve the
entire gland ; on the other hand, the hyperplastic changes produc-
tive of the condition may be entirely or largely limited to a single
lobe. As has already been intimated, the amount of disturbance
that results is dependent chiefly on the degree of obstruction that
exists to the posterior urethra; there also appears, however, to
be an undoubted effect on the extrusor capabilities of the bladder
in prostatic hypertrophy quite independent of urethral obstruc-
tion. In most cases the size of the prostate is, therefore, not of

488 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

SO much clinical significance as are those effects on the function of
the urethra and bladder that follow the enlargement. That this is
so, has been well exemplified in numerous cases recently reported,
in which great benefit followed the removal of the prostate in
cases in which the enlargement was not extensive.

Almost from the first hypertrophy of the prostate was classed
as a true tumor formation, and nearly all the earlier observers

c '

""» f , a

Fig. 235.— Microphotograph. Acute hyperplastic stage in hypertrophy of the prostate
showing active prolil'eratioii of connective tissue in the production of tibroid hypertrophy
of the prostate, a. Fibroblasts ; 6, acinus.

discuss the condition with this as a primary assumption. It was,
however, noticed that metastases did not follow in the wake of
these supposed tumors, as was the case in a considerable percen-
tage of true tumors of similar appearance. Finally, when the use
of the microscope became general and it was employed in the
study of prostatic hypertrophy, it was seen that the struc-
ture of these tumor-hke enlargements of the prostate was almost

HYPERTROPHY OF THE PROSTATE

489

identical in its elements, as well as in its arrangement, with normal
glandular structure. As a result of these studies the condition
now came to be considered as really of the nature of a hyperplasia,
and it was found possible to classify the prostatic hypertrophies,
independent of their form, into those made up chiefly of fibrous
tissue, those made up largely of muscle tissue, those consisting of
glandular elements, and finally those in which the admixture of
these elementary structures was in about the same proportion
as in the normal gland. It was now generally conceded that the

j^

Fig. 236.— MicTophotograph showing production of connective tissue in small sclerotic pros-
tate.

process was in truth more in the nature of a fibrous, adenoma-
tous, or muscular hyperplasia, and that the condition was not
truly neoplastic in origin. Notwithstanding this plain statement
of fact, there still exist many text-books — and among them excel-
lent works on pathology — that continue to treat of prostatic
hypertrophy as a tumor formation, pointing out that the develop-
ment of fibroid tumors in the analogous female organ, the uterus,
is of similar nature. Although the majority of the leading text-

490 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

books on pathology and genito-urinary surgery have discarded
this older theory, very few writers attempt to explain the manner
in which this hyperplasia is excited, and why, contrary to most
other hyperplastic processes, it is reported almost exclusively in
old age instead of in youth, where it might more reasonably be
expected to occur.

For the purpose of determining this question the writers under-
took the careful study of fifty-eight cases of prostatic hypertrophy,
and published the results in an article in the Journal of the
American Medical Association, April 26, 1902. Their efforts were
especially directed toward ascertaining, if possible, the nature of
this hyperplasia and its probable causative factors, in so far as these
could be learned from the anatomic aspects of the condition.
Briefly, it may be said that their conclusions have been in full
accord with the results of the masterly studies made in Krakow
by Ciechanowski. Very early in the work it became apparent
that, as a matter of fact, there were but two types of tissue hyper-
plasia to be dealt with, namely, a hyperplasia of the glandular
tissue and one of the connective tissue. In none of these cases
were the writers able to find more muscle tissue in the hyper-
trophied areas than had existed in the normal tissue of the area
involved; in fact, in most cases atrophy of the smooth muscle
was well in evidence, and many cases had proceeded on to actual
replacement of muscle by exudate or by young connective-tissue
fibrils and cells. It was then found that there was a distinct dif-
ference between the true cases of myoma of the prostate gland and
those of prostatic hypertrophy of old age.

In the other variety of prostatic hypertrophy, which, more-
over, is the form most frequently found involving the middle
lobe, the tumor is characterized by being made up mostly of
glandular tissue, supported by a more or less well-defined connec-
tive-tissue stroma. It is this particular form that, on account of
its close resemblance to adenoma, has largely substantiated the
tumor theory of the disease. Careful analysis of sections so cut
and orientated as to unite with the glandular acini of the normal
portions of the prostate soon convinced the writers that this type
was also to be included as merely hyperplastic and not as truly
neoplastic. In short, it was found that all varieties of prostatic

HYPERTROPHY OF THE PROSTATE 49 1

hypertrophy may be included under one of these heads, although
the conditions are frequently associated in the same gland.

Briefly stated, then, the cause of prostatic hypertrophy must
consist of factors chiefly operative during old age and that are
capable of causing growth of both epithelial and connective-tissue
elements of the gland, either singly or together, and entirely
distinct from the formation of true neoplasms.

Careful study of many sections from the fifty-eight cases of pros-
tatic hypertrophy examined has fully convinced the writers that
the hypertrophy is really inflammatory in origin. It was possible
to demonstrate in everv case either inflammatorv exudation or

A>i-jA«jd

Fig. 237. — Microphotograph. Hypertrophied prostate showing atrophy of acini in the fibroid
type: a, Atrophied and sclerosed acini ; b, newly formed fibrous tissue.

interstitial hyperplasia, one or both of sufficient degree fully to
account for the enlargement of those glands that would pre-
viously have been classified as fibromatous or myomatous. In
all these cases the formation of granulation or cicatricial tissue,
just as in any chronic productive inflammatory^ process, is clearly
demonstrable; and from the structural standpoint, no points
of divergence are to be made out. It remains then but to
reconcile with these findings the conditions seen in adenom-

492 ANATOMY, PHYSIOLOGY, AND PATHOLOGY OF PROSTATE

atous hyperplasia, which is found not only independently, but
also associated with the fibrous type just described. Careful
study of the glands, where the sections are taken from the per-
ipheral parts of these cases, shows a succession of cyst-like cavities
lined with epitheUal cells showing many evidences of proliferation.
As a rule, the cysts are filled by desquamated cells, generally
more or less broken down, by serum and amyloid bodies, by mucus,
and by other evidences of abnormal cell activity. In other
words, the picture presented is that of an adenomatous growth as it
might occur anywhere in the body. It is only when sections are
taken from the ducts of the glands just as they are about to enter
the urethra that we find the conditions that show the true nature
of this interesting picture. This examination has shown, in every
case of adenomatous prostatic hypertrophy, that the ducts are
occluded or obstructed from the pressure of an inflammatory
exudate in the more acute cases, or by hyperplastic connective
tissue about the ducts in the more slowly developing cases. It is
then clearly apparent that the occlusion of these ducts causes,
by the retention of secretion, the cyst-like dilatations of the acini ;
and that the proliferation of the alveolar cells first keeps pace
with the dilating saccule, and then, continuing, results in epithe-
lial desquamation.

From this description of the pathologic anatomy of prostatic
hypertrophy it is clearly evident why we have the fibrous type of
enlargement so frequently associated in the same gland with the
adenomatous form; for if the interstitial hyperplasia originate,
or be more marked in, the peripheral parts of the gland, the result
is that the acini become compressed, atrophied, and replaced by
connective-tissue growth, whereas if the process originate in, or be
most marked in or about, the ducts, occlusion of these passages
follows and the gland saccules become converted into adenoma-
like cysts. The writers' conclusions in this respect completely
corroborate the anatomic findings of Ciechanowski and of other
observers.

Taking for granted that this view of the pathologic anatomy
of prostatic hypertrophy is correct, one can then place no other
interpretation on the etiology of the condition than that it is
most certainly inflammatory. Reasoning purely from the ana-

HYPERTROPHY OF THE PROSTATE 493

tomic standpoint, but remembering the enormous variation and
range of inflammatory processes, it must be conceded that the con-
dition might be induced by any conditions or factors that will
cause the development of an inflammatory process in any portion
of the gland.

Certain of these factors have already been considered under
the heading of acute and chronic prostatitis. There is no question
in the writers' mind but that inflammatory processes in the pros-
tate, of whatever nature, might thus, as in any similar condition,
bring about these hypertrophic changes; which, as in all other
organs, tend to occur more often in senile than in youthful patients.
In a considerable number of cases the writers were able to con-
nect the inflammatory areas of the prostate directly with periure-
thral inflammation, and they again coincide with Ciechanowski in
his conclusion that the most frequent cause of prostatic hyper-
trophy is a primary posterior urethritis, usually of gonorrheal
origin. With this admission, however, it is not desired to exclude
other factors of inflammatory^ nature, such as might follow, for
instance, prolonged congestion with the production of new fibrous
tissue ; nor would the writers exclude other bacterial inflammatory
processes, although they believe that by far the larger number of
cases follow as a natural sequence on posterior urethritis.

CHAPTER XXVII

DIAGNOSIS AND TREATMENT OF DISEASES OF THE

PROSTATE

From the preceding chapter, deahng with the anatomy, phy-
siology, and pathologic anatomy of the prostate, the importance
of the proper treatment of inflammatory conditions of the deep
urethra — posterior urethritis — will be apparent. Ordinarily, the
treatment must be most careful and prolonged, lest so serious a
condition as hypertrophy of the gland follow as a sequel. Much
of the future improvement in the treatment of prostatic diseases
will undoubtedly be along the line of preventive measures. It is
difficult to comprehend how such conditions as prostatic hyper-
trophy, with incontinence of urine, and chronic cystitis of many
years' standing, altering the entire character of the mucous mem-
brane of the bladder, could ever be cured entirely or even improved
to a much greater extent than is now possible. When we con-
sider the ill effects that follow acute inflammatory processes in
the prostatic urethra, and the serious consequences that result
from the formation of scar tissue, it will readily be understood
that measures directed toward the prevention of such formation
would prove of the greatest value. Primarily, then, all measures
that tend to prevent or cure inflammatory conditions occurring
in the prostatic urethra are essential. It is to be hoped that a
better understanding of the serious after-effects of gonorrhea,
irregularities in the sexual life, irritations from urinary deposits,
and an earlier recognition of tuberculous infections will, in the
future, diminish the number of sufferers from prostatic disease.

ACUTE PROSTATITIS

Sjmaptoms and Diagnosis. — The fact that the majority of cases

of acute anterior urethritis are associated with acute posterior

urethritis is so well known as to require no discussion here.

Either acute or chronic posterior urethritis is almost always asso-

494

CHRONIC PROSTATITIS 495

ciated more or less with prostatitis, and with the methods at present
at our command it is difficult to differentiate very closely between
acute posterior urethritis and acute prostatitis. Clinically, a case
of acute posterior urethritis that presents considerable swelling in
or around the prostate, as ascertained by rectal touch, tenderness,
painful sensations in the region of the prostate, and a feeling of
weight and uneasiness in the perineum, is generally considered to
be one of prostatitis. If, in addition, the urine or pus expressed
by massage shows prostatic elements, the diagnosis can be made
with certainty.

Treatment. — This resembles closely the treatment of acute
posterior urethritis and later that of chronic prostatitis, and is
very similar, also, to that of chronic posterior urethritis. In
attacks of acute prostatitis attended with painful urination, and
especially if accompanied by a rise of temperature, rest in bed and
a light diet should be insisted on, together with the internal
administration of such drugs as will relieve the pain ; proper local
external applications of heat or cold should also be made. If
deemed advisable, leeches may be applied to the perineum, or the
perineum may be blistered. No local intraurethral application
should be made to the posterior urethra while acute symptoms
exist. This treatment, conducted for a period of from four or
five days to as many weeks, should cause the acute symptoms to
subside, when the treatment of chronic prostatitis, which now
ensues, should be begun. Occasionally, however, patients with
acute prostatitis grow worse, and abscess of the prostate, requir-
ing surgical interference, develops.

CHRONIC PROSTATITIS
Diagnosis and Symptoms. — The differential diagnosis of chronic
prostatitis from chronic posterior urethritis is very difficult,
the symptoms being almost alike and the conditions closely allied
clinically. The term chronic prostatitis implies an inflammatory
condition of the posterior urethra, in addition to which the symp-
toms pointing toward a prostatic involvement are well marked,
and prostatic elements are present in the expressed secretion;
in posterior urethritis the inflammatory condition is believed to
be, to a great extent, situated in the posterior urethra alone.

496 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

Before making a diagnosis of chronic prostatitis, a careful
examination of the urethral exudate (p. 104) should be made.
A review of this condition, as the result of the examination
of 116 cases of urethritis, was made by one of us in asso-
ciation with Dr. Blanchard, the pathologist at the City Hospital
some ten years ago, and microscopic findings in cases of pros-
tatitis so discovered exhaustively studied.' Roughly speaking,
if the urethra has been washed out, the patient made to urinate
in three glasses, then the prostate massaged, and the patient again
urged to urinate, the small amount of urine collected will be
found to be somewhat cloudy if the normal prostate has been
massaged. If prostatitis is present, the urine will be found to be
more or less coarsely turbid, and will also contain more shreds
than in the cloudy urine from the massage of the healthy prostate.

The clinical symptoms, such as pain in the region of the prostate
or perineum, increased frequency in urination, tenesmus, dis-
turbance of the sexual functions, and symptoms of neurasthenia,
all point toward prostatic involvement. The examination of the
prostate by the rectum is useful, as, in every case of those recorded
by us in the article just referred to, some change in the prostate
could be made out by the examining finger. The enlargement
present in the majority of cases seems to be located in one lobe,
or at least most marked there.

Treatment. — This is similar to the treatment of chronic poste-
rior urethritis; more good may, however, be expected to result
from the employment of purely local measures, such as massage
of the prostate; the nervous system is likely to be involved,
and more attention must therefore be directed toward improving
the general tone than is required in the treatment of chronic
posterior urethritis. The ordinary local treatment generally con-
sists either of irrigations or of instillations into, or of dilations of,
the posterior urethra.

In commencing the treatment of chronic prostatitis it is well
to tentatively make, through a small French silk catheter, a few
irrigations, at intervals of from one to three days, of four ounces

* " Observations on the Prostate," by Robert Holmes Greene, "Journal of
the American Medical Association," 1898.

CHRONIC PROSTATITIS 497

of the Ultzniann solution of phenol, alum, and zinc sulphate, of
each, from i : looo to i : 500. If these are well borne, later irriga-
tions of silver nitrate i : 10,000, made at the same intervals, are
recommended, or irrigations of albargin, from i : 2000 to i : 1000,
may be tried. In place of the irrigations, instillations of a few
drops of silver nitrate solution, one or two to one grains to the
ounce, may be used at intervals of from three to five days. After
the first two weeks of such treatment dilation of the posterior
urethra should be performed with a Kollmann dilator, and re-
peated once in five days or once a week, gradually extending
the size of the dilator until the urethra can be dilated to No. 40
or one or two numbers above. It is well then, if the patient can
be kept under observation, to continue the dilation at intervals
of at least once a month. In properly selected cases massage of
the prostate may be practised as an adjunct to the foregoing treat-
ment. If it appears to benefit it may be repeated as often as
the other treatment is carried out or at separate sittings.

As previously indicated, the local treatment of these cases should
extend at gradually lengthening intervals over a period of from
several weeks to months, in order to be successful. Confidence
on the part of the patient and patience on the part of the surgeon
are requisite.

It is difficult to determine when these sufferers from chronic
prostatitis or chronic posterior urethritis may be declared entirely
cured. This question is practically that of the curability of
gonorrhea. The absence of shreds in the urine is, so far as it
goes, a good indication, but they may recur at any time, and no
surgeon is justified in pronouncing a patient permanently cured
because of their temporary absence. The mere fact of the presence
or absence of the gonococcus in the secretion milked from the
prostate, while it has some clinical significance, does not prove
absolutely that a patient has or has not been entirely cured. In
the first place, it must be remembered that unless the observer
has had considerable experience, he may not be able, by staining
methods, definitely to distinguish the gonococcus from other
diplococci. Culture-tests demand a trained technician, and are
carried out ordinarily with great difficulty. Then, too, the ab-
32

498 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

sence of the gonococcus at any given examination does not nec-
essarily mean that it may not be again found in an examination
made later.

When, under proper observation at repeated examinations, the
gonococci diminish in number and finally disappear; when the
amount of pus is seen to diminish and no more pus-cells appear
microscopically; when the symptoms improve, so far as regards
indefinite pains, painful micturition, or pain connected with the
functionating of the sexual apparatus; when the urine and dis-
charge from the prostate, obtained by massage, clear up — the
patient may be pronounced as practically cured. He should then
be advised to present himself occasionally for observation, and he
should be informed that, as the result of dissipation or exhaustion
from some intercurrent disease, his troubles may return without
reinfection taking place. One of the questions often asked the
surgeon is as to the probability of the former patient carrying
infection to others. In giving advice on this point the surgeon
should exercise care and discrimination, and should be guided by
the circumstances surrounding any given case. Generally speak-
ing, a patient should not be advised to marry unless his urethra
is in such condition as to indicate cure; those who are already
married when infected should also receive prohibitive advice
unless the indications pointing to cure can be satisfactorily met.
It should also be remembered, first, that a great many women,
both married and unmarried, present somewhere in their urethral
or genital apparatus evidences of a chronic inflammatory process
that is not necessarily associated with any impurity on their part ;
and, second, that kindly nature seems to have arranged that in
many cases where men and women live together they become,
as it were, immune to each other's infecting organisms.

Prostatic Massage. — The value of prostatic massage in chronic
prostatitis can be determined only by experiment ; when properly
applied, it is frequently of use. On the other hand, if improperly
given or if applied to unsuitable cases, harmful results follow. The
writers were among the first in this country to observe the effects
of this mode of treatment. In 1894 ^^ was adopted by the Royal
Institute of Massage at Stockholm. In that year this procedure

CHRONIC PROSTATITIS

499

was carried out by a graduate of that institution under the per-
sonal direction of the writers on a patient with chronic prosta-
titis. The observations made at that time were that the swelling
in the prostate, as observed by examining it through the rectum,

Fig. 238.— Method of performing massage of the prostate.

was thereby diminished, but that the condition of the patient
was not materially improved. The method of procedure advo-
cated at that time was to massage around the prostate with a
circular rotatory motion of the forefinger, but not to massage
directly over the gland itself — the same procedure, in fact, that
skilful masseurs adopt for the relief of an acutely inflamed knee-
joint, the object being to stimulate circulation in the part, by
performing massage over the blood-vessels surrounding it, and to
diminish the danger of increasing the acute inflammation by

500 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

massaging directly over it. The writers believe that this is the
safest method in performing massage of the prostate. In acute
inflammatory conditions, such as a very acute prostatitis or acute
posterior urethritis, it is best to avoid massaging the prostate,
and the same holds good as regards the seminal vesicles. Shortly
after 1894 massage of the prostate came into popular use, and is
still employed by many surgeons in the treatment of chronic
prostatitis, the object being to press out all or a portion of the
contents of the gland into the posterior urethra. As soon as the
free evacuation of pus commences, the prostate may be massaged.
For this purpose it is advised that the patient lie over a chair or
table, that the forefinger, covered with a cot well lubricated, be
introduced into the rectum, and that the region of the prostate be
manipulated for from one to five minutes. This procedure is
sometimes followed by a feeling of great relief and benefit to the
patient, but not infrequently it is painful. If conducted too
vigorously in acute inflammatory conditions, it increases the
activity of the disease, frequently giving rise to an acute epidid-
ymitis. In other cases it may not give rise to acute inflammatory
disturbances, but seems to render the prostatic region sore. The
diminution alone in the size of the prostate, as ascertained by
rectal touch, may or may not be attended by improvement in the
general health of the patient. Accompanying diseased conditions
of the prostate, a form of hard edema may exist between the gland
and the rectal walls. The disappearance of this edema as a result
of massage does not necessarily indicate that the condition of the
prostate itself is much, if at all, improved. Massage of the prostate
is seldom employed alone in the treatment of chronic prostatitis.
As a rule, it is used in conjunction with intraurethral applications
to the prostatic urethra. If its use, once or twice a week, alone or
combined with other measures, is followed by a sensation of
relief and a feeling of betterment, and if the inflammatory condi-
tion of the prostate subsides under its use (indicated by a diminu-
tion of the inflammatory products of the discharge that is massaged
into the prostatic urethra and passed out on urination), it should
be continued for several weeks or months at gradually increasing
intervals. A study of the pathology of the inflammatory condi-

CHRONIC PROSTATITIS 5OI

tions that occur in the prostate helps to explain the otherwise
apparently contradictory conclusions often arrived at as the result
of prostatic massage. There are three classes of cases :

1. In those who suffer from pathologic hypertrophy of the
prostate massage is of no benefit, for the reason that in these
cases the mouths of the acini are occluded by inflammatory pro-
ducts, thus preventing the expression of the prostatic secretion.
The aged generally make up this class.

2. A mixed class, in some of whom the orifices of the acini of
the prostate are so occluded by inflammatory products that their
contents cannot be expressed, while others of the acini have
inflammatory products dipping down into them, the mouths of
the acini, however, being still pervious. Clinically, in these
cases, as in the previous class, it is noticed that massage of the
prostate renders the prostatic region sore, although, judging from
the amount and character of the secretion expressed, it would be
natural to presume that the effect of the massage was beneficial.

3. This class consists of those in whom the inflammatory pro-
ducts have dipped down into the prostatic acini, but enough scar
tissue has not as yet formed to obliterate the mouths of any num-
ber. It is among the members of this class that the best results
from massage of the prostate are observed to follow. A well-
known surgeon of Berlin has devised a method of performing
massage of the prostate that apparently has much to recommend
it. It is his custom, in cases of posterior urethritis or prostatitis,
to search with his finger in the rectum for a soft spot in the pros-
tate. If it is found, he massages the rectal wall over the soft spot
with a scratching motion, leaving the remainder of the prostate
untouched.

The writers' conclusions concerning the use of massage of the
prostate are:

First : That it should not be attempted in every case of chronic
prostatitis, but should be tentatively employed in carefully selected
cases, when, if apparently attended with good results, its use should
be continued.

Second: That the examination of the prostate itself, by the
rectal touch alone, is not necessarily a satisfactory guide as to
whether improvement has followed massage.

502 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

Third: That the older the patient, the less likely is prostatic
massage to be of benefit.

Fourth: That in performing massage it is more advisable to
massage around the prostate or over any softened or boggy area
than to attempt manipulations over the entire surface of the gland.

General Treatment. — Neurasthenia is so often associated with
conditions of chronic inflammation in the prostate that its nature
and its effects on the whole urinary and genital tract should be
better understood by the surgeon. Although neurasthenia is
rarely directly productive of anatomic diseased conditions, a very
slight lesion of the prostatic urethra or the prostate, accompanied
by general neurasthenia, will be extremely difficult to cure, or to
materially benefit the prostatic lesion, by even the most skilful
local treatment, unless the surgeon is also successful in the treat-
ment of the neurasthenia. If the nervous condition is properly
treated and the lesion is slight, the patient may be unaware that
any prostatic disorder existed.

Hypochondriasis is a more serious condition, and care should
be taken to differentiate it from neurasthenia. It is very often
associated with the latter, and may become intensified as the
neurasthenia improves. It may, of course, occur without any ac-
companying neurasthenia and without the occurrence of any lesion
in the urethra or prostate. Neurasthenia is becoming recognized
more and more as an entity with a physical basis, and is often
associated with anemia and lowered circulation. In many cases
worry, mental or surgical shock, or an infectious disease, such as
malaria, plays a part in its causation. Hypochondriasis, however,
seems associated with a perverted mentality, without evincing
any anatomic lesion that is at present recognizable.

It is well, therefore, in treating any lesion of the prostate or of
the prostatic urethra, to examine carefully into the general condi-
tion of the patient, and to improve any existing lowered condition
of circulation or nerve tone. Life in the open air, cold baths,
either plunge or sponge-baths, drip sheets, golf, tennis, and above
all swimming, — the latter exercise being a good one for developing
the muscles of the perineum, — are to be recommended in suitable
cases. An examination of the blood is often of value in directing

CHRONIC PROSTATITIS 503

the general treatment. If malarial plasmodia are found to be
present, quinin and arsenic are necessary; or if anemia is discov-
ered, the nonirritating form of iron salts may be given. Apart
from its value as a general tonic, iron is apparently of great service
for its local action on the neck of the bladder. It may be given
as the tartrate of iron and potash or combined with quinin, man-
ganese, nux vomica, ignatia, or coca. The glycerophosphates of
calcium seem often to do good. They should be given in large
doses, continuously, or at intervals extending over a period of
weeks and months. Owing to the intimate relations that exist
between the prostate and the rectum, care should be exercised
that the bowels are kept freely open. It is better, when possible,
for this purpose to rely on diet and exercise than on powerful
laxatives. A milk diet may, for a short time, be advisable in cer-
tain cases, and ordinarily, in patients with prostatic irritation, a
sufficient but economic diet, consisting of a moderate amount of
meat and green vegetables, with milk in some form at certain
hours of the day to keep up the fat-supply, is advisable; foods
rich in starch or sugar should be taken sparingly. Strawberries,
and particularly asparagus, are known to be irritating to the mu-
cous membranes of the tract, and should therefore be avoided,
as should also highly seasoned articles of food. Alcohol, unless
taken in very small quantities well diluted, is not advisable. Red
wines are generally too acid, the light white French wines, which
are not sweet, and the light Moselle wines, diluted with water,
are less harmful. The various carbonic waters, such as artifi-
cial Vichy, now so freely used, frequently tend to aggravate or
may even provoke irritation of the neck of the bladder if indulged
in excessively.

Of the resinous substances having a direct effect on the mucous
membrane of the neck of the bladder, tending to allay irritation,
kava-kava is among the best. Dram doses of the fluidextract
of kava-kava well diluted in water, and given three or four times
a day, are often of benefit if tolerated by the stomach. If the
urine is scanty, with a high specific gravity, spiritus aetheris nitrosi
in half -dram doses several times daily is of benefit, and salol and
urotropin are often useful. They are well borne when combined

504 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

in the same capsule. Sandalwood oil, alone or with kava-kava,
or powdered cubebs with sodium bicarbonate, sometimes has a
soothing effect. Dram doses of the latter stirred up in water are
well borne by the stomach and are occasionally of benefit. When
there is marked nervous irritability, with frequent micturition,
but no lesion of any magnitude, tincture of cantharides, in one-
drop doses administered several times a day, may be used with
advantage. For the relief of pain tincture of hyoscyamus or
suppositories containing opium or belladonna are occasionally
required, and suppositories of ichthyol may sometimes act well in
helping to overcome congestion. It has been the custom, in the
past few years, to recommend hot rectal irrigations for the relief
of inflammatory conditions at the neck of the bladder, and a great
many different apparatus for carrying out this treatment have
been invented; the writers have found, however, that as good
results can be attained otherwise, with less trouble and annoyance
to the patient. Apparatus for applying cold to the rectum have
also been devised, but have never come into general use, nor do
we recommend them.

In our experience extensive operative procedures, except for
abscess of the prostate of some considerable size, reference to
which will be made in the following article, are unnecessary for
the treatment of this condition. That such operation can be per-
formed as partial prostatectomy without serious after-results, and
that in certain cases improvement in the general condition of the
patient may follow, is not disputed, but our experience along
two different lines has led us to the conclusion expressed above.
Working along one of these lines of investigation we find if
these patients can be kept under observation, the deep urethra
dilated with a Kollmann dilator, irrigations of nitrate of silver,
which are not strong, used once or twice weekly, and the general
tone of the patients improved through proper hygienic mea-
sures, unless tuberculosis or some other intercurrent disease is
present, such patients improve rapidly and permanently. It is
in just such cases that massage of the prostate seems often to
be overdone, and not infrequently patients are found who have
also been overtreated in other respects. The other factor to

ABSCESS OF THE PROSTATE 505

which we wish to call attention is that of time. Patients are
occasionally seen by us who have had marked prostatitis many
years previously, who have come under observation, improved
somewhat under treatment, disappeared from view, and after sev-
eral years' absence reappeared to be treated for some other con-
dition, give a history of having had no treatment during the
interval, and in whom the prostate has been found to be in a
healthy condition.

ABSCESS OF THE PROSTATE

Various forms of abscess of the prostate may be seen clinically,
but the pathologic anatomy of all is very similar. It is only the
large abscesses that give rise to serious disturbances. They occur
at any age, and are occasionally of tuberculous origin. The most
common form is that which accompanies or follows an attack of
acute urethritis. In a large majority of cases the abscess, if
allowed to run its course, will burst into the floor of the prostatic
urethra, as described in a previous chapter; when this occurs,
healing may follow, or as more frequently happens, a chronic
prostatitis may be set up. Clinically, an abscess presents all the
symptoms of an intense posterior urethritis, the prostate being
sometimes enormously swollen and tender to the touch. Very
often a soft spot or a dimple-like depression can be felt upon its
surface.

It is best treated by rest in bed, the internal administration
of urinary antiseptics, sedatives and opium, if necessary, in
sufficient quantities to relieve pain. Such patients usually com-
plain of a sensation as if a cannon ball were suspended between
their legs. If the abscess does not open into the floor of the
urethra, it may burst into the rectum or through the perineum.
In doubtful cases it is best to watch the development and course
of the abscess for some time before proceeding surgically. If
the symptoms become worse, the patient losing weight and
strength, with indications of the onset of septicemia, and if the
abscess displays no tendency to open into the urethra, operative
procedures for its reUef must be considered.

A prostatic abscess may be opened from within the urethra,
by the method the writers prefer for the treatment of hypertrophy,

506 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

i. e., the Bryson method, which is fully described elsewhere;
or it may be opened by way of the perineum. At times a simple
semilunar incision is all that will be required, as the swollen
prostate may bulge toward the perineum. The prostate being
exposed through one of the incisions named in the previous chapter,
a knife should be pushed into the bulging portion, the pus evacu-
ated, the cavity washed out, and drainage instituted for a few days.
Opening the prostate through the rectum for the reUef of abscess, so
frequently recommended in the earlier text-books on surgery, is
a bad procedure and should not be resorted to.

