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The American
Journal of Urolog
GENITO-URINARY AND VENEREAL DISEASES
EDITED BY
WILLIAM J. ROBINSON, M. D.
OF NEW YORK
ASSOCIATE EDITOR :
LEO BUERGER, M. D.
VOL. VII
JANUARY-DECEMBER, 1911
THE UROLOGIC PUBLISHING ASSOCIATION
12 MT. MORRIS PARK WEST, NEW YORK
List of Contributors to
The American Journal
Vol. VII of
of Urology
Robert Burns Axdersox, Brooklyn, N. Y.
J. B. Barxey, Boston, Mass.
Frederick Bierhoff, New York City, X. Y.
Horace Blvxey. Boston, Mass.
Leo Buerger, New York City, X. Y.
Hugh Cabot, Boston, Mass.
Geza Greexberg. New York City, X. Y.
Arthur Holding, Albany, X. Y.
David J. Kaliski, New York City, X. Y.
E. L. Keyes, Jr., New York City, X. Y.
G. Kolischer, Chicpgo^ 111.
Irvix S. Koll, Chicago, 111.
H. Kraus, Chicago, 111.
F. Kreissl, Chicago, 111.
M. Krotoszyer, San Francisco, Cal.
A. Xelkex. New Orleans, La.
R. F. O'Xeil. Boston, Mass.
Victor C. Pedersex. New York City, X. Y.
Moritz Porosz, Budapest, Hungary.
A. Ravagoli, Cincinnati, O.
G. A. De Saxtos Saxe, New York City, X. Y.
H. J. Scherck, St. Louis, Mo.
Charles L. Scudder. Boston, Mass.
Johx C. Spexcer, San Francisco, Cal.
DeWitt Stettex. New York City, X. Y.
Charles S. Sterx, Hartford, Conn.
A. R. Stevexs. New York City, X. Y.
A. C. Stokes, Omaha, Xeb.
William \Varrex Towxsexd, Rutland, Vt.
E. Tomasczewski, Berlin, Germany.
Index to Principal Subjects
Anomaly of the Urinary Tract 442
Antimeningococcus Serum in Gonococcal Septicemia 35
Anuria, Reflex Calculus .... 160
Aponeuroses and Periprostatic Spaces, Periprostatic Suppurations . . 71
Bladder, Case of Extrophy of 34
Bladder, Complex Suturing of, After Suprapubic Section. By G.
Kolischer and H. Kraus 297
Bladder Developed Partly Within Its Ligaments with an Intersting Dis-
p^cement of the Peritoneum after Suprapubic Cystotomy ... 69
Bladder, Four Cases of Distention Due to Diabetes Insipidus .... 155
Bladder, Myofibroma of 30
Bladder, Present Status of Intravesical Operations for Tumors of. By
Horace Binney 300
Bladder, Removal of Hairpins from the Female ........ 444
Bladder, Sarcomas of 33
Bladder, Syphilis of . 413, 422, 493
Bladder, Tumor of, an Endovesical Method of Operating for .... 503
Bladder, Tumors of. By Chas. M. Harpster 483
Bladder, Tumors of, the Transperitoneal and Suprapubic Approach to.
By Chas. L. Scudder 313
B right's Disease, Hydremia in 450
Buerger's Urethroscope, An Attachment for. By Victor C. Pedersen . 312
Calculus Anuria in Single Kidney Treated by Urethral Cathe':erism . . 162
Calculus, Foreign Body 245
Calculi, Removing Renal 363
Cancer of the Urinary Organs, Clinical and Operative Notes on 73 Cases 66
Catheter, A New Model of Opaque 74
Catheter for Women, Urethro-Vesical Irrigating 36
Catheter Left in Deep Urethra and Bladder after Operation for Ex-
ternal Urethrotomy. By Henry J. Scherck 60
Chancroids Due to a Peculiar Cause 75
Chancroids, Phagedenic, Hot Air Treatment of 81
Chyluria, Unilateral, Due to Filaria Bancrofti Infection. By David J.
Kaliski 429
Coli-uria 42
Colon Bacillus Infections of the Urinary Tract, An Experimental and
Clinical Study of. By Irwin S. Koll 417
Conversion of Bladder Epithelium into Secreting Cylindrical Epithelium 499
Cystoscopist, Concerning the Armamentarium of the, with Special Refer-
ence to the LTse and Construction of Certain Types of Cystoscopes.
By Leo Buerger 327
Cystitis Cystica, Concerning 276
Cystitis, Involvement of Ureters in Acute 597
Cystitis, Urethro- and Chronic Cystic Urethritis 29
Cystotomy, Suprapubic, Modern Instruments for 195
Editorial Announcement 486
Endoscope for the Anterior Urethra, An Improved Operating and Ob-
servation 82
Epididymis, Treatment of Acute Gonorrheal. By John C. Spencer. . 22
Phenolsulphonephthalein as a Test for Renal Function before Operation.
By E. L. Keyes, Jr 125
INDEX
Phimosis and Circumcision, Some Untoward Consequences of. By Geo.
H. Edington 142
Phthaleine Test in Functional Diagnosis of the Kidneys 206
Posterior Urethra and Xeck of the Bladder, The Normal and Patholog-
ical. By Leo Buerger 1, 43, 110
Preputial Redundancy: An Operative Technique for Its Correction. By
William Warren Townsend . . 465
Prostate, A Recent Series of 200 Cases of Total Enucleation of . . . 280
Prostatectomy, Freyer's Method of . ... 198
Prostatectomy, Perineal. By Alex. Hugh Ferguson 146
Prostatectomy, Position Drainage in Suprapubic. By H. J. Scherck . . 27
Prostatectomy, Suprapubic or Perineal. By Dr. A. C. Stokes .... 261
Prostatectomy, the Ejaculatory Ducts and the Sexual Function after
Suprapubic 410
Prostatectomy, Time and Method for. By Benjamin Tenney . . . 134
Prostate, Massage of the. By Geza Greenberg 62
Prostate, Prevalent Misuse of in Gonorrhea 279
Prostatic Abscess, Remote Results Following Incision of . . . 411
Prostatic Hypertrophy, Contribution to Histology of 202
Prostatic Hypertrophy, Origin of 499
Prostatic Infection, Technique of Examination in . .... 77
Prostatic Lipoids and Prostatic Concretions . . 501
Prostatitis, Chronic Gonorrheal. By Robert Burns Anderson . . . 179
Prostitution and Venereal Diseases, Control of in This Country and
Abroad. By Frederick Bierhoff . 256
Pyelithotomy, Technique of 68
Pyelonephritis, Latent 363
Pyelonephritis of Pregnancy 414
Radiography in Urinary Lithiasis 415
Renal Diagnosis, Functional, in the Service of Surgery 66
Renal Function, Experimental Studies of Tests for 502
Renal Function, A Clinical Study of, by Means of Phenolsulphoneph-
thalein. By E. L. Keyes . . . . 367
Renal Function before Operation, Phenolsulphonephthalein as a Test for.
By E. L. Keyes, Jr 125
Renal Infections 365
Renal Neoplasms in Tuberous Sclerosis of the Brain 277
Renal Neoplasms Pathology of Malignant . 449
Renal Tuberculosis, Specific Therapy of 444
Renal Tumors, Interesting 445
Retention of L'rine, Case of 277
Roentgenological Examination of the Kidneys. By Arthur Holding . . 18
Salvarsan 38
Salvarsan, Intramuscular Injections of 225
Salvarsan, Treatment of Syphilis with 40
Salvarsan in Syphilis. By Chas. S. Stern 218
Salvarsan Treatment of Syphilis, Review of. By Prof. E. Tomasczewski 83
Sarcomas of the Bladder 33
Separator, Instrument for the Accurate Application of in Women . . 205
Septicemia, Antimeningococcus Serum in Gonococcal 35
Sexual Neurasthenia, Its Local and Hydrotherapeutic Treatment. By
Moritz Porosz 58
Spermatic Cord, Primary Malignant Neoplasms of. By DeAVitt Stetten 287
Epididymitis, Tubercular, an Analysis of 153 Cases. By J. Dellinger
Barney 459
Foreign Body Calculus 245
Genito-LTrinary Suggestions 457, 508
INDEX
Gonorrheal Ulcers, Multiple 41
Heetine in Treatment of Syphilis 1ST
Hermaphroditism, Pseudo, Report of a Case. By Henry J. Scherck . . 437
Heminephrectomy for Horse Shoe Kidney 448
Horse-Shoe Kidney, Heminephrectomy for 448
Horse-Shoe Kidney, Symptoms, Diagnosis and Treatment of ... 495
Hot Air Treatment of Phagedenic Chancroids 81
Hot Sounds, Technique of Hyperemic Treatment of Urethra by Means
of. By Moritz Porosz 10
Hot Sounds, Treatment of Urethra by, for Producing Hyperemia . . 15T
Hydremia in Cardiac and Bright's Disease 150
Hydronephrosis, Congenital -197
Hydronephrosis, Huge (Two Gallons Capacity) 325
Hydronephrosis, Pathology of 440
Hyperemic Treatment of the Urethra by Means of Hot Sounds, Tech-
nique of. By Moritz Porosz 10
Hypospadias, Massive Destruction of the Urethra in, After a Succession
of Attempts to Restore It. By G. A. De Santos Saxe .... 53
Kidney, Calculus Anuria in a S'nglis, Treated by Urethral Catheterism 162
Kidney, Functional Diagnosis of 452
Kidney, Function of the 447
Kidney, Gonococcus Infection of 79
Kidney, Horse-Shoe, Symptoms, Diagnosis and Treatment of ... 495
Kidney, Horse Shoe, Heminephrectomy 448
Kidney, New Case of So-Called Actino Primary Actinomycosis of . . 155
Kidney, Operations upon and Pregnancy 157
Kidney, Pathology and Pathogenesis of Cysts of 454
Kidnev, Pedicle of, Critical Study of the Various Methods of Dealing
With 227
Kidney, Percussion of 321
Kidney, Phthaleine Test in Functional Diagnosis of 206
Kidney, Polycystic ... . . 203
Kidney, Polycystic Rudimentary 441
Kidney, Report of a Case of Congenital Cystic Degeneration of . 282
Kidney, Roentgenological Examination of. By Arthur Holding ... 18
Kidney, Supernumerary Discovered During Fife 194
Kidnev, Surgical Methods of Determining the Condition of ... 235
Kidney, Tuberculosis of 324
Kidney, Tuberculosis of a Cystic 415
Knotted Bougies in the U/rethra or Bladder 191
Lactic Bacillus Cultures in the Treatment of Chronic Specific LTrethritis 80
Lithiasis, Urinary, Radiography in , 415
Massage of the Prostate. By Geza Greenberg 02
Mercury, Therapeutic Advantages of Using in the Colloid Form ... 74
Nephrectomy for Renal Tuberculosis, The End Results of 189
Nephrolithiasis, Bilateral; Left Nephrolithotomy 285
Nephrolithiasis in Infants 441
Nervous Reflex Phenomena in the LTrinary Organs in Cases of Appendi-
citis 70
Noguchi's Test in Syphilis . 41
Periprostatic Suppurations, Aponeuroses and Periprostatic Spaces . . 71
Sporotrichosis, Syphilis and 242
Society Proceedings, American FTrological Association 82
Society Proceedings, N. Y. Academy of Medicine, Genito-LTrinary Section 504
Sodium Cacodylate in Syphilis 78
Stricture of the Male Urethra, Congenital 31
INDEX
Suprapubic Section, Complete Suturing of Bladder After. By G.