Fig. 239.— Microphotograph showing corpora amylacea in abscess of the prostate.

A good plan, before performing any serious operation on the
prostate, is to massage the gland carefully, with a finger in the
rectum, and see if pus can be expressed. The writers have seen
cases of prostatic abscess of considerable size,- in which, as a
result of this massage, large quantities of pus were expressed,
the volume of the prostate, as felt by the examining finger in the
rectum, being immediately greatly reduced and a favorable course
followed.

Occasionally an abscess is found associated with, or simulating,
the prostatic hypertrophy of the aged; small prostatic abscesses
are also often a part of or associated with posterior urethritis.

PROSTATIC CALCULI 507

In these cases, massage of the prostate, if skilfully performed, fol-
lowed by irrigations with weak silver nitrate solution (i : 10,000),
may be of benefit. This treatment should be repeated at inter-
vals of from two days to a week, and should cover a period of
several months; later the posterior urethra should be carefully
dilated by means of a Kollmann dilator. Attention should also
be directed toward improving the health and strength of the
patient. The pus should be examined for tubercle bacilli. In
large prostatic abscesses of tuberculous origin, the surgical treat-
ment is that of abscesses due to other causes. When the presence
of tubercle bacilli has been demonstrated, the patient should be
placed amid the most favorable hygienic surroundings. In these
cases not much is to be expected from local measures. Irriga-
tions of mercury cyanid may be tried, or instillations of gomerol
may be used. Silver nitrate will be found to be too irritating.

Abscesses of the prostate have been reported following carbuncle
on the neck in patients who had never had gonorrhea. The}-
have been reported as causing edema of a septic nature in the
cavity of Retzius. They may follow pyemia or the grip. Mr.
Harmonic^ considers diabetics are particularly liable to have
abscess of the prostate. Mr. Minet, at the same meeting, con-
sidered the question of periprostatic abscesses, and found them
most often retroprostatic, retrovesical, or lateroprostatic. We have
recently operated on one case of this description, apparently of
gonorrheal origin. It has been thought by some that these pros-
tatic abscesses might remain latent for a number of years and
then show themselves. This view is probably true to some extent,
but the anatomic investigations which have been carried on by
us, and to which reference is made earlier in the chapter, tend to
show, if abscesses of the prostate are not so extensive as to give
rise to sepsis and demand immediate operation, in the course of
time the cavities become filled with cicatricial tissue.

PROSTATIC CALCULI

Generally speaking, two varieties of prostatic calculi may be
said to occur : one variety, that almost invariably comes from a
focus in the bladder, becoming later attached to the walls of
^ " Eleventh Session Assoc. Fran9aise Urology."

508 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

the prostatic urethra, and surrounded by urinary salts, gener-
ally phosphatic in character. These are, to be accurate, urethral
rather than prostatic calculi. In the other form the stones are
formed as the result of obliteration of the mouths of the acini and
the calcification of their retained exudate. They are generally
found in elderly persons. If they give rise to symptoms of distress
and inconvenience, they may be removed by making a perineal
incision and digging them out from the prostatic urethra, in a
manner similar to that by which the large lateral lobes are re-
moved. A third variety of prostatic calculi are occasionally seen ;
these are phosphatic in character, extremely minute, and resemble
somewhat the scales of a very small fish. They are to be found
lining the posterior urethra and dipping down into the prostatic
follicles. When necessary they may be removed through the or-
dinary perineal incision, such as would be made for a tight stric-
ture. Clinically, their presence may be discovered upon examining
the urine, or on their striking the end of some instrument, such as
the Thompson searcher ; or they may be observed under the endo-
scope. The same methods will serve to show the presence of the
impacted larger prostatic urethral calculi, first mentioned, whereas
the true prostatic calculi forming in the body of the prostate can
sometimes be diagnosed by making a rectal examination at the
same time that the instrument is introduced into the bladder.
Occasionally, gravel passing out of the bladder into the prostatic
urethra on its way down from the kidney will give rise to pain and
distress, causing a spasm of the prostatic urethra which may be so
severe as to provoke hemorrhage. For the relief of the spasm the
patient should be ordered to urinate while lying in a warm bath;
large quantities of fluid should be drunk, and hyoscyamus, kava-
kava, and perhaps glycerin in large doses, administered.

PROSTATIC HYPERTROPHY
Diagnosis. — As has been pointed out, prostatic hypertrophy, ana-
tomically speaking, instead of being confined to the aged, as is com-
monly believed, may occur in comparative youth, provided severe
inflammatory processes have previously existed in the prostatic
urethra. If this enlargement is extensive enough, it will interfere
somewhat with the complete emptying of the bladder. Prostatic

PROSTATIC HYPERTROPHY 509

enlargement of so severe a degree may exist that, after urination,
several ounces of urine may be retained, without giving rise to
clinical symptoms of any importance if the urine does not become
infected, and if the patient does not become exhausted as the
result of intercurrent disease. If the bladder muscle and the
fibers surrounding the neck of the bladder and the prostate are
weakened because of some systemic disorder, then prostatic
obstruction may cause retention. If acute inflammation attacks
the base and neck of the bladder as the result of infection,
as from gonorrhea or following the passage of an unclean instru-
ment, an enlargement of the prostate tends to retard recovery
from such inflammation. Such cases are frequently encountered,
very often presenting no marked clinical symptoms except a
slight chronic posterior urethritis that does not yield readily to
treatment, and the presence of residual urine varying in amount
from one to eight ounces. It is sometimes difficult, in these
cases, to determine what form of prostatic enlargement is present —
whether of the lateral lobes, the third lobe, or of both. In most
enlargements, however, the two side lobes are involved to a greater
or less extent. The form of prostatic enlargement may be deter-
mined, or diagnosis aided, by introducing a catheter into the
bladder and passing it back to the posterior surface of the viscus.
All the urine in the bladder, or the residual urine, if the patient
has urinated, should be allowed to run out through the catheter,
which should then be withdrawn very slowly. After one or two
inches of the catheter have been returned, more urine — from 2
drams to 4 ounces — may flow out of the end of the instrument,
tending to show the presence of a pocket in the bladder, often
due to a third lobe enlargement. On withdrawing the catheter
still farther, only a few drops — a half dram or so — of urine that
may have remained within the urethra will escape. In examin-
ing a patient, with chronic retention, if a large amount — over
eight ounces — of residual urine is found, the bladder should not
be emptied completely at the first examination, unless some other
fluid is injected in place of the urine, as the too sudden empty-
ing of an overdistended bladder may give rise to cystitis, hemor-
rhage, or shock.

The diagnosis may sometimes be made by passing a Kollmann

5IO DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

dilator into the bladder and screwing it up about No. 30. A
contraction will be felt, offering a very strong resistance to any-
further distention of the neck of the bladder by the dilator. It
is often possible, in these cases, to dilate to within one number
of the point at which the contraction is felt without producing
discomfort, and without any marked difference being noticed
as regards obstruction to the distention of the instrument up
to that point. At that particular point and beyond strong re-
sistance is met. Ordinarily this is evidence either of stricture
at the bulbomembranous junction or of the results of inflamma-
tory conditions deeper in toward the neck of the bladder, condi-
tions not infrequently found associated with prostatic hypertrophy.
In healthy urethras No. 40 can often be reached on the scale of
the dilator without contraction becoming apparent. A searcher
may be passed, rotated to one side and withdrawn until it is caught,
then rotated to the other side of the bladder, and the same pro-
cedure gone through, any difference to the extent it can be with-
drawn being noticed on the marker on the searcher, also completely
rotated and then brought forward. By this means the approxi-
mate size of the prostate may be arrived at. It should also be
examined with a searcher or sound in the bladder and a finger
in the rectum, and, finally, in a doubtful case, the view obtained
through the cystoscope will be of great diagnostic aid to the com-
petent observer.

In making a diagnosis of prostatic hypertrophy care must be
taken not to confound the diflficulty in micturition due to this
condition or to stricture with that due to diseases of the nervous
system or of the kidney, or to simple muscular weakness due
to age or exhausting disease of the bladder-wall. Ciechanowski
has found, by making careful measurements of the bladder mus-
cular tissue, comparing the bladder-walls of the aged and of the
young, that there is likely to be a diminution — a very large one,
of some 50 per cent, or more — in the amount of muscular tissue
of the bladder- wall of the aged, even when no acute inflammatory
condition of the bladder- wall exists.

Symptoms. — ^The clinical symptoms of prostatic hypertrophy
have been previously mentioned and are generally well understood.
The most prominent are increased frequency in micturition,

PLATE XVI

Hypertrophy of the lateral lobes of the prostate with the tumor presenting
inside the bladder and showing an oval calculus lodged in a sacculation pos-
terior to the enlarged prostate. (From a specimen in the Carnegie Laboratory
Museum.) (Natural size.) a, Thickened and inflamed folds of the bladder
mxicosa ; b, calculus lodged in sacculation of the bladder wall; c, enlarged
lateral lobes of prostate ; d, root of the penis showing slight degree of enlarge-
ment of prostate outside of bladder.

PROSTATIC HYPERTROPHY 511

with apparent loss of muscular power to perform the act, the
increase being most noticeable at night or toward early morning ;
diminution in the size of the stream, and, following attacks of
cold or of dissipation, very probably a history of retention.

In those cases presenting the clinical appearance of chronic
posterior urethritis, together with a resistance to a Kollmann
dilator in the prostatic urethra at about No. 30 French, associated
with retention of urine — from 4 to 8 ounces — and proving rebel-
lious to the simple treatment of posterior urethritis — that is, not
showing a marked tendency to get well under hygienic treatment,
as ordinary cases of posterior urethritis often do — we may be quite
sure that we are dealing with prostatic hypertrophy. The cases
of so-called chronic contraction of the bladder neck, as described
by some specialists, are to be found in this class. There is no
reason why, anatomically, there should not be chronic contraction
of the bladder neck. The old belief that stricture, meaning by
that the formation of scar tissue, could not exist in the prostatic
urethra was found to have no anatomic foundation. The scar
tissue forming in the deep urethra may give rise to the so-called
third lobe enlargement or enlargement of the lateral lobes of the
prostate in the manner already described. It may also, through
infiltrating into the surrounding tissue, cause bands of cicatricial
tissue to form in the prostatic urethra. Bands do occasionally
exist, but are of comparatively rare occurrence. The writers
believe that these cases, which have been .considered by some
observers under the heads of chronic contraction of the bladder
neck, are due chiefly to third lobe prostatic enlargement; but
whether due to this or to infiltration of scar tissue in the prostatic
urethra, the writers have never seen any uncomplicated case that
needed operative treatment for its relief, beyond such as might be
furnished by dilatation with the Kollmann dilator and treatment
of any accompanying posterior urethritis.

Treatment.— Dilatation of the prostatic urethra at intervals of
a week or two weeks, carefully performed by means of the Koll-
mann dilator, together with or alternating with solutions of silver
nitrate of varying amount and strength, and proper constitutional
treatment, will benefit very markedly those cases of contraction
at the neck of the bladder for which no radical operation is re-

512 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

quired. These same measures are the ones to be adopted in almost
any case of prostatic hypertrophy, in the hope that, through
distention of any cicatricial tissue, some of the acini may be
opened, and the neck of the bladder toned up to the point of recov-
ering its energy and properly performing its functions.

If treatment along the lines indicated fail, after it has been
thoroughly tested over a period of weeks or months, and the dis-
turbances incident to the prostatic hypertrophy increase, as shown
by a more frequent demand for the use of the catheter on account
of complete or partial retention, two modes of procedure are open
to the patient. One is to adopt the so-called catheter Ufe, and the
other is to undergo a radical operation for the relief of the prostatic
obstruction. So much has been written concerning catheter life
that nothing remains to be said. Unfortunately, the cases of old
prostatics requiring some such measure for their relief are numer-
ous. The surgeon, some member of the patient's family, and,
later on, when possible, the patient himself, may draw the urine
by means of a soft-rubber, velvet-eyed catheter of the smallest
size that will empty the bladder without consuming much
time. If the velvet-eyed soft catheter is introduced with diffi-
culty, the Mercier or a bicoude may be used instead. Before
using, the catheter should be carefully sterilized by immersing it
in boiUng water. SteriHzed white vaselin, which is sold in small
tubes, makes the best lubricant for these cases. The frequency
with which the catheter must be used will depend upon the indi-
vidual case. Early in the history of their catheter life patients
may be able to use the catheter three times a week ; the intervals
are gradually shortened until it is used daily, and then every six
to eight hours. It was generally believed, in the past, that,
after emptying the bladder, it was a good plan twice a day, daily,
or two or three times weekly, to wash out the organ. In certain
cases, probably, the bladder is washed out too often. Each case
should be a law unto itself. Of the solution to be used for bladder
lavage, boric acid is probably to be preferred ; in some cases listerine,
well diluted, or salt and water may be used ; ordinarily unirritat-
ing and unstimulating preparations give the best results. Oxy-
cyanid of mercury i : 5000 may be tried. If the patient does not
do well on the catheter life, a radical operation for the cure of the

PLATE XVII

Senile hypertrophy of the prostate, showing resulting tortuous stricture
of the posterior urethra and atrophy of the bladder. (From a specimen
in the Carnegie Laboratory Museum.) (Natural size.) a, Atrophied bladder
showing hyjjertrophy of the rugae; h, urethra; c, encapsulated "adenomatous"
nodules of enlarged prostate.

PROSTATIC HYPERTROPHY 513

prostatic enlargement may be attempted. Beyond the discom-
fort and annoyance incident to the use of the catheter, patients
may continue its use for years without manifesting any serious
disturbance. One patient under the writers' observation has
been obliged to use the catheter for twenty-five years. In many
cases, on the other hand, the adoption of catheter life seems to be
the beginning of the end. Within a few months or a few years
recurrent attacks of cystitis, associated often with pyelonephritis,
occur, and a general septic condition, followed by death, ensues.
What relief, then, can conscientiously be offered any prostatic
case that has reached a point at which the posterior urethra will
no longer react to stimulating measures, such as dilation or irri-
gations, and where the neck of the bladder cannot be made to
recover its tone ?

The death-rate following operation for the relief of a prostatic
enlargement is comparatively small. In well-selected cases it
should not, if properly performed by one of the methods advised,
be above 5 per cent. In a series of operations that may be
called emergency operations, which must be performed for the
immediate relief of a patient suffering from prolonged retention,
and in which a general septic condition is present, the death-rate
will naturally be higher, a fact that should not be set down as
due to the operation. The writers are inclined to recommend
emergency operations — that is, if a patient with retention due
to prostatic hypertrophy is in such a condition that a perineal
section or a suprapubic cystotomy is required for the relief of the
condition, they consider it good surgery ordinarily to remove the
prostate at the same time, through the same opening, by one of
the methods about to be described.

What can be promised in regard to improvement in selected
cases if recovery from prostatectomy ensues? In performing a
radical operation on a man who has a distended bladder and is
obliged to depend upon the catheter, who has had chronic cystitis
for many years, with a thickening of the bladder-walls and incon-
tinence of urine due to the cystitis, a certain amount of reUef
can be promised and the dangers of sepsis lessened. It cannot
be promised, however, that the bladder-walls will lose their thick-
ening, that the mucous membrane of the bladder will become the
33 .

514 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

same as that of a young man, that the muscles of the neck
will soon recover their tone, or that a man who has been unable
to control the act of urination for a long time will recover that
power and never again exhibit residual urine. A well-selected
case, receiving proper after-treatment, will probably be benefited,
so that the patient's condition, say three months from the date
of the operation, will be better than it would have been if the
operation had not been performed. To a man about to begin
the catheter life, who still has some control over the muscles
at the neck of the bladder, who is not entirely dependent upon
the catheter, although he may have had a few attacks of
retention, more hope of relief can be promised, or at least ex-
pected. The muscles may so recover their tone that he will
not be subject to retention, and he may be able to empty his
bladder, the danger of sepsis will be averted, his condition be
rendered more comfortable, and the catheter life may be entirely
avoided or postponed and life prolonged. As regards the sexual
function, if it is not already gone, it is likely to become lost,
although not necessarily, as a result of the operation. This
should be clearly stated to the patient before operating either in
emergency or in selected cases. There is some slight danger,
apart from the danger of death immediately following the opera-
tion, of a rectal or suprapubic fistula being left behind, and recur-
ring unpleasant attacks of relapsing orchitis or epididymitis are
quite likely to follow.

Operation. — Only two methods of relief by operation on the
prostate will be here considered in detail: the intra-urethral
and the suprapubic. In addition to these two methods of
removing the prostate, a general method of operating has been
described (p. 472), by means of which, through a perineal in-
cision, the rectum may be separated from the urethra, prostate,
and seminal vesicles, making a road by which any of these
organs may be reached. Removal of the prostate from without
the capsule, though not recommended, maybe effected in this way.

For the operative work on the prostate in this country great
credit is due to John P. Bryson, of St. Louis, and to Samuel Alex-
ander, of New York. Dr. Bryson, about two years before his
death, wrote a paper describing certain methods of operating on

PROSTATIC HYPERTROPHY

515

the prostate ; in this he stated that at that time he had operated
on 1 1 6 cases. So far as can be determined, the methods employed
by these two operators are very similar, if not identical. The

Fig. 240.— Bryson's operation for relief of prostatic hypertrophy. The staff is introduced and
incision into apex of prostate being made.

procedure consists of digging out the lateral lobes and the third
lobe of the prostate with a finger inside the- prostatic urethra,
through an incision such as is ordinarily made in the perineum
for the reUef of urethral stricture, and that has been described

5l6 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

under that heading (page 416). An incision having been made
through the perineum and through the urethra on to a guide
placed in the bladder, the guide is withdrawn, the finger intro-
duced into the wound, into the urethra, and as far into the bladder
as possible. With the other hand over the pubes, the surgeon
pushes down the bladder and the prostate so far that they
can be made to meet the finger in the urethra. It will generally
be found, on introducing the finger into the urethra, that quite
a tight contraction can be felt just ahead of the tip of the digit.
Generally, in an enlarged prostate, the prostatic urethra is nec-
essarily lengthened and contracted as a result of the growth. In
this case there may not be room enough to allow the finger to meet
the bladder-wall, and the surgeon should cut down upon the floor
of the urethra, with a small narrow bistoury, as near the anterior
part of the incision as is required. If necessary, he may cut a
little farther back, so as to slightly loosen the surrounding tissue,
thus assisting the finger well up into the prostatic urethra and
mouth of the bladder. Great care should be taken during the
entire procedure — and this is most important — not to wound
the rectum, thus avoiding the formation of a recto-urethral fistula.
An assistant may introduce a finger into the rectum, or, while
this nick is being made on the floor of the deep urethra, the
surgeon may insert his finger, covered with a glove. Instead of
cutting, a Kollmann dilator may be placed in the bladder and
the prostatic urethra dilated to No. 45. This may be done before
or after making the perineal incision. Any bands in the prostatic
urethra having now been dilated or incised sufficiently readily
to admit the forefinger, a nick should be made in the wall of the
urethra on each side from the inside. It is important to remember
that this slight cut is made from inside the urethra out into the
side lobes of the prostate. Just as a nasal surgeon operating on
the nose by means of a probe breaks into the ethmoid cells, a sur-
geon operating on a case of prostatic hypertrophy should break
through the urethral wall, working from the inside with his finger
into the cells of the prostate lying on each side of the urethra.
Any instrument desired may be used to make the first nick, a
blunt-pointed instrument being better than a knife for this purpose.
The writers employ a periosteal elevator. Having made the nick,

PROSTATIC HYPERTROPHY

517

the surgeon should work his finger into the opening, keeping up the
counter-pressure with the other hand over the bladder, and, by
moving his finger about, bring up whatever prostatic mass he
may encounter. The ease with which the mass or masses often
shell out is astonishing. They resemble small uterine fibroids.

v^\ ^^

Fig.24i.—Brysoti's operation for relief of prostatic hypertrophy, showing forefinger of
right hand enucleating while first and second fingers of left hand are making counter-pressure
from space of Retzius. Neither bladder nor peritoneum have been opened.

Having shelled out all the masses into the prostatic urethra, and
having freed them from any attachments, a dressing forceps should
be introduced into the urethra from the perineal wound, and the
pieces removed through the perineal opening; the finger should
then be inserted into the perineal opening, into the prostatic ure-

5l8 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

thra, and into the opening in the side of the urethra again, to ascer-
tain if any more masses exist. One side having been cleaned out,
a slit should be made in the other side of the urethra, and any
growth remaining there removed. The masses may be single
and the size of a marble, or they may be so large and so numerous
as to fill a coffee-cup, this being dependent on the size of the pros-
tate. It may not be necessary, if the nicks are made on each side
and a third lobe enlargement exists, to make another opening at
the base of the third lobe in the floor of the prostatic urethra and
enucleate this, for the surgeon's finger in one or both of the side
nicks will probably work its way toward the front far enough to
enucleate the third lobe through one of the openings made in the
urethra from which the side lobes were removed. If one remains
it may be removed through a slit at its base, in the same manner
as removal of the side lobe was effected. It will be noticeable
that, as the enucleation proceeds and the bunches are removed,
the prostatic urethra wdll become more and more flexible and less
rigid, and that the hand on the abdomen, above the pubes,
pushing the neck of the bladder to meet the finger in the ure-
thra, will meet less and less resistance. This point is important,
for if the prostatic urethra can be reached by the surgeon's finger
so that a nick can be made in the side of it and the enucleation
proceed, while the hand above the pubes, the bladder being empty,
presses the prostate down from above, the necessity for making
any suprapubic opening may be avoided. If the prostatic urethra
cannot be reached, — it is generally only in very fleshy subjects
that this is the case, — a suprapubic incision should be made, just
as would be done if suprapubic cystotomy were to be performed,
except that the bladder need not be opened. When the bladder
is reached, the gloved hand of an assistant may be placed in the
prevesical space just above that viscus.

This is quite roomy, and through it the neck of the bladder
may be pushed down toward the operating finger.

Dr. John P. Bryson was the first operator, so far as is known,
to discover this method of utiHzing the prevesical space.

In some cases, particularly in the infirm, the very aged, or in
certain emergency operations, it may be well to perform a preli-
minary suprapubic cystotomy, and, at any time within the

PROSTATIC HYPERTROPHY ,519

following week, probably within the next day or two, to
remove the prostate through an incision in the perineum by the
method just described. In such cases an assistant's finger is
introduced into the bladder, pressing the prostate down toward
the perineum, thus making it easier for the operator, with his
finger in the perineal wound, to reach the prostatic urethra.
Ordinarily, however, it is not necessary either to open the bladder
or to pass a hand into the prevesical space. After the operation
an ordinary perineal tube, of the size of the largest catheter,
should be introduced into the bladder, the end being allowed
to protrude through the perineal wound. Strips of gauze should
be carefully packed all around the tube introduced through
the prostatic urethra into the bladder, to lessen the danger of
secondary hemorrhage. Before introducing the tube the cavities
from which the portions of the prostate have been excavated
should be dried as carefully as possible, and the finger, well smeared
with 10 per cent, iodoform in vaselin, should be applied to their
surfaces in a thorough and painstaking manner. Iodoform, 10
per cent., dissolved in vaselin and melted, should also be injected
through a glass syringe between the dressing on the tube and the
urethra. For this suggestion, which we consider an excellent
one, we are indebted to our friend Dr. Henry H. Morton, of
Brooklyn, the idea having been conceived by his associate. Dr.
H. E. Frazer. The hemorrhage at the time of the operation is
slight and easily controlled by douches of warm salt solution.
At the end of six days the perineal tube may be removed, the
wound allowed to granulate as after an operation for stricture
of the urethra, and the patient permitted to get out of bed. This
method of operating has been criticized by some because of the
danger of wounding the rectum. This accident is the result of
either carelessness or ignorance on the part of the operator.

Among the many advantages of this operation are the follow-
ing: It is, when properly conducted, a simple operation; it does
not remove or cut through any more muscle or capsule than is
required; if it does not remove the whole prostate, so much the
better, so long as it removes the part that is diseased. The
various operations that necessitate going outside the prostate
through the perineum seem a little more heroic than the exigen-

520 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

cies of the ordinary case demand for the relief of prostatic hyper-
trophy, or they remove more of the prostate than is required.
The advantage that this operation has over removal of the pros-
tate through a suprapubic opening alone is that it seems the best
method for removing the side lobes of the prostate ; and while these
lobes may not be the causative factors in certain forms of reten-
tion of urine, still there is evidence to support the view that they
are responsible for the varicose condition of the veins at the base
of the bladder, which seems to aggravate that constant irritation
almost always found in cases of prostatic hypertrophy. Following
the operation a small projecting mass of tissue remains in the floor
of the prostatic urethra, and care must be taken in introducing
the perineal tube and packing not to bend it backward into the
bladder.

REMOVAL OF THE PROSTATE THROUGH A SUPRAPUBIC

OPENING

The subject of suprapubic cystotomy has been considered in

connection with bladder surgery, and it is little more difficult to

Fig. 24a/— Fenwick's operation. Fin-
ger entering prostatic urethra (after Fen-
wick).

Fig. 243.— Fenwick's operation. Finger
pushed sideways through wall of prostatic ure-
thra (after Fenwick).

remove a third lobe of the prostate by means of a suprapubic
cystotomy than it is to perform the operation of opening the

SUPRAPUBIC REMOVAL OF PROSTATE 521

bladder. The bladder having been opened and the interior

Fig. 244. — Fenwick's operation. Finger Fig. 245. — Fenwick's operation. Finger
pushing between capsule and gland (after Fen- pushed still farther (after Fenwick).

wick).

carefully inspected, an incision may be made over any prostatic
growth that may present itself, and the mass be dug out in much

Fig. 246.— Prostatic capsule emptied of its con-
tents with torn ends of prostatic urethra above and
below. B, B, Bladder base ; u, urethra ; c, capsule
(after Fenwick).

Fig. 247.— The same healed,
ends lining shrunken prostatic
capsule and fusing at c' c (after
Fenwick).

the same manner as in the operation just described. This manner
of operating has many advocates, and in properly selected cases it

522 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

may be considered the operation of choice. After the growth has
been dug out by the flnger or pinched out by forceps, or teased out,
a Httle at a time, the ordinary methods of checking hemorrhage
should be employed, and a drainage-tube inserted in the bladder.
If it seem desirable, an incision may be made in the perineum and
perineal drainage established as well.

E. Hurry Fenwick, in a recent paper entitled " Vital Points in
the Technic of Suprapubic Enucleation of the Prostate for Benign

Fig. 248.^Retations of the prostate and the base of the bladder: P, Prostate; B, bladder;

R, rectum.

Enlargement of that Gland," advocates the method of enucleating
the lateral lobes of the prostate, which is similar to the Bryson
method just detailed, with the exception that, as shown by his
illustrations (figs. 242 to 247), he enucleates through the suprapu-
bic opening. He claims that, by enucleating these lobes through
breaking into the side walls of the prostatic urethra — (i) there
is less danger of injuring the vesical neck ; (2) the wholesale destruc-

SUPRAPUBIC REMOVAL OF PROSTATE 523

tion of the prostatic urethra, with its afferent seminal ducts, is
obviated ; (3) the rough manipulations of the membranous urethra
ordinarily accompanying the usual enucleation through the supra-
pubic route are rendered unnecessary. If a third lobe is present,
it may be removed separately through an anterior or a posterior
incision. He claims that enucleation of the prostate through the
suprapubic route as ordinarily carried out causes sterility, and is
likely to give rise to the formation of a dense mass of cicatricial
tissue at the neck of the bladder. His method is shown in the
accompanying illustrations (figs. 242 to 247).

Dr. Eugene Fuller, of New York, was the first to extensively
advocate a method for the removal of the entire prostate supra-
pubically; his method is practically that adopted by Dr. P. J.
Freyer, about to be described.

Dr. P. J. Freyer describes in detail the manner in which he oper-
ates as follows^ :

' ' A catheter having been introduced into the urethra and
allowed to remain there, and the prostate being pushed up by the
finger into the rectum, remove the prostate, scouring through the
mucous membrane with the finger-nail, gradually detaching it
by insinuating the finger-tip in succession behind, outside, and in
front of one lateral lobe, this separating the capsule from the
sheath. The finger is then swept in a circular fashion from with-
out inward, in front of and to the inner side of the lobe, detaching
this from the urethra, which is felt covering the catheter, and
pushed forward toward the symphysis between the lateral lobes,
which will, as a rule, have separated along their anterior com-
missure in the course of the manipulations. The other lobe is
attached and treated in the same manner. The finger is next
pushed well downward behind the prostate, and the inferior sur-
face of the gland is peeled off the triangular ligament. When
the prostate is felt free within its sheath and separated from the
urethra, with the finger in the urethra, aided by that in the bladder,
it is pushed into the bladder through the opening in the mucous
membrane which, during the manipulations, will have become
considerably enlarged. The prostate, which now lies free in the

^ "Clinical Lectures on the Enlargement of the Prostate," New York,
1906.

524 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

bladder, is withdrawn with strong forceps through the suprapubic
wound."

He lays considerable stress on the use of a large drainage-
tube introduced just through suprapubic wound, but not
allowed to strike the base of the bladder. Daily, through this
tube, the bladder is gently irrigated. The tube is a large one,
that the urine and clots may escape through it freely, and con-
sequently there might be no straining in dilating the cavity or
disturbance of the blood-clot which forms in the excavation. The

%ladderWkll

iplse..

Triangular

-Sheath.

Fig. 249. — Suprapubic removal of the prostate (redrawn from P. J. Freyer).

tube should, as a rule, be removed at the end of four days, and
the bladder irrigated by a nozzle placed in the suprapubic opening.
In this operation the prostatic urethra is torn across, and some
portion removed without apparently increasing the mortality.