Kolischer and H. Kraus 297
Syphilis, Acquired, in a Subject Who Presented at Birth the Signs of
Secondary Hereditary Syphilis 243
Syphilis and Sporotrichosis 242
Syphilis, Hectine in Treatment of 187
Syphilis, Is Early Malignant, Really Syphilis? 162
Syphilis, Xoguchi's Test in 41
Syphilis of the Bladder 413, 422, 493
Syphilis, Review of the Salvarsan Treatment of. By Prof. E. Toma-
sczewski 83
Syphilis, Salvarsan in. By Chas. S. Stern 218
Syphilis, Sodium Cacodylate in 78
Syphilis, Tertiary, of the Urethra, and Urethral Fistulae 456
Syphilis, Treatment of with Salvarsan 40
Tonsilitis and Genito -Urinary Disorders 244
Tubercular Epididymitis, An Analysis of 153 Cases. By J. Dellinger
Barney 459
Tuberculosis, Genital 283
Tuberculosis of Kidneys 324, 415
Tuberculosis, Renal, Specific Therapy of 444
Tuberculosis, Renal, The End Results of Nephrectomy for 489
Ureteral Catheterization, Infection Following. By A. Xelken . . . 404
-Ureter, Case of Double * 164
Ureter, Treatment after Gynecological Operations of the Injured and
Non-Injured 443
Ureter, Treatment of Stones in 188
Urethra, Congenital Diverticula of 502
Urethra, Double Rupture of 164
Urethra, Instruments for Treatment of Posterior 202
Urethral Hemorrhages. By A. Ravagoli 306
Urethra, Tertiary Syphilis of, and Urethr; 1 Fistulae 456
Urethra, Treatment of by Hot Sounds for the Purpose of Producing
Hyperemia 157
Urethra, Unusual Case of Congenital Malformation 190
Urethritis, Acute, of Chemical Origin, with Report of Three Cases . . 318
Urethritis, A Rational and Efficient Method of Treating Acute Gonor-
rheal. By F. Kreissl 247
Urethritis, Chronic Proliferative, Endourethral Operative Work in . . 492
Urethritis, Lactic Bacillus Cultures in the Treatment of Chronic Specific 80
Urethritis, Treatment* of Chronic by Aspiration Method 160
Urethritis, Treatment of Gonorrheal 237
Urethritis, Urethral Pains Occurring in Completely Cured 156
Urethro-Cystitis and Chronic Cystic Urethritis 29
Urethroscope, An Attachment for Buerger's. By Victor C. Pedersen . 312
Urethroscopy, Technique of Posterior 450
Urethrotomy, External, Causes of Failure of. By H. A. Kraus . . . 407
Urine, Retention of 277
Urologists of the Middle Ages 121
Urology — Past. Present and Future. By M. Krotos-zyer 292
Vaccines and the Sera of Gonococci and Other Pyogenic Organisms :n
Urologv, Summary of Results Reported from use of in Urologv. Bv
R. F. O'NeU . . 209
Vaccines in Treatment of Infections of the Urinary Tract. Bv Hugh
Cabot ' 131
Vesical Stone and Its Management, with Special Consideration of Litho-
lapaxy. By F. Kreissl . . 167
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII JANUARY, 1911 No. 1
Contributed by the Author to The American Journal of Urology.
THE NORMAL AND PATHOLOGICAL POSTERIOR
URETHRA AND NECK OF THE BLADDER
A STUDY WITH THE CYSTO-URETHROSCOPE
By Leo Buerger, M.A., M.D.
Assistant Adjunct Surgeon and Associate in Surgical Pathology, Mount
Sinai Hospital; Associate Surgeon, Har Moriah Hospital, N. Y.
IN previous publications I described a new cysto-urethroscope
by means of which it is possible to obtain pictures of the neck
of the bladder and posterior urethra, which are both upright
and free from distortion. Having employed the instrument in
more than 300 cases, including both private and polyclinic patients
during the past year, it seems to me that a report of my own ex-
periences may be of some value in stimulating further investiga-
tion along these lines. In the exposition of my subject I shall
devote myself to the following themes: First, anatomical land-
marks ; second, elementary principles underlying the use of the
instrument, and technic ; third, the normal pictures of the neck of
the bladder and urethra ; and fourth, pathological lesions.
In order to facilitate localization of the findings obtained by
cysto-urethroscopy, it is expedient to divide up the posterior ure-
thra in an arbitrary way, taking certain well defined landmarks,
such as the annulus urethralis or margin of the internal sphincter
of the bladder, and the colliculus seminalis, in determining the ex-
tent of each portion. The sub-divisions that I have found most
useful in practice are the following:
The Sphincter margin (mn) with superior (roof), inferior
(floor) and lateral portions (sides) ; the pars prostatica (C) and
the pars membranacea (B). (Fig. 1.)
1
2 THE AMERICAN JOURNAL OF UROLOGY
We divide the prostatic urethra into :
A. Supramontane portion between sphincter margin and colliculus,
with a roof, later walls (sides) and floor (U).
B. Montane portion with a roof, sides and floor (T).
The floor of the supramontane portion shows the fossula pros-
tatica (FP), and the floor of the montane portion contains the
colliculus (urethral crest) and lateral sulci (sulci laterales). If we
regard the complete ridge or verumontanum as the urethral crest,
or crista urethralis, it seems best for topographical reasons, to
distinguish the following parts : Posteriorly (towards the blad-
der) there are frequently a number of small bands that lie in the
fossula prostatica and pass in to the crista urethralis. These shall
be called posterior frenula. They belong both to the supramon-
tane portion and to the montane. The crista shows a posterior
gradual inclination (crista posterior) or declive (S), a central
prominence, or summit, and the anterior distal slope, the acclive
(R). We shall drop the term urethral crest and speak only of a
colliculus showing a summit, acclive (anterior crista) and declive
(posterior crista). The valleys on either side of the colliculus are
the sulci laterales.
The membranous urethra (B, Fig. 1) receives the terminating
fold of the acclive and anterior crista, and also has a roof, side
walls and floor.
THEORETICAL, AND TECHNICAL, CONSIDERATIONS
I need not dwell here on the theory involved in the develop-
ment of the cysto-urethroscope, for this has been already described
elsewhere.* It will suffice to note a few fundamental facts. It is
to be remembered that in our optical system, a prism is employed
by virtue of which upright and right-angled images are obtained.
It may be well to say here that the deflection of the rays of light
is not quite 90 degrees, so that the telescope looks slightly for-
ward. Theoretically there is a certain advantage in a slight
obliquity of the axial ray ; for the center of the area of illumina-
tion and the middle of the field will then coincide. In the inter-
pretation of the pictures, however, we can disregard this slight
deviation from the canonical displacement of 90 degrees.
* American Journal of Surgery , May, 1910.
URETHRA AND NECK OF BLADDER 3
As for the size of the field, this is determined by the size or
width of the fenestra when the mucous membrane is in contact with
it. As the mucous membrane falls away (which occurs whenever
there is a fossa, or which is artificially brought about by the in-
jection of fluid) the size of the actual field increases, just as in the
case of the cystoscopy Thus the diameter of the field will vary
from 4 to 7-16 of an inch.
When the " inner field," or virtual image or that which ap-
pears to the eye, is 3-4 or an inch in diameter, the canonical size
for the instrument, objects lying in the plane of the fenestra are
enlarged about three diameters. When the mucous membrane of
the urethra is in contact with the fenestra of the instrument, the
actual field is about 1-4 of an inch in diameter. As the mucous
membrane is made to fall away from the window by the injection
of the irrigating fluid, the field becomes larger and the objects
become proportionally smaller. Thus at a distance of about 1-20
of an inch we are able to see a circle measuring 5-16 of an inch in
diameter; at 1-10 of an inch, a circle 6-16 of an inch; and at 1-6
of an inch, the field measures 7-16 of an inch in diameter.
The adoption of an optical system of short focal distance
and of but meagre magnifying power at close range, secured
for the author's cysto-urethroscope that much desired quality
of being able to bring properly into view objects lying very near
to the prism. In addition to this advantageous feature we em-
ployed a form of illumination that is excellent for near work,
namely, a prismatic roof illumination.* In the cysto-urethroscope,
therefore, we have conditions which are admirably fitted for the
investigation of near objects, making it possible to see the minutiae
of the markings of the mucous membrane with great distinctness.
In the male, but a limited portion of the mucous membrane of the
bladder can be brought into view. No difficulty will be encoun-
tered in locating the ureters and in studying the whole of the
trigone. The sphincteric margin can be perfectly studied, but
there are portions of the juxta-sphincteric mucous membrane
(namely, that portion which lies in the bladder) that may escape
*In more recent models the prism has been substituted by an obliquely
placed lamp shedding its rays through a glass window. Either type of
illumination (prism or direct variety) has been found satisfactory.
4 THE AMERICAN JOURNAL OF UROLOGY
our observation. This is especially true as regards that portion
of the mucous membrane of the bladder which adjoins the roof of
the sphincter. It is because of our inability to depress the penis
sufficiently, and consequently of our inability to approximate the
fenestra and the mucous membrane in question, that the failure
to bring this portion into view results. In the female, on the other
hand, the shortness of the urethra makes it possible to make wide
excursions with the cysto-urethroscope, and the instrument becomes
a better one for vesical observation. For practical purposes it is
quite sufficient to be able to see the trigone, ureters and sphincter.
Although we regard the simultaneous employment of the
author's right-angled telescope * together with the irrigation
method (Goldschmidt) as affording us the most accurate pictures
of the posterior urethra, we must admit that even this combina-
tion may permit the tyro to misinterpret some of the pictures.
Thus, although the prismatic illumination is adequate for near
objects, the more remote objects, such as the dilated bladder mu-
cosa, remain insufficiently lighted. When the bladder is somewhat
distended and the fenestra is at the sphincter margin, the failure
to illuminate the bladder is shown in Fig. 6, where the upper dark
zone corresponds to the mucosa of the bladder and the lower light
portion represents the sphincteric margin and beginning of the
supramontane floor. In practice this restricted lighting property
is not a disadvantage, since the optical apparatus too is best
adapted to near objects.
Although we believe that the colors seen with the telescope of
the cysto-urethroscope equal in exactness of reproduction those
seen with the ordinary cystoscope, certain changes may be pro-
duced by the pressure of the instrument, by spasm on the part of
the bladder neck, and by prolapse of the urethral mucous mem-
brane. Thus, as the instrument is drawn into portions of the ure-
thra which are narrow, the pressure effect upon the mucous mem-
brane is sometimes manifest, and we can see the mucous membrane
become blanched and the capillaries and vascular streaks turn pale.
A little experience, however, will tell us at once when the pallor
is a true one, for it requires but slight manipulation or holding of
*This telescope may be used in other cavities for near work; such as in
the oesophagus, mouth, nasal passages, etc.
URETHRA AND NECK OF BLADDER
5
the instrument at rest for a moment to bring about a return of
the vascular flow and a restoration of the normal color.
As for prolapse of the mucous membrane, this takes place most
readily in the region of the colliculus when it is turgid or when it
is inflamed. It occurs in the bulbous urethra when irrigation is
stopped, or when one of the faucets is open. Any marked re-
dundancy of mucous membrane coupled with an absence of dis-
tention by irrigation will tend to make the mucous membrane fall
into the window of the instrument. If we take sufficient precaution
to follow exactly the technic described later in the paper, it will
rarely happen that we are disturbed by prolapsing mucous mem-
brane. Even if this does occur, vision is not altogether interfered
with, increased magnification and slight darkening being the re-
sult.
In passing from the trigone over the floor of the supramon-
tane urethra, we must bear in mind that the sphincteric margin
may be rather prominent., Owing to the declivity of the floor of
the supramontane region, and also to the downward inclination
of the trigone, slight, variations in the appearance of the sphinc-
teric and juxta-sphincteric regions will inevitably depend upon the
differences in position of the instrument. Thus, if we depress the
ocular considerably in viewing the floor of the supramontane region,
we may slightly transilluminate the sphincter margin, and the pic-
ture will change accordingly. Villous growths and hypertrophies
in this region, therefore, must be studied from different points of
view, the shaft of the instrument being made to follow the plane
of the parts to be seen.
We need not dwell on the optical principles involved in the
interpretation of the pictures seen with the cysto-urethroscope, for
they are the same as those belonging to a Nitze cystoscope with an
upright field. It is only for the region of the sphincter that a
word of explanation may be advisable. Fig. 7 illustrates diagram-
matically the floor, roof and lateral aspect of this region. The
shaded areas represent the non-illuminated bladder, which appears
in the upper part of the field when the fenestra of the instrument
is turned downward. Although the floor of the sphincter presents
a horizontal slightly convex line, the roof and side walls show
marked concavities. In interpreting these pictures it must be re-
6 THE AMERICAN JOURNAL OF UROLOGY
membered that when the fenestra looks down the far point of the
field is at a point north (Fig. 2). On rotation of the cyTsto-
urethroscope, the fenestra pointing to the right side of the patient,
the far point is east. In viewing the roof the far point of the field
is south, and looking at the left part of the sphincter the far point
of the field lies at the west. The concave lines, therefore, do not
represent the curve of the urethra in a plane perpendicular to the
shaft of the instrument but they illustrate the sphincter margin
in a plane parallel to the shaft. In other words, the concavities
presented by the roof, side walls and floor are directed towards
the bladder and not towards each other.
Technique: Inasmuch as this has already been discussed in a
previous paper, I wish here only to allude to those improvements
which have developed during the course of my practical experience
with the instrument. After introduction with the obturator and
irrigation of the bladder when the contents are turbid, the telescope
is inserted and an irrigator which is situated about three feet above
the level of the table is attached to one of the lateral faucets. The
other faucet remains closed and is opened in order to evacuate the
bladder. When we desire to bring about prolapse of the urethral
mucous membrane irrigation is made to cease temporarily, or, to
secure considerable prolapse, the discharging faucet may be opened
for a moment. But a very small amount of fluid is allowed to en-
ter the bladder and we begin the examination of the empty bladder,
noting, if we wish, the peculiarities of the case in hand, and study-
ing the points that are to be described in a separate chapter. The
flow is then again started and allowed to continue throughout the
examination, being only made to stop for special reasons or while
emptying the bladder. If we do not care to study the collapsed
bladder, we begin the search for the ureters, which are usually
easily found when the bladder is filled with but a small amount of
fluid, viz., from 30 to 100 c. c. In some instances, when the has
fond is very deep, the trigone may be carried far downward on
dilatation, making the finding of the ureters more difficult. In
such cases it is best to seek the ureteral orifices after having allowed
most of the fluid to run out. The examination of the trigone is
next in order, and during this process it is best to raise the ocular
of the instrument so as to bring the fenestra fairly close to the
URETHRA AND NECK OF BLADDER 7
mucous membrane. The scrutiny of the sphincteric margin is now
begun ; its whole circumference can be brought into view by simple
rotation of the shaft. For observation of the juxta-sphincteric
portions of the bladder, we should have very little fluid in the blad-
der, and carry the shaft of the instrument far in the opposite
direction. We usually examine the floor of the supramontane and
montane regions next. This accomplished, the fenestra is pushed
into the bladder, turned upward and withdrawn for the examina-
tion of the roof of the supramontane, montane regions and of the
side walls. The membranous urethra and bulb are the last to en-
gage our attention. As regards the bulbous urethra we must not
loose sight of the fact that its capacity and dilatability vary con-
siderably in different individuals ; that when it is not distended its
appearance is very rugous, and that when it is filled ad maximum
it may lie so far away from the fenestra that the field becomes
somewhat obscure. We must then manipulate the evacuating
faucet as well as the irrigating flow in order to obtain the proper
distance for most satisfactory observation. The sharp limiting
margin, marking the junction between the bulbous and penile ure-
thra, as shown in Fig. 19, will serve as a reliable landmark for
the recognition of its peripheral boundary.
For those using the cysto-urethroscope for the first time, the
following more detailed description of the various parts of the
instrument may be of service :
Familiarize yourself with the following parts before attempting to use
the instrument:
1. THE SHEATH (Fig. 3) WITH ITS DETACHABLE BEAK (a),
FENESTRA WITH CATHETER NOTCH (b), LAMP, ILLUMIN-
ATING WINDOW (Fig. 4m), IRRIGATING FAUCETS (d), COU-
PLING (c), AND LOCKING SCREW (e). Remove the curved beak,
inspect lamp and lamp socket (Fig. 4g). A short straight tip may be
substituted for the curved one. Keep the screw joint and beak anointed
with the special wax provided for that purpose.
2. THE TELESCOPE (Figs. 4 and 5), with CATHETER CHANNEL (k),
CATHETER OUTLET (o), LOCKING FORK (p), the DEFLECTOR
for a CATHETER (y) or high frequency electrode, the FILIFORM
DEFLECTOR (x) ; and the TELESCOPIC JOINTS (j), at the end of
the telescope, for the reception of the deflectors.
For ureteral catheterization, or fulguration, adjust the larger de-
flector, after having capped the catheter outlet with the proper per-
8 THE AMERICAN JOURNAL OF UROLOGY
forated rubber tip. Place the deflector so that the catheter or electrode
will emerge as near to the ocular end of the fenestra as possible. To
probe the utricle and ejaculatory ducts use the finer curved filiform de-
flector. For observation alone, close the catheter outlet with a closed tip.
3. THE OBTURATOR, WITH LOCKING FORK (Fig. 3f).
TECHNIQUE.
A. Use ordinary cystoscopic preparations, and in sensitive individuals
anesthetize the urethra with 2% Novocain or 2% Alypin Solution.
Employ: (1) A connecting tube for irrigation through one faucet.
(2) An irrigator filled with boric acid solution situated 3 to 4 feet
above the level of the patient.
B. Test the lamp, watching the illuminated ground glass window. A great
deal of light is not required, inspection being done at close range. Short
circuiting is prevented by keeping the screw joint of the beak smeared
with wax. Adjust deflector according to requirements. Note that the
deflectors may cut off a tiny part of the field.
C. Introduce instrument with obturator into the bladder; remove obturator.
D. Wash bladder if necessary through sheath.
E. Insert telescope; adjust connecting tube to one irrigating faucet, both
faucets being closed.
F. Inspect the collapsed bladder. Start the flow and examine trigone,
ureters and vesical sphincter. After the sphincter has been examined
proceed to the inspection of the floor of the prostatic urethra, and then
view the roof and side walls.
If the telescope becomes soiled with secretion, remove and clean it
without disturbing the position of the sheath. The distended bladder
may be emptied at any time through the other faucet, after pushing the
instrument inward so that the fenestra lies in the bladder.
N. B. ON THE MANAGEMENT OF THE DEFLECTORS:
Try the deflectors before introducing the sheath. If they slide into
the joints too easily, spread the two limbs. Adjust in the proper posi-
tion so as to get maximum deflection. This is obtained by giving the
deflector a slight bend so that it tends to spring away from the telescope.
Make a mental note o'f the proper position by observing just how much
of the field (if any) is obscured by it. Usually only a minute section of
the field is encroached upon; sometimes not any of the field is cut off.
The Normal Pictures
The Empty Bladder: A splendid opportunity for studying
the movements of the walls of the bladder, as well as for viewing
the normal configuration of the parts about the vesical orifice, is
afforded us by reason of the instrument's capacity for producing
reliable pictures in the presence of a minimum amount of filling
fluid. Thus the form of the orificium internum could be investi-
gated in the case of the empty bladder just as well as with varying
degrees of distension of that organ.
To Illustrate Dr. Buerger's Article.
a e
Fig. 3
EXPLANATIONS OF FIGURES.*
Fig. 1. Schematic drawing showing author's method of dividing up the
posterior urethra and bull). The exact proportions are not adhered
to, the bulb being relatively too small in the figure.
Fig. 2. Schematic representation of the far point of the field; when the
fenestra of the cysto-urethroscope is at the black circle, the arrow-
point indicates the most distant part of the field.
Fig. 'A. Sheath erf author's cysto-urethrnscope with obturator in place: a, beak;
b, fenestra with notch; c, coupling for current; d, faucets; e,
locking screw; f, obturator.
"All the half-tone drawings are exact reproductions of pictures seen
through the cysto-urethroscope. The drawings were made while the artist was
looking through the instrument.
American Journal of Urology, January, 1911.
To Illustrate Dr. Buerger's Article.
g m h
Fig. 4
Fig. 5
Fig. 6
Fk;. 8 Fig. <) Fig. 10 Fig. 11
Fig. 4. Cysto-urethroscope with disposition of light and lens system dia-
grammatically shown: b, fenestra; g, lamp socket; 1, screw joint of
beak; h, objective with cap; j, telescopic joint for deflectors:
k, catheter channel; m, illuminating window.
Fig. .5. Telescope of the cysto-urethroscope: h, objective; j, telescopic joint;
k, catheter groove; o, catheter outlet; p. locking fork; s, ocular; x,
filiform deflector; y, catheter deflector.
Fig. 6. Floor of the urethral aspect of the internal sphincter.
Fig. 7. Diagrammatic representation of the internal sphincter.
Fig. 8. Trigone and overhanging roof of the empty hladder.
Fig. 9. Divided overhanging vesical roof of the empty hladder.
Fig. 10. Roof of the empty hladder falling down on the sphincter as viewed
with the fenestra pointing down and to the right.
Fig. 11. Sharp notch at roof of internal sphincter.
American Journal of Urology. January, 1911.
URETHRA AND NECK OF BLADDER 9
It is in the collapsed state that the physical conditions are such
as to permit of a rather extensive view of the mucosa, with mini-
mum excursions of the instrument. As has already been pointed
out elsewhere, the evacuation of the bladder offers a means of
bringing into view parts which would be beyond the pale of the
visual capacity of the optical system.
Let us now turn our attention to a few of the typical pic-
tures of the orifice of an empty male bladder. Keeping the sphinc-
teric margin in the center of the field we see only the red trigone.
A slight push inward will reveal a different view, the trigone being
below and the pale bladder mucosa encroaching upon and over-
hanging it in an oblique fashion (Fig. 8). On passing deeper
inward, in the direction from before backward, the obliquity of the
folds of the prolapsing roof is lost until their margins become al-
most parallel enclosing an oblong strip of plicated dark red tri-
gonal mucosa (Fig. 9).
In order to avoid possible misconception, it may not be amiss to
emphasize the fact that in the interpretation of these views of the
empty bladder obtained with the cysto-urethroscope, the displace-
ment produced by the instrument must be taken into account.
Thus in the Figs. 8 and 9, showing two bulging walls that appear
to overhang the floor of the bladder, careful consideration reveals
the fact that we are not dealing with two distinct side walls, but
with a protrusion of the roof. For instead of meeting the tri-
gone, the collapsed vertex is moulded around the shaft of the in-
strument. The roof of the bladder, therefore, is practically
divided into two lateral portions as long as the instrument looks
down upon the floor.
Turning 15° to 30° to the right or left from the primary
position (which shows the inferior margin of the sphincter), the
line representing contact of the roof of the bladder and sphincter
is brought into view (Fig. 10). Often there is a single convex
wall of pale mucosa meeting the red sphincteric ring, but at times
we encounter an additional intermediate fold intruding into the
angle betwen sphincter and bladder.
On rotation of the cysto-urethroscope to either side (with
an added motion of translation in the form of a slight withdraw-
ing pull) we see that the sphincter margin is covered by the pro-
10 THE AMERICAN JOURNAL OF UROLOGY
lapsed roof. Still turning the instrument in the same sense, the
typical angular superior margin is encountered, the triangular
incisure being covered by the bulging pale roof of the bladder
(Fig. 11). It would appear from an analysis of these illustra-
tions that the vesical roof falls downward and forward on the in-
ternal orifice, meeting the trigone. Under normal conditions it
covers the bladder surface of the sphincter or the annulus ure-
thralis. In some cases, two lateral projections insinuate themselves
at points on either side of the internal meatus. With the instru-
ment in situ, a certain distortion is inevitable, leading to the pro-
duction of the pictures just described.
(To be continued in the February issue)
Contributed by the Author to The American Journal of Urology.
THE TECHNIQUE OF THE HYPEREMIC TREATMENT
OF THE URETHRA BY MEANS OF HOT SOUNDS
By Dr. Moritz Porosz, Budapest, Hungary.
THE application of hyperemia to the urethra by means of
the hot sound may be secured by allowing hot water to
flow through a hollow double-channeled instrument, with-
out permitting any contact of water with the urethra itself. In
the following description I intend to call attention to the simplest
method of applying this treatment. In large cities every special-
ist has in his office a hot-water apparatus in addition to the or-
dinary water faucets. If a hot-water apparatus be used the
method which may otherwise seem complicated becomes very simple.
The thermometer in the irrigator shows the exact temperature of
the water in the container. The patient sits upon a chair and holds
the sound in one hand, in order to retain it in position. The in-
strument is a straight conical hollow sound, provided with an in-
flow and outflow (Fig. 1). The inflow is connected with an irri-
gator jar, which is raised one and a half or two meters above the
floor. The outflow of the water which has passed through the
sound is led into a vessel which stands at the patient's feet. The
patient holds the control stopcock in his other hand (Fig. £).
In my description of this method {Deutsche medizinische
Wochenschrift, 1909) I stated that lukewarm water must be used
HYPEREMIC TREATMENT OF URETHRA 11
at first when beginning the treatment, because the urethra is not
accustomed to the unusually hot water, and consequently the
patient feels the sudden application of heat as a painful or dis-
agreeable sensation. For this purpose I have found my old ar-
rangement for washing the bladder quite satisfactory. I con-
nected the tube of the hot-water apparatus with the tube of the
cold-water faucet so that the water in the irrigating tube would
represent the temperature of the mixture. The connection is
made by means of a small coupling and a rubber tube, as pictured
in Fig. 3. When the proper temperature has been secured, the
gas flame under the hot-water heater is extinguished and the hot
water is allowed to flow into the tube. In order to obtain some
lukewarm water at the beginning of the treatment, the connection
with the hot-water receptacle is made at the start when the flame
is first lighted. Thus the thermometer can be watched as its mer-
cury rises. The temperature in the large receptacle gradually
sinks, the colder water, being heavier, remains near the bottom of
the irrigator and the temperature of the water above becomes
gradually warmer as one approaches the surface, provided the
irrigator be not shaken. This physical property can be utilized
by filling the rubber tube and the lower part of the irrigator with
lukewarm, or even with cold water. When the irrigator is now
connected with the heating sound, the water which is at the bot-
tom of the irrigator and which is lukewarm or cold first flows
THE AMERICAN JOURNAL OF UROLOGY
Fig. 2
HYPEREMIC TREATMENT OF URETHRA 13
through the sound. Then as the water flows off, the warmer
lavers in turn flow through the sound, and so the patient gradually
becomes accustomed to the heat, until the proper temperature
reaches the urethra.
Control observations were made by measuring the tempera-
ture of the outflowing water. This was done by holding the ther-
mometer directly under the outflowing stream of water. This
indicated the exact temperature.