It will be noticed that care is taken to avoid disturbing the
blood-clot which forms in the excavation at the bottom of the
wound by the use of this large drainage-tube. This really has
a great deal to do with the low mortality rate which he reports.
It is our belief, in these suprapubic operations and the Bryson

SUPRAPUBIC REMOVAL OF PROSTATE

525

operation, that it is septic absorption through the wound in the
mucous membrane which is generally the cause of death. That
is why we are inclined to think that the comparatively simple
procedure of the use of vaselin and iodoform in the Bryson oper-
ation, as mentioned above, the suggestion of Dr. H. E. Frazer,
will be found of great benefit.

Fig. 250.— Removal of the prostate outside the capsule through straight perineal incision.
The membranous urethra is opened on a grooved staff; the rectal tissues are pulled down-
ward (after Deaver).

European surgeons advocate largely the use of the retention
catheter for drainage purposes in these operations. The writers,
after considerable experience with the instrument, cannot so recom-
mend it, for in a large number of cases its use has been followed
by inflammation or ulceration, necessitating its discontinuance.
If it is deemed advisable, a perineal incision may be made either
before or immediately after the suprapubic incision, the prostate

526 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

being extracted suprapubically, aided by the fingers of an assistant
in the perineal wound.

The after-treatment of the suprapubic operation for the reUef
of an enlarged prostate resembles that following suprapubic cystot-
omy for the removal of a stone or a tumor. In l-Vance it is a
popular custom to remove the prostate through a half-moon

Fig. 251.— Removal of the prostate outside the capsule through straight perineal incision.
By means of Fergusson's depressor the prostate is pulled well down into the perineum.
The sheath of the prostate has been incised over each lateral lobe (after Deaver).

incision, a speculum being used to depress the floor of the recto-
vesical space. The prostate being reached, the capsule is opened
and turned back to each side like a cuff, the prostatic urethra
incised, then with or without the use of a depressor, the side lobes
removed, and the third lobe, if present, is removed by introducing
a finger through the incision into the bladder, inverting the third

SUPRAPUBIC REMOVAL OF PROSTATE

527

lobe through the wound in the prostatic urethra and thus remov-
ing it. A retention catheter into bladder emerging through
meatus; another drainage-tube into rectovesical space. This is
practically the operation of Proust and Albarran.

The reported results of operations in a manner similar to this
are very good. In order to get the patient into the proper position,

Fig. 252.— Removal of prostate outside the capsule through straight perineal incision. By
blunt dissection and with the aid of Murphy's hooks as tractors each lateral lobe is removea
in turn. Drain with tube in bladder or through the perineal wound, the tube being welf
packed (after Deaver).

SO that the space may be afforded for the use of the speculum to
open up the rectovesical space, it is necessary to place the patient
on a box of certain shape and supporters for the legs of a certain
form should be used. These are illustrated in the following plates,
and can be obtained through Tiemann & Co., New York. A
very popular operation, when it is desired to remove a prostate

528 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

from outside the capsule and by the perineal route, is to make a
long, straight, perineal incision ; also incise the membranous urethra,
and with a Fergusson depressor pull the prostate down into the
perineal wound and then enucleate it, as shown in the illustrations
(figs. 250 to 252). Speaking from a strictly surgical point of

Fig. 253. — Illustrating leg supporters and position of patient for removal of prostate in
Albarran and Proust's operation (redrawn from Pierre Duval).

view, the operation, as performed in France, whereby the prostate
is exposed through a semilunar incision through the perineum,
and well brought into view through a proper-shaped speculum,
by which the space is opened, is a useful one, from the fact that
no excavation in the mucous membrane is left behind through

SUPRAPUBIC REMOVAL OF PROSTATE

529

which septic absorption can take place, as is the case when the
suprapubic method is followed or the Bryson operation performed.
The operation just mentioned, however, unless the surgeon is
familiar with the rectovesical space, is attended with danger of
wounding the rectum, and ordinarily should take longer than
either the Bryson or the suprapubic operation to perform.

Fig. 254. — Illustrating the removal of prostate; incision through prostatic urethra.
Speculum in position at base of figure. Method of Albarran and Proust (redrawn from
Pierre Duval).

The simple procedure mentioned before, of applying iodoform
and vaselin after the Brvson operation, or the use of the large
drainage-tube of Freyer, tends to obviate the danger of sepsis to a
very marked degree.

From personal and contributed experience the writers are
inclined to recommend the perineal route, performed in the man-
ner described under the name of the Bryson operation. Where,
however, the enlargement is almost entirely of the third lobe ; where
34

530 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

there is but slight congestion due to varicose veins at the base of the
bladder, and where the proper after-treatment of the suprapubic
wound can be secured, the removal of this third lobe of the pros-
tate by the suprapubic route may at times be advisable.

TUMORS OF THE PROSTATE

Excluding prostatic hypertrophy, which the writers consider
non-neoplastic and inflammatory in nature, tumors of the pros-
tate gland occur less frequently than is generally believed. Fibro-
mata of the prostate, which are commonly reported, usually occur
as a result of inflammation and are but rarely true idiopathic
neoplasms. Myomata, invariably of the smooth muscle type, are
occasionally seen, but seldom grow to large size or have any clinical
significance. Sarcoma of the prostate is rare, except when it
occurs in the course of a general sarcomatosis. Hypernephroma
of the prostate occurs as a somewhat rare metastatic growth, the
writers having seen but two cases. Its recognition clinically is of
but slight importance, however, since it appears only in hopeless
conditions in which metastasis is general and beyond surgical
relief. Carcinoma of the prostate gland is unquestionably the
most frequent form of tumor, although prostatic cancer was for-
merly considered a very rare condition ; Alberran and Halle were
the first to recognize and report its frequency of occurrence. The
writers have found it most often in hypertrophied prostates, in
which the interstitial hyperplasia and inflammatory exudate, with
the resulting epithelial proliferation, frequently give rise to the
development of cancerous growths in the enlarged gland, just as
similar conditions also induce malignant disease in the mammary
gland. Young, in a recent publication, finds cancerous altera-
tions present in about 7 per cent, of his cases of prostatic hyper-
trophy, fully corroborating the statement previously made regard-
ing its frequency. On account of the great clinical importance of
prostatic cancer it has seemed best to discuss it fully under a
separate heading.

Carcinoma of the Prostate. — In few, if any, of the organs of the
body are the changes that transform a simple inflammatory process
to a cancer more easily demonstrated than in the prostate. First,
the simple inflammatory process obliterates the mouth of one of

TUMORS OF THE PROSTATE

531

the acini of the prostate ; epithelial cells are thrown off inside the
acini and are unable to escape; the distention of the acini, as
mentioned in connection with the pathology of prostatic hyper-
trophy, goes to make up, to a great extent, the various enlargements
of the organ. Just so long as these cells remain inside the acini
a simple inflammatory process is present; as soon as these cells
break through the acini and invade the surrounding tissues cancer
occurs. If one could tell what process causes these cells, at one
time benign, to remain within the walls of the acini, and later on

Fig. 255.— Microphotograph of cancer of the prostate.

to wander under malignant impulses through the surrounding
tissues, the problem as to the nature of cancer occurring in any
portion of the body would be solved.

Cancer of the prostate was first recognized in 181 7. At that
time this growth, together with sarcoma and the ordinary so-called
hypertrophy of the prostate, was considered under the head of
cirrhus tumor ; it is only during the past few years that a differen-
tiation has been made between cancer and sarcoma of the prostate.
Still more recently, as the result of the large number of sections
made through prostates, cancer of small size has been found to

532 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

occur — so small as occasionally to be confined to one lobe of the
organ.

It is not easy, from statistics at present obtainable, to draw
positive conclusions as to the frequency with which primary can-
cer of the prostate really appears; but, since the so-called hyper-
trophied prostate in the aged is a chronic inflammatory process,
cancer may be expected to follow in a large proportion of such
cases, just as it follows chronic inflammation attacking other
glands of the body. Cancer of the prostate is being reported with

Fig. 256. — Microphotograph showing development of cancer in a sclerotic hypertrophied

prostate.

increased frequency, and when it is remembered that a cancer
may be so small as to be situated entirely within one lobe of the
prostate, it may be seen how easily such growths may escape
recognition. A case of very small cancer of the prostate was
operated upon by one of the writers. Being confined to one lobe,
it was discovered only after the prostate had been removed and
sections made through it. It had been, nevertheless, the cause
of much suffering, giving intense perineal pain. The prostate
was otherwise comparatively healthy. Three years after the
operation there was no indication of recurrence.

TUMORS OF THE PROSTATE

533

In a paper published by the writers/ the findings of a careful
examination of fifty-eight enlarged prostates are set forth: in
three of these cancer was present. The writers are convinced that
cancer of the prostate occurs in from 5 to lo per cent, of old men
suffering from prostatic hypertrophy, and, further, that occa-
sionally cancers that are believed to occur primarily in other por-

pig, 257.— Total removal of prostate. Membranous urethra is incised (redrawn from

Pierre Duval).

tions of the body, are really secondary to unrecognized prostatic
carcinomata.

Glandular metastasis occurs in about nine-tenths of those cases
of cancer of the prostate so far advanced as to be easily recogniza-
ble. About 30 per cent, exhibit inguinal gland enlargement,
the axillary and subclavicular glands being those next most com-
monly affected.

1 Greene and Brooks: " Hypertrophy of the Prostate," 1903.

534 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

Age. — It is difficult, from the literature on the subject, to state
definitely the earliest age at which cancer of the prostate may
occur. One case is recorded occurring in a man of thirty-eight;
the average age, however, seems to be over fifty, and in one series
of nineteen cases it was sixty -eight. In a large majority of the
cases recorded a history of symptoms pointing toward prostatic
disorders, of several years' standing, is generally given.

Fig. 258. — Total removal of prostate. Prostate being removed (redrawn from Pierre

Duval).

Cachexia. — This symptom has been strongly dwelt upon by most
writers on the subject. It may be of diagnostic value in so far as
its comparatively sudden appearance in old prostatics, without
other accountable reason, would naturally indicate that a malig-
nant disease might be developing; or it might tend to increase
the value of any other evidence pointing in that direction.

TUMORS OF THE PROSTATE

535

Pain. — Pain almost invariably accompanies cancer of the pros-
tate, and may be the first symptom to awaken the suspicion of
the existence of malignant disease. The pain may be referred to
the prostate, — that is, to the perineal region, — to the rectum, to
the back over the region of the kidney, to various portions trav-
ersed by branches of the sciatic nerve, to the region of the bladder,
or to the glans penis. It may apparently arise directly from the

Pig. 259.— Total removal of prostate. Neck of bladder stitched to membranous urethra,
prostate having been removed (redrawn from Pierre Duval).

prostate, or indirectly from the pressure of glands that may have
become infected. As has been said, it may be the first symptom
to give rise, in the mind of the observer, to the suspicion of malig-
nant disease, and as it may occur before metastasis into the neigh-
boring lymphatics has taken place. Persistent pain occurring in
an old prostatic, without other explanation to account for it,
should ordinarily lead to early surgical intervention.

536 DIAGNOSIS AND TREATMENT OF PROSTATIC DISEASES

Hematuria. — Next to pain, bloody urine, occurring perhaps in
50 per cent, of cases, is the most common symptom in cancer of
the prostate. Careful use of the cystoscope will determine in
any given case the cause of the bloody urine.

Physical Examination. — The amount of residual urine is of no
particular diagnostic value. Cases of cancer of the prostate have
been reported in which hardly any residual urine was present — in
one case only a tablespoonful. This is not remarkable in view
of the fact that cancer may occur without sufficiently increasing
the size of the prostate to cause marked obstruction to the urinary
outflow. It must also be remarked that almost all these cases
give a history of previous gonorrhea or injury.

The size and feel of the prostate, as ascertained by rectal touch
or by urethral examination, are probably not in themselves of
any great diagnostic value, except as a means of comparison.
These prostates may feel hard, nodular, or even soft. A sensa-
tion conveyed to the rectal touch as of a bunch in the prostate,
or the feel of a cyst, the contents of which cannot be removed by
massage of the gland, is considered by some as diagnostic of can-
cer. Examinations made to compare the size and consistency at
different times may thus be of value. In an old prostatic whose
gland has remained of about the same proportion for a long time,
as determined by rectal or urethral examination, a sudden increase
in size is indicative of malignant disease or inflammatory exacer-
bation. Cancer of the prostate is more likely to arise in the lateral
lobes or in one of them rather than in the so-called third lobe.

Prognosis. — In these cases the prognosis is, of course, grave, and
where metastasis has begun, almost invariably fatal. The writers
believe that if the diagnosis is made early enough, the cancer may
be eradicated by surgical interference. Almost all the cases re-
ported as having been operated upon have done badly so far as
cure is concerned. In the writers' case, previously referred to, the
recovery which took place after the operation was in all probability
due to the fact that the prostate was removed before the cancer
had time to cause glandular metastasis.

Treatment. — The treatment may be considered under three
heads — preventive, palliative, and curative.

Preventive. — The ultimate analysis of the question of preventive

TUMORS OF THE PROSTATE 537

treatment seems to lead to the conclusion that if gonorrhea or
any urethral inflammatory process could be prevented in the
first place, cancer of the prostate would become much less fre-
quent, for it is now well established that chronic posterior ure-
thritis is a very frequent complication of acute urethritis. More
and more evidence is being brought out to demonstrate that chronic
posterior urethritis and chronic prostatitis go hand in hand ; that
the latter plays a causative role in the formation of the so-called
prostatic hypertrophy, and that this in turn, reasoning from
analogy, plays a part in the formation of cancer. It would seem
also that more prolonged and careful treatment of chronic pos-
terior urethritis and prostatitis would tend to prevent the so-called
hypertrophy and, secondarily thereto, the cancer.

Palliative. — From the literature on the subject it will be seen
tjiat in most recorded cases of cancer of the prostate the diagnosis
has been made only after metastasis had taken place and general
systemic infection occurred. Consequently the operations at-
tempted in the hope of effecting a cure have proved failures. Some-
thing may be said, however, in favor of operations performed for
the purpose of prolonging life, or, more particularly in the later
stages of the disease, for the relief of symptoms, especially pain.
From the writers' experience with palliative operations in tuber-
culosis and cancer occurring in other portions of the genito-
urinary tract, they conclude that such operations are justifiable in
prostatic carcinoma, but they believe that they should not be
attempted if they are likely to make the progress of the disease
more distressing to the patient.

Curative. — So far, the only curative procedure known consists
in removing the cancerous prostate before metastasis has taken
place. Now that this condition is receiving more attention, it is
to be hoped that an earlier recognition will result in the recovery
of a larger number of patients.

In certain forms of cancer of the prostate total extirpation of
the prostate, with amputation of the prostatic urethra, as illus-
trated in the method of Proust (figs. 257, 258, and 259), may
be found necessary.

CHAPTER XXVIII
THE TESTICLE AND EPIDIDYMIS

ANATOMY

The testicle is a compound tubular gland of complicated struc-
ture. It produces a secretion,, the spermatozoa, which form the
essential of the seminal discharge.

The testicle is invested by a reflection of the peritoneum. This
gives it its outer or serofibrous coat, which is not applied close to
the surface of the organ, but is derived as it passes from the abdom-
inal cavity into the scrotum; this is known as the tunica vagi-
nalis.

The gland is inclosed and limited by a strong, thick cap-
sule called the tunica alhuginea. This is a dense, unyield-
ing membrane of white color; it is composed of compact bundles
of white fibrous tissue that interlace in various directions. Its
inner layer is richly supplied with blood-vessels and is sometimes
called the tunica vasculosa.

In the interior, fibers from the tunica albuginea are prolonged
from the posterior border for a short distance into the gland, so
as to form the complete vertical septum called the corpus high-
morianum, or the mediastinum testis. This septum contains the
larger blood-vessels of the gland.

From the front and sides of the mediastinum are given off nu-
merous slender fibrous cords and imperfect connective-tissue septa
that radiate from the mediastinum toward the opposite wall of
the albuginea, with which the ends of the septa blend. In this
manner the gland is divided off into from loo to 200 more or less
imperfect lobes. The septa, although made up of connective
tissue, also contain a few smooth muscle-fibers and transmit
branches of the mediastinal arteries to all parts of the gland struc-
ture. They also inclose certain large connective-tissue cells, the
cytoplasm of which is rich in metaplasm.

538

PLATE XVIII

lateral sur/acf

inferior exit:

a

i

Jif iJ of lobiilti of tunicit

€pi,ii,i,imis '/"^"'y'"'/ <>'»"«""'' spermatic cord x

b^jf o/cpidiH/mis

spermatic
cord

I ^ cremoster)

ductus aberrans

head of t'^t^^'

.-■epididyL ,;^g.

^ appendix oj
epididymis

medial surface

leiior border
spermatic cor.

/ 'yanica vaginalis
' communis

9^M tunica vaginalis propria
superior ligament of epididymis

sinus of epididymis

posterior border of testis
inferior ligament of epididymis

tail of epididymis

tunica vaginalis communis

head of epididymis
appendix of testis
appendix of epididymis

a. The testis and epididymis with their investing membranes seen from
in front, b, seen from the lateral surface; c, the testis, epididymis, and the
jiroximal portion of the vas deferens. The tunica albuginea has been com-
pletely removed from the epididymis and partly from the testis; the tubiili
contorti of the lowest lobule of the testis have been isolated (Sobotta and
McMurrich).

ANATOMY 539

The glandular or secreting portion of the testis is inclosed and
supported by this connective-tissue framework just described,
made up of the tunica albuginea, the mediastinum, and the septa.
The glandular portion consists of the seminiferous tubules and of
their excretory ducts. Each compartment or lobe contains two,
three, or more tubules, all of which extend out from the medias-
tinum in a comparatively straight course, but become greatly
convoluted and entwined about one another as they extend toward
the periphery. The length of the individual tubule varies some-
what when straightened out — some of them are found to be as
much as twenty inches long.

The seminiferous tubules may be divided into three portions —
the convoluted tubules, the loops of which make up the bulk of the
lobe; the straight tubules, which are the terminations of the con-
voluted tubules and are found at the apex of the lobule ; and the
tubules into which the straight tubes empty, and which are seen
in the mediastinum ; these make up the rete testis.

The seminiferous tubules are lined throughout with epithelium,
which varies in different portions of the tubule and presents, in
parts, a complicated arrangement. In all portions the epithe-
lium is laid down on a basement membrane composed of several
layers of flattened endothelioid connective-tissue cells; outside
this cellular layer a fibrillar membrane is found.

The active secretory function of the tubule takes place in the
convoluted portions, and it is here that we find the epithelium
taking on its most complicated arrangement and form.

In the convoluted tubules three varieties of epithelial cells are
found: first, the cells arranged on the basement membrane,
named the spermatogonia; next, a layer of cells, often two or three
deep, called the spermatocytes, and, finally, the innermost of all,
the spermatids.

The spermatogonia are of two varieties: first, and most numer-
ous, the irregular polygonal or oval cells whose nuclei are rich in
chromatin; between these, at irregular intervals, are seen certain
tall, thin cells that project upward nearly into the lumen of the
tubule, and are called the columns of Sertoli or the susten-
tacular cells. These take no active part in the formation of the
spermatozoa, but only support the polygonal cells so closely

540 THE TESTICLE AND EPIDIDYMIS

crowded around them, from which the spermatozoa develop.
This development takes place from the rapid division of the poly-
gonal cells, after an interval of rest, these primary spermatocvtes,
grouped about the columns of Sertoli divide again, so that, finally,
each primary spermatocyte is doubled; next each spermatocyte
divides into two spermatids, each of which incloses a centrosome
and is very rich in chromatin derived from the original nucleus.
Cytoplasm is somewhat scanty in the spermatids.

From the spermatids are developed the spermatozoa, but the
manner in which this development takes place is still an undecided
question. At any rate, the chromatin of the spermatids cleaves,
and from the resulting stages the spermatozoa are formed from the
chromatin. Some believe that the entire spermatozoon is derived
from the chromatin, whereas others hold that only the head and
body are so formed, the tail being derived from the cytoplasm.

Spermatogenesis does not take place in every part of the testicle
at the same time. Some tubules are in a quiescent or resting
stage, while others carry on the secretory function; then the active
cells pass to a resting stage, and the recuperated ones take up
the active function.

The straight tubules are much smaller than the convoluted
tubules, and are lined by a single layer of low columnar or cuboid
cells.

In the rete testis the tubules, now excretory ducts, vary much
in size and shape — from narrow clefts and channels to large open
tubules; they are Hned by a single layer of flattened epithelial
plates.

The tubules of the rete testis coalesce to form about ten or
twelve tubules called the vasa efjerentia, which emerge from the
limitations of the testis and are thrown into numerous folds, mak-
ing up the globus major or the head of the epididymis. The tubes
are lined by a simple or stratified columnar epitheHum which is
covered with long cilia which, in the fresh condition, wave away
from the testis. This epithelium is arranged on a thick, fibrous
wall in which are included some smooth muscle-fibers.

The body and tail of the epididymis are made up of the convolu-
tions of the tubules, which in turn are a continuation of those
which make up the globus major; and this is continued as the

PATHOLOGY OF DISEASES OF THE TESTICLE 54 1

Spermatic duct or the vas deferens, which is a tubule about 20 inches
in length, extending from the epididymis to the root of the penis.
The walls of the vas deferens are made up, first, of an internal
coat of ciUated epithelium laid down on a somewhat thick base-
ment membrane, beneath which is a quite thin layer of areolar
connective tissue, followed by an inner circular and an outer
longitudinal coat of smooth muscle.

The vas deferens passes through the prostate gland to the neck
of the bladder, where it presents on each side an ampulla or dila-
tation that empties through the ejaculatory duct into the urethra.

Blood and Nerve Supply. — The testicles and epididymis are nour-
ished by the spermatic arteries, which arise directl}'^ from the aorta.
The veins of both testicle and epididymis unite as they ascend
along the cord, about which an intimate venous anastomosis,
known as the pampiniform plexus, is formed. The nerves are
derived from the sympathetic system and the spermatic plexus
is connected with the renal and aortic plexuses.

The lymphatics follow the general course of the blood-vessels
and drain into the lumbar lymph-nodes.

THE PATHOLOGY OF DISEASES OF THE TESTICLE
Defects. — Complete absence of the testicles is occasionally met as a
congenital defect, being usually associated also with absence
of the epididymis, vas, and seminal vesicles. The absence of a
single testicle, the result of some defect of development, is rela-
tively a common occurrence, but is usually due to some disease
of the nutrient arteries in the early stages of development; such
being the case, it is not uncommonly seen when both vas and
epididymis of the same side are present.

Cases of supernumerary testicle are occasionally reported, but a
microscopic examination demonstrates that in most cases the sup-
ernumerary bodies are not true testicles. Such conditions ordi-
narily give rise to no symptoms. The differential diagnosis must
generally be made from hydrocele and hernia.

Micro-orchia or hypoplasia of one or both testicles is a rela-
tively frequent condition. As a rule, it is associated with other
defects of development, although it is occasionally seen in other-
wise normal persons. As a rule, when both organs are involved,

542 THE TESTICLE AND EPIDIDYMIS

the body shows lack of sexual development, the general type of
an asexual individual pertaining. In nearly all instances the
organs represent delayed development, and are found in a stage
representing early formation. Spermatogenesis does not take
place, and, in so far as its influence on the body as a whole is
concerned, the testicle may be considered as practically absent.

Monorchidism or cryptorchidism is the condition in which one
or both organs are retained in the abdominal cavity, in the exter-
nal or internal ring, or in the inguinal canal, and fail to pass into
the scrotum. The condition depends upon prenatal disease, such
as abnormal closure of, or a small inguinal canal, a short guber-
naculum, or adhesions to the abdominal or pelvic viscera. Under
such conditions the organs are not infrequently more or less hypo-
plastic, although in many cases of double cryptorchidism func-
tion may be perfect. Spermatogenesis, however, is, as a rule,
considerably below the normal in these cases.

When the organ is so markedly misplaced as to cause discom-
fort, or where a tendency to the formation of hernia exists, surgi-
cal intervention is occasionally desirable. Under other circum-
stances, however, except in youth, normal placement of the organ
is usually unnecessary, except when done for cosmetic purposes,
and little is to be expected in the way of increased functional
ability.

Ordinarily such conditions give rise to no symptoms. If a tes-
ticle is retained in the abdomen, the differentiation from congenital
absence of a testicle is attended with difficulty, and apparently
but little can be done in either instance ; if retained in the inguinal
canal, it is ordinarily easy to feel and recognize. It is believed by
some that retained testicles have a tendency to become malignant.
The treatment of the condition is either negative or surgical.

Hypertrophy of the testicle is a rare condition, except where it
occurs as a compensatory process in cases of monolateral congenital
hypoplasia or disease in early youth. When the condition occurs,
it takes place by enlargement of the spermatic tubules; it is
very questionable if the true formation of new tubules ever takes
place.

Atrophy of the testicle appears most frequently as a result of
chronic inflammatorv disease in which necrosis or loss of substance

PATHOLOGY OF DISEASES OF THE TESTICLE

543

has taken place, with subsequent interstitial hyperplasia and a
normal retraction that takes place in scar formation. Atrophy
may also occur in marasmus, extreme old age, and in general
nutritive disorders of pronounced degree. Endarteritis and
sclerosis involving the nutrient arteries of the organ may also
cause atrophy. Pressure on the spermatic artery, as from an
improperly fitting truss, may occasionally cause atrophy.

The diagnosis of a marked degree of atrophy is simple ; when the
atrophy is not extreme, it is somewhat more difficult. Marked
atrophy is generally associated with loss of the sexual functions.
The treatment would necessarilv consist in the treatment of causa-

Fig. 260. — Showing the relations of the testis and epididymis in acute orchitis. T, T, Testis ;
E, E, epididymis ; A, sagittal section ; B, horizontal section (Kocher).

tive conditions, together with such local measures as may be
most practical in the particular instance.

Fatty metamorphosis of the testicle is occasionally seen. In
this condition the entire parenchymatous tissue may be replaced
by masses of adipose tissue or fat; it is usually seen in extreme
old age or in long-standing wasting diseases, such as chronic tuber-
culosis or syphilis.

A diagnosis is not usually easily made. It may sometimes be
suspected in men who exhibit an excessive amount of adipose tissue
combined with marked loss of sexual power.

Acute Orchitis. — Etiology. — Acute orchitis occurs most fre-

544

THE TESTICLE AND EPIDIDYMIS

quently from direct infection of the testicular substance by the
infectious processes of the epididymis, vas deferens, or seminal
vesicles. It is, therefore, usually seen as an accompaniment or
sequence of urethritis of various types. True orchitis is much less
frequent than is generally believed, the condition being often con-
founded with epididymitis.

It may also arise in certain specific types of general disease
with local testicular manifestations. This is particularly well
demonstrated in mumps, typhoid fever, and variola.

Pathologic Anatomy. — Acute orchitis is usually manifested by
the occurrence of edema, hyperemia, and swelling of the inter-
stitial tissues of the
organs, with resulting
compression, degener-
ation, and desquama-
tion of the parenchy-
matous epithelium.
The hyperemia may
pass on to a true hyper-
eniic extravasation, or
the leukocytic infiltra-
tion may become asso-
ciated with necrosis
and eventually with
suppuration. In the
mild inflammations
recovery takes place
by absorption of the inflammatory exudate, and the degenerated
epithelium is replaced by hyperplasia of the normal remaining
cells of the spermatic tubules. When absorption is incomplete,
or in those cases in which loss of substance has taken place, inter-
stitial hyperplasia occurs, oftentimes resulting in tubular atrophy,
and the process may become transformed in this manner into one
of chronic orchitis.

The symptoms of acute orchitis are swelling of the testicle,
pain in the scrotum and loins, and general systemic disturbances.
It is often associated with acute urethritis, following injury, and
also with tuberculosis and syphilis, although the type presented

Fig.261.— lUustratiiie the relations of the epididymis
and testis in acute epididymitis. In the first figure the
head of the epididymis is chiefly affected and in the
second figure the tail. T,T, Testis; E, E, epididymis ;
S, S, spermatic cord (Kocher).

PATHOLOGY AND SYMPTOMS OF DISEASES OF THE TESTICLE 545

in the two last-named conditions is somewhat different from acute
orchitis as ordinarily seen. Under ordinary circumstances, within
two or three weeks after its onset, resolution tends to take place
and the swelling subsides. It must be differentiated from epi-
didymitis, neoplasms, hernia, and hydrocele. It is not infre-
quently associated with acute epididymitis, and the diagnosis
may be reached by manipulating the swollen mass, making
out the lines of demarcation between the epididymis and the tes-

f^^

r

fli

^

^^^g

Fig. 262. — Tubercular orchitis (natural size). From a specimen in the Museum of Carnegie

Laboratory.

tide, and finding the body of the testicle proper swollen and tender
on pressure. When not associated with acute epididymitis, it is
comparatively easy to make out the line of demarcation between
the epididymis by its normal shape, and the inflamed, enlarged,
and tender testicle.

Chronic orchitis usually follows as a direct sequence of the
acute t5T)e of the disease. It may also occur in chronic arterial
affections. In either case it is characterized by proliferation and
35

546 THE TESTICLE AND EPIDIDYMIS

thickening of the interstitium, with atrophy of the tubular ele-
ments. If the disease progresses, the organ becomes very small
and hard, and is frequently the seat of various forms of infiltration,
particularly the calcareous variety. Ordinarily there are no
distinctive symptoms associated with chronic orchitis, and it is
sometimes difficult to diagnose from similar conditions due to
tuberculosis or at times from new-growths. It may occur as a
complication of mumps, and is believed to be due at times to
rheumatism or malaria, although no cases have come under
the writers' observation in which this could be definitely demon-
strated.

Tubercular Orchitis. — -Tubercular orchitis has its origin, as a
rule, in tubercular epididymitis. In a considerable number of
cases it appears to follow simple epididymitis as a secondary
process. It apparently occurs in many cases as a primary proc-
ess in the epididymis, the infection having apparently been
derived through the lymphatics or the vas deferens. Infection
by the blood-vessels probably also Occasionally occurs. In some
cases the disease has followed direct traumatism to the testicle.
In these instances the process probably develops in the loctis
minora resistentia, very likely from organisms derived from a
quiescent and perhaps unrecognized lymphatic lesion.

As a rule, the tubercle formation is associated with active growth
on the part of the connective tissue, oftentimes with pus-formation
and extensive necrosis. The process ij generally quite active,
and is not infrequently followed by general lymphatic involve-
ment, and particularly by a general miliary tuberculosis. Active
caseation is the rule, and in relatively long-standing cases calcare-
ous infiltration occurs. In almost all instances of tubercular
orchitis the process eventually extends out into the tunica vagi-
nalis and involves the scrotum proper, causing induration and
ulceration of the skin. Tubercular orchitis may be found asso-
ciated with neoplasms. One of the authors has been recently
shown a case of this nature by Dr. Theodore Kuhne. The pri-
mary lesion was a tubercular orchitis following a blow on the
gland received while playing foot-ball. Shortly after the injury
rapid isolated growth took place at the site of the trauma, and
the nature of the mass was most puzzUng clinically. Microscopic

EPIDIDYMITIS 547

examination showed tuberculosis, with the necrosed area infiltrated
by spindle-cell sarcoma. The subsequent history of this case
showed the sarcoma to have originated in the kidney, with early
metastasis in the testis.

The symptoms of tubercular orchitis are ordinarily pain, swelling,
and ulceration. In some cases no manifestations may be present
except the presence of tumor in the testicle proper or in the epi-
didymis. When necrosis takes place, superficial ulcerations form.
The disease must Be differentiated from gumma, malignant disease,
and the after-result of simple orchitis following injury or gonorrheal
or other infectious processes. Under ordinary circumstances, the
general systemic manifestations of tuberculosis are present and
tend to make the diagnosis clear. The condition is sometimes
associated w-ith a slight, brownish-yellow discharge from the
urethra. The presence of tubercle bacilli in such discharge con-
firms the diagnosis.

Syphilitic Orchitis. — The testicle frequently becomes the seat
of gummata in tertiary syphilis, and not uncommonly may be so
diffusely involved as to present a close gross resemblance to tu-
bercular orchitis. In secondary syphilis intertubular areas of small
round-cell infiltration, often with more or less caseation, are seen.

Symptoms. — Ordinarily, beyond the enlargement, orchitis due
to syphilis does not present many symptoms. Breaking down or
gumma leads to ulcerations, which may be mistaken for tubercular
ulcerations or those due to malignant disease. In such instances
the diagnosis is aided by observing the effect of a vigorous course
of specific medication. If is very difficult, by means of a physi-
cal examination alone, to differentiate between a tubercular infil-
tration into the testicle and an infiltration due to small gum-
mata. Gumma in its most frequent form is very commonly con-
fused with new-growths, and no case of tumor or ulcerating inflam-
mation of the testes should be operated upon until antisyphilitic
treatment has been tried. Numerous cases have, in the experience
of the authors, impressively illustrated the wisdom of this step.

Epididymitis. — This is an inflammatory condition of the epidid-
ymis, and on account of the great mass of blood-vessels entering
into this structure, is prone to be very active in its manifestations.
It may be divided into two forms — acute and chronic.

548 THE TESTICLE AND EPIDIDYMIS

Acute epididymitis is ordinarily due to extension of the inflam-
mation from an acute urethritis from the posterior urethra to the
vasa deferentia and to the epididymis, which becomes swollen and
painful. This condition may affect one or both epididymes,
and may develop at any time in the course of acute urethritis.
Ordinarily it may run a course of two or three weeks' duration,
reaching its height generally at the end of the second week.

Symptoms and Diagnosis. — Within two or three days after the
onset of the first symptoms, swelling, pain, and general systemic
discomfort develop. The pain extends upward along the course
of the cord into the groin, and occasionally into the abdomen.
The pain may be very intense in character and associated with
general malaise. In the majority of cases a slight rise in tempera-
ture occurs.

The differential diagnosis from acute orchitis has previously
been mentioned. In acute epididymitis not associated with acute
orchitis the body of the testicle proper can be made out; it is
normal in size and not tender on pressure, whereas the swollen
epididymis is extremely painful. In acute epididymitis the cord
is also swollen to some extent. Ordinarily, at the end of from two
to three weeks, the acute symptoms have disappeared, and more
or less resolution has taken place. Nodules of inflammatory
infiltration are often left behind, absorb very slowly, or frequently
exist throughout life. Acute epididymitis is a common cause of
sterility, the inflammatory products obstructing the canal of the
vas deferens or causing some change either in its expulsive power
or in the character of the secretion. Occasionally, after an
attack of acute epididymitis, while undergoing resolution, relapses
occur. These relapses are, as a rule, more painful and associated
with greater systemic disturbance than accompanied the original
attack.

Chronic epididymitis may be diagnosed only with difficulty
on physical examination, although, under ordinary circumstances,
some nodules of thickening may be detected either at the head or
at the tail of the epididymis. A history of a previous acute at-
tack of epididymitis is also given. The inflammatory products
that are present in chronic epididymitis not infrequently serve as a

TORSION OF THE CORD 549

nidus or predisposing agent for the development of tubercular
disease of the epididymis or testicle.

As showing the necessity for the thorough and prolonged treat-
ment of chronic epididymitis, so careful an observer as Casper
makes the following statement: "I can state that the majority
of childless marriages in which the husband is at fault had de-
pended upon a double epididymitis. It always leaves nodules
behind, also predisposes to tuberculosis."

Torsion of ihe Cord. — This is a condition in which the cord is
twisted. It is seen more often with a retained testicle, but occa-
sionally with one which has descended. As a result of some violent
muscular effort, the testicle becomes displaced and a condition
resembling an acute orchiepididymitis ensues. The diagnosis
can generally be made from the history of the case, and when the
inflammatory condition admits, from the discovery of the lesion
on physical examination. The condition is very rare.

Treatment. — Cases should be carefully observed, and if the in-
flammatory process continues after simple measures have been
used, early incision is advisable, cleaning out of the clots,
straightening, if possible, the cord, thus attempting to save the
testicle. This failing, testicle should be removed in the manner
described in the following chapter.

Much more frequent, though still rare, is a condition of orchi-
epididymitis due to strain set up through violent muscular effort,
in which the cord has apparently been wrenched, but the testicle
not displaced.

One of us has had under his care three cases of this character,
and have considered them as due to a wrench of the cord. White
and Martin' have in their work written most exhaustively and
interestingly on this and allied conditions. They have observed
twelve cases, and consider it due to one of three causes: First,
contracture of the cremaster muscle ; second, from rupture of the
veins; and third, from marked lesions, and they mention under
this heading, infection passing from posterior urethra along the
vas. The prognosis should be guarded. In one of the cases occur-
ring in the practice of one of us it was finally necessary to remove
the testicle. The treatment is similar to that of torsion of the cord.
' " Genito-urinary Diseases and Syphilis," Phila., 1906.

550 THE TESTICLE AND EPIDIDYMIS

Spermatocele is a retention cyst of the testicle or epididymis,
the contents of which are spermatic fluid. They are ordinarily
of slow growth, have the appearance and characteristics of cysts,
and sometimes cause pain if congestion -of the organs exists. They
may be congenital or may be due to trauma. Although not
infrequently reported, judging from our clinical and pathologic
experience, such cysts are quite unusual.

Treatment. — Enucleation of the sac.

Tumors of the Testicle. — According to some authors, tumors
of the testicle are rare; in the writers' experience, however,
they are not uncommon. Not infrequently they are confused
with various forms of orchitis, notably with the tubercular and
syphilitic varieties. Even after removal of the tumors their gross
appearance is very often misinterpreted by surgeons of wide ex-
perience. It is, therefore, essential that a microscopic examination
of the tissues be made before an absolute differential diagnosis
is made between new-growths of the testicle and orchitis — particu-
larly the tubercular, syphilitic, or actinomycotic forms. For-
tunately, the treatment in all cases, with the exception of the syphil-
itic, is practically the same ; and clinically a course of the iodids
is prescribed as a matter of routine in most cases of testicular
growth before operative measures are adopted. In many cases,
particularly when erosion of the scrotum has taken place, material
may be conveniently secured for microscopic examination, and this
should be done whenever possible. The writers do not, however,
advocate the practice of cutting through the intact scrotum into a
tumor of the testicle for the sole purpose of securing material for
microscopic examination, for they believe that in a certain number
of cases this procedure tends to favor dissemination and the early
production of metastases. On the other hand, particularly when
both testicles are involved, it is excellent practice to prepare the
case for operation, — that is, for castration, — and, in the course of
the operation, to select and remove a segment of tissue, submitting
4t to immediate examination by the frozen section method, so that
the proper treatment may at once be decided on and dangerous
delays avoided. The writers have seen several cases in which
serious errors resulted from the disregard of this simple precaution.

Tumors of the testicle, excluding, of course, those of purely

TUMORS OF THE TESTICLE 551

inflammatory origin, may be conveniently divided into three
classes: the cystic, the benign, and the malignant.

Cystic Tumors of the Testicle. — Retention cysts of the testicle
usually occur as the result of localized areas of inflammatory dis-
ease that cause occlusion of one or more of the excretory tubules,
either in the body of the testicle or, more frequently, in the rete
or tubuli eff"erenti. Cysts thus formed commonly contain a more
or less turbid, milky fluid, in which the presence of spermatozoa and
broken-down epithelial cells may be demonstrated. Occasionally,
particularly in long-standing cases, the cysts may contain a clear
serum, and be separated from the surrounding structures by well-
defined capsules of connective tissue. In a certain number of
cases these retention cysts may be multiple and may closely simu-
late colloid carcinoma or other forms of malignant disease.

Papillomatous adenocystomata are benign growths involving
the testicle somewhat rarely, and characterized by the formation
of cystic cavities lined by columnar epithelium, which, being in
an active state of proliferation, may grow into the cavity of the
cysts, eventually filling them with friable masses of proliferating
cells. These tumors possess, in general, many of the character-
istics of the papillary adenocystoma of the ovary, and, like
these growths, are prone eventually to become malignant ahd to
set up metastases, particularly by direct transmission. It seerns
probable that these cystic tumors may eventuate from the reten-
tion cysts previously described, or perhaps from persistent rem-
nants of Miiller's canal.

Dermoid cysts of the testicle are rare, and are relatively very
much less frequent than a similar growth found rather commonly
in the ovary. As a rule, gross examination is all that is required
for their identification.

Parasitic cystic tumors of the testicle are very rare in this country,
although one occasionally encounters echinococcus cysts of the
testicle, most often, however, in foreigners, and even then with
great infrequency.

Benign Tumors of the Testicle. — The benign tumors of the
testicle are fibroma, chondroma, osteoma, and adenoma. Of
these, the chondroma is, in the writers' experience, seen most
frequently.

552 THE TESTICLE AND EPIDIDYMIS

Fibromata are usually found originating from the tunica vagi-
nalis, from the tissue of the albuginea, or in the rete testis. They
are generally small and, as a rule, cause but little or no dis-
turbance.

Testicular chondroma may arise in any part of the organ, and
may attain considerable size. These tumors are very prone to be
associated either with carcinomatous or, more frequentlv, with
sarcomatous growths. Though innocent in immediate nature,
they should always be removed,

Osteomata are most commonly found associated with the carti-
laginous tumors or with the myxoma.

True adenoma of the testicle is of rare occurrence. Adenoma
is commonly found associated with carcinomatous growths of the
organ, and since all adenomata are very prone to become malignant
if allowed to remain, they should be removed.

Of the malignant tumors of the testicle, sarcomata have most
frequently come under the writers' observation. As a rule, these
tumors presented lesser degrees of malignancy, occurring as fibro-
sarcoma or chondrosarcoma. Early removal generally warrants
a better prognosis than in most cases of sarcoma occurring else-
where. Sarcomata are very commonly confused clinically with
tuberculosis and syphilis of the testicle, which they strongly re-
semble in their gross anatomic appearance.

Primary carcinoma of the testicle is somewhat rare, although
carcinomatous invasion from an epithelioma of the scrotum, com-
monly known as "chimney-sweep's cancer," is relatively frequent.
The prognosis in carcinoma of the testicle is less favorable than in
sarcoma, owing to the abundant lymphatic supply and to infec-
tion of the inguinal lymph-nodes, which commonly results early
in the progress of the disease.

Of the more unusual forms of malignant tumors of the testicle,
the writers have seen several cases of hypernephroma and endothe-
lioma. On account of the great variety of these tumors, how-
ever, and the fact that their treatment is similar to that demanded
in sarcoma and carcinoma, a more detailed description is not war-
ranted.

Varicocele. — This condition consists of an enlargement of the
veins and cords in the pampiniform plexus. The diagnosis is

HYDROCELE

553

easily made by feeling the mass, a sensation being imparted to
the touch as if a bunch of thick worsted were grasped. Varicocele
gives rise to very few symptoms, although it is believed to cause
occasional attacks of neuralgia in the scrotal region. Beyond the
application of a suspensory bandage, no treatment is required.
When, however, the enlargement is very extensive, .the mass being
half the size of the palm of the hand, operative procedure is called

Fig. 263 —Bilateral hydrocele (Frisch and Zuckerkandl).

for. For a further consideration of the subject, see the chapter
on the Treatment of Diseases of the Testicle.

Hydrocele. — Hydrocele of the cord, which is quite common, is
almost invariably a localized condition, giving rise to the formation
of cystic tumors in the cord, ordinarily of the size of a large marble,
and filled by a clear serous fluid. Care should be taken that
these tumors are not mistaken for hernia, which they sometimes
resemble, and from which they can be differentiated by the fact
that the hernial pouch can be usually returned to the abdominal

554 THE TESTICLE AND EPIDIDYMIS

cavity, the patient lyjng on the back and the pouch being pressed
upward; in hydrocele the mass cannot be thus returned.

In hydrocele there is an accumulation of fluid in the tunica
vaginalis testis; the condition can be diagnosed by inserting a
hypodermatic needle into the mass, when, if hydrocele is present,
a clear, slightly yellow fluid will escape from the needle or can be
withdrawn. Besides hernia, the only other condition that at all
resembles hydrocele is supernumerary testicle.

The ordinary hydrocele is an accumulation, in the serous sac of
the testicle, of fluid resulting from some change that takes place
in the walls lining the tunica vaginalis testis. The nature of the
pathologic change is not well understood. The accumulation
gives rise to a pear-shaped swelling in the scrotum. Generally,
the condition is unilateral, but double hydrocele of the tunica
vaginalis is not very uncommon. The latter gives rise to a pear-
shaped swelling involving the entire scrotum; this swelling is at
times enormous; the sac will occasionally hold a pint or more of
fluid.

The diagnosis is easily made from the shape of the swelling and
from the characteristic resistance on palpation ; it can be confirmed
by introducing a hypodermatic needle and examining any fluid that
may escape. It is unattended with any inflammatory reaction,
and does not, ordinarily, give rise to pain. It more commonly
attacks the young, in which case tuberculosis sometimes plays a
part, or the condition may be congenital. It is also very fre-
quently found in later life, often associated with some change in
the prostate or walls of the bladder. Hydrocele is in all proba-
bility temporarily associated with attacks of acute epididymitis or
orchitis, and ordinarily, in such cases, subsides without special
treatment.

Tapping is a conservative measure.

The term acute hydrocele has been applied to represent the
accumulation of fluid in the tunica vaginalis which accompanies
the acute inflammatory condition of the testicle or the epididy-
mis just mentioned, while chronic hydrocele is applied to the
more ordinary condition, of which we treat in detail. It is
customary, in addition to the other measures, to diagnose the
various forms of hydrocele by the so-called light test, which con-

ELEPHANTIASIS OF THE SCROTUM 555

sists in a light being placed on one side of the sac, the bladder
coming between the light and the eye of the observer, these sacs
being translucent.

There are, in addition, several forms of congenital hydrocele
caused by some communication between the tunica and the
abdominal cavity, or due to retention of some of the fetal bodies.
They are comparatively rare and easy to destroy, their diagnosis
presenting no great difficulty, and they should be treated as hydro-
cele of the cord.

Multilocular Cysts. — Although probably they occur but
seldom, occasionally multilocular cysts are met with in forming
a hydrocele. We have operated on one such case. They can
be diagnosed before operation, which is probably rarely done, if
on aspiration only a small amount of fluid comes away. The
treatment should be that of ordinary hydrocele.

Hematoma of the Cord.^ — In this condition a tumor is present
in the cord, which may be encysted, or may extend well along the
length of the cord. It is due and made up of an infiltration of
blood from the blood-vessels. These tumors are caused by an
injury to the cord of some character. The diagnosis is easy from
the history of the case, the presence of a hard, non-translucent
tumor, which does not involve the testicle or the epididymis,
and which is not reduced when the patient is in a reclining posi-
tion, as would be the case if a hernia were present.

The treatment is to open the tumor. If possible, remove any
cystic wall present. The infiltration may be so diffuse, as in the
case treated by one of us, that this procedure cannot be carried
out. Scraping out the infiltrated material, however, is eventually
followed by a gradual absorption of any thickening that may
remain in the cord.

ELEPHANTIASIS OF THE SCROTUM
Elephantiasis of the scrotum is due to some defect in the circu-
lation through the lymph-canals, such as might result from the
formation of cicatricial tissue following an operation or a wound
of the scrotum, or it may be due to the presence of the filaria
sanguinis hominis. Elephantiasis due to the filarial parasite is
extremely rare in this country, although it is of common occurrence

556

THE TESTICLE AND EPIDIDYMIS

in India and in certain parts of Europe ; most of the cases, there-
fore, that are seen here have either been imported from foreign
countries or are due to the first-mentioned cause. In its incipi-
ency, it somewhat resembles varicocele; on palpation, a slight
thickening can be felt in the scrotal contents, and as time goes on
the scrotal wall becomes more and more thickened and enlarged.

Fig. 264.— Elephantiasis of the scrotum (Frisch and Zuckerkandl).

until a dense pachydermatous mass is formed. The process is
unattended with pain, and the disease progresses very slowly.
The freedom from pain and the slow growth serve to differentiate
it from malignant tumors. The treatment is surgical and is re-
ferred to in the following chapter.

CHAPTER XXIX
THE TREATMENT OF DISEASES OF THE TESTICLE

THERAPEUTIC MEASURES

But little need be said regarding the medical treatment of dis-
eases of the testicles. These affections are, however, so common
that the general practitioner should have a good understanding
of the surgical treatment of these diseases, and the surgeon should
have a clear knowledge of the various procedures that should be
adopted before surgical interference is resorted to. When the lat-
ter is indicated, it usually is necessarily radical.

It should be borne in mind that the testicle and its covering are
particularly prone to be the seat of tertiary syphilitic deposits.
The writers have seen them in persons who gave no history of the
presence of primary or secondary lesions. These syphilitic de-
posits, as is well known, disappear rapidly under syphilitic medica-
tion. In a doubtful case, where the testicle or the epididymis is
greatly enlarged, it is well to give full doses of mixed treatment or of
potassium iodid, in addition to which applications of a mercurial
ointment may be employed or mercurial inunctions may be applied
to other portions of .the body than the testicle, and the scrotum
anointed with iodin-vasogen, which should be well rubbed in.

Repeated attacks of epididymitis or orchitis without apparent
cause should give rise to the suspicion of syphilis being a factor
in the case. The medicinal treatment of the most common forms
of testicular inflammatory conditions, viz., epididymitis or orchitis
of gonorrheal origin, should be divided into two classes — one
having a direct effect on the testicular inflammation, and the other
on the system generally. Of the first class of remedies, the tincture
of Pulsatilla apparently exerts a benign influence, given early in
the attack in drop doses repeated hourly — ten or twelve times in
twenty-four hours. The second class of remedies consists of tonics
containing iron and quinin, which are of great value in these con-
ditions for the purpose of maintaining or improving the general

557

558 TREATMENT OF DISEASES OF THE TESTICLE

health. Very rarely in an attack of epididymitis, particularly
in relapsing cases, the pain is so severe that morphin hypoderma-
tically is necessary for its relief.

The tendency of tuberculosis to attack the testicle should always
be borne in mind. Occasionally this is the only organ in which
the disease makes itself manifest. Acquired hydrocele, especially
in young persons, is apt to be of tuberculous origin. In addi-
tion, small deposits of inflammatory products caused by tubercu-
losis— so small as hardly to be perceptible — are not infrequently
to be found in the testicle or the epididymis. It is interesting
to observe, in these cases, how a slight injury will cause these
tuberculous products, which may lie dormant for months and years,
to serve as the starting-point of an inflammation involving the
testicle and the epididymis. Of three cases of this type en-
countered, who gave a history of the same slight injury, — slipping
without falling on the pavement,— in two there was no history of
gonorrheal infection; in the third, some twenty years had elapsed
since gonorrheal manifestations had presented themselves; in
the three cases each developed an acute orchi - epididymitis.
In the first two of these cases the inflammatory symptoms dis-
appeared in a few days under rest and the application of a
lead-and-opium wash. In the third case, because of the good re-
sults obtained in the first two cases, a very favorable prognosis
was given. In spite of similar treatment, however, pus rapidly
developed; this was evacuated and the cavity cleaned out,
but in from twenty-four to forty-eight hours the remainder of the
testicle had become so completely disorganized that removal was
imperative.

The three cases just described are good examples of what is to
be expected from tuberculous invasion all along the urinary tract.
Not even an experienced observer can prognosticate what the out-
come will be or whether or not an operation will be necessary.
The prostate and seminal vesicles, when involved in tuberculous
processes, are apparently not quite so likely to cause serious sys-
temic manifestations.

In making a diagnosis of any given obscure case, the practitioner
should carefully examine the testicle for evidences of tuberculosis or
syphilis ; frequently the only lesions of these diseases that can be

THERAPEUTIC MEASURES

559

well marked out are found here. Internal medication other than
that indicated for the disease itself is of no apparent benefit in the
treatment of tuberculosis of the testicle or its covering.

As regards external measures for the relief of acute inflammatory-
conditions of the testicle, such as acute orchitis and acute epididy-
mitis, rest in bed, when it can be secured, is imperative. While
resting, the testicles should be supported on a bridge placed be-
tween the legs, running across under the legs just anterior to the
scrotum. This bridge may be constructed of a towel passed around

Fig. 265 .^Showing " bridge " for support of scrotum in epidid}miitis.

the legs or of adhesive plaster. In these acute inflammations the
ordinary local applications, such as are used for similar conditions
occurring elsewhere in the body, are indicated. Generally they
consist of either heat or cold, using that which gives the most relief.
There is some danger of sloughing following the too prolonged
use of the ice-bag, and for this reason it is safer to employ heat.
Lead-and-opium wash, applied on bits of gauze, as hot as can be
borne, changing as often as it becomes cool, is, in the writers'
experience, productive of much comfort, and is to be advised when

56o

TREATMENT OF DISEASES OF THE TESTICLE

the services of a constant attendant can be obtained. An applica-
tion consisting of opium and belladonna ointments, equal parts,
is serviceable. These ointments may be applied on a piece of lint,
over which an oiled silk dressing should be placed, retained in
position by a suspensory bandage. When the acute process has
somewhat subsided, ordinarily in a few days, which is generally
evidenced by a diminution of pain, even when the swelling re-
mains, patients may be allowed to sit up, but should be cautioned
against moving about for a few days, because of the danger of
relapse. The applications previously advised may be continued,
or a lo per cent, ichthyol ointment may be used ; or, if desired, the
scrotum may be painted with lo per cent, guaiacol diluted in

alcohol, or with a solution of

A,. .B' silver nitrate, 40 or 60 grains

to the ounce. When the acute
inflammatory processes, such

A* a:

B*B'

Fig. 266.— Bandage for scrotum.

as are associated with epididymitis or orchitis, have disappeared,
small foci of inflammatory products will very often be found re-
maining in the testicle or epididymis. In order to secure the best
results, local applications to the scrotum in the region of such foci
should be made for many weeks and months. A 10 per cent, oint-
ment of lead iodid may be used, or the iodin-vasogen may be applied
daily. When such conditions are believed to be tuberculous,
vasogen and guaiacol may be used; if syphilitic origin is sus-
pected, a 5 per cent, ammoniated mercury ointment may be ap-
plied. It is hardly necessary to mention the necessity of institut-
ing proper constitutional and hygienic treatment, as well as
local measures for the relief of any lesions of the urethra that
may exist.

OPERATION FOR HYDROCELE

561

SURGERY OF THE TESTICLE AND ITS COVERING

In considering the surgical treatment of diseases of the testicle,
the operative procedures for the relief of diseased conditions of the
covering of the testicle come first in order. Of these, hydrocele
is the most common.

Fig. 267.— Bandage for scrotum.

Operation for Hydrocele
This, as has been said, is a very common affection; it may
involve the entire tunica or only a portion ; it may be lobulated.
Hydrocele, which may involve the covering of one or both
36

562

TREATMENT OF DISEASES OF THE TESTICLE

testicles, and which is seen in both the young and the old, is so
frequently met that many attempts have been made to devise an
ideal operation for its cure, but thus far these attempts have been
futile. The simplest operation for the relief of hydrocele is that
which consists of tapping by means of a trocar ; this is an operation
that almost every practitioner is called upon to perform at some

Fig. 268.— Tapping a hydrocele.

time. Even in this simple operation, however, proper attention
must be given to details in order to secure the best results. When
possible, in tapping a hydrocele, it is well to have the services of an
assistant. After aseptic precautions have been observed, the assis-
tant locates the testicle in the mass, holding it with one hand,
and making the bag of fluid protrude in such a manner as to render
it as tense as possible. The surgeon then selects the most promi-

OPERATION FOR HYDROCELE 563

nent part of the bulging mass, washes it with some antiseptic
solution, and sprays the point where it is purposed to introduce
the trocar with ethyl chlorid; the smallest trocar that it is prac-
ticable to use, which should be sharp and sterile, should be plunged
quickly and deeply through the covering of the testicle into the
sac, and the fluid allowed to escape into a proper receptacle.
After the fluid has escaped, the surrounding areas should be sub-
mitted to a sort of milking process, in order to be certain that no
fluid has been left behind in the folds of the tunica; the trocar
should then be quickly withdrawn and a strip of adhesive plaster
placed over the site of the puncture. Occasionally, even in the
hands of an experienced operator, particularly when the services
of an assistant are not to be had and when the walls of the sac
have become very much thickened, the testicle is wounded by
the trocar. As a rule, beyond the pain it causes, no particular
harmful results follow this accident.

It has been a common custom for a great many years to inject
into the sac, through the trocar, a few drops of a powerful de-
structive agent, with the object of setting up an adhesive inflam-
mation between the walls of the tunica that will cause them to
adhere and thus prevent the reformation of fluid. This method
is sometimes successful. The fluid most generally used for the
purpose is phenol ; not more than five or ten drops of 95 per cent,
pure phenol should be used. A few drops of a strong solution of
iodin may be employed. The reaction following this procedure
is generally marked. For several days swelling and pain are
severe, but gradually subside, and, in fortunate cases, the fluid
does not return.

Personally, the writers prefer one of the radical operations,
three of which are at the present time in use. The old opera-
tion consists in making a lengthy incision through the skin
down to the tunica, carefully dissecting away the tissues on each
side, and tying off any bleeding points ; when the tunica is reached,
it is a good plan to hook it before puncturing the sac with a knife,
for, simple as the procedure is, it is sometimes difficult, if the sac
is punctured too soon and the fluid suddenly escapes, to map out
and bring into the field of vision the proper walls of the sac. The
sac having been hooked, it can then be punctured and a small

564

TREATMENT OF DISEASES OF THE TESTICLE

artery forceps immediately applied to the wall of the sac on
each side of the incision; the fluid having escaped, a finger
may be introduced into the sac and the testicle examined; if
desired, it may be brought out through the sac, looked at, and
returned.

In the older method of performing the operation quite a long
incision was made, and a few sutures were passed through the
wall of the tunica, brought out through the skin of the scrotum

Fig. 269/— Eversion of tunica vaginalis for the cure of hydrocele.

so as to fasten the wall of the tunica to the scrotum, and the wound
then packed with gauze, which was removed in a few days; this
left a fistulous opening which took some time to heal, but was often
successful in curing the annoying hydrocele. In the second
method, which is a modification of the first, many surgeons, after
incising the sac, remove the tunica almost entirely, and then,
under proper antiseptic precautions, immediately sew up the in-

OPERATION FOR HYDROCELE

565

cision. This method has many followers, and is at the present
time very generally used.

The third method, originally devised by the French, but erro-
neously credited to the Germans, is to make the incision through
the sac, releasing the fluid ; a finger is then inserted into the wound,

Fig. 270. — Operation recommended for the radical cure of hydrocele: i. Opening sac; 2,
packing cavity with gauze ; 3, method of stitching opening.

and the testicle pulled out, which has the effect of turning the sac
inside out — in other words, inverting it; the skin wound is then
sutured immediately over the testicle. From without inward then
the order would be : first, skin ; second, testicle ; third, sac ; instead
of — first, skin ; second, sac ; third, testicle, as is the normal order.
This procedure almost absolutely prevents any recurrence of

566 TREATMENT OF DISEASES OF THE TESTICLE

fluid in the sac. When, however, the walls of the sac are very
thick, this procedure cannot be carried out, for when the testicle
is pulled out through the wound and the sac inverted, the mass
is so large that there is not skin enough in the scrotum to cover it.
The writers were among the first to perform this operation in this
country; they also published one of the first articles in English
describing it.