I found in these experiments that the beginning of the treat-
ment may be made with water at 35 to 36 degrees Centigrade in
the outflow tube and that this temperature was not felt at all by
the patient. When the outflow measures 40 degrees he begins
to feel that the water is becoming warm. A temperature of 42
or 43 degrees C. is borne even by sensitive, nervous patients. At
44 to 45 degrees in the outflow, the patient feels that the sound
is quite hot, but this temperature is borne by nearly every patient,
and in some instances very resistant patients could bear 50 degrees
C. in the outflow. In such cases, however, the sound seemed to
have burned the epithelium of the meatus, so that the latter was
sensitive for several days and a thin eschar had formed. The ure-
thra itself, however, bore this temperature well.
As the result of these measurements I found that by regu-
lating the stopcock I could reach an average temperature of 45
degrees in the outflow, when the receptacle contained water at a
variety of temperatures.
Thus, when the water in the irrigator was at 60 degrees, I
was able to get 45 degrees in the outflow stream by merely allow-
ing a thinner stream of water to pass through the apparatus.
With a larger stream I could get 45 degrees in the outflow from a
receptacle containing water at from 50 to 52 degrees C. The lar-
ger the number of thermal units passed through the apparatus in
a given time unit, the greater was the heat communicated to the
urethra. When the water was allowed to gush out suddenly, the
patient felt that the heat was greater, but the control thermometer
showed also a higher temperature. If the stream of water was al-
lowed to flow slowly a lower temperature was noted by the patient
and was registered by the thermometer.
I did not take the trouble to make calculations of the relation
of the velocity of the stream to the heat emitted, for in the first
14 THE AMERICAN JOURNAL OF UROLOGY
place I could not make these measurements, and in the second place
these complicated calculations are of no practical value. The pa-
tients themselves, anyway, regulate the heat satisfactorily. In my
first article, already referred to, I stated that there was a differ-
ence of from 8 to 10 degrees C. between the water which flowed
Fig. 3
in and that which flowed out, so that the urethra absorbed from 8
to 10 degrees of heat. Later, however, I discovered that the con-
necting tubes, the receptacle and the vessel in which the container
stands are all sources of loss of heat. The temperature varies at
different seasons and depends upon the temperature of the room.
When the fluid in the irrigator is shaken the temperature in
HYPEREMIC TREATMENT OF URETHRA 15
every layer of the fluid becomes equalized. Patients will not bear
an initial stream of 45 or 46 degrees, but if they are gradually
accustomed to it, they will bear as high as 54 and 55 degrees,
provided the velocity of the stream be appropriately regulated.
Whenever the patient feels that the sound is very hot, he in-
terrupts the stream by shutting the cut-off upon the connecting rub-
ber tube and thus the sensation of heat is at once relieved. The
same takes place if the stream is partly shut off. The patient thus
is enabled to get intervals of rest, after which he can tolerate the
action of the heat for a longer period. The patient thus has in
his own hands the regulation of the degree of heat, and in this
manner avoids too great suffering. The heat does not cause pain,
but is tolerable. The stream may also be regulated with the
cylindrical cut-off pictured in Fig. 4. On moving the ring one
millimeter, the temperature of the. outflowing water can be altered
to the extent of one or two degrees. This regulation is much
more safe and more delicate than the ordinary method, or that
with Leiter's stopcock.
I usually allow two liters of fluid to pass through the sound.
If the receptacle contains water at 50 to 52 degrees C. and the
outflow measures 45 degrees, it takes from eight to ten minutes
to pass this amount of water through the sound. If the tempera-
ture is higher in the receptacle, and if the outflow is to measure 45
degrees, the water must be allowed to flow more slowly, and the
treatment lasts from twelve to fifteen minutes. When the patient
feels very warm and begins to perspire, I do not force matters, but
interrupt the treatment.
The mucous membrane of the urethra becomes very red after
the treatment. The temperature of the surface at the lower as-
pect of the urethra was found to be 41 degrees ; while at the upper
surface the thermometer placed in contact with the cavernous
bodies registered but 39 1-2 degrees. The difference is due to the
greater thickness of the layers of tissues between the source of heat
and the thermometer.
After the treatment the urethra is sensitive to the passage of
urine. This sensitiveness continues sometimes on the next day if
the heat has been very great, and in such cases the treatment is
omitted on that day. In rare cases treatment has to be omitted on
the third day also.
16 THE AMERICAN JOURNAL OF UROLOGY
Vomer recommends the use of a hot sound heated by an elec-
tric apparatus, which can heat the sound up to a glow. In order
to prevent overheating a rheostat is employed. This is a con-
venient method, but in my opinion the heat cannot be as easily
regulated with the electric apparatus as with my own method, and
the patients cannot themselves regulate the heat as they can by
the water system. Moreover, hot water and an irrigator can be
provided anywhere, so that the only special instrument needed is
a sound.
Vomer himself mentions the disadvantages of his method.
He cannot get a thin enough sound. My sounds can be manu-
factured as small as 14 F., or even smaller, though in my opinion
a smaller sound is not necessary. In strictures of smaller calibre
one can more easily avoid making false passages by employing
bougies. Anybody who has had the opportunity to struggle with
rigid, easily bleeding and quickly relapsing strictures will appreci-
ate the brilliant, rapid and safe successes which can be obtained
in such cases with the hot sound.
In strictures of the posterior urethra, one may use in addition
to the straight, hot sounds, an electric psychrophore (Fig. 5),
with the difference that the beak alone is not isolated with hard
rubber.
I demonstrated my instruments for the application of hy-
peremia to the urethra in 1908 at the first Congress of German
Urologists, where I also read a paper regarding my experience
with this method. Experiences with this treatment since then
have convinced me that the use of the hot sound constitutes an
excellent therapeutic method in the treatment of sub-acute and
chronic urethritis, as well as in softening infiltrates and dilata-
tion of strictures.
On the other hand, my expectation of being able to destroy
gonococci in acute gonorrhea, by applying a temperature of over
40 degrees to the urethra, was not realized. The acutely inflamed
urethra not only does not bear high temperatures, but even in
those cases in which I succeeded in applying heat of over 40 degrees
to the urethra in this condition, I failed to destroy the goncocci.
The temperature was measured externally upon the surface of the
skin, as was later done also by Vomer. This simply is another
HYPEREMIC TREATMENT OF URETHRA IT
proof that the life of the gonococcus is different in vitro from that
which takes place in the body cavities.
For this reason the success of the treatment in infiltrates and
strictures was all the more satisfactory. When these lesions were
the causes of urethral discharge and of the presence of gonococci
therein, then the cure of these conditions and the disappearance of
the secretions was completely successful.
I do not mean to say that the mucous shreds floating in the
urine disappeared in every case. I must admit that I expected
this, and in many cases I succeeded in obtaining this result. But
the mucous shreds were always to be found in the morning urine.
The causation of this phenomenon could not be discovered even
with a urethroscope. The open follicles of Morgagni were filled
with mucus, but were healthy and not inflamed, and could not be
regarded as evidences of disease.
The treatment considerably increased the dilatability of stric-
tures. With the aid of the hot sound I have been able to dilate
without a single drop of blood strictures which had been treated
repeatedly by others and which had bled easily. In one or two
cases I was able to determine after considerable intervals that the
normally dilated urethral calibre had remained as such for months
and had not again become narrowed.
I was also able to observe. that in cases of infiltrates and stric-
tures, the urethral discharge which is so frequently present, but
which rarely contains gonococci, disappeared without the use of
any irrigations or injections, simply through the dilatation of the
narrowed portions up to the normal calibre.
Encouraged by these experiences, I made an attempt to treat
with the hot sound cases of non-gonorrheal urethritis in which I
encountered foreign, non-pathogenic bacteria. In such cases we
do not know with certainty whether these bacteria are associated
with the urethritis as a mixed infection, or whether they are the
organisms which cause the mucoid discharge. At first, I thought
that the hot sound was a useful measure in such cases, but in one
or two cases I found that I could not avoid the use of astringents.
I must admit, therefore, that the hot sounds alone do not lead to a
definite cure in some of these cases, yet it is well to try them in
obstinate cases on account of the sometimes surprising success
which follows their use.
Contributed by the Author to The American Journal of Urology.
ROENTGENOLOGICAL EXAMINATIONS OF THE
KIDNEYS
By Arthur Holding, M.D., Albany, N. Y.
BY careful technique in the preparation of the patient and in
the making of radiographs, shadows can be obtained of
most calculi in the urinary tract so that their size, loca-
tion, character, and number can be determined accurately. The
enormous increase in the number of nephrotomies done for calculus
since Rbntgen's discovery and the frequency of the diagnosis of
calculus being made to-day as compared with a decade ago is a
significant testimony to the efficacy of the X-rays in kidney exam-
inations. Very rarely a calculus will be of such soft consistence
or so obscured by the bulk of the patient or the patient presents
himself with such a distended abdomen that the calculus will not
cast a sufficent shadow to be registered on the radiograph.
The essentials in radiographing the urinary tract are :
1. An apparatus giving a maximum of direct rays and a minimum
of inverse, indirect or secondary rays ;
2. Fixation or compression of the parts to be examined ;
3. An exposure while the patient holds his breath.
Long experience has demonstrated certain dicta in regard to
Rontgenological examinations of the urinary tract, which are a?
follows :
1. A positive diagnosis of calculus should only be made after the
entire urinary tract has been radiographed and the shadow of
the lesion has been duplicated in at least two radiographs.
2. A negative diagnosis of calculus is only justified when the
radiographs show the outlines of the transverse processes of
the vertebrae, the psoas muscles and the kidney.
3. The visible outline of the kidney on the X-ray plate is evidence
that the radiograph is one of superior excellence. It is not
always possible to show these details in very large patients
or in those whose bowels have not been properly prepared
previous to the examination.
4. The correct interpretation is often more important and quite
as difficult as the making of radiographs of sufficient excel-
18
X-RAY EXAMINATIONS OF THE KIDNEYS 19
lence to be trustworthy. Pseudo-calculus shadows may be
caused by,
a, Foreign bodies as Blaud or silver pills, bullet in the back,
and the like ;
b, Calcification, of cartilages, lymph-nodes, arteries, veins,
phleboliths, spiculae of bones ;
c, Folds of intestines particularly when enveloped in adhe-
sions ;
d, Enteroliths ;
e, Prostatic calculi ;
f, Gall stones (rarely) ;
g, Tuberculosis of the kidney in chronic lesions with calcifi-
cation ;
h, Artefacts, as finger-marks, stains from uneven development,
flaws in plates, etc. ;
i, Sesamoid bones near spine of the ischium ;
j, Finally, there occur shadows at rare intervals, pseudo-
calculi, for which no satisfactory explanation can be
found short of an autopsy.
5. Misled by pseudo-calculus shadows, a wrong diagnosis may lead
to a useless and humiliating operation. In this method of
examination, therefore, it is essential to have the best radio-
graphs obtainable, and still more important to interprete
these radiographs correctly. On the other hand, some of the
most skillful surgeons have failed to find the stones at opera-
tion when a positive radiograph diagnosis has been made ;
subsequently the patients have passed stones corresponding in
number, shape and size to shadows obtained on the radio-
graphic plates; therefore, if the surgeon fails to find stones
at the operation, when the stones are clearly shown on the
X-ray plate, it does not necessarily mean that the stones are
not there.
6. Neglect of proper intestinal preparation before radiographic
examination is indefensible.
7. Under the best conditions radiography is the most reliable
method of diagnosis of calculus at our disposal. In selected
cases it will be found to be an advantage to check the X-ray
findings by cystoscopy and urethral catherisation. To verify
20 THE AMERICAN JOURNAL OF UROLOGY
a diagnosis of pseudo-calculus it may be necessary to demon-
strate the path of the ureter by catherising the ureters, using
a bismuth ureteral catheter, and radiographing with it in
situ.
8. The symptoms of a calculus of the kidney may be on one side
when the calculus is in the kidney on the other side of the
patient. (Reno-renal reflex.)
9. " With a limited knowledge of the science, radiographs have
been made which did not have sufficient detail to justify a
negative or positive diagnosis, and persons without sufficient
experience have made negative or positive diagnosis on these
plates." (Cole.)
10. Most patients having typical attacks of renal colic do not
have calculi, and, on the other hand, only very few of the pa-
tients who have calculi have symptoms sufficiently character-
istic to justify an operation.
11. The physician who sends his patient to a radiographer to be
examined should see to it that the patient's bowels have been
properly prepared over a course of at least one, and in some
cases, two or three days preceding the examination.
12. The radiographer who examines a patient whose bowels have
not been properly prepared previously, who makes a diagnosis
of a calculus from plates obtained under such conditions and
demands no further examination under proper conditions,
is a menace to public safety.
13. A very considerable number of cases which have been diagnosed
as sub-acute or chronic appendicitis have ultimately proved
to be cases of calculus.
14. Characteristic symptoms of nephrolithiasis have presented in
cases which proved to be cholecystitis ; renal tuberculosis ;
renal cancer ; hypernephroma ; pyelitis ; empyema of the renal
pelvis ; bacilluria ; hydronephrosis ; cystic kidney ; prostatic
disease or calculi ; seminal vesiculitis ; diseases of the urinary
bladder; essential hematuria, or that associated with scurvy,
purpura, or leukaemia; chronic appendicitis; diseases of the
spine, especially osteo-arthritis and Pott's disease in the adult ;
muscular rheumatism with spasm of the muscles of the back ;
flatulence.
X-RAY EXAMINATIONS OF THE KIDNEYS 21
15. In women, the passing of wax-tipped catheters may give valu-
able information, but this method is not of as much value in
men because of structural differences necessary in the male
cystoscope.
16. The absence of pain and danger of infection in making the
radiographic examinations, and the information gained as
to the positive size and surfaces of stones (whether rough or
smooth, therefore, whether movable or not), and the number
of calculi present, make the radiographic method the one of
preference ; to be supplemented by other methods if necessary.
17. The larger the calculus the less typical are the symptoms ; the
small calculi give the most typical attacks of colic.
The day when the medical profession will be satisfied with a
radiograph made by an orderly, a nurse, or any person who is not
an expert, is past. The day of the X-ray 44 photographer " is
past. The day of the X-ray 44 diagnostician " is here. The day
when the medical profession will have sufficient experience in read-
ing plates to decide for themselves whether the plate has sufficient
detail to justify a diagnosis, I pray will soon come.
Other diseases of the kidneys that can be demonstrated by
radiographs are nephroptosis, tumors, hydronephrosis, pyoneph-
rosis, ureteral anomalies. In cases where the kidney can be out-
lined in the radiographs a diagnosis of the presence or absence of
a floating kidney by the use of Lange's technique is possible, but
ordinarily simpler methods will establish the diagnosis of floating
kidney. Tumor outlines and chronic tuberculosis of the kidneys
have been demonstrated in radiographs.
18. The X-rays are not as often used as they should be.
19. Economy in cash by neglecting to have an X-ray examination
often means extravagance in human suffering.
98 Chestxut Street.
Contributed by the Author to The American Journal of Urology.
TREATMENT OF ACUTE GONORRHEAL
EPIDIDYMITIS :
CONSERVATIVE CONTRASTED WITH SURGICAL METHODS,
By John C. Spencer, M.D.
Assistant Professor of Genito-Urinary Surgery, Medical Department of the
University of California, San Francisco, Calif.
SINCE Bevan (1) states that 20 per cent, of all cases of acute
gonorrhea are complicated by acute epididymitis, cases of
the latter must come under the observation of the general
practitioner fairly frequently.
The usually stormy course of the affection demands relief for
the patient in the promptest manner. As a fundamental principle
all treatment of the urethra locally should absolutely cease for the
time. This includes any form of injection or irrigation.
Surgical Methods. Surgical methods will be considered first.
A brief resume of the work in this direction need not take us back
beyond a few years. In this country one of the earliest advo-
cates of surgical relief for the condition was Hagner, who in 1906
and again in 1908 treated the subject quite exhaustively. The
operation consists in an incision through the skin of the scrotum
and through the tunica vaginalis directly into the inflamed epi-
didymis, the patient being under the influence of a general anes-
thetic. In the same year Bazet (4) reported 65 cases similarly
treated. Cunningham (5) recommends the incision operation.
Likewise Gross (6), modifying the recommendations of the others,
however, by advising its use only in certain selected cases. Kreissl
(7) and certain German surgeons, i. e., Baehrmann (8) and Ernst
(9), are strong advocates of surgical interference, but confine the
same to puncture of the inflamed epididymis with a small trocar.
The chief claim made by the advocates of either method is that the
agonizing pain is immediately relieved ; the fever disappears ; the
leucocyte-count is lowered, and, upon recovery from the anesthetic,
the patient is euphoric. The further advantage is claimed that
the patient is confined to bed for from 4 to 5 days, and the wound
*Read at the regular monthly meeting of the San Francisco County
Medical Society, September 13, 1910.
22
ACUTE GONORRHEAL EPIDIDYMITIS
heals in from 8 to 15 days, with a cigarette-drain left in for
from 4* to 6 days. The seminiferous tubules are injured so
slightly, if at all, that upon complete restitution the testicle is left
unimpaired. Pus-foci are not always discoverable, but sometimes
appear as miliary points. Occasionally a fairly large suppurative
focus will be opened. Ernst claims that the average course
following puncture is about 6 days. The puncture is recommended
to be performed with a very small trocar or aspirating needle.
Gentle aspirations may be added, thus withdrawing more or less
bloody fluid. Hagner makes the further claim for the incision
method that the induration rapidly disappears and that the ure-
thral discharge decreases. With regard to the latter claim it is
worthy of note that the general experience is that during the acme
of the epididymis the urethral discharge becomes very scanty or
even disappears, to reappear as the inflammation subsides in the
testicle.
Local Applications. Until within recent years, by non-opera-
tive procedures, the various stock antiphlogistic measures have had
the changes rung on them, including the use of sedatives and
opiates. The average of general measures seems to have narrowed
itself to the confinement of the patient to bed; the use of a suit-
able support for the inflamed organ ; the application of moist heat
preferably, or ice in some instances. In the use of medication
locally for the relief of pain Guaiacol seems to stand out pre-
eminently. Diluted with alcohol and glycerin, according to the
tolerance of each individual, the mixture is painted on the scro-
tum of the affected side, its application being extended upward
toward the abdominal ring if there be pain along the course of
the vas deferens. The analgesic action of the Guaiacol is strik-
ingly prompt in some instances. It must not be forgotten, how-
ever, that this powerful remedy may exert powerful and even
depressant effects upon the patient. Again, its action may be
excessively caustic at times, causing complete desquamation of the
epidermis, thus increasing the possibility of infection. In some
patients the caustic effects of the remedy completely overshadow
the pain of the epididymitis, calling for relief from the former.
If Guaiacol so applied relieves without untoward results it is al-
most ideal for counteracting the most striking and distressing
symptom — pain.
24 THE AMERICAN JOURNAL OF UROLOGY
It is only necessary to refer to ointments containing mer-
cury, belladonna, ichthyol or similar venerable remedies for this
affection as affording slight, if any, demonstrable relief. They
succeed in placing the patient in a state of smeary, black unclean-
ness, most distressing to the average individual. That old stand-
by, lead and opium lotion, applied hot, whatever the questionable
virtue residing in the external application of the main ingredients,
at least gives some relief because of the moist heat.
Magnesium Sulphate. Tucker (10) in 1908 recommended
somewhat empirically the use of a saturated solution of magnesium
sulphate for the relief of erysipelas, having used the same in the
form of hot fomentations on more than 700 patients as a basis on
which to found his conclusions. Subsequently he was led to em-
ploy the same in various inflammatory conditions, including epi-
didymitis. In the latter condition, experience has led me to adopt
its use to the exclusion of all other forms of local application. It
should be borne in mind that in certain susceptible individuals its
use after a week or so may be followed by an annoj^ing and ob-
stinate erythema. It relieves the pain quite promptly, usually
within a few hours after its application, although tenderness and
swelling persist for a somewhat longer period. The solution is
applied on several thicknesses of gauze and the whole is covered
with oil-silk tissue. The compress is kept constantly moistened,
the solution being poured along the edges. This dressing is not
to be disturbed otherwise oftener than twice in 24 hours. The
comparative cleanliness of this form of local application, and the
very prompt and positive relief of pain it affords, makes it a most
valuable addition to our therapeutic armamentarium in the treat-
ment of epididymitis. It is almost superfluous to refer to the neces-
sity of keeping the patient's channels of elimination functionating
freely by an occasional mercurial and the daily administration of
a mild saline, in order to insure soft evacuations and a more or
less depleted condition of the pelvic venous system.
Urethritis Posterior. Of almost uniform coincidence with
epididymitis is a deep urethritis or a urethro-cystitis, involving the
entire canal as well as the bladder about the internal orifice. This
will be evidenced by frequent and painful micturition and tenes-
mus. At times, depending upon the intensity of the inflammation,
ACUTE GONORRHEAL EPIDIDYMITIS 25
in the deep urethra, a small amount of blood may appear at the
end of urination. Bloody urine may also occur through the reflux
of blood into the bladder from an intensely congested deep urethra.
These conditions call for relief urgently. Balsamics are most
useful adjuvants. Santal oil, preferably its salicylic acid ester
because of its minimum disturbing effect upon the stomach and
because it is not followed by renal pain, usually has a decidedly
soothing effect. A very simple and effective relief for the tenes-
mus is the use of a hot sitz-bath once or more in 24 hours. Not
infrequently the use of an opiate is called for. Then Codein in
0.06 gm., dose in suppository, best fulfils the indication. The
fluid extract of Piper methysticum (Kava Kava) in combination
with some alkali and possibly fluidextract of Hyoscyamus form
useful adjuvants in the treatment. The well-known antiseptic
action of formaldehyde in the form of Hexamethylenetetramin
serves to modify more or less the noxious activity of the flora
responsible for the urethral condition and is a valuable aid to this
extent. It should not be forgotten that some patients develop
irritability of the bladder neck from this latter drug.
Vaccines. We now come to the use of vaccines. As a pre-
liminary, I cannot do better than to -quote Adami (11). He says:
" Thus as a final principle it may be laid down — and I do this
with a full sense of the necessity and responsibility that attaches
thereto — that vaccine therapy is not to be undertaken by the or-
dinary practitioner ; there are too many dangers attaching thereto ;
and with this corollary that, excellent as may be the stock vac-
cines prepared by certain firms, to advertise these light-heartedly
and recommend them and their employment far and wide deserves
the commendation of this association and all interested in the well-
being of their fellow-men."
To this the author may only add his humble testimony that
the use of a serum or bacterin, with its powerful possibilities, is
not to be lightly undertaken. The effect of the first injection on
the patient should be carefully watched and subsequent injections
modified as required. The phenomenon of anaphylaxis should be
anticipated by inquiry as to the patient's past experience with
serums, if any. In certain foudroyant or stubborn cases only the
use of an autogenous vaccine is followed by appreciable relief.
Rarely some cases are not even affected by these. The majority
26 THE AMERICAN JOURNAL OF UROLOGY
seem to respond fairly well to the use of the ordinary stock vac-
cines or bacterins. Injected into the substance of the larger
gluteal muscle, the initial dose may be 50 million devitalized,
gonococci and subsequently carried as high as 500 millions. These
injections may be repeated as often as every third day. The
author has yet to observe any untoward general effect following
many such injections in all strengths. At most, a trifling ten-
derness at the site of injection, lasting perhaps 24 hours, follows
in some.
In comparison with the old expectant methods the use of
bacterins has a distinctly modifying effect upon the course of the
epididymitis, both as regards the severity of the symptoms and
the course of the disease. It may be stated in general terms that
unless a noticeable reaction follows the use of a vaccine no very
decided effect upon the course of the disease may be looked for.
The experience of the author in the use of vaccines, followed as
it is by the most striking change in the clinical picture — cessa-
tion of the agonizing pain, fall of temperature, subsidence of the
swelling to a marked degree and a general euphoric condition of
the patient — has led him to adopt the use of vaccines as one of
the first therapeutic measures in the treatment of gonorrheal
epididymitis. Similar experience is recorded by Swinburne of New
York (12). He says: "I have found the serum of the greatest
assistance in epididymitis, both acute and relapsing. In many
cases, when given in the earliest stages, I have seen the disease
aborted. Of such value have I found the serum in these cases
that although in the past two years I have looked for cases on
which to perform the Hagner operation for epididymitis, I have
not yet met a case when I felt justified in doing it."
Conclusions. In conclusion and by comparison it would seem
that the protagonists of the various surgical methods of treating
acute gonorrheal epididymitis offer in behalf of the operative meth-
ods immediate relief from the severe and often agonizing pain
of the disease. While such relief is a great desideratum, the opera-
tion involves the use of a general anesthetic, presumably with main-
tenance in a hospital and an open wound, which, under very favor-
able conditions, closes in as early as six days.
In view of the aborted cases following the use of serums or
vaccines, and the very marked moderation of the symptoms by
SUPRAPUBIC DRAINAGE 27
the use of the local and internal methods above referred to, the
author has still to be convinced that the subjection of a patient
to a fairly serious surgical intervention in order to obtain results
practically similar to those obtained by non-surgical methods,
as regards relief of symptoms and shortening the course of the
disease, is warranted or advisable in the face of the results thus far
obtained.
Butler Building.
References :
1. Keen's Surgery. Vol. 4.
% Hagner, F. R. Oct. 13, 1906.
3. Hagner, F. R. Arm. of Surgery, Dec, 1908.
4. Bazet, L. Amer. Jour, of Urology, June, 1909.
5. Cunningham, J. H., Jr. Bost. Med. and Surg. Jour.,
Nov., 1908,
6. Gross, L. Amer. Jour, of Urology, June, 1909.
7. Kreissl. Ref. by Ernst, seqq.
8. Baehrmann. Deutsche med. Wchschr., 1903, No. 40.
9. Ernst. Berliner Mm. Wchschr., V. 46, Nos. 10-1.
10. Tucker, H. Ther. Gazette, March, 1907.
11. Adami, J. G. Symposium on Vaccine Therapy, Mtg.
of Ass'n of Amer. Physicians, Wash., D. C, May 4,
1910.