The reaction following this operation is generally marked, and
the patient should be kept in bed for a week or two, at the end of
which time the swelling of the testicle, which as a rule takes place,
subsides. Following any of these operations rest in bed should
be insisted upon so long as the testicle is swollen, and warm or
cooling applications, if it seem best, should be made to the
inflamed parts. At times severe pain in the abdomen follows
the removal of fluid from the sac. In these cases morphin may
be given, the pain generally lasting only a few hours.

The ideal operation for the radical cure of hydrocele has not
yet been discovered ; the following method of operation, however,
seems to us to possess certain advantages deserving of considera-
tion. One of these is that it tends to preserve the function of the
testicle. By removing the tunica the natural covering of the
testicle is destroyed, and it would seem to follow, as a matter of
course, that the adhesion with connective tissue that would take
place between the testicle and the skin, through its power of con-
traction, would have a bad effect upon the functional capacity of
the organ. The same objection holds good for the operation of
inversion of the tunica just mentioned. Excluding these two
operations, the old-fashioned operation first described now remains
to be considered. As against this method may be mentioned the
fact that it was not always successful, often leaving a sinus that
was likely to persist for many weeks.

From a suggestion of Dr. Ramon Guiteras, the writers were led to
adopt, in their hospital and private practice several years ago, a
method for which they claim no particular originality, since it is
merely a modification of the old operation ; it is, however, genially
successful, and is comparatively easy to perform. To obtain the
best results it is necessary that great care should be given to detail
and to asepsis. The operation may be performed in the surgeon's

OPERATION OF EPIDIDYMECTOMY 567

office, the patient being sent home in a carriage. The scrotum
having been rendered aseptic, cocain is injected over the site of the
proposed incision; ethyl chlorid is next sprayed on, and a small
incision, about an inch in length, much smaller than was the
custom to use in the original operation, is made down into the sac,
and the fluid allowed to escape. The walls of the tunica and scro-
tum are now carefully stitched together with many very fine catgut
sutures. If great care as regards cleanliness and sterilization is
not observed in performing this operation, and if the wound
does not receive the proper after-care, infection, followed by slough-
ing in the wound between the skin and the tunica, is likely to take
place. After the scrotum and skin have been carefully sutured, a
very narrow, ribbon-shaped strip of gauze is introduced into the
wound and packed down quite firmly. To obtain the best results
it is necessary to leave the gauze in the sac for at least four, and
possibly ten, days, provided there has been no rise in temperature,
and that the discharge gives off no offensive odor, or that no unto-
ward symptom arises rendering its earlier removal advisable. At
the end of this time the gauze may be removed and the patient
allowed to leave his bed and go about. Any existing sinus will
close in a few days, instead of persisting for weeks or months, as
was formerly the case when the original operation was performed.
The modifications here described may seem unimportant, but
experience has convinced the writers that they are worth while,
for when the hydrocele is cured as the result of this operation,
the testicle still retains its natural covering.

Encysted hydroceles of the cord are generally small, and are often
mistaken by the laity for a supernumerary testicle. They are
generally about the size of a marble, and give rise to no pain or
suffering. They should be aspirated with a fine needle or fine
trocar, and their entire contents allowed to escape; when this is
done, they disappear and do not return.

Epididymectomy

This operation consists in removing the whole or a portion of the

epidid^'mis. An incision is made through the scrotum, and the

epididymis exposed; beginning at the tail of the epididymis, it

may be dissected off, working from tail to the head. The culdesac

568 TREATMENT OF DISEASES OF THE TESTICLE

of the tunica vaginalis supports the tail of the epididymis from
the testicle proper, thus rendering dissection of the former easy
unless it is bound down by adhesions. The blood-supply is more
abundant about the head than about the tail of the epididymis.
Instead of removing the entire body, only a portion of the epididy-
mis may be removed, as the surgeon sees fit.

After the epididymis, or a portion of it, has been removed,
and all bleeding points have been carefully ligated, the wound
should be packed lightly with gauze and allowed to granulate;
or, if healthy, it may be completely sewed up, as much of the
albuginea as possible being sewed over the resected area. There is
much diversity of opinion regarding the value of this operation.
It has received a great deal of attention from writers, and many
favorable results have been claimed for it, particularly in cases of
tuberculosis of, the epididymis or testicle. When the epididymis is
removed, wholly or in part, a portion of the testicle itself may, if
desired, be removed simultaneously, or a cheesy nodule in the
epididymis may be simply curetted out and packed with iodoform
gauze. So far as personal observation goes, the favorable results
claimed for epididymectomy have not been substantiated. This
operation is perhaps indicated in some cases of actual or suspected
tuberculosis of the epididymis. It is very rarely demanded for any
other disease. In a case of tuberculosis the operation may be un-
dertaken, and, if it proves unsuccessful, the entire organ may be
removed later on. It should be borne in mind that these tubercu-
lous infections sometimes progress rapidly, and that an incomplete
operation, such as this is, tends occasionally to hasten the progress
and disseminate the disease. The patient's condition should,
therefore, be watched very carefully; following the operation he
should be seen often, and the surgeon should be prepared to per-
form castration at a moment's notice.

Castration
Castration, or the removal of the testicle, is generally required
either for tumor of the testicle, generally of a malignant type,
or, most often, for tuberculosis; occasionally injury necessitates
its removal. Castration was formerly practised for the relief of
enlarged prostate, but at present this procedure has been aban-
doned in the treatment of that condition. In view of the fact

OPERATION OF CASTRATION

569

that the operation is consented to only as a last resort, and that
any right-minded surgeon would hesitate to practise it unless the
necessities of the case urgently demanded it, castration is not often
performed unnecessarily.

Ordinarily, castration is a very simple operation. An incision
about two or three inches long, extending from the upper border
of the scrotum up into the groin, is made through the skin and

Fig. 271.— A, Operation of castration. B, Method of tying stump of the cord.

fascia down to the cord; the cord is isolated, and with the tes-
ticle attached, is pulled out through the opening; ligatures are
then placed about it, and with a knife or scissors the cord is
severed below the ligature and the testicle thus removed. The
edges of the wound in the scrotum are brought together, and a
small gauze drain is inserted at its lower angle and allowed to
remain for a few days. Ordinarily, the writers advocate an inci-
sion longer than laid down in text-books on surgery, extending to-
ward the bottom of the scrotum, and longer than shown in the
illustration, for the purpose of securing better drainage. It is gen-

570 TREATMENT OF DISEASES OF THE TESTICLE

erally considered good surgery, in removing the testicle, to perform
the amputation as high up on the cord as practicable. Some writers
also recommend separating the vas deferens from the cord, pulling
on it gently, and dissecting it away wherever possible; in other
words, attempting to "unravel" it, so to speak, so that in some
cases it will be possible to amputate it an inch or two higher than
is the cord. This is done in the belief that the more of the vas
deferens removed in tuberculosis of the testicle, the less tendency
is there for the seminal vesicles to become infected. In a case
occurring in the writers' hospital service, in which this modifica-
tion of the operation was very successfully performed, an in-
tensely painful rectal neuralgia followed; this tended to discour-
age us with the procedure. Although in other cases the vas was
unraveled and amputated as high as possible without any bad after-
results, the writers do not believe that they have accomplished
any particular good by so doing, and consider it a procedure of
little value, and believe it better to divide the cord without un-
raveling the vas. In dividing the cord below the ligature, the
ligature is allowed to remain; in some cases the portion below
sloughs oflF and considerable swelling takes place in the extreme end
of the stump of the cord. To obviate this the writers place a tem-
porary ligature about the cord before amputating, and then sever
the cord; the Ugature is then loosened slightly and, with very
small artery forceps, the bleeding points that appear in the stump
are picked up carefully and ligated with fine catgut, after which the
ligature is removed entirely. Following the amputation and re
moval of the testicle it is generally wise to leave a small drain at
the bottom of the wound for a few days. Considerable local re-
action around the stump of the cord immediately follows the oper-
ation, and marked swelling, that seems inclined to extend up the
abdomen, may occur. If proper attention is paid to drainage and
an ice-bag applied, this will generally diminish. In some cases
changing the position of the patient, so as to secure better drainage,
is in itself enough to cause an increasing and angry-looking swelling
to disappear entirely. In removing a testicle that has become
very much enlarged, particularly as the result of malignant dis-
ease, the infiltration around the testicle is so extensive that it ap-
pears as if it were in a mold. In such cases it must be dissected out
with considerable care. After its removal the thickened mass

OPERATION' FOR RETAINED TESTICLE 57 1

may be dug out from the scrotal walls, care being taken not to in-
jure the dividing wall between the two testicles.

Treatment for Inguinal Retention of the Testicle
In the writers' personal experience these cases occur with com-
parative frequency. They are of congenital origin, the testicle
rarely giving trouble when retained in the abdomen. They seldom
give rise to pain; when they do, however, operation should be
performed. The condition manifests itself as a mass in the groin,
resembling hernia, for which it is sometimes mistaken. Two
forms of operation are employed for the relief of these cases:
one consists in removing the mass, and the other aims to restore
the organ to the scrotum and anchor it there. The operation of
removal should be carried out in the same manner as the ordinary
operation of castration, the incision being made in the groin over
the misplaced organ. It is a very difficult matter to anchor a
misplaced testicle permanently in the scrotum, and where it is so
anchored, it is doubtful if it will ever possess any functional ac-
tivity. The good results from various operations that have so
often been reported have not been attained in the writers' practice,
and they are generally inclined, therefore, particularly when the
case to be operated upon is an adult, to recommend removal of
the organ. The difficulty in all operations for effecting retention
of a misplaced organ in the scrotum is that the cord has become so
shortened that when the testicle is brought down into the scrotum
and anchored there, the tension of the cord will soon cause it to
ascend again into the groin. Another difficulty is that of obtain-
ing a sufficiently long cord to allow of the organ being brought well
down into the base of the scrotum. The following method of
operating on this class of cases is the one that will probably give
the best results. It is the operation devised by Dr. Arthur D.
Bevan, of Chicago. The testicle is exposed in the inguinal region.
The vaginal process of peritoneum is divided and ligated above it
as a hernial sac; the portion of peritoneum that surrounds it is
closed by a purse-string suture. The cord is lengthened by pulling
upon it and dissected free from connective tissue ; a place is made
for the testicle in the scrotum and it is, with its artificial tunica
vagina, brought down into it and kept there by a purse-string
suture run through the neck of the scrotum. If sufficient length

572 TREATMENT OF DISEASES OF THE TESTICLE

of cord cannot be obtained, the spermatic blood-vessels may be
ligated, trusting to the artery of the vasa deferentia to nourish the
testicle.

There are several other methods of treatment for this condition.
Dr. Paul Coudray^ claims that where hernia is not associated
with the ectopia that massage and traction, together with the use
of a properly applied bandage, will in time cause the organ to
remain in the scrotum, while with hernia it is necessary to do a
radical operation. Another method that has frequently been
advocated is to pull the testicle through a slit in the bottom of
the scrotum and allow it to remain in that position for a time,
the contraction of the scrotal wall preventing it from slipping
upward into the groin.

C. B. Keetly- brings the testicle through the bottom of the
scrotum, then makes an incision in the corresponding portion of
the thigh of the same extent as the incision in the bottom of the
scrotum, attaches the testicle to the cellular tissue underneath
the skin, and sews together the opening in the skin and the scrotum.
He reports a considerable number of cases operated on in this man-
ner. In detail his procedure is as follows: " The testicle and cord
having been thoroughly freed from everything but the musculo-
librous bands form in the gubernaculum, which are generally
attached to the pillars of the external ring, especially the internal
pillar, the gubernaculum is divided, as far away as possible from
the testicle. A pair of forceps is then passed from below upward,
through the hole in the scrotum, and the gubernaculum is seized
by it and pulled right through the scrotum until it can be seen
through the hole in the skin of the scrotum. At the same time the
tunica vaginalis testis should also be pulled down into the scrotum,
although it is not absolutely necessary to keep the testis in its
serous bag. Indeed, I have often omitted to attend to this point.
The posterior borders of the aperture of the skin of the scrotum
and thigh are next united by continuous silkworm-gut suture
left long at both ends. Now the gubernaculum testis is sutured
with strong catgut to the fascia lata of the thigh, and lastly the
original silkworm-gut suture is used to complete the union of the

' " Traitment de I'ectopie Testicularie, oar Male," " La Progres Medical,"
January, 1907.

^ " Lancet," 1895.

OPERATION FOR RETAINED TESTICLE

573

skin apertures in the scrotum and thigh to one another. The
hernia which is generally present is operated on for radical cure
in the way the surgeon thinks best for the individual case."

This method was first demonstrated in 1894. The authors
recommend to leave the testis attached to the thigh for five
months. Fritz de Beule^ recommends the same procedure, having
devised the operation before becoming acquainted with the work

Fig. 272. — Method of retaining testicle in thigh (redrawn from Keetly).

of C. B. Keetly. His procedure is about the same, with the excep-
tion that he releases the testicle retained in the thigh at the end
of about five weeks. Gersuny and Witzel developed a method of
opening the wall which divides the scrotum into two halves, and
places the right testicle in the left cavity and the left testicle in
the right. Very recently Dr. Simard- has reported a case oper-

1 "Anal. Soc. Belg. de Chir.," 1906.
* " Bull. Med. de Quebec," 1907.

574 TREATMENT OF DISEASES OF THE TESTICLE

ated on in this manner in which, after the end of six months,
the results were found to be good. We have seen one case which
had been operated upon by the Keetly method in which apparently
good results had been achieved, and are inclined to believe, judging
from the histories of reported cases, that in a proportion of cases
this method will be found efficacious. It is claimed by the author
that, through operating in this manner, the life of the testicle is
not destroyed.

The Treatment of Atrophy of the Testicle
For the local treatment of atrophy of the testicle some form of
electricity has for many years been advocated. The interrupted
or continuous current or static electricity is employed. When
the first-named currents are used, one of the electrodes is applied
over the lower portion of the spine and the other along the peri-
neal and scrotal tissues. Such measures should, however, be
adopted tentatively, and the strength and duration of the applica-
tion modified to meet the demands of the individual case.

The Treatment of Injuries to the Testicle
The treatment of injuries of the testicle is largely dependent upon
their severity. Patients should be put to bed and the scrotum
supported in a manner similar to that recommended for the treat-
ment of other acute inflammatory conditions. Either hot or cold
applications, according to which affords the most reUef, should be
used. The ice-bag is ordinarily the best external application, but,
as previously mentioned, it must be remembered that sloughing
is likely to follow its too prolonged use.

After a severe injury, such as a violent kick, considerable swell-
ing is likely to occur, and an effusion of blood that gives rise to a
hard tumor, known as a hematocele, may occur. These hemato-
celes may persist for weeks or months. If they are not eventually
absorbed, they should be removed. Penetrating wounds, either
immediately or shortly after they have been received, sometimes
permit the testicle to prolapse through the scrotum, and occasional
hernia of the testicle results. In these cases, either with or
without hernia, the organ should be replaced and the wound
sutured under proper antiseptic precautions. Whenever practic-
able, the testicle should be replaced as soon as possible after the

OPERATION FOR VARICOCELE 575

injury, before adhesions between it and the surrounding tissue have
had an opportunity to form.

The Treatment of Varicocele
There is probably no other condition that has offered a more
lucrative field for the practice of charlatanry than varicocele.
This condition, which consists of an enlargement of the veins
of the spermatic cord, very rarely gives rise to any physical symp-
toms or effects any damage if allowed to go untreated; the feeling
of weight, uneasiness, burning, and the like in the scrotum, or
pain in the back, often thought to be caused by it, being, we
think, due to neurasthenia, or possibly reflex from some inflam-
matory condition in the urethral tract. Very often, however, it
produces mental distress. The application of a suspensory ban-
dage is, in most cases, all that is required. When surgical pro-
cedure is demanded, one of three types of operation may be
chosen.

The first, subcutaneous ligation, has, to a great extent, become
obsolete. It is, nevertheless, recommended by many, and various
methods of performing it have been described in the older text-
books on surgery, to which reference is made. We do not com-
mend it.

The second type of operation aims to reduce the redundancy
of the scrotum, by effecting ablation of part of the sac. This
procedure is probably as useful as any, as, owing to the cicatricial
tissue contraction following the operation, it makes a natural
suspensory bandage of the scrotum itself. It is performed as
follows: The testicles are pushed up toward the inguinal gland,
and the base of the scrotum is pulled down and seized between
the first and second fingers of the left hand, which are pushed up
against the testicles in a manner similar to that of a barber when
cutting the hair of the head. A properly fitting clamp is then
applied. Any one of the appliances that have been specially
devised for the purpose, or any large clamp with a curve, or two
clamps from side to side, meeting end to end, may be employed.
Just above them, between the clamps and the testicle, a few
U-shaped sutures should be placed, the fold of scrotum below
the clamp cut through, and the portion 6i scrotum below the

576 TREATMENT OF DISEASES OF THE TESTICLE

clamp removed. The clamps are then removed, any bleeding
points ligated, and, if necessary, a few more sutures taken.
The patient is put to bed and kept there, and a dry dressing is
applied until the wound has healed.

The third method of operating consists in making an incision
down on to and separating the cord, in much the same manner
as if the testicle were to be removed by castration, except that
the incision should be somewhat lower. After the cord has been
isolated well down to the epididymis and the mass of veins that go
to make up the varicocele has been recognized, the cord should be
examined very carefully between the thumb and forefinger. The
vas deferens, in the midst of the cord, will be recognized as a very
small cord by itself, which feels like a piece of wire ; the sensation
it imparts to the touch is so distinctive that once felt, it will
afterward be easily recognizable. Great care must be exercised
lest the vas deferens be incised ; it should be separated from the
remainder of the cord, and the portion of the cord containing the
most distended veins should be tied across with two ligatures, one
being placed well down toward the epididymis and the other about
an inch above. The intervening inch of the cord, containing many
of the enlarged veins, should be removed by an incision across the
cord immediately above the lower and just below the upper liga-
ture, and the excised piece removed; then the two amputated
ends of the cord should be brought together, and the ligatures
that run across the cord having been left long, should be tied to-
gether, thus bringing the two separate ends of the cord into approx-
imation. In other words, the cord is an inch shorter than it was
before the operation; the vas deferens, however, which has not
been interfered with, is the same length as it originally was.
The ligatures having been tied, the skin incision is then sutured.
It is unnecessary to employ drainage, but the patient should be
put to bed and should be kept there for a few days, or until the
swelling that takes place at the point where the two ends of the
cord are brought together, and that makes a bunch of considerable
size, has reached its height, otherwise an annoying orchi-epididy-
mitis occasionally follows. If desired, the surgeon may employ a
combination of methods: quite a large portion of the skin at the
side of the scrotum may be removed, or the two operations of

OPERATION FOR TUMORS OF THE TESTICLE 577

ablation of the lower portion of the scrotum and excision of the
veins, as just described, may be performed.

The Treatment of Tumors of the Testicle
In all cases of tumors of the testicle where malignancy is strongly
suspected the writers advocate early and radical operative meas-
ures. All doubtful cases should first be submitted to thorough
antisyphiUtic treatment, followed by operation if this proves
unsuccessful. As a rule, the clinical and gross anatomic aspects
of the tumor are sufficient to estabUsh the diagnosis, the extent
and nature of the operation being then determined at the operating
table. For instance, a sessile tumor, as well as some teratomata,
may be removed and the testicle allowed to remain if attached
to it only by a small pedicle, in this way perhaps preserving the
integrity of the testicle. Whenever possible, a rapid histologic
examination, by means of frozen sections, should be made during
the operation. The writers have known the most serious results to
follow delay; it cannot, therefore, be impressed too strongly on
practitioners that, in the early stages of tumors of the testicle, a
fairly good prognosis as to recurrence may be given if early opera-
tion is permitted, whereas delay is almost invariably followed by
such wide dissemination as to render treatment of little or no avail.
The x-rsLY, radium, or the Coley toxins should be used only in
inoperable cases or when operation is refused.

Irrigation and Drainage of the Seminal Duct and
Vesicle Through the Vas Deferens
Recently^ Dr. William T. Belfield reports on the practicability
of using the vasa deferentia as a canal from which drainage of the
seminal duct may take place, or through which the seminal ves-
icles may be reached by injected fluid. His procedure is as follows :
Through a half-inch incision, under local anesthesia, the vas is ex-
posed. A transverse or longitudinal incision into the vas opens the
canal, and the blunted needle of a hypodermatic syringe may be
passed into the minute canal and a watery solution of any desired
agent injected ; this liquid traverses the vas and the ampulla and

^Abstract from "Proceedings of the American Association of Genito-
urinary Surgeons," June, 1906.

37

578

TREATMENT OF DISEASES OF THE TESTICLE

distends the seminal vesicle. This writer states that 30 minims is
the amount of fluid that can safely be used without causing sper-

Fig. 273.-— Illustrating method of operating for relief of elephantiasis of scrotum.

Pig- 274'— Illustrating method of operating for the relief of elephantiasis of scrotum.

matic colic and retention of urine. If desired, the vas may be
kept open by passing a fine silkworm-gut suture through the

OPERATION FOR ELEPHANTIASIS 579

lumen of each cut end. He states that by means of this method
he has successfully treated perivesiculitis and allied conditions.

Treatment of Elephantiasis
The illustrations given clearly define the surgical procedure
necessary for the relief of this condition, two semilunar incisions
meeting one another at the penoscrotal angle and at the raphe of
the perineum near the anus. The testicles should be located,
pulled forward, and any attachments between them and the back
of the scrotum severed. Then the mass is removed and the opera-
tive field covered by bringing the tissues together by the fine of
incision shown. It is recommended by Berger and Hartmann
that the patient rest in bed for two days preceding the operation,
with the scrotal contents elevated; through this procedure the
mass will be softened and the testicles be more easily located
in the growth.

CHAPTER XXX

SEXUAL NEUROSES

Neuroses of the genito-urinary system are of such frequent
occurrence as to demand brief consideration here. Patients are
constantly applying to the general practitioner for the relief of
symptoms that must be classed as neuroses or functional dis-
turbances of the sexual organs. The classification of these symp-
toms is very difficult, and their treatment is still more so. Only
the more important divisions will be considered here ; for a more
complete description the reader is referred to the work of E.
Finger, "Der Storungen der Geschlechtsfunctionen des Mannes,"
in the "Handbuch der Urologie," edited by Dr. Anton v. Frisch
and Dr. Otto Zuckerkandl, Wien, 1906. There is also quite an
exhaustive article on the subject in Casper's "Urologie." Refer-
ence may also be made to any of the most recent works on mental
and nervous diseases.

Under the heading of neuroses of the sexual organs it has been
customary to consider disturbances in the function, including
such conditions as, first, pollutions, under which heading should
be grouped such disorders as spermatorrhea, prostatorrhea, and
urorrhea. These unnatural emissions are particularly marked
during defecation, or are abnormal in character or frequency.
Second, impotence, which is the complete or partial inability to
perform the sexual act. More or less connected with it are the
various types of sexual weakness when not due to the natural con-
ditions of youth or old age. Third, sterility, which is the term
used to express the inability to impregnate healthy females. This
last condition has been classified into divisions made up of indi-
viduals who are sterile through impotency and those whose semen
is unfertile.

The writers take the same stand as does F'inger, in his article
previously referred to, that such conditions as spermatorrhea and
prostatorrhea are but symptoms pointing to some diseased state.

580

SEXUAL NEUROSES 58 I

For example, the discharge of semen, if it should occur during
defecation or during micturition, may be an evidence of paralysis
of the ejaculatory duct, which in turn may be due to peripheral
nerve disturbance following a catarrhal inflammation at the neck
of the bladder, or to some organic disease of the spinal cord. Clini-
cally, the discharge that occurs under these conditions is more
likely to be either a urorrhea, in which no other elements are found
microscopically than those normal to the urethra, or, what is still
more common, a prostatorrhea, in which the discharge microscopic-
ally gives evidence of coming from the prostatic gland. If leuko-
cytes are found in abnormal proportion in any of these discharges,
this would be indicative of inflammation existing in the urethra,
prostate, or seminal vesicles, and could be anatomically consid-
ered as chronic urethritis or seminal vesiculitis. Microscopic ex-
aminations of the urethral discharge would, of course, help mate-
rially to differentiate the conditions.

For convenience of description, we divide this subject into
three general classes: (i) Those in which there is some organic
disease of the urinary or sexual apparatus. (2) Those in which
the condition is due to a general disease or habit, to a mental de-
fect, or to a lesion of the nervous system. (3) Those cases in
which there is a combination of the general disease or mental dis-
order, with actual lesions or pathologic disturbances in the genito-
urinary tract. This last class would, therefore, be a mixed one,
made up of members of the other two classes in some of whom the
organic disturbances, and in others the psychic phenomena, would
predominate.

Class I. — In considering the first class, — those patients in
whom there exists some essential organic lesion in the genito-
urinary tract, — we find that chronic posterior urethritis and pros-
tatitis, onanism, coitus reservans, and too frequent sexual inter-
course may be considered as the four principal causative factors.
Examination of these cases gives evidence that chronic catarrhal
and inflammatory conditions of the prostate and of the seminal
vesicles are often due to these causes. It is believed by some that,
clinically, these conditions of the prostate and seminal vesicles
present different pictures, varying according to their respective
causes.

582 SEXUAL NEUROSES

The clinical symptoms — and this refers to a chronic and not to
an acute inflammatory state — are a burning sensation during, and
an increased desire for, micturition and a sensation of burning
and pressure in the bladder and perineum. Endoscopic examina-
tion shows that the colHculus seminalis may be much enlarged, and
the pars prostatica chronically inflamed. In addition, an excitable
sexual weakness may be present. Finger believes that the excit-
able weakness from sexual excess and that from coitus reservans
resemble each other closely, whereas excitable weakness due to
onanism resembles that due to chronic urethritis, except that it is
somewhat slower in presenting itself. Clinically, the symptoms
due to coitus reservans, occurring as they generally do in men of
middle age or over, resemble very much the earlier symptoms of
prostatic hypertrophy. In fact, any one of the four causes men-
tioned may, in time, become the exciting factor of prostatic hyper-
trophy, owing to the formation of cicatricial tissue, the result of
the chronic inflammation closing up the mouths of the prostatic
acini; or it may be the cause of prostatic atrophy, owing to the
formation of cicatricial tissue between the acini, which compresses
them, and is followed by parenchymatous atrophy. A reference to
the pathology of this condition will be found under the head of
Diseases of the Prostate.

Among the abundant proofs that the inflamed conditions men-
tioned are traceable to the four causes given are the evidences
of chronic inflammation existing at the neck of the bladder ; these
evidences consist of the presence of shreds, lecithin bodies, and ex-
cessive numbers of leukocytes in the urine; and, as revealed by
the endoscope, a chronic inflammatory condition with enlarge-
ment of the colliculus in the pars prostatica. It seems reasonable
to assume that, as this chronic inflammatory condition takes place,
it causes a similar condition of the nerve-endings in that portion
of the body ; and that this interferes with the proper conductiv-
ity between the nerves and the spinal cord and brain, giving rise
to a complication that may be termed a sexual neurasthenia. The
inflammatory conditions, their causes, relation, and the symptoms
they give rise to are well demonstrated.

Further, in addition to the symptoms previously cited, there
are present the manifestations of general neurasthenia. Follow-

SEXUAL NEUROSES 583

ing the stage marked by frequent pollutions and early ejaculations,
a second stage generally succeeds, according to Casper, charac-
terized by neuralgia of the lumbosacral plexus and impaired
potency; this is followed by a third stage, in which the neu-
rasthenia may extend up the spinal cord, causing a cerebro-
spinal neurasthenia. With this multiplicity of symptoms there
are associated derangements of the circulatory and digestive
apparatus.

The differential diagnosis between sexual neurasthenia and
neurasthenia due to some other cause, but in which there may be
disturbances of the sexual function as a symptom, is, however,
extremely difficult. These cases of general neurasthenia, which
are more often due to heredity, worry, or malaria than to any
other factors, may be differentiated from sexual neurasthenia in the
following manner :

In general neurasthenia there is no disease of the pars prostatica
or but so slight an organic disturbance that it is not in itself suf-
ficient to give rise to the condition. In these patients, as would
be expected, the disease-picture is a changing one. If they are
impotent or semi-impotent, there are times when normal potency
alternates with excitable weakness, and these symptoms follow
one another at short intervals. Sexual symptoms in these cases
run parallel with the other symptoms of neurasthenia, or a cer-
tain alternation of symptoms is noticeable — as, for instance,
those of sexual neurasthenia predominating one day, gastric
symptoms another, and the symptoms of cerebrospinal neuras-
thenia another. In sexual neurasthenia, on the other hand,
sexual symptoms are constantly evident, perhaps combined
in greater or less degree with the general neurasthenic manifes-
tations.

The writers have endeavored to describe briefly the symptoms
and the pathology, so far as they are known up to the present
time, of what may properly be termed sexual neurasthenia, which,
as the reader will easily perceive, also embraces certain forms
of impotence, spermatorrhea, and similar conditions.

Space does not permit a consideration of all the conditions that
could properly come under the first division. Impotence due to
trauma, malformations of the genital apparatus, ulceration, gan-

584

SEXUAL NEUROSES

grene, neoplasm, small frenum, warts, and elephantiasis could all
be considered in this class. It may be due to shrinking of the
corpora cavernosa, in whole or in part,
which may occur as the result of age.
Hydrocele, epididymitis, and orchitis all
belong here. Sterility may also be due
to some of the above causes.

The prognosis for the cure of the pa-
tients in this class is that for the cure of
the inflammatory conditions, the neuras-
thenia, and the impotence, and is good in
those cases in which the original cause can
be made out and eradicated.