12. Swinburne, G. K. Trans. Amer. Urol. Ass'n, V. 3, 199.
13. Schindler, C. Deutsche med. Wchschr., 1906, No. 51.
14. Heinze, KL Dermatol. Ztschr., March, 1908,
15. Spitzer, E. Vortr. vor d. Wiener dermatol. Verein, Dec,
1907.
Contributed by the Author to The American Journal of Urology.
POSITION DRAINAGE IN SUPRAPUBIC
PROSTATECTOMY
By H. J. Scherck, M. D., St. Louis, Mo'.
Visiting Genito-Urinary Surgeon to the City Hospital, Missouri Pacific Hos-
pital, Chief Dept. Genito-Urinary Diseases, Jewish Dispensary, St. Louis.
A NEW METHOD IN RELATION TO SUPRAPUBIC DRAINAGE
THE unbiased surgeon of to-day realizes that there exist
cases in which the suprapubic route is to be preferred to
the perineal, and vice versa. It is the writer's opinion
that were the question of drainage properly solved, the number
28 THE AMERICAN JOURNAL OF UROLOGY
of cases operated upon by the suprapubic route would be decidedly
increased. The suggestion for the adoption of the following
method came as a result of observing a confrere perform the
Gilliam operation, in which the position herein described was
utilized.
In three patients recently operated upon for enlarged pros-
tate, I have placed them upon the abdomen immediately after
operating, having first secured a large-sized drainage tube by
suture in the wound. This tube should have an opening of at
least one inch, and the end of it allowed to dip into, but not
reach, the fundus of the bladder. In the lower portion of the
tube are two good-sized openings made on either side. Upon the
completion of the enucleation the tube is introduced into the open-
ing of the bladder, the size of the tube depending upon the size of
the bladder wound, never less, however, than one inch. The con-
traction of the walls of the bladder around the tube is sufficient,
in the majority of instances, to prevent leakage.
The tube is secured by suture through the abdominal wall.
It is cut even with the surface of the abdomen, and a large absorb-
ing dressing of gauze and cotton is placed over it. The patient
is returned to bed and placed upon his abdomen, and if he com-
plains of being uncomfortable, on account of his posture, the nurse
is instructed to change the position by allowing him to lie on his
side or back for a few moments at a time. It is surprising, how-
ever, how little complaint is noted on account of this position,
which naturally favors drainage, prevents those complications
which poor drainage induces, and lessens the tendency toward
the development of post-operative pneumonia incited by stasis in
the lungs, a likelihood developing from the usual position.
What effect this procedure may have on kidney complications
and post-operative bleeding, I am not at this time prepared to
state.
The dressings can be changed as often as it is found neces-
sary. My first idea was to carry a tube through a hole in the
mattress into a receptacle underneath the bed, but objections were
noted in regard to this, the principal one being that it limited
the movements of the patient and made pressure on the tube likely.
The drainage tube in these cases can be removed after the time
CURRENT UROLOGIC LITERATURE 29
usually adopted in ordinary suprapubic prostatectomy. My ex-
perience is too limited to notice any special objections to the
method that I have outlined above, and this preliminary report
of detail of technique is made so that it may be tried out and a
proper estimate of its value determined.
309 Century Building.
Review of Current Urologic Literature
FOLIA UROLOGICA
November, 1910
1. Urethro-cystitis and Chronic Cystic Urethritis. By Leo Buerger.
2. Myofibroma of the Bladder. By Victor Blum.
3. Gonococcal Toxemia. By T. M. Townsend and J. J. Valentine.
1. Urethro-cystitis and Chronic Cystic Urethritis. — Leo
Buerger says that since he has employed his cysto-urethroscope in a
routine way in the large number of patients, he has frequently encount-
ered a condition which he wishes to designate as urethro-cystitis or
chronic cystic urethritis. Although his observations have not yet been
thoroughly worked out, it seems well to call attention to them, so that
the lesions in question may become the subject of further study. In
the present article, he reports briefly upon some twenty cases, giving
in detail the lesions in fourteen of these. After a brief outline of
the workings of the cysto-urethroscope.Buerger proceeds to describe
and to illustrate a number of cases in which cysts were found in the
posterior urethra. There seem to be two types of cystic disease of
the neck of the bladder and the posterior urethra. The first of these
is due to inflammatory causes, and is gonorrheal in origin; the second
is due to retention, and belongs to the involution changes of the senile
period. The inflammatory cysts which belong to true chronic cystic
urethritis are most frequently found in the supramontane portion,
although they are also seen in the other portions of the pars pos-
terior. In two of the patients, the verumontanum was found markedly
diseased. The cysts varied considerably in size, from about a milli-
metre to five millimetres or more in diameter. At times, a confluent
form was met with, but usually the cysts were discreet, hemispherical,
with a slight tendency to become oval, and when the light was prop-
30 THE AMERICAN JOURNAL OF UROLOGY
erly regulated, they appeared as small, pearly-white spheres, over
which small blood vessels ramified. When the illumination is in-
sufficient the cystic nature of these bodies does not appear, but they
seem to be solid hypertrophies. A number of illustrations are given,
showing some remarkable pictures of cystic urethritis. Clinically
considered, all the cases have had one or more attacks of gonorrhea.
Some of them gave a history of complications. The symptoms varied
markedly. There were disturbances of urination in two cases, and
in one, severe pain during micturition. One patient had been treated
for a number of years by various specialists, and it was found that
he had a number of small cysts in the roof of the posterior urethra.
The treatment of these cysts consists in incising them or puncturing
them under control of the eye, by means of a specially-constructed
knife, which can be adapted to the cysto-urethroscope. Incision
should be thorough, so as to obliterate the cysts completely. If there
are many cysts, the treatment should be divided into two or three
sittings, with intervals of about a week or ten days. In the case in
which there was marked disturbance of urination, improvement oc-
curred to a distinct degree after the incision of the cyst. In two
cases no improvement occurred after incision.
2. Myofibroma of the Bladder. — Blum reports the following
case: A young man was taken ill with a profuse hematuria, without
any other urinary symptoms. A marked rise of temperature sud-
denly appeared, and it was supposed that he had a pericystic suppura-
tion. Upon suprapubic incision a tumor, the size of a fist, was dis-
covered on the posterior wall of the bladder. The tumor was ede-
matous, and had a twisted pedicle. It was removed in the course of
two operations at different times, and on examination was found to
be a myofibroma. The patient made a good recovery. The sub-
mucous type of myoma is the most common type of this tumor in
the bladder. The symptoms accompanying these tumors are char-
acteristically as follows: When no infection has taken place, there
is profuse bleeding, a palpable tumor, symptoms of pressure upon the
rectum and, at times, urinary retention. After infection, the symp-
toms are those of very severe cystitis, with gangrene and ulcerations
as well as the presence of a palpable tumor. When the pedicle of
the tumor becomes twisted, as in the present case, the symptoms are
those of a rapidly-developing pericystitis. In the case of small
tumors, the cystoscope will aid in diagnosis. Sometimes there will be
particles of the tumor voided in the urine. In other cases, the diag-
nosis can be made only by incision.
CURRENT UROLOGIC LITERATURE 31
3. Gonococcal Toxemia. — Townsend and Valentine complain
of the confusion which exists at present in the designation of general
gonococcus infection, — inasmuch as no distinction is usually made
between gonococcal toxemia, septicemia and pyemia. Gonococcal
toxemia was known, clinically, before its etiology was recognized.
The demonstration of the gonotoxin furnished an explanation for its
development. Gonococcal toxemia is accompanied by general malaise,
headache, pain in the back, loss of appetite, rises of temperature, and
leucocytosis, occurring at the start of an uncomplicated gonorrheal
urethritis. The authors report a case of gonococcal toxemia in a
man 44 years of age. This was the first attack of gonococcus in-
fection in this patient. Rises of temperature occurred on the twelfth
day and continued until the thirty-eighth day. The range of the
fever was from 100 to 103.8° F. The only successful treatment
consisted in high enemas of a 6 per cent, solution of magnesium sul-
phate, at a temperature of 70° F. After the ninth irrigation, the
temperature sank to normal. One pint of the magnesium sulphate
solution was allowed to flow into the rectum, and repeated every six
hours. The condition improved notably after the first enema. Four
days later office treatment was begun for the urethritis. The above-
mentioned treatment has a threefold effect: Firstly, it reduces fever
temporarily by the absorption of a quantity of fluid whose tempera-
ture is considerably below that of the body. Secondly^ the enemas
produce copious evacuations, and thus elimination of toxins through
the intestine, and thirdly, they produce a derivation of the local in-
flammatory effects.
ZEITSCHRIFT FUR UROLOGIE
Vol. IV, No. 11 (1910)
1. Two Rare Malformations of the Male Genitals. By Fritz Neu-
mann.
2. Congenital Strictures of the Male Urethra. By Carl R. Wilckens.
3. Sarcomas of the Bladder. By Chassia Munwes.
4. Cystic Dilatation of an Accessory Ureter. By S. P. Von Fedoroff.
2. Congenital Strictures of the Male Urethra. — Wilckens
contributes a complete study of congenital strictures. The best classi-
fication of these strictures, in his opinion, is that of Englisch. This
author divides obstructions of this sort into those which are present
during fetal life and disappear later, and those which remain per-
32 THE AMERICAN JOURNAL OF UROLOGY
ruanently. Among the first group are included adhesions of the
epithelial lining of the urinary canal, adhesions of the same character,
at the mouth of the ureter, the formation of valves and twists in the
ureter which are obliterated later in life, adhesions obliterating the
inner orifice of the urethra as well as the outer, atresia of the prepuce,
etc. In the second group, the permanent lesions, Englisch includes
valves and stenoses. Valves may occur in various parts of the urin-
ary tract, especially at the entrance of the ureter into the renal pelvis,
less frequently, at the neck of the bladder or in the bladder itself,
in the prostatic urethra, in the anterior urethra, at the meatus, or at
the orifice of the prepuce. Stenoses may be found at all the orifices
and at any part of the urethra, particularly at the boundary of the
membranous urethra and the bulb, at the posterior end of the navicu-
lar fessa, and at the meatus.
Congenital strictures of the urethra were not regarded as of
great importance until Bazy, in 1903, called attention to their fre-
quency. The most interesting type of congenital strictures are those
characterized by valve-like malformations of the posterior urethra.
An instructive case of this kind, is reported by the present author.
In a boy of two years, who died of diphtheria, the urethra at autopsy
seemed normal in its glandular and cavernous sections. At the
boundary-line between the membranous and prostatic urethra, how-
ever, there were found two longitudinal folds of mucous membrane,
which constituted two lateral valves, enclosing pockets, the concavity
of which was turned towards the bladder. A very small space was
left between these valves for the passage of urine. The kidneys
showed the presence of an advanced degree of chronic nephritis and
hydronephrosis, particularly on the left side. Other cases of a simi-
lar type, were reported by Tolmatscheff (3 cases), Budd, Velpeau,
Schlagenhaufer, Commandeur, Bonnet and Reboul, etc. One feature
is common to all the reports, save that of Velpeau, namely, the pres-
ence of a valve-like formation at the lower end of the posterior ure-
thra, and distinct lesions in the urinary organs situated above the
valves. The genesis of these valve-like stenoses is to be looked for
in an exaggerated development of folds which exist normally. Usu-
ally the stenosis is accompanied by dilatation of the urethra, the blad-
der, or the renal pelvis above the valve. Naturally, the degree of
damage to the upper tract depends upon the extent of the obstruction.
Congenital stenoses of the urethra very quickly terminate fatally.
Death may occur in utero, — as the result of circulatory disturbances
which are dependent upon the pressure of the distended bladder upon
CURRENT UROLOGIC LITERATURE SS
the umbilical arteries. In other cases, death occurs at a very early-
age. The symptoms of this congenital anomaly are often very ob-
scure. In some cases, however, there is a suspiciously-thin stream of
urine or prolonged dribbling. Incontinence of urine, during the day
or at night, may also be present. In addition to difficulty and pain on
urination, there may be also hematuria. None of these symptoms,
however, were present in the case reported. The only thing that
called attention to the urinary apparatus, in this case, was the al-
buminuria.
3. Sarcomas of the Bladder. — Munwes contributes a very com-
prehensive study of sarcomas of the bladder, with statistics, show-
ing the frequency of the various forms, etc. While modern methods
of diagnosis are certainly of value in the detection of bladder tumors,
yet even the cystoscope cannot be relied upon to detect sarcoma, inas-
much as this tumor very frequently resembles epithelial growths.
Exploratory incision, therefore, can alone be relied upon. As re-
gards the results of treatment, there were 76 cases operated upon out
of the 107 cases collected and studied. In 44 cases, a suprapubic
operation was performed, in 11 cases a perineal incision was used, in
3 laparotomies were performed (owing to the size of the tumors).
In one case, the tumor was approached through the sacral route and
in another through the vaginal. In 6 cases, the character of the in-
cision was not stated, and in 9, the tumor was removed in women,
through the dilated urethra.
Endovesical operations cannot be expected to produce permanent
results in these cases, as the sarcoma frequently involves the entire
thickness of the bladder wall. Total extirpation of the bladder has
been performed in a number of cases. Thus Goldenberg collected 26
cases, with a mortality of 61.5 per cent. Rafin collected SO cases,
with a mortality of 56.6 per cent., but only two patients were recorded
as permanently cured.
In the present study of 69 cases of bladder sarcomas operated
upon in various ways, there was permanent cure in 3 cases, apparent
cure for a short period of observation in 13 cases, cures followed by
recurrences, in 15 cases; death several weeks or months after the oper-
ation, in 11 cases, death a few days after operation; in 21 cases, and
death without any data as to the time when it occurred, in 6 cases.
In the cases in which death occurred within the first few days
after operation, death was caused in five instances, by
shock, reflex anuria, embolism, hemorrhage, sudden collapse, and
pneumonia, respectively. In the remaining 9 cases, the cause of
M THE AMERICAN JOURNAL OF UROLOGY
death was not stated definitely. In 8 cases, in which simple resection
of the bladder wall was performed, the mortality was 12 J per cent.
A much higher mortality was noted in those cases in which, in addi-
tion to the bladder wall, there had been a resection of the ureters.
Four out of five patients, thus operated upon, died.
Thus far, it appears that operative results have been very unfav-
orable in sarcomas of the bladder. Rafin found that most of the
patients, even among those who survived the operation, died within
a year after the tumor had been removed. The question arises
whether it is advisable to remove these tumors. This must be answered
in the affirmative, when we consider how rapidly these patients perish
without operative aid. The patient has nothing to lose, but, in many
cases, his life may be prolonged. The operation should be performed
early, and should be as radical as possible. In conclusion, the author
reports a case of bladder sarcoma, in a woman aged 77.
ANNALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Vol. II, No. 21, November, 1910
1. Extrophy of the Bladder. By Dr. Stefanesco-Galazzi.
2. Note upon a Case of Gonococcal Septicemia, Treated with Injec-
tions of Antimeningococcic Serum. By Dr. Strominger.
3. The Radical Treatment of Urethral Strictures by the Excision of
the Narrowed Portion. By Dr. Choltzov.
1. A Case of Extrophy of the Bladder. — Stefanesco-Galazzi
reports the case of a boy ten years of age, with a very striking ex-
trophy of the bladder, and a complete division of the external geni-
tals, including absence of the anal sphincter. The interesting feature
of this case was the association of genital malformations. The boy's
hair was cut short and his features were not delicate, but he wore
skirts, and since early childhood, had constantly voided his urine in-
voluntarily. At the time of his birth, the midwife declared the child
to be a girl, but as he grew older his sex became more and more
apparent, so that he was prompted to be a boy, the father compromis-
ing by cutting his hair, and allowing him to wear skirts. Examina-
tion showed that he was indeed of the male sex, but the vesical ex-
trophy and the complete division of the genitals in the median line,
were so marked that it was not to be wondered at that his sex had
remained doubtful in the eyes of his parents. In the entire litera-
CURRENT UROLOGIC LITERATURE 35
ture, the author was unable to find another case in which such pro-
found malformations in the genitals existed, in connection with vesi-
cal extrophy. He considers the case as an illustration of the theory
of the origin of extrophy of the bladder. This malformation is pro-
duced by an arrest of development in the course of which, the anal
membrane, which closes anteriorly, in the normal subject, is absent.
This closure completes the continuity of the urethra and the external
genitals. The farther back we go into fetal life, the more open we
find these organs, and the lower their opening towards the perineum.
In the present case, the anal orifice was so close to the bladder that
we might say that the primitive cloaca, which opens in the fetus by
two closely superimposed openings, practically had remained un-
changed. Between the two canals there was but a centimetre, and
the only median organ was a small tubercle, which might be regarded
as a dependence of the old cloacal stopper.
As regards the treatment of these cases, a number of procedures
have been devised, none of which is absolutely successful. The diffi-
culty lies in the absence of the vesical sphincter, so that the patient
remains unable to hold his urine after the operation as he was before,
although the operation does remove the exposed red, bleeding and
sensitive surface of the bladder. In the present case, it might be
possible to perform a plastic operation, but besides the vesical incon-
tinence which would remain, there would also be rectal incontinence,
and it would then be difficult to protect the patient from infection.
It might be better to try to divert the flow of urine into the rectum,
but, in this case, there would be no advantage in performing Maydl's
operation, for example, as the patient could not keep the urine in his
rectum, owing to his anal incontinence. It might be possible to per-
form an extensive operation which would first render the intestine
continent, and then implant the bladder therein, but this would be
extremely difficult and would afterwards be a source of danger from
infection of the urinary tract. It is best, therefore, to leave the child
alone with his infirmity, rather than to perform a brilliant operation,
which would kill him in a short time.
2. Antimeningococcic Serum in Gonococcal Septicemia. —
Strominger reports the. case of a man, aged 49; who had been infected
with gonorrhea on Dec. 10th, 1909- A few days later he had an at-
tack of retention, for which a catheter had to be passed. A few
days afterwards he felt chills, fever, accompanied by sweat and gen-
eral malaise. The temperature rose every evening, in spite of anti-
pyretics. He was seen by the author two months later, in a state
36 THE AMERICAN JOURNAL OF UROLOGY
of extreme emaciation, with slight jaundice, dry tongue, complaining
of fever, attacks of perspiration and acute pain in the right shoulder.
Examination of the various organs was negative, but the urethral se-
cretions contained numerous gonococci. Blood cultures were nega-
tive. Believing that the patient was suffering from general gono-
coccus toxemia, the. author injected antimeningococcus serum prepared
by Wassermann, of Berlin. The doses he used were 10 c. c, given
every other day, in four injections. The temperature gradually fell,
and did not rise again. Local treatment was resumed, and the pa-
tient was completely cured.
ANNALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Vol. II, No. 22, November, 1910
1. Smooth Muscular Tumors of the Bladder. By M. Heintz-Boyer
and Dore. (To be continued.)
2. A New Urethro- Vesical Irrigating Catheter for Women. By
Lucien Wormser.
2. Urethro-Vesical Irrigating Catheter for Women. — Lucien
Wormser employs irrigations of the urethra and bladder with large
quantities of antiseptic solutions in urethritis in women. He remarks
in introducing the subject that urethritis may be frequently discovered
in women if one takes the trouble to examine attentively all patients
who complain of pain in the abdomen. The author prefers irriga-
tions to the use of internal medication because the latter method is
slow, uncertain and often inefficient. The solutions employed are of
potassium permanganate in cases of gonorrheal urethritis, or solutions
of mercury bichloride or oxycyanide in cases of urethritis due to the
common bacteria. The strength of the solution should be gradually
increased and if the lavage be properly applied the results will always
be very satisfactory.
The ordinary irrigating instruments are first used in the urethra
where they cleanse this canal, and are then gently introduced into
the bladder. The bladder is slowly filled until the patient feels the
desire to void it, and then the patient is allowed to expel the fluid
through the urethra. In Wormser's opinion this method of irrigation
of the urethra is insufficient, because it is too superficial. Conse-
quently, he has had the idea of devising a new irrigating tube which
would provide for the continuous irrigation of the urethra, and at
CURRENT UROLOGIC LITERATURE 37
the same time for the entrance of the solution into the bladder.
Accordingly, he has had constructed by Gentile a metallic, urethro-
vesical irrigator, which fulfils these two requirements.
The irrigating tubes connected with the rubber tube of an irri-
gating tank, the pressure being regulated in the usual manner. The
instrument consists of a straight tube, ending in an olive, the shoul-
der of which is provided with two lateral openings, intended for vesi-
cal lavage. Three centimeters behind the olive there are six orifices
arranged spirally over a distance of three centimeters, which corre-
sponds to the length of the female urethra. Over the tube of the irri-
gator a sliding cuff is provided whereby the orifices may singly or
totally be closed at will.
The method of employing this irrigator is as follows: After the
external genitals and the vagina have been thoroughly washed, and
after the urethral orifice has also been cleansed, the connection is
made with the irrigator, the sliding cuff remaining over the orifices
(Fig. 1), in order to protect the operator from the jets of fluid
which would otherwise issue from these openings. As the olive is
introduced into the urethra the sliding cuff is pushed back in virtue
of the perforated disk which has been provided at its end (Fig. 2).
The sound is pushed forward along the urethra until the six orifices
are exposed, as in Figure 3. In this position the bladder is washed
through the two openings in the olive, while the six openings in the
tube remain opposite the urethra and wash the latter with a rotatory
spiral stream (Fig. 3). The sound is removed after the lavage, by
slowly withdrawing it and at the same time pushing the cuff forward
to occlude the openings. The patient can then void the fluid remain-
ing in the bladder.
Fig. d, 2, 3.
38 THE AMERICAN JOURNAL OF UROLOGY
ANN ALES DES MALADIES VENERIENNES
Vol. V, Xo. 11, November, 1910
1. Arsenobenzol (Salvarsan) in the Treatment of Syphilis. By Dr.
Bayet.
2. Treatment of Syphilis with Salvarsan. By A. Jambon.
1. Arsenobenzol (Salvarsan). — Bayet, of Brussels, has em-
ployed Ehrlich's remedy in 100 cases, and summarizes the present
status of the question of the treatment of syphilis by means of the
new compound. He employed YVechselmann's technique, using a very
slightly alkaline or neutral suspension. An important point is to
have the volume injected as small as possible, if practicable not greater
than 5 c. c. In order to get a solution as concentrated as this, he
advises the use of a ten per cent, solution of sodium hydrate. He
prefers to inject subcutaneously in the interscapular region, and finds
that there is less suffering after the injection when this method is
pursued than with the ordinary injections in the buttocks. Iodide is
used to paint the skin before the injection, and collodion is employed
to seal the puncture. In most cases there is very little pain until
the night after the injection, when a dull ache appears and lasts for
a few days. Usually the infiltration is absorbed without unpleasant
effects, but sometimes the center of the swelling softens, and in eight
cases out of a hundred a focus of necrosis developed. Curiously
enough, these foci of necrosis appeared only in persons with tertiary
or para-syphilitic lesions.
Usually no temperature elevation was noted, but in seven per
cent, of cases there was some fever, while in some cases in which
fever had been present before the injection the temperature fell after
the dose had been administered. In three cases an interesting com-
plication was noted in the shape of swellings of the joints with rather
marked pains and all the appearances of rheumatism, occurring about
the fifteenth day after the injection. These symptoms were accom-
panied by slight fever and disappeared within a few days. In two
cases there were also generalized erythematous eruptions which re-
sembled antitoxin rashes. The urine did not show any changes in
any of the cases, nor was there any disturbance of urination. Vision
and hearing were not affected, and in no case was there anything
which would lead to the suspicion of arsenic poisoning. The effects
of the injections were so mild that in some cases the injections were
given in the office or dispensary without asking the patient to go
CURRENT UROLOGIC LITERATURE 39
to bed. A very general effect was improvement in the general con-
dition and increase in weight.
On the basis of the 100 cases injected, Bayet formulates the fol-
lowing conclusions as to the effects of arsenobenzol :
(a) It is undeniable that the new remedy constitutes a most
powerful antisyphilitic agent. It acts with remarkable efficiency both
in the secondary and the tertiary stages.
(b) The action of arsenobenzol when compared with that of
mercury and the iodides is more direct, more immediate, and more
constant than that of the old remedy.
(c) In certain cases arsenobenzol acts with promptness when
mercury and the iodides prove inefficient. This alone would entitle
the new remedy to an important place in therapeutics.
(d) Arsenobenzol does not seem to have any action upon para-
syphilitic lesions.
(e) In some isolated cases of secondary and of tertiary lesions
the new remedy does not show any well-marked efficiency.
(f) Relapses occur in a rather considerable number of cases.
The question of relapses is one of the most important in this
connection. Naturally we are not prepared as yet to report definitely
upon the frequency of these relapses. In one case of mutilating
syphilis of the face in which excellent and rapid results were ob-
tained, there was a relapse a month after the healing had taken place
and a new ulceration rapidly spread. A second injection was given
and the ulcer healed in a few days. Probably the first dose of 30
centigrams had been too small. In another case of secondary syphilis
of the larynx the hoarseness rapidly disappeared, but there was a
relapse four weeks later. It is impossible to say definitely as yet
whether or not arsenobenzol permanently cures. Unfortunately the
announcement was made that a single injection is intended to cure,
and both physicians and the public believed this. The trouble is that
we have no way at present of knowing when syphilis is cured, al-
though the change from a positive to a negative serum reaction is
a favorable sign. A suspicious circumstance, however, is the ex-
treme resistance of the serum reaction in many cases treated with
" 606." A persisting positive reaction certainly may be taken as a
sign of failure to cure. Another important point is the fact that
in many cases in which the chancre has been cured there was a per-
sistence of the glandular swellings. One cannot declare a case of
syphilis cured in the presence of persistent glandular enlargement.