Treatment. — The exciting cause should
be removed, the general health improved,
and proper local treatment instituted for
the chronic inflamed condition at the
neck of the bladder if this be present.
If removing the cause and building up the
general health are not sufficient, mental
therapeutics may do good. Some benefit
may accrue from giving the patient a clear
description of his condition. Tonics of
iron, manganese, and phosphorus are to
be prescribed. Sea-bathing, exercise in
the open air, and some occupation that will
divert the patient's mind from the local
disturbance should be recommended.

The local treatment should be carried
out with the vitmost gentleness, as these
neurasthenic patients are very easily irri-
tated and react badly to any treatment
that is at all heroic. The passing of a silk
bougie, followed later by the Kollmann
dilator, irrigations or instillations of
weak solutions of silver nitrate, and pros-
tatic massage may all be employed tentatively and their effect
observed. The application of an ointment, for example, one con-

Fig.27S. — Meschung sound for
application of cold.

SEXUAL NEUROSES 585

taining i per cent, of aristol, on a grooved sound or on a Young's
ointment applicator will prove of benefit. By introducing a
straight endoscope and touching the colliculus once a week with a
silver nitrate solution (10 per cent.) applied by means of a cotton-
wound applicator, good may be accomplished. An instrument
known as the psychrophore, or a Meschung sound, by means of
which cold can be applied to the prostatic urethra, has been recom-
mended in the treatment of such cases by many writers. It is
somewhat inconvenient to use, and probably gives no better results
than can be obtained from the use of the other methods previ-
ously mentioned. Above all, sexual continence or the regulation
of the sexual life, as by marriage, is to be recommended.

If the functional disturbances are due to new-growths, ulcera-
tion, gangrene, too short a frenum, or other malformation, proper
surgical treatment should be instituted. Sterility is not infre-
quently due to the past effects of a double epididymitis, but cases
due to malformation have also occurred. Gyurkowchty's exami-
nation of 6000 young men, however, showed malformations pres-
ent in only three.

Where a double orchi-epididymitis, causing a stenosis of the vas
deferens, is responsible for steriUty, an operation for its rehef
may be performed ; this is done by anastomosing the vas deferens
by an incision about three-fourths of an inch long with the back of
the epididymis. This operation is difficult to perform on account
of the small caliber of the vas deferens. A small buttonhole may
be made in the vas, and a suture run through each angle, uniting
with the incision in the epididymis. This operation has been per-
formed in comparatively few cases, and complete reports concern-
ing it have not been published ; it seems, however, to have been
successful in some cases.

It should be remembered that in some cases a previous organic
lesion of the deep urethra may have been treated and cured, and
yet later, for some reason, a general neurasthenia may develop.
Such patients would belong to class 2, and should be referred to
the family physician or to the neurologist for treatment.

Class 2. — As in this class of patients the disorder is due to a
general defect or to a disturbance of the nervous system, it
embraces those in whom the functions of the sexual apparatus

586 SEXUAL NEUROSES '

are disorganized because of some diseased condition organically
independent of the sexual organs. General acute diseases, such
as typhoid fever and pneumonia, or the chronic general diseases,
such as nephritis, malaria, and conditions in which there is in-
volvement of the spinal cord, as locomotor ataxia, myelitis, and the
like, may interfere with the sexual functions. This is especially
evident in certain drug habits, as in alcoholism, morphinism, and
the like. Certain psychic causes would also come under this head,
e. g., psychic paresthesia, which may provoke seminal emissions
without erection. Preponderance of psychic inhibition, insuf-
ficient stimulation of excitable centers, or sudden disturbances of
reflex action may all tend to disturb the sexual function. The
various forms of intoxication, as, for example, diabetes and lead-
poisoning, could be considered as coming under this head, and
may tend to cause functional disturbances or impotence, and
cause the libido to be retained.

It is very interesting to observe how carefully and dogmati-
cally some writers, particularly the Germans, have classified these
various causes, which, after all, are only conjectural, attributing
impotence to too small a center in the brain to cause the proper
reflex activity that gives rise to erection, or to too weak a stimula-
tion in the brain center supposed to regulate the sexual act. Al-
though, as previously stated, the treatment of this class of patients
should properly be relegated to the family physician or the neurol-
ogist, the surgeon should, nevertheless, be sufficiently familiar
with mental and nervous diseases to be able to differentiate them
from organic disease of the sexual apparatus. The mistake is
frequently made of overlooking organic diseases of the spinal cord.

Treatment will necessarily consist primarily in the elimination
of the causative factors.

Class 3. — This being a mixed class, in which there is a combina-
tion of general or mental disorders with the presence of actual
lesions in the genito-urinary tract, the diagnosis is particularly
difficult. There may be two or three different factors at work,
and these belong in class i or 2. As fairly representative of this
third class may be mentioned the not uncommon case of a man
with a slight chronic posterior urethritis, whose mind is immovably
fixed on his urethra, to the exclusion of all else ; or that of a man

SEXUAL NEUROSES 587

suffering from some general disease, such as neurasthenia due to
malaria, lead-poisoning, or the early stages of tuberculosis. Such
a patient generally presents evidences of some slight organic dis-
ease, most often of the deep urethra, and this is not infrequently
overtreated and too little attention given to the constitutional
disorder. On the other hand, when the treatment is undertaken,
enough attention may not be given to the symptoms in the urinary
tract, all the efforts being directed toward improving the patient's
general condition.

In this class of cases the prognosis as regards the recovery of
loss of function of the sexual apparatus is dependent upon so
many factors that no general statement can be made. In these
patients, more than in those of the other two classes, success is
largely the result of good judgment and skilful treatment by sur-
geon or physician. When the varying causes that play a part in
the disturbance can be ascertained, the physician may be able to
institute a course of treatment that will restore the normal condi-
tion, whereas the surgeon, confined to a narrower field, might be
unable to accomplish equal results.

Obviously, no definite general plan of treatment can be laid
down for patients of this class. The case must be treated as a
whole, attention being first directed to the dominant conditions.
Incidentally all local lesions of an irritative character should re-
ceive proper local or general treatment; there is, however, no
more severe test of the physician's judgment and ability than is
demanded for the successful management of these cases.

INDEX.

Abdominal nephrectomy, 268
Ablation of kidney, 275
Abscess of Cowper's glands, 424
treatment, 425
of Littre's glands after urethritis,

371
of prostate, 505

treatment, 505
peninephritic, 162
peri-urethral, in female, 440

Absence of kidney, 2 1 3

Acetone in urine, 94

Acid, phosphoric, in urine, 92
sulphuric, in urine, 92
uric, 91, 134
urine, substances in, loi

Actinomyces fungi in urine, 104

Adenocarcinoma of bladder, 308

Adenocystoma, papillomatous, of tes-
ticle, 551

Adenoma of kidney, 245
of testicle, 552

Afferent artery, 130

Albarran's method of estimating
excretory activity of kidneys, 74

Albuminuria, 93

exophthalmos in, 148

Alexander's operation for hypertro-
phy of prostate, 514

Alkaline urine, substances in, 103

Amaurosis, uremic, 150

Amblyopia, uremic, 150

Ammonio-magnesium phosphate in
urine, 103

Ammonium urate in urine, 103

Amputation of penis, 457
in continuity, 459

Amyloid casts in urine, 100

Anastomosis, lateral, of ureters, 289
Israel's operation, 290
rectal, of ureters, 293

Anemia in nephritis, 140, 141
treatment of, 141
of prostate, 483

Anesthesia, 86

apparatus, Ferguson's, 87

Angioma of kidney, 245

Anomalies in arterial supply of kid-
neys, 216

Aplasia of bladder, 299
Arnott's probe, 420
Arteria rectae, 1 29
Arterial arcade of kidney, 1 29

supply of kidneys, anomalies in,

216
Arteries, helicine, 463
Artery, afferent, 130

efferent, 130
Atony of bladder, 301

treatment, 301
Atrophy of testicle, 542

treatment of, 574

Bacillus, colon, in urine, 104

green-pus, in urine, 103

proteus, in urine, 104

smegma, in urine, 104

timothy hay, in urine, 104

tubercle, in urine, 104
Bacteria, Gram's method of staining,

in urine, 103

as cause of suppurative nephritis,
i6i
Bacterial content in gonorrheal ure-
teritis, III
in simple urethritis, 109
Balanitis prseputialis, 462
Bandage, scrotal, 560, 561
method of applying, 85
triangular, method of forming, 84
Beck's operation for hypospadias of
glans, 454
for scrotal hypospadias, 455
Bertini's columns, 128
Bessel-Hagen's operation for plastic
repair of denudations of skin of
penis, 446
Bevan's operation for inguinal reten-
tion of testicle, 571
Bierhoff cystoscope, 61

modification of Nitze-Albarran

cystoscope, 66
supports for legs in cystoscopy, 58
Bigelow's evacuator, 322

lithotrite, 322
Bile-pigments in urine, 95

589

590

INDEX

Bistoury, Gouley's, 421

Bladder, abnormities in shape and

size of, 300
adenocarcinoma of, 308
anatomy of, 298
aplasia of, 299
atony of, 301

treatment, 301
blood-supply of, 299
carcinoma of, 308
continuous catheterization of, in

Bright's disease, 275
dilatation of, 300
diseases of, 299

diagnosis, 310

treatment, 310
distortion of, 300
diverticulum of, 300, 360
epithelioma of, 308
evacuator and obturator, Chis-

more's, 324
exstrophy of, 299

Bottomley's operation for, 352

diagnosis, 347

Harrison's operation for, 354

Maydl's operation for, 348-350

Segond's operation for, 351-353

Sonnenberg's operation for, 346,

347

treatment, 347
extirpation of, total, 357
fibroma of, 307

foreign bodies in, diagnosis of, 345
cystoscopic appearances in, 59
treatment of, 345
hernia of, 358

diagnosis, 358

treatment, 359
inflammation of, 303. 'See also

Cystitis.
injuries of, diagnosis, 354

treatment, 355
malformations of, acquired, 300

congenital, 299
mucous coat of, 299
muscular coat of, 298
myoma of, 307
myxoma of, 307
nerve-supply of, 299
papilloma of, 306
pathology of, 299
perforations of, 301
physiology of, 298
puncture of, 328
rupture of, 300, 355

diagnosis, 355

treatment, 356
sarcoma of, 309
serous coat of, 298
stone in, cystoscopic appearances
in, 59

Bladder, stone in, diagnosis of, 318
litholapaxy for, 322
remarks on removal of, 328
suprapubic cystotomy for, 329

lateral incision, 336
symptoms of, 319
treatment of, 318
submucous coat of, 299
syphilitic disease of, 305
tumors of, 305

cystoscopic appearances in, 59
diagnosis, 340
innocent, 306
malignant, 307
treatment, 340
wounds of, diagnosis, 354
treatment, 355
Blindness, uremic, 150
Blood in acute nephritis, 140

in chronic interstitial nephritis, 142
in diseases of kidney, 139
in nephritis, 140
in new-growths of kidney, 140
in parenchymatous nephritis, 141
in tubercular nephritis, 140
in uremia, 142
Blood-casts in urine, 100
Blood-corpuscles, red, in urine, 100
Blood-pressure and pulse chart, 146

in diseases of kidney, 144
Blood-supply of bladder, 299
of kidney, 1 26

minute anatomy, 129
of testicles and epididymis, 541
Bottomley's operation for exstrophy

of bladder, 352
Bougie, Greene's, 413
Bougies, 35
k boule, 37
filiform, 36
Bowels, condition of, in examining, 19
Bowman's capsule, 123, 128
Bridge for support of scrotum in

epididymitis, 559
Bright's disease, 166

acute> pathology of, 167
symptoms of, 177
treatment of, 182
chronic degenerative type of,
pathology, 175
diagnosis of, 178
food in, 190

personal hygiene in, 187
treatment of, 186
continuous catheterization of

bladder in, 275
course of, 177

decapsulation of kidney in, 276
diagnosis of, 177
operative treatment of, 275
pathology of, 166

INDEX

591

Bright' s disease, prognosis of, 180
symptoms of, 177
treatment of, 181
surgical, 275
Brown's ureter-catheter cystoscope,

62
Bry son's operation for hypertrophy

of prostate, 514
Bubo, 448

Cabot's curet and forceps for bladder-
work for use with cystoscope, 62
Cachexia in cancer of prostate, 534
Calcium carbonate in urine, 103
Calcium-oxalate crystals in urine, 102
Calculus in urethra, 449
prostatic, 507
renal, 234

diagnosis, 239
nephrotomy for, 265
pathology, 234
pyelotomy for, 266
symptoms, 238
treatment, 240
ureteral, 280

operations for, 296
vesical, diagnosis of, 318
litholapaxy for, 322
remarks on removal of, 328
suprapubic cystotomy for, 329

lateral incision, 336
symptoms of, 319
treatment of, 318
Calices of kidney, 1 28
Capsule, fibrous, of kidney, 127

of Bowman, 123, 128
Caput gallinaginis, 480
Carcinoma, chimney-sweep's, 552
of bladder, 308
of female urethra, 442
of kidney, 246

of penis and gumma of penis, dif-
ferentiation, 459
of prostate, 532
age occurring, 534
cachexia of, 534
frequency of, 532
hematuria in, 536
pain in, 535 . .
physical examination in, 536
prognosis, 536
treatment of, 536
curative, 537
palliative, 537
preventive, 536
of testicle, 552
Caruncles of female urethra, 443
Castration, 568
Casts, amyloid, in urine, 100
blood-, in urine, 100

Casts, epithelial, in urine, 100
fatty, in urine, 100
granular, in urine, 100
hyaline, in urine, 100
in urine, 99
pus-, in urine, 100
waxy, in urine, 100
Catarrhal cystitis, 304
urethritis, acute, 367
chronic, 367
Catheter, Hutchinson'Si for applying
ointments to urethra, 389
life, 512
Malecot, 35
Mercier's, 410
bicoude, 34
coude, 34
Pezzer, 35
Ultzmann's, 41
Catheterization, 41

continuous, of bladder, in Bright's

disease, 275
method of passing instrument in, 42
of ureters, 60

with reverse cystoscope, 66
with ureteral catheter cystoscope
of straight type, 63
Catheters, 32

Cells epithelial, in gonorrheal ure-
thritis, no
in simple urethritis, 108
pus-, in gonorrheal urethritis, no

in urine, 97
sustentacular, 539
Cercomonas intestinalis in urine, 104
Cervical secretion, examination of,

119
Chancre of penis, 448
Chancroid of penis, 448
Chemic composition of urine, 133
Chimney-sweep's cancer, 552
Chismore's bladder evacuator and
obturator, 324
evacuating lithotrite, 323
Chlorids in urine, 91
Chondroma of testicle, 552
Chyluria, 95
Circumcision, 464

in adult, 465
Cloudy urine, 30
Collecting tulaule of kidney, 129
Colon bacillus in urine, 104
Columns of Bertini, 128

of Sertoli, 539
Compensation in renal disease, 134
Compensatory hyperplasia of kidney,

137
Condyloma of female urethra, 443
Conjugate sulphates in urine, 92
Conjunctiva, edema of, in renal dis-
eases, 148

592

INDEX

Conjunctivitis, gonorrheal, 392
Convoluted tubules, 539
Corpora cavernosa, 362
Corpus highmorianum, 538

spongiosum, 363
Corpuscles, red, in urine, 96
Cortex of kidney, 127
Cowperitis, urethral exudate in, 115
Cowper's glands, 365
abscess of, 424
treatment, 425
Crisis, Dietl's, 218
Crura of penis, 362
Cryptorchidism, 542
Crystalline deposits in urine, loi
Crystals, calcium-oxalate, in urine,

102
Cylindroids in urine, 99
Cystic kidney, 214

tumors of testicle, 551
parasitic, of testicle, 551
Cystin in urine, 102
Cystitis, 303

acute, cystoscopic appearances in,

57

diagnosis of, 311

symptoms of, 311

treatment of, 311
catarrhal, 304

chronic, cystoscopic appearances
in, 57

diagnosis of, 313

treatment of, 313
internal, 313
local, 314
diagnosis of, 311
etiology of, 303
gonorrheal, 311

non-tubercular ulcerative, cysto-
scopic appearances in, 58
phlegmonous, 305
purulent, 304
treatment of, 311
tubercular, 305

cystoscopic appearances in, 59

diagnosis of, 315

treatment of, 315
Cystoscope, Bierhoff's, 61
Brown's, 62
Lewis', 61
Meyer's, 55

Nitze-Albarran, Bierhoff's modifi-
cation of, 66
Nitze's, 54

operating, 57
reverse, catheterization of ureters

with, 66
Shapiro, 57
Cystoscopic appearances, 57

in acute cystitis, 57

in chronic cystitis, 57

Cystoscopic appearances in foreign
bodies in bladder, 59
in non-tubercular ulcerative cys-
titis, 58
in stone in bladder, 59
in tubercular cystitis, 59
in tumors in bladder, 59
Cystoscopy, 54

position of patient in, 56
practical, 56
Cystostomy, 337

Cystotomy, suprapubic, for removal
of prostate, 520
for stone in bladder, 329
lateral incision, 336
Cysts, dermoid, of testicle, 551
hydatid, of kidney, 243
multilocular, of spermatic cord, 555
of ureter, 279
retention, of testicle, 551

Decapsulation of kidney in Bright's

disease, 276
Defects, congenital, of prostate, 481
Dermoid cysts of testicle, 551
Dietl's crisis, 218
Dilatation of bladder, 300

of female urethra, 439
treatment, 439
Dilators, Kollmann's, 407
Displaced kidney, 217
Displacements of kidney, 213
Distortion of bladder, 300
Diverticulum of bladder, 300, 360
Double pyonephrosis, 158
Drainage in nephrotomy, 262

EcHiNOCOCCUS booklets in urine, 104

Edebohls' incision for nephrectomy,

271

in operations on kidney, 254

method of fixation of kidney, 260

of nephropexy, 260
pad for operations on kidneys, 255
Edema of conjunctiva in renal dis-
eases, 148
of eyelids in renal diseases, 148
Efferent artery, 130
Elephantiasis of scrotum, 555

treatment of, 579
Embolic infarction of kidney in sup-
purative nephritis, 160
Encysted hydrocele of cord, treat-
ment of, 567
Endocarditis, gonorrheal, 402

treatment, 403
Endoscope, Valentine's, 51
Endoscopy, 50
Endothelioma of testicle, 552

INDEX

593

urinary

urinary

Epididymectomy, 567
Epididymis, auatomy of, 538

blood-supply of, 541

body of, 540

head of, 540

lymphatics of, 541

nerve-supply of, 541

tail of, 540
Epididymitis, 547

acute, 548

bridge for support of scrotum in,

559

chronic, 548

diagnosis of, 548

medicinal treatment of, 557

symptoms of, 548
Epispadias, 456

Thiersch's operation for, 456
Epithelial casts in urine, 100

cells in gonorrheal urethritis, no
in simple urethritis, 108
Epithelioma of bladder, 308
Epithelium in urine, 97
Erythrocytes in urine, 96
Evacuator, Bigelow's, 322
Examination, caliber of
stream in, 21

character of urine in, 23

condition of bowels in, 19

diminished amount of
excretion in, 20

history of previous diseases in, 23

incontinence of urine in, 22

inspection in, 24

instrumental, 31
of kidney, 60

methods of, 17

microscopic, of urine, 95

micturition in, 20

of kidneys, for diagnostic purposes,
252

of prostate, 27

of secretions, 29

of urethral exudate, 104

of urine, 88

of vagina, 29

physical, 25

questions in, 17, 18

sexual life in, 24

urethral discharge in, 19

urinary retention in, 22
Exophthalmos in albuminuria, 148,

149
Experimental polyuria test for per-
meability of kidney, 74
Exploration of kidney, operations

for, 254
Exstrophy of bladder, 299

Bottomley's operation for, 352

diagnosis, 347

Harrison's operation for, 354

38

Exstrophy of bladder, Maydl's opera-
tion for, 348-350
Segond's operation for, 351-353
Sonnen berg's operation for, 346,

347
treatment of, 347
Extirpation of bladder, total, 357
Exudate, examination of, from female
genitals, 118
urethral, examination of, 104
in chronic gonorrheal urethritis,

1 12
in Cowperitis, 1 1 5
in gonorrheal urethritis, 109
in prostatitis, 113
in simple urethritis, 108
in vesiculitis, 1 14
purulent, 105
Eye, gonorrhea of, from urethritis,
392
prognosis, 393
symptoms, 393
treatment, 393
hemorrhage of, in renal diseases,
148
Eyelids, edema of, in renal diseases,
148

Fat in urine, 95
Fatty casts in urine, 100
Female genitals, examination of secre-
tions and exudates from, 118
Fenwick's operation of suprapubic

enucleation of prostate, 522
Ferguson's anesthesia apparatus, 87
Fibroma of bladder-wall, 307
of kidney, 244
of prostate, 530
of testicle, 552

polypoid, of female urethra, 444
Fibrous capsule of kidney, 127
Filaria sanguinis hominis in urine,

104
Filiform bougies, 36
Fistula of ureter, 282

urethral, in pendulous urethra,
operation for, 427
operations for, 427
perineal, operations for, 428
urethrorectal, diagnosis, 430
operations for, 429
prognosis, 430
treatment, 430
local, 431
operative, 432
palliative, 431
Tuttle's operation for closure of,

431 . . ,.

urethrorectopenneal, diagnosis, 430

operations for, 429

594

INDEX

Fistula, urethrorectoperineal, prog-
nosis, 430
treatment, 430
local, 431
operative,' 432
palliative, 431
Floating kidney, 216
fixation of, 258
Forceps, Thompson's urethral, 449
Foreign bodies in bladder, cysto-
scopic appearances in, 59
diagnosis of, 357
treatment of, 357
in urethra, 449
Formaldehyd sterilizer, 79
Fossa navicularis, 366
Fractures of penis, 447
Fragments of tumors in urine, 98
Freyer's method of removmg pros-
tate, 523
tube, 335
Fuller's incision for removal of semi-
nal vesicles, 474, 476
Fungi, actinomyces, in urine, 104
Fusion of kidneys, 213

Genitals, female examination of

secretions and exudates from, 118
Genito-urinary system, neuroses of,
580
prognosis, 584, 587
treatment, 584, 586, 587
German method of abortive treat-
ment of urethritis, 379
Gersuny and Witzel's operation for

inguinal retention of testicle, 573
Glands, Cowper's, 365
abscess of, 424
treatment, 425
Littre's, 366

abscess of, after urethritis, 371
Tyson's, 364
Glans penis, 363
Glass syringes, 40

tests for locating seat of urethritis,
30, 375
Globus major, 540
Glomerulus, 124
of kidney, 130
Goldhorn's stain for spirochaeta pal-
lida, 121
Gonococcus, biologic characteristics
of, 368
in gonorrheal urethritis, 1 10
in urine, 103
Gonorrhea of eye from urethritis, 392
prognosis, 393
symptoms, 393
treatment, 393
of mouth from urethritis, 392

Gonorrhea of rectum from urethritis,

392
Gonorrheal conjunctivitis, 392
cystitis, 31 1
endocarditis, 402
treatment, 403
iritis, 396
rheumatism, 397
causes, 397
course, 398
diagnosis, 399
prognosis, 400
treatment, 400
urethritis, 367. See also Urethritis.
Gorget, Teale's, 417
Gouley's bistoury, 421

points of whalebone guides, 412
sound and guide, 411
Gram -negative organisms, 108
Gram-positive organisms, 108
Gram's method of staining bacteria,

107
Granular casts in urine, 100
Gravity, specific, of urine, 89
Greene and Brooks' abortive treat-
ment of urethritis, 378
Greene's bougie, 413
Green-pus bacilli in urine, 103
Gumma of kidney, 21 1

of penis and cancer of penis, dif-
ferentiation, 459
Guyon's tube, 335

Harrison's operation for exstrophy

of bladder, 354
Hay bacilli, timothy, in urine, 104
Hayden-Janet syringe, 40
Helicine arteries, 363
Hematoma of spermatic cord, 555

treatment, 555
Hematuria in cancer of prostate, 536
Hemorrhage in nephrectomy, 271

of eye in renal diseases, 148
Henle's ascending loop, 129

descending limb, 129

loop, 129
Hernia of bladder, 358
diagnosis, 358
treatment, 359
Hodgkin's disease, tumor-like masses

in kidney in, 247
Horseshoe kidney, 214
Hutchinson's catheter for applying

ointments to urethra, 389
Hyaline casts in urine, 100
Hydatid cysts of kidney, 243
Hydrocele, 553

acute, 554

chronic, 554

encysted, treatment of, 567

INDEX

595

Hydrocele, operation for, 561

tapping of, 562
Hydronephrosis, 219
acquired, 222
congenital, 221
diagnosis, 224
etiology, 220
in predisposing to suppurative

nephritis, 159
pathologic anatomy, 220
results, 224
surgery of, 285
symptoms, 224
treatment, 225

Trendelenburg's operation for, 287
Hydronephrotic sac, resection of, 289
Hyperemia of prostate, 483
Hypernephroma, 247
of prostate, 530
of testicle, 552
Hyperplasia, compensatory, of kid-
ney, 137
Hypertrophy of prostate, 485

Alexander's operation for, 514
Bryson's operation for, 514
diagnosis, 508
operations for, 514
pathology of, 487
symptoms of, 486, 510
treatment of, 511
operative, 514
Hypochondriasis in chronic prosta-
titis, 502
Hypoplasia of testicle, 541
Hypospadias, 450

of glans. Beck's operation for, 454

operations for, 453

scrotal. Beck's operation for, 455

operations for, 455
varieties, 453

Incision, Edebohls', for nephrec-
tomy, 271
in operations on kidney, 254
for removal of seminal vesicles
474, 476
Israel's in operations on kidney,

254
for nephrectomy, 270
Kocher's, for removal of seminal

vesicles, 473, 475
Kraske's, for removal of seminal
vesicles, 472, 475
Rydygier's modification
of, 472, 475
loin, in operations on kidney, 254
Senn's, for removal of seminal vesi-
cles, 474, 475
transverse, in operations on kid-
ney, 254

Incision, Von Dittel's, for removal of
seminal vesicles, 473, 475
Zuckerkandl's, for removal of semi-
nal vesicles, 473, 475
Incontinence of urine in children, 302

in examining, 22
Indican in urine, 94
Indigo-carmin test for permeability

of kidney, 74
Infarction, embolic, of kidney, in
suppurative nephritis, 160
of kidney in acute infectious dis-
eases, 154
uric-acid, 237
Infectious diseases, acute, diseases of
kidney in, diagnosis of,
156
prognosis of, 1 56
treatment of, 156
infarction of kidney in, 154
kidney in, 152

nephritis in, prognosis of, 155
treatment of, 155
Inflammation of bladder, 303. See
also Cystitis.
of ureters, 279
Inguinal retention of testicle, treat-
ment for, 571
Inspection in examination, 24
Instrumental examination, 31

of kidney, 60
Instruments, urethral, care of, 77
lubricants for, 81
sterilization of, 78
Interstitial nephritis, chronic, blood

in, 142
Iritis, gonorrheal, 396
Israel's incision for nephrectomy, 270
in operations on kidney, 254
method of lateral anastomosis of
ureter, 290

Janet syringe, 40

Janeway's sphygmomanometer, 144

KaTHETERPURINE, 82

Keetly's operation for inguinal reten-
tion of testicle, 571
Kidney, 123

ablation of, 275

absence of, 213

adenoma of, 245

amount of work done by, 73

anatomy of, 124

angioma of, 245

arterial arcade of, 129

supply of, anomalies in, 216

blood-supply of, 1 26
minute anatomy, 129

596

INDEX

Kidney, calices of, 128
carcinoma of, 246
collecting tubule of, 129
compensatory hyperplasia of, 137
congenital lobulation of, 213
cortex of, 127
cystic, 214

decapsulation of, in Bright's dis-
ease, 276
diseases of, blood in, 1 39

blood-pressure in, 144
compensation in, 134

edema of conjunctiva in, 148
of eyelids in, 148

hemorrhage of eye in, 148

in acute infectious diseases,
diagnosis of, 156
prognosis of, 156
treatment of, 156

ocular manifestations, 148
displacements of, 213, 217
distal tube of 1 29
embryology of, 123
examination of, for diagnosis, 252
fibroma of, 243
fibrous capsule of, 127
floating, 216

fixation of, 258
fusion of, 213
glomerulus of, 130
gumma of, 211
horseshoe, 214
hydatid cysts of, 243
in acute infectious diseases, 152
in syphilis, 210
infarction of, in acute infectious

diseases, 154
injuries of, 229

prognosis, 231

treatment, 232
instrumental examination of, 60
irregular tubule of, 1 29
labyrinth of, 127
lesions of, in uremia, 197
lipoma of, 244
lymphatics of, 1 26
malformations of, 213

congenital, 213
malposition of, congenital, 214
medulla of, 127
medullary rays of, 127
movable, 216

diagnosis of, 217

Dietl's crisis in, 218

fixation of, 258

Edebohls' method, 260

pathology of, 216

treatment, 218
myoma of, 245

new-growths of, blood in, 140
operations for exploration of, 254

Kidney, operations on, 252
papilloma of, 245
pelvis of, 128

lavage of, 277
permeability of, experimental poly-
uria test for, 74
indigo-carmin test for, 74
methylene-blue test for, 71
phloridzin test for, 70
tests for, 69
physiology of, 130
proximal convoluted tubule of, 1 29
pyramids of, 128
rhabdomyoma of, 245
sarcoma of, 246
second tube of, 129
sensory nerve-supply of, 127
spiral tube of, 1 29
stone in, 234
diagnosis, 239
nephrotomy for, 265
pathology, 234
pyelotomy for, 266
symptoms, 238
treatment, 240
suppurative diseases of, polynu-

clear leukocytosis in, 139
surgery of, 252
tuberculosis of, 204. See also

Tuberculosis of kidney.
tumor-like masses in, in lympho-
sarcoma, 247
tumors of, 243

diagnosis, 249
nephrectomy in, 274

treatment, 251
wounds of, 227
prognosis, 227
treatment, 228
Kinks of ureters, 282
Knife, Rand's, 419
Kocher's incision for removal of semi-
nal vesicles, 473, 475
Kollmann's dilators, 407

method of diagnosing urethritis, 375
probe, 52
Kraske's incision for removal of semi-
nal vesicles, 472, 475
Rydygier's modification
of, 472, 475
Kiister's operation for stricture of
ureter, 286

Labyrinth of kidney, 127
Lacunae of Morgagni, 366
Lavage of pelvis of kidney, 277
Leucin in urine, 102
Leukocytes in urine, 97
Leukocytosis, polynuclear, in suppu-
rative diseases of kidney, 139

INDEX

597

Lewis' dilating bulb, 6i

double ureter-cyst oscope, 6i

Lipoma of kidney, 244

Litholapaxy, 322
technic of, 324

Lithotrite, Bigelow's, 322
Chismore's evacuating, 323

Littre's glands, 366

abscess of, after urethritis, 471

Lobulation, congenital, of kidneys, 213

Loffler's methylene-blue stain, 106

Loin incision in operations on kidney,

254
Loop of Henle, 1 29
Lubricants for urethral instruments,

81
Lymphatics of kidney, 126

of testicles and epididymis, 541
Lymphosarcoma, tumor-like masses

in kidney in, 247

Maisonneuve's urethrotome, 414
Malecot catheter, 35
Malformations, congenital, of female
urethra, 436

of bladder, acquired, 300
congenital, 299

of kidney, 213
congenital, 213

of ureters, 279
Malignant tumors of bladder, 307
of female urethra, 442

treatment, 443
of testicle, 552
Malpighian body, 1 23, 1 28
Malposition, congenital, of kidneys,

214
Massage, prostatic, in chronic prosta-
titis, 498
Maydl's operation for exstrophy of

bladder, 348-350
Mayo attachment to surgical table

for operations on kidney, 255
Meatotome, Otis', 404
Meatotomy, 403
Meatus urinarius, 366

stricture of, from urethritis, 403
Mediastinum testis, 538
Medulla of kidney, 127
Medullary rays of kidney, 127
Membranous urethra, anatomy of, 365
Mercier's bicoude catheter, 34

catheter, 410

coude catheter, 34
Meschung's sound, 584
Mesonephros, 1 23

Metamorphosis, fatty, of testicle, 543
Metanephros, 123
Methylene-blue stain, Loffler's, 106

test for permeability of kidney, 71

Meyer's cystoscope, 55

Micro-orchia, 541

Microscopic examination of urine, 95

Micturition in examining, 20

Monorchidism, 542

Morgagni, lacunae of, 366

Mouth, gonorrhea of, from urethritis,

392
Movable kidney, 216

diagnosis of, 217

Dietl's crisis in, 218

fixation of, 258

Edebohls' method, 260

pathology of, 216

treatment, 218
Mucus in urine, 97
Myoma of bladder, 307

of kidney, 245
Myxoma of bladder, 307
of prostate, 530

Nephrectomy, 266
abdominal, 268
by morcellement, 273
Edebohls' incision for, 271
hemorrhage in, 271
in tumors of kidney, 274
Israel incision for, 270
partial, 268
remarks on, 270
transperitoneal, 268
Nephritis, acute, blood in, 140
treatment of, 182
anemia in, 140, 141
treatment of, 142
blood in, 140

chronic inflammatory variety of,
pathology, 173
interstitial, blood in, 142
treatment of, 186
in acute infectious diseases, prog-
nosis of, 1 55
treatment of, 155
ophthalmoplegia in, 149
parenchymatous, blood in, 141
retinitis in, 149, 150
suppurative, 157

bacteria in urine as cause of, 161

causes of, 157

diagnosis of, 162

embolic infarction of kidney in,

160
hydronephrosis in predisposing

to, 159
treatment of, 165
treatment of, 181
tubercular, blood in, 140
Nephropexy, 258"

Edebohls' method, 260
Nephrostomy, 262

598

INDEX

Nephrotomy, 262

drainage in, 262

for stone in kidney, 265
Nerve-supply of bladder, 299

of testicles and epididymis, 541

sensory, of kidneys, 127
Neurasthenia in chronic prostatitis,
502

sexual, 583
Neuroses of sexual organs, 580
prognosis of, 583, 587
treatment of, 582, 583, 587
New-growths of kidney, blood in, 140
Nitze-Albarran cystoscope, Bierhofif's

modification of, 66
Nitze's cystoscope, 54

operating cystoscope, 57
Nodules, saddle-shaped, of penis, 447

Ocular manifestations of renal dis-
eases, 148
Operations, preparation of patient
for, 83
of surgeon for, 86
Ophthalmia, gonorrheal, 392

neonatorum, 395
Ophthalmoplegia in nephritis, 149
Orchi-epididymitis from . strain of

spermatic cord, 549
Orchitis, acute, 543
etiology of, 543
pathologic anatomy of, 544
symptoms of, 544
chronic, 545
syphilitic, 547

symptoms of, 547
tubercular, 546

medical treatment of, 558
symptoms of, 547
Osteoma of testicle, 552
Otis' meatotome, 404

metallic bougie k boule, 37
urethrometer, 38, 415

Pain in cancer of prostate, 535

Papillima of bladder, 306
of kidney, 245

Papillomatous adenocystoma of testi-
cle, 551

Paraphimosis, 463
treatment of, 464

Parasitic cystic tumors of testicle,

551
Parenchymatous nephritis, blood in,

141
Patent urachus, 360

treatment, 361
Pelvis of kidney, 1 28

. lavage of, 277

Penis, 445

amputation of, 457

in continuity, 459
anatomy of, 362
carcinoma of, and gumma of penis,

differentiation, 459
chancre of, 448
chancroid of, 448
crura of, 362

denudations of skin of, Bessel-
Hagen's ojjeration for plas-
tic repair of, 446
Reich's operation for plastic
repair of, 446
fractures of, 447
growths of, 447
gumma of, and cancer of penis,

differentiation, 459
injuries of, 445

treatment, 445
saddle-shaped nodules of, 447
tumors of; 447
ulcerations on, 448
wounds of, 445
treatment, 445
Perforations of bladder, 301
Perineal hypospadias, operations for,

455
urethral fistula, operations for, 428
Perinephritic suppuration, 161
Peri-urethral abscess in female, 440
Permeability of kidney, experimental
polyuria test for, 74
indigo-carmin test for, 74
methylene-blue test for, 71
phloridzin test for, 70
tests for, 69
Permeable urachus, 299
Pezzer's catheter, 35
Phimosis, 462

treatment of, 462
Phlegmonous cystitis, 305
Phloridzin test for permeability of

kidney, 70
Phosphate, ammonio-magnesium, in

urine, 103
Phosphates, amorphous, in urine, 102
Phosphorus in urine, 92
Pigments, bile-, in urine, 95
Polynuclear leukocytosis in suppura-
tive diseases of kidney, 139
Polypoid fibroma of female urethra,

444
Polyuria test, experimental, for per-
meability of kidney, 74
Potassium, urates of, in urine, 101
Preformed sulphates in urine, 92
Preparation of patient for operation,

on testicle, 84
for suprapubic section, 84

INDEX

599

Preparation of surgeon for operation,

86
Probe, Arjnott's, 420

Kollmann's, 52
Pronephros, 123
Prostate, abscess of, 505
treatment, 505
anatomy of, 480
anemia of, 483
calculus of, 45
carcinoma of, 532. See also Car-

citwnia of prostate.
congenital defects of, 481
diseases of, diagnosis and treat-
ment, 494
examination of, 27
fibroma of, 530
hyperemia of, 483
hypernephroma of, 530
hypertrophy of, 485. See also

Hypertrophy of prostate.
injuries of, 482
myoma of, 530
physiology of, 481
removal of, through suprapubic
opening, 520
Fenwick's method, 522
Freyer's method, 523
sarcoma of, 530
tumors of, 530
wounds of, 482
Prostatic massage in chronic prosta-
titis, 49 8
sinus, 364

urethra, anatomy of, 364
Prostatitis, 483
acute, 483

diagnosis of, 494
symptoms of, 494
treatment of, 495
chronic, 485

diagnosis of, 495
hypochondriasis in, 502
neurasthenia in, 502
prostatic massage in, 498
symptoms of, 495
treatment of, 495
urethral exudate in, 113
Proteus bacillus in urine, 104
Psychrophore, 585
Pulse in uremia, 200
Puncture of bladder, 328
Purulent urethritis, acute, 368
cystitis, 304
urethral discharges, 105
Pus, green, bacilli of, in urine, 103
Pus-casts in urine, 100
Pus-cells in gonorrheal urethritis, 1 10

in urine, 97
Pyeloplication and ureter correction,
291

Pyelotomy for stone in kidney, 266
Pyonephrosis, double, 158
Pyramids of kidney, 1 28

Rand's tunneled knife, 419
Reaction of urine, 90
Rectal anastomosis of ureters, 293
Rectum, gonorrhea of, from urethritis,

392
Red blood-corpuscles in urine, 96
Reich's operation for plastic repair

of denudations of skin of penis, 446
Renal tissue, 128
Resection of hydronephrotic sac, 289

of urethra, 425
Rete testis, 539
Retention cysts of testicle, 551

inguinal, of testicle, treatment for,

571
of urine from urethritis, treatment,

409
Retinitis in nephritis, 149, 150
Rhabdomyoma of kidney, 245
Rheumatism, gonorrheal, 397

causes, 397

course, 398

diagnosis, 399

prognosis, 400

treatment, 400
Rupture of bladder, 300, 355

diagnosis, 355

treatment, 356
of urethra, 422

diagnosis, 423

treatment, 423
Rydygier's modification of Kraske's
incision for removal of seminal
vesicles, 472, 475

Saddle-shaped nodules of penis, 447
Sarcoma of bladder, 309
of female urethra, 443
of kidney, 246
of prostate, 530
of testicle, 552
Scrotal bandage, 560, 561
method of applying, 85
triangular, method of forming, 84
hypospadias, operations for, 455
Scrotum, bridge for support of, in
epididymitis, 559
elephantiasis of, 555
treatment, 579
Searcher, 39
I Thompson's, 39

Secretion, cervical, examination of,
I 119

j examination of, 29
i from female genitals, 118

6oo

INDEX

Secretion, seminal, examination of,

"5
vaginal, examination of, 119
Section, suprapubic, preparation for,

84
Sediment, urinary, 96
Segond's operation for exstropliy of

bladder, 351-353
Seminal irrigation and drainage of
duct through vas deferens, 577
secretion, examination of, 115
vesicles, 470

diseases of duct, 470

treatment, 471
Fuller's incision for removal of

duct, 474, 476
irrigation and drainage of duct

through vas deferens, 577
Kocher's incision for removal of

duct, 473, 475
Kraske's incision for removal of
duct, 472
Rydygier's modification
of, 472, 475
Senn's incision for removal of

duct, 474, 475
Von Dittel's incision for removal

of, 473. 475
Zuckerkandl's incision for re-
moval of, 473, 475
Seminiferous tubules, 539
Senn's incision for removal of semi-
nal vesicles, 474, 475
Sensory nerve-supply of kidneys, 127
Separation of urine, 68
Septum pectiniforme, 362
Sertoli, columns of, 539
Sexual life in history of patient, 24
neurasthenia, 583
organs, neuroses of, 580
prognosis, 584, 587
treatment, 584, 586, 587
Shapiro cystoscope, 57
Sinus pocularis, 365, 480

prostatic, 364
Skene's ducts, 435
Smegma bacillus in urine, 104
Sodium, urates of, in urine, loi
Sonnenberg's operation for exstrophy

of bladder, 346, 347
Sound, Meschung, 584
Sounds, 38

Specific gravity of urine, 89, 133
Spermatic cord, hematoma of, 555
multilocular cysts of, 555
strain of, orchi-epididymitis

from, 549
torsion of, 549
treatment, 549
duct, 541
Spermatids, 539

Spermatocele, 550
treatment, 550

Sj^ermatocytes, 539

Spermatogenesis, 540

Spermatogonia, 539

Spermatorrhea, 1 1 7

Spermatozoa in urine, 99

Sphygmomanometer, Janeway's, 144

Spiral tube of kidney, 1 29

Spirochaeta pallida, examination for,
120
Goldhorn's stain for, 121

Staff, W'heelhouse's, 420

Stain, Goldhorn's, for spirochaeta pal-
lida, 121
Gram's, for bacteria, 107
Loffler's methylene-blue, 106

Staphylococcus in urine, 103

Sterilization of urethral instruments,

7«
Sterilizer, formaldehyd, 79
Stone in bladder, cystoscopic appear-
ances in, 59
diagnosis of, 318
lithola.paxy for, 322
remarks on removal of, 328
suprapubic cystotomy for, 329

lateral incision, 336
symptoms of, 319
treatment of, 318
in kidney, 234
diagnosis of, 239
nephrotomy for, 265
pathology of, 234
pyelotomy for, 266
symptoms of, 238
treatment of, 240
in ureter, 280

operations for, 296
Straight tubules, 539
Strain of spermatic cord, orchi-
epididymitis from, 549
Streptococcus in urine, 103
Stricture of female urethra, 438, 440
diagnosis of, 438
treatment of, 438
of meatus urinarius from urethritis,

403
of ureter, 280, 282

Kiister's operation for, 286
operations for, 296
of urethra from urethritis, 372, 404
location of, 405
symptoms of, 404
treatment of, 405
impassable, from urethritis,
treatment, 409
Struma lipomatodes aberratae renis,

247
Subconjunctival hemorrhage in renal
diseases, 148

INDEX

6oi

Sugar in urine, 94

Sulphates, conjugate, in urine, 92

preformed, in urine, 92
Sulphur in urine, 92
Supernumerary testicle, 441
Suppuration, perinephritic, 161
Suppurative diseases of kidney, poly-
nuclear leukocytosis in, 139
nephritis, 157

iDacteria in urine as cause of, 161

causes of, 157

diagnosis of, 162

embolic infarction of kidney in,

160
hydronephrosis in predisposing

to, 159
treatment of, 165
Suprapubic cystotomy for removal of
prostate, 520
for stone in bladder, 329
lateral incision, 336
section, preparation for, 84
Surgeon, preparation of, for opera-
tion, 86
Sustentacular cells, 439
Syphilis, kidney in, 210
Syphilitic disease of bladder, 305
orchitis, 547

symptoms of, 547
Syringe, Hayden-Janet, 40
Janet's, 40

Ultzmann's, for instillation, 41
Syringes, 40
glass, 40

Tapping of hydrocele, 562
Teale's gorget, 417

Test, experimental polyuria, for per-
meability of kidney, 74
glass, for locating seat of urethritis,

30
indigo-carmin, for permeability of

kidney, 74
methylene-blue, for permeability

of kidney, 71
phloridzin, for permeability of

kidney, 70
Testicle, adenoma of, 552
anatomy of, 538
atrophy of, 542

treatment, 574
benign tumors of, 551
blood-supply of, 541
carcinoma of, 552
chondroma of, 552
cystic tumors of, 551
defects of, 541
dermoid cysts of, 551
diseases of, pathology, 541

treatment, 557

Testicle, diseases of, treatment, thera-
peutic measures, 557
endothelioma of, 552
faulty metamorphosis of, 543
fibroma of, 552
hypernephroma of, 552
hypertrophy of, 542
hypoplasia of, 541
inguinal retention of, treatment for,

571
injuries of, treatment, 574
lymphatics of, 541
malignant tumors of, 552
nerve-supply of, 541
operations on, preparation for, 84
osteoma of, 552

papillomatous adenocystoma of, 551
parasitic cystic tumors of, 551
retention cysts of, 551
sarcoma of, 552
supernumerary, 541
surgery of, 561
tumors of, 550

treatment, 577
wounds of, treatment, 574
Tests for permeability of kidney, 69
Thiersch's operation for epispadias,

456
Thompson's searcher, 39

urethral forceps, 447
Timothy hay bacilli in urine, 104
Torsion of spermatic cord, 549

treatment, 549
Transperitoneal nephrectomy, 268
Transplantation of ureter, 291
Traumatism of female urethra, 436
treatment of, 437
of ureter, 280
Trendelenburg's operation for hydro-
nephrosis, 287
Trichomonas vaginalis in urine, 104
Tube, distal, of kidney, 129
second, of kidney, 1 29
spiral, of kidney, 1 29
Tubercle bacillus in urine, 104
Tubercular cystitis, 305

cystoscopic appearadces in, 59
diagnosis of, 315
treatment of, 315
nephritis, blood in, 140
orchitis, 546
medical treatment of, 558
symptoms of, 547
Tuberculosis of kidney, 204
course, 205
diagnosis, 207
embolic or descending infection,

205
infection by ascending inocula-
tion, 205
diagnosis of, 207

6o2

INDEX

Tuberculosis of kidney, pathology,
204
prognosis, 209
treatment, 209
of ureter, 281
Tubule, collecting, of kidney, 129
convoluted, 539
irregular, of kidney, 1 29
proximal convoluted, of kidney, 1 29
seminiferous, 539
straight, 539
urinary, 128
Tumors, benign, of testicle, 551
cystic, of testicle, 551
fragments of, in urine, 98
in bladder, cystoscopic appearances

in, 59
innocent, of bladder, 306
of female urethra, 443
treatment, 444
malignant, of bladder, 307
of female urethra, 442

treatment, 443
of testicle, 552
of bladder, 305
diagnosis, 340
treatment, 340
of female urethra, 442
of kidney, 243

diagnosis, 249
nephrectomy in, 274

treatment, 251
of penis, 447
of prostate, 530
of testicle, 550

treatment of, 577
of ureters, 279

parasitic, cystic, of testicle, 551
Tunica albuginea, 362, 538
vaginalis, 538
vasculosa, 538
Tuttle's operation for closure of

urethrorectal fistula, 432
Tyrosin in urine, 102
Tyson's glands, 364

Ulcerations of penis, 448
Ulcerative cystitis, non-tubercular,

cystoscopic appearances in, 58
Ultzmann's catheter, 41

syringe for instillation, 41
Urachus, 298

patent, 360
treatment, 361

permeable, 299
Urates of potassium in urine, 10 1

of sodium in urine, loi
Urea, 134

in urine, 90
Uremia, 192

Uremia, blood in, 142
diagnosis of, 200
lesions of kidneys in, 197
prognosis of, 202
pulse in, 200
treatment of, 202
urine in, 200
Uremic amaurosis, 150

amblyopia, 150
Ureter, anastomosis of, lateral, 289
Israel's operation, 290
anatomy of, 278
catheterization of, 60

with reverse cystoscope, 66
with ureteral catheter cystoscope
of straight type, 63
cysts of, 279
diseases of, 279

diagnosis of, 283
fistula of, 282
inflammation of, 279
kinks of, 282
malformations of, 279
pathologic anatomy of, 279
physiology of, 278
rectal anastomosis of, 293
stone in, 280

operations for, 296
stricture of, 280, 282

Kiister's operation for, 286
operations for, 296
surgery of, 285
transplantation of, 291
traumatism of, 280
tuberculosis of, 281
tumors of, 279
wounds of, 283

operations for, 295
Ureter-catheter cystoscope. Brown's,

62
Ureter -cystoscope, Lewis', 61
Ureterectomy, 296
Ureteropyeloneostomy, 287
Ureterotomy, 296
Urethra, anatomy of, 364
calculi in, 449
diseases of, 367
female, 435

anatomy of, 435
carcinoma of, 442
caruncles of, 443
condyloma of, 443
congenital malformations of, 436
dilatation of, 439
treatment, 439
examination of, 437
innocent tumors of, 443

treatment, 444
malignant tumors of, 442

treatment, 443
polypoid fibroma of, 444

INDEX

603

Urethra, female, sarcoma of, 443
stricture of, 438, 440
diagnosis, 438
treatment, 438
traumatisms of, 436

treatment, 437
tumors of, 442
foreign bodies in, 449
membranous, anatomy of, 365
penile portion of, anatomy, 365
prostatic, anatomy of, 364
resection of, 425
rupture of, 422
diagnosis, 423
treatment, 423
spongy portion of, anatomy, 365
stricture of, from urethritis, 372
location of, 405
symptoms of, 404
treatment of, 405
impassable, from urethritis,
treatment, 409
Urethral discharge in examining, 19
exudate, examination of, 104

in chronic gonorrheal urethritis,

1 12
in Cowperitis, 1 15
in gonorrheal urethritis, 109
in prostatitis, 113
in simple urethritis, 108
in vesiculitis, 1 14
purulent, 105
fistula in pendulous urethra, opera-
tion for, 427
perineal, operations for, 428
forceps, Thompson's, 449
instruments, care of, 77
lubricants for, 81
sterilization of, 78
Urethritis, 367

abortive treatment of, 378
abscess of Littre's glands after,

371
acute anterior, course of, 373
symptoms of, 373
treatment of, 383
early local, 386
catarrhal, 367
posterior, symptoms of, 374

treatment of, 388
purulent, 368
bacterial content in, in
bacteriology of, 368
chronic anterior, symptoms of, 374
treatment of, 385
catarrhal, 367

diagnosis, 376
posterior, diagnosis, 377
symptoms of, 374
treatment of, 388
urethral exudate in, 112

Urethritis, complications of, .391

diagnosis, 374

epithelial cells in, no

German method of abortive treat-
ment of, 379

glass test for locating seat of, 30,
375

gonococcus in, no

gonorrhea of eye from, 392

prognosis, 393

symptoms, 393

treatment, 393

of mouth from, 392

of rectum from, 392

gonorrheal, bacterial content in,
in
chronic, urethral exudate of, 112

epithelial cells in, 1 10
gonococcus in, 1 10
pus-cells in, 1 10
urethral exudate in, 109

Greene and Brooks' abortive treat-
ment of, 378

impassable stricture of urethra
from, treatment, 409

in female, 440
treatment of, 441

Kollmann's method of diagnosing,

375 .
mode of infection in, 369
pathologic anatomy of, 369
pathology of, 367
pus-cells in, no

retention of urine from, treat-
ment, 409
simple, bacterial content in, 109

epithelial cells in, 108

urethral exudate in, 108
stricture of meatus urinarius from,

403
of urethra from, 372, 404
location, 405
symptoms, 404
treatment, 405
symptoms of, 372
treatment of, resume, 390
urethral exudate in, 109
Young's method of diagnosing, 375
Urethrometer, 37

Otis, 38
Urethrorectal fistula, diagnosis of, 430
operations for, 429
prognosis of, 430
treatment of, 430
local, 431
operative, 432
palliative, 431
Tuttle's operation for closure of,

432
Urethrorectoperineal fistula, diagno-
sis of, 430

6o4

INDEX

Urethroiectoperineal fistula, opera-
tions for, 429

prognosis of, 430

treatment of, 430
local, 431
operative, 432
palliative, 431
Urethrotome, Maisonneuve's, 414

Otis, 415
Urethrotomy, 420
external, 416

without a guide, 420
internal, 413
Uric acid, 91, 134

infarction, 237
Urinary constituents, 90

excretion, diminished amount of,

in examining, 20
fever, 26

treatment of, 27
sediment, 96
stream, caliber of, 21
tubule, 128
Urine, 132
acetone in, 94
acid reaction of, 133
^ substances in, loi
actinomyces fungi in, 104
albumin in, 93
alkaline, substances in, 103
ammonio-magnesium phosphate in,

103
ammonium urate in, 103
amorphous phosphates in, 102
amount passed, 89
amyloid casts in, 100
bacteria in, 103

as cause of suppurative nephritis,
161
bile-pigments in, 95
blood-casts in, 100
calcium carbonate in, 103

oxalate crystals in, 102
casts in, 99

cercomonas intestinalis in, 104
chemic composition of, 133
chlorids of, 91
cloudy, 30

collection of specimen of, for exami-
nation, 88
colon bacillus in, 104
color of, 133

conjugate sulphates in, 92
constituents of, 92
crystalline deposits in, loi
cylindroids in, 99
cystin in, 102
decrease in amount of, 89
echinococcus-hooklets in, 104
epithelial casts in, 100
epithelium in, 97

Urine, erythrocytes in, 96
examination of, 88
fat in, 95
fatty casts in, 100
filaria sanguinis hominis in, 104
fragments of tumors in, 98
gonococcus in, 103
granular casts in, 100
hyaline casts in, 100
in uremia, 200
incontinence of, in children, 302

in examining patient, 22
indican in, 94
leucin in, 102
leukocytes in, 97
microscopic examination of, 95
mucus in, 97
organized deposits in, 96
phosphorus in, 92
preformed sulphates in, 92
proteus bacillus in, 104
pus-casts in, 100
pus-cells in, 97
reaction of, 90
red blood-corpuscles in, 96
retention of, from urethritis, treat-
ment, 409

in examining, 22

operations for, 285
sediment in, 96
separation of, 68
smegma bacillus in, 104
specific gravity of, 89, 133
spermatozoa in, 99
staphylococcus in, 103
streptococcus in, 103
sugar in, 94
sulphur in, 92

timothy hay bacillus in, 104
trichomonas vaginalis in, 104
tubercle bacillus in, 104
tyrosin in, 102
urates of potassium in, loi

of sodium in, 101
urea in, 90
uric acid in, 91
waxy casts in, 100
Urorrhea, 1 1 8
Uterus masculinus, 480

Vagina, examination of, 29

Vaginal secretion, examination of, 119

Valentine's endoscope, 51

irrigating outfit, 386
Varicocele, 552

treatment of, 575
Vas deferens, 541

irrigation and drainage of semi-
nal duct and vesicle through,
577

INDEX

605

Vasa efferentia, 540
Verumontanum, 365
Vesicles, seminal, 470

diseases of, 470
treatment, 471

Fuller's incision for removal of,

474, 476
irrigation and drainage of,

through vas deferens, 354
Kocher's incision for removal of,

473, 475

Kraske's incision for removal of,

472, 475
Rydygier's modification
of, 472, 475
Senn's incision for removal of,

474, 475

Von Dittel's incision for removal

of, 473, 475
Zuckerkandl's incision for re-
moval of, 473, 475
Vesiculitis, 471
treatment of, 471
urethral exudate in, 114
Voelcher and Joseph's indigo-carmin
test, 74

Von Dittel's incision for removal of
seminal vesicles, 473, 475

Waxy casts in urine, 100

Wheelhouse's staff, 420

Wounds of bladder, diagnosis of,

354

treatment of, 355
of kidney, 227

prognosis, 227

treatment, 228
of penis, 445

treatment, 4.45
of prostate, 482
of testicle, treatment oT, 574
of ureter, 283

operations for, 295

Young's method of diagnosing
urethritis, 375

Zuckerkandl's incision for removal
of seminal vfesicles, 473, 475

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of what might justly be called "Successful Pub-
lishing."

A Complete Catalogue of our Publications will be Sent upon Request

S.'irXDE/^S' BOOKS ON

Bonney on Tuberculosis

Tuberculosis. By Sherman G. Bonney, M. D., Professor of
Medicine, Denver and Gross College of Medicine, Denver. Octavo
of 850 pages, with original illustrations.

JUST READY

Dr. Bonney' s work embodies the results of wide personal experience in cb-
serving and treating tuberculous patients, especially those suffering from the
pulmonary form. His book is a thorough and complete treatise of the entire sr.b-
ject of tuberculosis, taking up every region of the body and every secondary
involvement that can occur. The section on Physical Signs of Pulmonary
Tuberculosis- is really a complete monograph on the physical diagnosis of diseases
of the chest. As is to be expected, treatment is particularly full and practical.
There are chapters on prophylaxis ; open-air treatment, fully illustrated ; diet ;
sanitarium and climatic treatments ; therapeutic measures to alleviate distress-
ing symptoms ; and drug and vaccine therapeutics. Dr. Bonney has taken espe-
cial care to have his illustrations as practical as his text. There are over two
hundred original pictures, twenty-four of them being in colors. Of special value
will be found the sixty ,r-ray photographs. Indeed, it is the most practical work
on tuberculosis yet published.

Todd*s Clinical Diagnosis

Manual of Clinical Diagnosis. By J.ames Campbell Todd,

M. D., Associate Professor of Pathology in the Denver and Gross

College of Medicine, Denver. i2mo of 500 pages, fully illustrated.

Flexible leather.

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This new manual presents those important laboratory methods that have
proved of actual clinical value, together with a clear interpretation of results.
Designed for the practitioner and student, it is extremely practical, the methods
selected being those which require the least complicated apparatus and the
least expenditure of time, so that, with this volume, the practitioner will be
enabled to examine his clinical material in his own laboratory. As more can be
learned from a good picture than from any description, especial attention has been
given to the illustrations, each one really illustrating, each one being unusually
helpful. Practically all the microscopic structures mentioned, all unusual appa-
ratus, and many of the color reactions are shown in the pictures.

THE PRACTICE OF MEDICL\E

Anders*
Practice of Medicine

A Text-Book of the Practice of Medicine. By James M. Anders,
M, D., Ph. D., LL. D., Professor of the Practice of Medicine and of
Clinical Medicine, Medico-Chirurgical College, Philadelphia. Hand-
some octavo, 1317 pages, fully illustrated. Cloth, ^5.50 net; Sheep
or Half Morocco, $7.00 net.

RECENTLY ISSUED-NEW (8th) EDITION

The success of this work is no doubt due to the extensive consideration given
to Diagnosis and Treatment, under Differential Diagnosis the points of distinction
of simulating diseases being presented in tabular form. Among the new subjects
added are Parasitic Infusoria, Febrile Tropical Splenomegaly, Aplastic Anemia,
jr-Rays in Leukemia, Polycythemia with Splenic Tumors, Stokes-Adams' Disease,
Sahli's Desmond Test, Intestinal Auto-intoxication, and Senile Dementia,

Wm. E. Quine, M.D..

Professor of Medicine and Clinical Medicine, College of Physicians and Surgeons, Chicago.
" I consider Anders' Practice one of the best single-volume works before the profession at
this time, and one of the best text-books for medical students."

DaCosta's Physical Diag^nosis

Physical Diagnosis. By John C. DaCosta, Jr., Associate in
Clinical Medicine, Jefferson Medical College, Philadelphia. Octavo of
600 pages, with original illustrations.

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Dr. DaCosta' s work is a thoroughly new and original one. Every method
given has been carefully tested and proved of value by the author himself.
Normal physical signs are explained in detail in order to aid the diagnostician in
determining the abnormal. Both direct and differential diagnosis are emphasized.
The cardinal methods of examination are supplemented by full descriptions of
technic and the clinical utility of certain instrumental means of research — ^blood
pressure estimation, graphic study of arterial and venous pulses, exploratory
puncture, etc. The 230 entirely original illustrations are unusually practical, yet
at the same time artistic.

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Sahli's Diagnostic Methods

Editors: Francis P.Kinnicutt, M,D., and Nath'I Bowditch Potter, M.D.

A Treatise on Diagnostic Methods of Examination. By Prof.
Dr. H. Sahli, of Bern. Edited, with additions, by Francis P. Kinni-
CUTT, M. D., Professor of Clinical Medicine, Columbia University, N. Y. ;
and Nath'l Bowditch Potter, M. D., Visiting Physician to the City
and French Hospitals, N. Y. Octavo of 1008 pages, profusely illustrated.
Cloth, ;^6.50 net; Half Morocco, $8.00 net.

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Dr. Sahli's great work, upon its publication in German, was immediately
recognized as the most important work in its field. Not only are all methods
of examination for the purpose of diagnosis exhaustively considered, but the ex-
planation of clinical phenomena is given and discussed from physiologic as well
as pathologic points of view. In the chemical examination methods are described
so exactly that it is possible for the clinician to work according to these directions.

Lewellys F. Barker. M. D.

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" I am delighted with it, and it will be a pleasure to recommend it to our students in the
Johns Hopkins Medical School."

Friedenwald and Ruhrah
on Diet

Diet in Health and Disease. By Julius Friedenwald, M. D.,
Clinical Professor of Diseases of the Stomach, and John Ruhrah,
M. D., Clinical Professor of Diseases of Children, College of Physicians
and Surgeons, Baltimore. Octavo of 728 pages. Cloth, ;^4.0o net.

RECENTLY ISSUEU-NEW (2d) EDITION

This work contains a complete account of food-stuffs, their uses, and chemical
composition. Dietetic management in all diseases in which diet plays a part in
treatment is carefully considered. The feeding of infants and children, of patients
before and after anesthesia and surgical operations, and the latest methods of
feeding after gastro-intestinal operations are all taken up in detail.

George Dock. M. D.

Professor of Theory Und Practice and of Clinical Medicine, University of Michigan.

" It seems to me that you have prepared the most valuable work of the kind now available.
I am especially glad to see the long list of analyses of different kinds of foods. "

PRACTICE OF MEDICINE

GET A • THE NEW

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Illustrated Dictionary

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The American Illustrated Medical Dictionary. A new and com-
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Pharmacy, Chemistry, and kindred branches ; with over lOO new and
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Borland, M. D., Editor of " The American Pocket Medical Diction-
ary." Large octavo of 840 pages, bound in full flexible leather.
Price, ;$4.50 net ; with thumb index, ;^5.oo net.

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yet by the use of thin bible paper and flexible morocco binding it is only i }(
inches thick. In this new edition the book has been thoroughly revised, and
upward of two thousand new terms have been added.
Howard A. Kelly, M. D., Professor of Gynecology, Johns Hopkins University, Baltimore.

"Dr. Dorland's dictionary is admirable. It is so well gotten up and of such convenient
size. No errors have been found in my use of it."

Goepp*s
State Board Questions

state Board Questions and Answers. By R. Max Goepp, M. D.,
Professor of Clinical Medicine, Philadelphia Polyclinic. Octavo of
684 pages. Cloth, 1^4.00 net; Half Morocco, $5.50 net.

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Every graduate who desires to practice medicine must pass a State Board
Examination, and to aid him in successfully passing such an examination this work
will be of inestimable value. Dr. Goepp has taken great pains to collect the many
questions asked in the past by Boards of the various States, and has arranged and
classified them under subjects in such a manner that the prospective applicant can
acquire the knowledge on any branch with the least difficulty.

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Pusey and Caldwell on
X-Rays

in Therapeutics and Diagnosis

The Practical Application of the Rontgen Rays in Therapeutics
and Diagnosis. By William Allen Pusey, A. M., M. D., Professor
of Dermatology in the University of Illinois ; and Eugene W. Cald-
well, B. S., Director of the Edward N. Gibbs X-Ray Memorial Labo-
ratory of the University and Bellevue Hospital Medical College, New
York. Handsome octavo of 625 pages, with 200 illustrations, nearly
all clinical. Cloth, ^5.00 net; Sheep or Half Morocco, $6.50 net.

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TWO LARGE EDITIONS IN ONE YEAR

Two large editions of this work within a year testify to its practical value to
both the specialist and general practitioner. Throughout the work it has been
the aim of the authors to elucidate the practical aspects of the subject, and to
this end the text has been beautifully illustrated with clinical pictures, showing
the condition before the use of the X-rays, at various stages of their application,
and the final therapeutic result obtained. Details are also given regarding the use
and management of the apparatus necessary for X-ray work, illustrating the
descriptions with instructive photographs and drawings. In making the revision
the histories of the cases cited have been brought down to the present time.

OPINIONS OF THE MEDICAL PRESS

British Journal of Dermatology

" The most complete and up-to-date contribution on the subject of the therapeutic action
of the Rontgen rays which has been published in English."

Boston Medical and Surgical Journal

" It is indispensable to those who use the X-rays as a therapeutic agent ; and its illustrations
are so numerous . . . that it becomes valuable to every one."

New York Medical Journal

" We have nothing but praise for this volume, the combined work of two authors than
whom no one is better fitted by training or experience to write in his individual field."

PRACTICE OF MEDTCIXE

Rolleston on the Liver

Diseases of the Liver, Gall-bladder, and Bile-ducts. By H.

D. Rolleston, M. D. (Cantab), F. R. C, P., Physician to St. George's
Hospital, London, England. Octavo volume of 794 pages, fully illus-
trated, including a number in colors. Cloth, ;^6.oo net.

ENTIRELY NEW-RECENTLY ISSUED

This work covers the entire field of diseases of the liver, and is the most
voluminous work on this subject in English. Dr. Rolleston has for many years
past devoted his time exclusively to diseases of the digestive organs, and any-
thing from his pen, therefore, is authoritative and practical. Special attention is
given to pathology and treatment, the former being profusely illustrated.

Medical Record, New York

"The most extensive treatise on diseases of the liver yet published in English. ... It re-
flects an unusual degree of experience in a difficult but highly important branch of study."

Boston's
Clinical Diagnosis

Clinical Diagnosis. By L. Napoleon Boston, M.D., Adjunct
Professor of Medicine and Director of the Clinical Laboratories, Med-
ico-Chirurgical College, Philadelphia. Octavo of 563 pages, with 330
illustrations, many in colors. Cloth, ^4.00 net.

RECENTLY ISSUED— NEW (2d) EDITION
TWO EDITIONS IN ONE YEAR

Dr. Boston here presents a practical manual of the chnical and laboratory
examinations which furnish a guide to correct diagnosis, giving only such methods,
however, which can be carried out by the busy practitioner in his office as well
as by the student in the laboratory. In this new second edition the entire work
has been carefully and thoroughly revised, incorporating all the newest advances.

Boston Medical and Surgical Journal

■■ He has produced a book which may be regarded eminently as a practical and service-
able guide. . . . The illustrations are both numerous and good."

SAUNDERS' BOOKS ON

AMERICAN EDITION

NOTHNAGEL'S PRACTICE

UNDER THE EDITORIAL SUPERVISION OF

ALFRED STENGEL. M.D.

Professor of Clinical Medicine in the University of Pennsylvania; Visiting
Physician to the Pennsylvania Hospital.

It is universally acknowledged that the Germans lead the world in Internal Medicine ; and
of all the German works on this subject, Nothnagel's " Specielle Pathologic und Therapie "
is conceded by scholars to be without question the best Practice
of Medicine in existence. So necessary is this book in the study
of Internal Medicine that it comes largely to this country in the
original German. In view of these facts, Messrs. W. B. Saunders
Company arranged with the publishers of the German edition to

BEST IN
EXISTENCE

issue an authorized American edition of this great Practice of Medicine.

The work has been issued in twelve volumes, and those subjects selected that are of the
greatest importance to the physician engaged in general practice.
In fact, these volumes contain the real essence of the entire
work, so that the purchaser obtains at less than half the cost
the cream of the original. This work is a Practice of Medicine
for the General Practitioner.

FOR THE
PRACTITIONER

PROMINENT
SPECIALISTS

The work has been translated by men possessing thorough knowledge of both English and
German, and each volume has been edited by a prominent specialist. It has thus been brought
thoroughly up to date, and the American edition is more than a mere translation ; for, in addi-
tion to the matter contained in the original, it represents the very
latest views of the leading American and English specialists in the
various departments of Internal Medicine. Moreover, as each
volume has been revised to the date of its publication by the
eminent editor, the objection that has heretofore existed to treatises
published in a number of volumes has been obviated, since the subscriber receives the com-
pleted work while the earlier volumes are still fresh. The American publication of the entire
work is under the editorial supervision of Dr. Alfred Stengel, who has selected the subjects
for the .American Edition, and has chosen the editors of the different volumes.

The usual method of publishers when issuing a publication of
this kind has been to require physicians to take the entire work.
This seems to us in many cases to be undesirable. Therefore, in
purchasing this Practice physicians are given the opportunity of
subscribing for it in entirety ; but any single volume or any num-
ber of volumes, each complete in itself, may be obtained by those who do not desire the com-
plete series. This latter method offers to the purchaser many advantages which will be
appreciated by those who do not care to subscribe for the entire work. Subscription.

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PRACTICE OF MEDICINE.

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Per volume : Cloth, S5>00 net
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Typhoid and Typhus Fevers

By Dr. H. Curschmann, of Leipsic. The entire volume edited, with
additions, by William Osler, M. D., F. R. C. P., Regius Professor of Med-
icine, Oxford University, Oxford, England. Octavo volume of 646 pages,
fully illustrated.

Smallpox (including Vaccination), Varicella, Cholera Asiatica,
Cholera Nostras, Erysipelas, Erysipeloid, Pertussis, and
Hay Fever

By Dr. H. Immermann, of Basle ; Dr. Th. von Jurgensen, of Tiibingen ;
Dr. C. Liebermeister, of Tiibingen ; Dr. H. Lenhartz, of Hamburg ;
and Dr. G. Sticker, of Giessen. The entire volume edited, with additions,
by Sir J. W. Moore, M.D.. F. R. C. P. I., Professor of Practice, Royal Col-
lege of Surgeons, Ireland. Octavo, 682 pages, illustrated.

Diphtheria, Measles, Scarlet Fever, and Rotheln

By William P. Northrup, M. D., of New York, and Dr. Th. von Jur-
gensen, of Tubingen. The entire volume edited, with additions, by William
P. Northrup, M. D., Professor of Pediatrics, University and Bellevue Hos-
pital Medical College, New York. Octavo, 672 pages, illustrated, including
24 full-page plates, 3 in colors.

Diseases of the Bronchi, Diseases of the Pleura, and Inflam-
mations of the Lungs

By Dr. F. A. Hoffmann, of Leipsic ; Dr. O. Rosenbach, of Berlin ; and
Dr. F. Aufrecht, of Magdeburg. The entire volume edited, with additions,
by John H. Musser, M. D., Professor of CHnical Medicine, University of
Pennsylvania. Octavo, 1029 pages, illustrated, including 7 full -page colored
lithographic plates.

Diseases of the Pancreas, Suprarenals, and Liver

By Dr. L. Oser, of Vienna ; Dr. E. Neusser, of Vienna, and Drs. H.
Quincke and G. Hoppe-Seyler, of Kiel. The entire volume edited, with
additions, by Reginald H. Fritz, A. M., M. D., Hersey Professor of the
Theory and Practice of Physic, Harvard University ; and Frederick A.
Packard, M. D., Late Physician to the Pennsylvania and Children's Hos-
pitals. Octavo of 918 pages, illustrated.

Diseases of the Stomach

By Dr. F. Riegel, of Giessen. Edited, with additions, by Charles G.
Stockton, M. D., Professor of Medicine, University of Buffalo. Octavo of
835 pages, with 29 text-cuts and 6 full-page plates.

Diseases of the Intestines and Peritoneum Recently issued

By Dr. Hermann Nothnagel, of Vienna. The entire volume edited, with
additions, by H. D. Rolleston, M. D., F. R. C. P., Physician to St. George'.s
Hospital, London. Octavo of 11 00 pages, finely illustrated.

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Tuberculosis and Acute General Miliary Tuberculosis

By Dr. G. Cornet, of Berlin. Edited, with additions, by Walter B.
James, M. D., Professor of the Practice of Medicine, Columbia University,
New York. Octavo of 806 pages.

Diseases of the Blood [Anemia, Clilorosts, Leukemia, and Pseudoleukemia)

By Dr. P. Ehrlich, of Frankfort-on-the-Main ; Dr. A. Lazarus, of Char-
lottenburg ; Dr. K. von Noorden, of Frankfort-on-the-Main ; and Dr.
Felix Pinkus, of Berlin. The entire volume edited, with additions, by Alfred
Stengel, M. D., Professor of Clinical Medicine, University of Pennsylvania.
Octavo of 714 pages, with text-cuts and 13 full-page plates, 5 in colors.

Malarial Diseases, Influenza, and Dengue

By Dr. J. Mannaberg, of Vienna, and Dr. O. Leichtenstern, of Cologne.
The entire volume edited, with additions, by Ronald Ross, F. R. C. S. (Eng.),
F. R. S., Professor of Tropical Medicine, University of Liverpool ; J. W. W.
Stephens, M. D., D. P. H., Walter Myers Lecturer on Tropical Medicine,
University of Liverpool ; and Albert S. Grunbaum, F. R. C. P., Professor
of Experimental Medicine, University of Liverpool. Octavo of 769 pages,
illustrated.

Diseases of Kidneys and Spleen, and Hemorrhagic Diatheses

By Dr. H. Senator, of Beriin, and Dr. M. Litten, of Berlin. The entire
volume edited, with additions, by James B. Herrick, M. D., Professor of the
Practice of Medicine, Rush Medical College. Octiivo of 815 pages, illust.

Diseases of the Heart

By Prof. Dr. Th. von Jurgensen, of Tubingen ; Prof. Dr. L. Krehl,
of Greifswald ; and Prof. Dr. L. von Schrotter, of Vienna. The entire
volume edited, with additions, by George Dock, M. D., Professor of Theory
and Practice of Medicine and Clinical Medicine, University of Michigan,
Ann Arbor. Octavo of 848 pages, fully illustrated.

SOME PRESS OPINIONS

London Lancet {Typhoid volume)

" We welcome the translation into English of this excellent practice of medicine. The
first volume contains a vast amount of useful information, and the forthcoming volumes are
awaited with interest."

Journal American Medical Association ( Tuberculosis volume)

" We know of no single treatise covering the subject so thoroughly in all its aspects as
this great German work. ... It is one of the most exhaustive, practical, and satisfactory
works on the subject of tuberculosis."

Medical News, New York { Liver volume)

" Leaves nothing to be desired in the way of completeness of information, orderly arrange-
ment of the text, thoroughgoing up-to-dateness, handiness for reference, and exhaiistive dis-
cussion of the subjects treated."

EACH VOLUME IS" COMPLETE IN ITSELF AND IS SOLD SEPARATELY

MA TERIA MEDICA.

Stevens*
Modern Therapeutics

A Text-Book of Modern Materia Medica and Therapeutics. By

A. A. Stevens, A. M., M. D., Lecturer on Physical Diagnosis in the
University of Pennsylvania. Octavo of 670 pages. Cloth, ^3.50 net.

RECENTLY ISSUED— NEW (4th) EDITION
Adapted to the New (1905) Pharmacopeia

Dr. Stevens, by his extensive teaching experience, has acquired a clear,
concise diction that adds greatly to his work's pre-eminence. In this edition
new articles have been added on Scopolamin, Ethyl Chlorid, Theocin, Veronal,
and Radium, besides much new matter to the section on Radiotherapy. The
numerous changes in name or strength of various drugs and preparations, as
called for by the new Pharmacopeia, have also been made. The work includes
the following sections : Physiologic Action of Drugs ; Drugs ; Remedial Measures
other than Drugs ; Applied Therapeutics ; Incompatibility in Prescriptions ; Table
of Doses ; Index of Drugs ; and Index of Diseases ; the treatment being eluci-
dated by more than two hundred formulae.

University Medical Magzizine

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and it will be found a reliable guide and sufficiently comprehensive."

Camac*s

£poch-Making Contributions

Epoch-Making Contributions in Medicine and Surgery. Col-
lected and arranged by C. N. B. Camac, M, D., of New York City.
Octavo of 450 pages, illustrated.

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Dr. Camac has collected some of the most important epochal articles in
medicine and surgery — articles that record masterpieces of scietitific research — and
has presented them in the original, together with a portrait and a brief biographic
sketch of the discoverer. The articles included are : Antisepsis (Lister), Circula-
tion (Harvey), Percussion (Auenbnigger), Auscultation (Laennec), Anesthesia
(Morton), Puerperal Fever (Holmes), \'accination (Jenner).

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Thornton's Dose-Book

Dose-Book and Manual of Prescription-Writing. By E. Q. Thorn-
ton, M, D., Assistant Professor of Materia Medica, Jefferson Medical
College, Phila. Post-octavo, 392 pages, illustrated. Flexible Leather,
^2.00 net.

Recently Issued — New (3d) Edition

Dr. Thornton, in making this revision, has brought his book in accord with
the new (1905) Pharmacopeia. Throughout the entire work numerous references
have been introduced to the newer curative sera, organic extracts, synthetic com-
pounds, and vegetable drugs. To the Appendix, chapters upon Synonyms and
Poisons and their antidotes have been added, thus increasing its value as a book
of reference.

C. H. MUler, M. D.,

Professor of Pharmacology, Northwestern University Medical School, Chicago.

" I will be able to make considerable use of that part of its contents relating to the correct
terminology as used in prescription-writing, and it will afford me much pleasure to recommend
the book to my classes, who often fail to find this information in their other text-books."

Lusk on Nutrition

Elements of the Science of Nutrition. By Graham Lusk, Ph.D.,
Professor of Physiology in the University and Bellevue Hospital Med-
ical College. Octavo of 325 pages. Cloth, ^2.50 net.

RECENTLY ISSUED

This practical work deals with the subject of nutrition from a scientific stand-
point, and will be useful to the dietitian as well as the clinical physician. There
are special chapters on the metabolism of diabetes and fever, and on purin metab*
olism.

Lewellys P. Barker. M.D..

Professor of the Principles and Practice of MedicinCy Johns Hopkins University.
" I shall recommend it highly. It is a comfort to have such a discussion of the subject."

Mathews' How to Succeed in Practice

How to Succeed in the Practice of Medicine. By Joseph M.
Mathews, M.D., LL.D., President American Medical Association,
1898-99. l2mo of 215 pages, illustrated. Cloth, $1.50 net.

MATERIA MEDICA. 13

Sollmann*s Pharmacology

Including Therapeutics, Materia Medica, Pharmacy,
Prescription -writing. Toxicology, etc.

A Text-Book of Pharmacology. By Torald Sollmann, M. D.,
Professor of Pharmacology and Materia Medica, Medical Department
of Western Reserve University, Cleveland, Ohio. Handsome octavo
volume of 1070 pages, fully illustrated. Cloth, ;^400 net.

RECENTLY ISSUED— NEW (2d) EDITION

Because of the radical alterations which have been made in the new (1905)
Pharmacopeia, it was found necessary to reset this book entirely. The author
bases the study of therapeutics on a systematic knowledge of the nature and
properties of drugs, and thus brings out forcibly the intimate relation between
pharmacology and practical medicine.

J. F. rotheringham. M. D.

Prof, of Therapeutics and Theory and Practice of Prescribing Trinity Med. College, Toronto.
" The work certainly occupies ground not covered in so concise, useful, and scientific a
manner by any other text I have read on the subjects embraced."

Butler's Materia Medica

Therapeutics, and Pharmacology

A Text-Book of Materia Medica, Therapeutics, and Pharmacology.

By George F. Butler, Ph. G., M. D., Professor and Head of the
Department of Therapeutics and Professor of Preventive and CHnical
Medicine, Chicago College of Medicine and Surgery, Medical Depart-
ment Valparaiso University. Octavo of 702 pages, illustrated. Cloth,
i^4.oo net ; Half Morocco, ;^5.50 net.

JUST ISSUED— NEW (dth) EDITION

For this sixth edition Dr. Butler has entirely remodeled his work, a great part
having been rewritten. All obsolete matter has been eliminated, and special atten-
tion has been given to the toxicologic and therapeutic effects of the newer com-
pounds. A classification has been adopted which groups together those drugs
the predominant action of which is on one system of organs.

Medical Record, New York

•• Nothing has been omitted by the author which, in his judgment, would add to the com-
pleteness of the text, and the student or general reader is given the benefit of latest advices
bearing upon the value of drugs and remedies considered.

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Hatcher and SoIlmann*s
Materia Medica

A Text-Book of Materia Medica : including Laboratory Exercises
in the Histologic and Chemic Examination of Drugs. By Robert A.
Hatcher, Ph. G., M. D., of Cornell University Medical School, New
York City ; and Torald Sollmann, M.D., of the Western Reserve Uni-
versity, Cleveland, Ohio. i2nio of 411 pages. Flex, leather, ^2.00 net.

RECENTLY ISSUED— A NEW WORK

This work is a practical text-book, treating the subject by actual experimental
demonstrations.

Journal of the Americaoi Medical Association

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Eichhorst*s Practice

A Text-Book of the Practice of Medicine. By Dr. Hermann
EiCHHORST, University of Zurich. Translated and edited by Augus-
tus A. EsHNER, M.D., Professor of Clinical Medicine, Philadelphia
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Bulletin of Johns Hopkins Hospital

" This book is an excellent one of its kind. Its completeness, yet brevity, the clinical
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Tuberculosis. By Norman Bridge, A. M., M. D., Emeritus Pro-
fessor of Medicine in Rush Medical College, in affiliation with the
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Medical News, New York

" Thoroughly representative of our practical methods of diagnosis and treatment of the
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PRACTICE, MATERIA MEDICA, Etc. 15

The American Pocket Medical Dictionary. 5th Ed. Recently issued

The American Pocket Medical Dictionary. Edited hy W. A. Newman Dor-
land, M. D., Assistant Obstetrician to the Hospital of the University of Pennsylvania.
Containing the pronunciation and definition of the principal words used in medicine
and kindred sciences, with 64 extensive tables. rie.\ible leather, with gold edges,
#1.00 net ; with thumb index, $\.2^ net.

"I can recommend it to our students without reserve." — J. H. Holland. M. D., of the Jefferson
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Vierordt's Medical Diagnosis. Fourth Edition, Revised

Medical Diagnosis. By Dr Oswald Vierordt, Professor of Medicine, Univer-
sity of Heidelberg. Translated from the fifth enlarged German edition by Francis
H. Stuart, A. M., M. D. Octavo, 603 pages, 104 wood cuts. Cloth, ^^4.00 net;
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" Has been recognized as a practical work of the highest value. It may be considered indispensable
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Cohen and Cshner's Diag^nosis. Second Revised Edition

Essentials of Diagnosis. By S. Solis-Cohen, M. D., Senior Assistant Professor
in Clinical Medicine, Jefferson Medical College, Phila. ; and A. A. Eshner, M. D.,
Professor of Clinical Medicine, Philadelphia Polyclinic. Post-octavo, 382 pages ; 55
illustrations. Cloth, $1.00 net. Jn Saundey-s' Qiiestion-Compend Series,

" Concise in the treatment of subject, terse in expression of iSiCt."— American Journal of the
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Recently Issued

Morris* Materia Medica and Therapeutics. New (7th) Ediion

Essentials of Materia Medica, Therapeutics, and Prescription-Writing.
By Henry Morris, M. D., late Demonstrator of Therapeutics, Jefferson Medical
College, Phila. Revised by W. A. Bastedo, M. D., Instructor in Materia Medica and
Pharmacology at Columbia University. 1 2mo, 300 pages. Cloth, ;^I.oo net. In Saunders'
Question- Compend Series.

" C.innot fail to impress the mind and instinct in a lasting manner. "—ij»^<«/<7 Medical Journal.

Williams* Practice of Medicine Recently issued

Essentials of the Practice of Medicine. By W. R. Williams, M.D.,
formerly Instructor in Medicine and Lecturer on Hygiene, Cornell Universiiy ; and
Tutor i'n Therapeutics, Columbia University, N. Y. l2mo of 456 pages, illustrated.
In Saunders' Question- Compend Series. Double number, $1.75 net.

.« 1. f mr Recently Issued

Stoney's Materia Medica for Nurses New (3rd) Edition

Materia Medica for Nurses. Bv Emily M. A. Stoney, Superintendent of the
Training School for Nurses at the Carney Hospital, South Boston, Mass. Handsome
i2mo volume of 300 pages. Cloth, $1.50 net.

" It contains about everything that a nurse ought to know in regard to Aryi^s." -Journal of the
American Medical Association.

Recently Issued
Grafstrom's MechanO-therapy Second Edition. Enlarged

A Text-Book of Mechano-THERAFY (Massage and Medical Gymnasticsl. By
Axel V Grafstrom, B. Sc, M. D., Attending Physician to Augustus Adolphus Orphan-
age, lam'estown, N. Y.' i2mo, 200 pages, illustrated. $1.25 net.

"Certainly fulfills its mission in rendering comprehensible the subjects of massage and medtoU
gymnastics."— 7V<?K> York Medical Journal.

1 6 SAUNDERS' BOOKS ON PRACTICE, Etc.

Jakob and Eshner's Internal Medicine and Diagnosis

Atlas and Epitome of Internal Medicine and Clinical Diagnosis. By Dr.
Chr. Jakob, of Erlangen. Edited, with additions, by A. A. Eshner, M. D., Pro-
fessor of Clinical Medicine, Philadelphia Polyclinic. With 182 colored figures on
68 plates, 64 text-illustrations, 259 pages of text. Cloth, $3.00 net. In Saunders^
Hand-Atlas Series.

" Can be recommended unheiitatingly to the practicing physician no less than to the student."

BuUttin 0/ Johns Hopkins Hospital.

Lockwood's Practice of Medicine. ^^Lf^^i^

A Manual of the Practice of Medicine. By Geo. Roe Lockwood, M. D.,
Attending Physician to the Bellevue Hospital, New York City. Octavo, 847 pages,
with 79 illttstratioDS in the text and 22 full-page plates. Cloth, ^^4.00 net.

Barton and Wells* Medical Thesaurus

A Thesaurus of Medical Words and Phrases. By W. M. Barton, M. D., and
W. A. Wells, M. D., of Georgetown University, Washington, D. C. i2mo of 535
pages. Flexible leather, $2.50 net; thumb indexed, ^3.00 net.

Jelliffe's Pharmacognosy

An Introduction to Pharmacognosy. By Smith Ely Jelliffe, Ph. D., M. D.,
of Columbia University. Octavo, illustrated. Cloth, $2.50 net.

Stevens' Practice of Medicine New (8th) EUUtion— Recently issued

A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D.,

Professor of Pathology, Woman's Medical College, Phila. Specially intended for

students preparing for graduation and hospital examinations. Post-octavo, 556 pages,
illustrated. Flexible leather, ^2.50 net.

Paul's Materia Medica for Nurses Recently issued

Materia Medica for Nurses. By George P. Paul, M. D., Assistant Visiting
Physician and Adjunct Radiographer to the Samaritan Hospital, Troy, N. Y. i2mo of
240 pages. Cloth, $1.50 net.

Saunders' Pocket Formulary New (8th) Edition— Recently issued

Saunders' Pocket Medical Formulary. By William M. Powell, M. D.
Containing 1831 formulas from the best-known authorities. With an Appendix con-
taining Posologic Tiible, Formulas and Doses for Hypodermic Medication, Poisons and
their Antidotes, Diameters of the Female Pelvis and Fetal Head, Obstetrical Table,
Diet-list, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from
Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, etc.,
etc. In flexible leather, with side index, wallet, and flap, ^1-75 net.

Gould and Pyle's Curiosities of Medicine

Anomalies and Curiosities of Medicine. By George M. Gould, M. D., and
Walter L. Pyle, M. D. An encyclopedic collection of rare and extraordinary cases
and of the most striking instances of abnormality in all branches of Medicine and Sur-
gery, derived from an exhaustive research of medical literature from its origin to the
present day. Octavo of 968 pages, 295 engravings, and 12 full-page plates. C'oth,
$3.00 net ; Half Morocco, ^4. 50 net.

Monro's Manual of Medicine

Manual of Medicine. By Thomas Kirkpatrick Monro. M. D., Fellow of,
and Examiner to, the Faculty of Physicians and Surgeons, England. Octavo of 901
pages, illustrated. Cloth, $5.00 net

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