40 THE AMERICAN JOURNAL OF UROLOGY
2. Treatment of Syphilis with Salvarsan (606). — Jambon,
of Lyons, reports his experience with " 606 " in ten cases. He is
convinced that the new remedy is both efficient and free from danger.
It is also easily administered. He prefers the neutral suspension,
because it is not painful and easily prepared. He employs in pref-
erence the procedure of Wechselmann-lange, rather than the method
involving the use of an oily base as recommended by Levy-Bing. The
danger in using " 606 " should not be exaggerated, for it is not
greater than that inovlved in using morphine and other strong drugs
in daily use. A careful examination of the patient is necessary before
the remedy is administered, and the dose should be proportionate to
the weight of the patient. It is best to give 60 or 70 centigrams as
an initial dose, if possible, and three weeks later in many cases it is
well to give a second injection when the urine no longer contains ar-
senic. The second injection is necessary to prevent relapses.
3. Treatment of Syphilis with Salvarsan (606) — Burnier
reviews the experiences of the past six months with " 606." While
the impression generally created by the communications which have
been published during this period is that Ehrlich has discovered a
remedy against syphilis which is distinctly superior to any which
have been recommended, yet we are even at this early date aware of
the fact that the single injection of " 606 " does not cure syphilis.
Arsenobenzol presents certain advantages over mercury. It acts in
cases in which mercury has failed and a single injection produces
results which can be obtained with eight or ten injections of insoluble
salts of mercury during a period of from five to six weeks. The
patient should remain in the hospital from four to sixteen days. As
yet the technique of administration is by no means perfect, although
much progress has been made in this direction. The most striking
effects of the remedy were noted in the tertiary cases. A number of
cases of cerebral syphilis and of paralysis have been improved, while
some of the symptoms of tabes have been relieved by the new treat-
ment. Good results were also obtained by some authors in ocular
syphilis, and a few cases of hereditary infection have shown remark-
able results. Relapses have already been noted in numerous cases,
and some writers go so far as to say that a single dose is never suf-
ficient. Fraenkel and Grouven employ an initial dose of 40 centi-
grams, a second dose of 70 centigrams after two weeks, and a third
dose of 80 to 100 centigrams, or even to 120 centigrams after two
weeks more.
CURRENT UROLOGIC LITERATURE 41
AX X ALES DES MALADIES VENERIENNES
Vol. V, No. 12, December, 1910
1. Xoguchi's Method of Serum Diagnosis in Syphilis. By Daisy
Orleman Robinson.
2. Circumscribed Sclerosing Dermatitis of the Mucous Layer of the
Prerjuce in Connection with Late Syphilis. By G. Berrotti.
3. A Case of Multiple Gonorrheal Ulcers. By G. Mestschersky.
4. Cutaneous or Mucous Syphilitic Lesions in the Course of General
Paralysis. By M. H. Cesbron.
1. Xoguchi's Test in Syphilis. — Robinson says that syphilis
may be diagnosticated in the laboratory without any clinical observa-
tion of the patient. The original technique of Wassermann is very
complicated and one of the practical modifications thereof, which is
at the same time very accurate and trustworthy, is that of Xoguchi.
The author has employed this method in 416 cases of various skin
diseases in patients of the Northwestern Dispensary and the Xew
York Polyclinic. Of these cases 180 were clinically diagnosed as
syphilis. The results in the syphilitic cases corresponded to those
found by other observers. The reaction was positive in 100 per cent,
of hereditary syphilis; in 93.7 per cent, of secondary syphilis; in 86.2
per cent, of primary "syphilis ; in 79-9 per cent, of tertiary syphilis;
and in 69-6 per cent, of latent syphilis. In 236 cases of various non-
syphilitic skin diesases the reaction was invariably negative.
3. Multiple Gonorrheal Ulcers. — Mestchersky reports a
case of multiple serpiginous ulcers due to gonorrheal infection. The
ulcers occurred upon the external genitals and were chronic in char-
acter, and on examining the secretions there were found staphylococci
and gonococci, although the latter could not be cultivated. The treat-
ment consisted of external applications of a ten per cent, protargol
solution and the cauterization of subcutaneous fistulous tracts with
silver nitrate. Internally a sandal-wood oil preparation was given.
Under this treatment the ulcers gradually healed. An interesting
fact was that the gonococci appeared in the secretions of the ulcera-
tions only after the application of a strong solution of protargal.
The infection was evidently in the lymphatic system of the tissue of
the scrotum, for the ulcers were accompanied by chronic lymphangitis
and by involvment of the neighboring lymphatic glands.
42 THE AMERICAN JOURNAL OF UROLOGY
Coli-uria. H. M. McCrea (The Practitioner, September. 1910,
p. 246) says that until recently this condition has been of more inter-
est to the pathologist than to the clinician ; but it is now recognized as
a clinical entity., owing to the fact that a definite line of symj)toms is
now known to accompany it. The first description of infection of
the urinary tract by the Bacillus coli communis appeared in 1894.
It was then described as a " coli-cystitis." The term " coli-uria "
is more fitting as a general designation for infections of any part of
the urinary tract with this class of germs. The disease is most com-
mon in young children, and occurs most frequently in the female sex.
Pregnancy seems to predispose towards this infection. The infection
takes place (a) from without, i. e., as an ascending infection (in
infants this is explained easily by the fact that the napkins are in-
fected with the bacillus coli) ; (b) infection by contiguity, from
neighboring organs, namely, from the bowels into the bladder or
kidneys; (c) infection by the blood stream. Clinically, the cases are
divided into those of a simple bacilluria, those accompanied by cystitis,
those characterized by pyelitis, and, lastly, those with pyelonephritis.
Several typical cases are reported by the author.
The treatment of coli-uria is divided into drug treatment and
vaccine therapy. The drug treatment aims to render the urine al-
kaline, to encourage the work of the kidneys, and to secure antisepsis.
Copious amounts of fluids should be given and the citrate or acetate of
potassium should be administered in moderate doses. Urotropin may
be also used, although opinions differ as to its value. The author gives
one grain of urotropin to a child one year old. Vaccines have been
most successful in the treatment of this affection. They must be
autogenous, i. e., prepared from the particular organism causing the
infection. Three million is a suitable initial dose for a child one year
old, and twenty-five million for an adult. The dose should be re-
23eated in two days' time, and then the interval gradually extended,
according to the progress of the case.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII FEBRUARY, 1911 No. 2
Contributed by the Author to The American Journal of Urology.
THE NORMAL AND PATHOLOGICAL POSTERIOR
URETHRA AND NECK OF THE BLADDER*
A STUDY WITH THE CYSTO-URETHROSCOPE
By Leo Buerger, M.A., M.D.
Assistant Adjunct Surgeon and Associate in Surgical Pathology, Mount
Sinai Hospital; Associate Surgeon, Har Moriah Hospital, N. Y.
THE Supramontane Region: Although it is difficult to set
an exact peripheral limit to the supramontane portion, it
is expedient to describe the antomical features of this
region separately, because it differs so strikingly from the mon-
tane portion, both in the pathological lesions and in the distin-
guishing topographical landmarks.
The floor presents a picture quite distinct from that of the
lateral wall and roof. Its markings seem to be prolongations of
those of the trigone. L^sually the floor takes a decline downward
from the sphincter margin towards the periphery, terminating in a
small depression, which we call the fossula prostatica. The mu-
cous membrane of this region is of a deeper red than that of the
roof and sides of the sphincteric margin. The reason for this is
evident when we remember that at the margin the transition into
the bladder occurs. At the sides and roof the bladder is pale, and
at these situations the sphincter margin shows rather a transition
from pale vesical to red urethral mucous membrane. At the floor
of course this change is absent, the trigonal mucous membrane
being of deeper red. As for the markings, we usually find longi-
tudinal vessels which show a tendency to converge towards the
periphery, taking their source from the sphincteric margin and
* Continued from January.
43
44
AMERICAN JOURNAL OF UROLOGY
passing towards the fossula prostatica. Although in most cases
we find a perfectly smooth, thin mucous membrane which seems to
be tightly adherent to the musculature and connective tissue of the
sphincter, certain cases present redundancy of mucous membrane,
so that slight longitudinal folding takes place (Fig. 12). It is
in the cases where this plication occurs that we are also more apt
to find a deeper excavation of this region, so that instead of a
gradual transition from trigone into flor of pars supramontana,
we see a change into a deep valley, at the bottom of which there
are longitudinal folds. Although we must admit that the placing
of lateral limitations to the floor of the supramontane region is
rather arbitrary, it is not difficult in some cases to recognize the
side walls, for they may be strikingly prominent. In other cases,
however, the change into the side walls is not abrupt, but takes
place in the form of a gradual curve.
The side walls and roof present nothing worthy of note. The
roof sometimes shows longitudinal vascular striations which are
somewhat paler than those of the floor, but at other times these
are not apparent and there seems to be a network of irregular
larger vascular channels which lie in slight elevations of mucous
membrane.
In practice it is also expedient to keep in mind the fact that
the supramontane region contains a distal and a proximal portion.
The proximal part, or beginning of the posterior urethra, corre-
sponds to the true internal sphincter. Under the mucous membrane
lies the strong muscle which closes the bladder. It is not sur-
prising, therefore, that the mucous membrane here should show
some variation from the peripheral part, or that which is included
in the prostate. The mucous membrane or sphincteric portion is
apt to show a deeper red, whereas the peripheral or prostatic part
becomes paler and smoother. Distally the floor of the pars supra-
montana contains the fossula prostatica, in which lie the posterior
frenula. The latter are tiny ridges which pass backward from
the foot of the declive, diverging as they are traced backward to-
wards the sphincter. These ridges vary both in number, in size
and inclination. Sometimes there are only two; at other times as
man}' as five can be made out. In the normal urethra they have
a sharp summit, whereas in pathological condition their tops be-
come rounded. From their general appearance one gains the im-
URETHRA AND NECK OF BLADDER
45
pression that a cross section of these bands would often be triangu-
lar in shape.
In the examination of this region it is important to obtain
adequate illumination. When the fossula prostatica is very deep
the amount of light diminishes. We overcome this by the expedi-
ent of raising the ocular of the instrument and pressing the fenes-
tra against the floor of the urethra. If we use only' a moderate
amount of light, relative brightness of successive fields gives us
an indication of the distance of the mucous membrane from the
fenestra. Thus * as soon as we meet with a fossa or a sharp de-
cline in the level of mucous membrane, a diminution in the intensity
of the light occurs. This is well illustrated when we pull the in-
strument out from the sphincteric margin towards the fossula pros-
tatica. The downward f obliquity of the floor of the pars supra-
montana then becomes evident, although it is not marked in all
cases. When a great deal of light is employed these fine nuances
are not in evidence.
Fig. 6 shows the typical floor of the sphincteric margin with
the beginning of the pars supramontana. There is a dark area
above which corresponds to the non-illuminated bladder. The
sphincteric margin shows a slight prominence in the center, which
has been termed by anatomists, " uvula vesicae." The longitudinal
and slightly converging vascular striations are well shown.
Whereas this figure shows the type of floor of pars supramontana
in which there is no abrupt transition into the side walls, Fig. 12
shows quite a different picture. Here we would gain the impres-
sion that there is a hypertrophy of the side walls, such as occur in
prostatic enlargement. The figure shows the two prominent and
bulging lateral walls and a central valley* the floor of the supra-
montane portion, with a number of longitudinal folds. In my own
experience, this type is infrequent, although a very slight pro-
trusion inward on the part of the side walls is seen in a fairly large
number of cases.
It is at the level of the fossula prostatica that we begin to
meet with the larger, plainly visible prostatic ducts. Although
these are not always apparent, we are apt to encounter them if we
examine closely the depressions between the posterior frenula at the
*If too much light is used, these facts cannot be appreciated.
fWhen the patient is in dorsal decubitus.
46
AMERICAN JOURNAL OF UROLOGY
foot of the declive. The posterior frenula are well shown in Fig.
IS, where they are so prominent that they obliterate the fossula
to a certain extent. At the foot of the declive, and even posterior
to this, we find slit-like openings, veritable foveae, which at times
are hidden by the adjoining ridges. They can be best demon-
strated by allowing the irrigating fluid to suddenly distend the
urethra. By means of a fine filiform bougie we can probe these
ducts. However, they are usually so small (except at their orifice)
that the bougie will but enter a millimeter or two. In the normal
urethra the fossula has a pale yellow red color. The longitudinal
or converging striations of the floor of the pars supramontana do
not occur, but instead, we see very fine vessels. At times this
region is completely bald and it is difficult to make out any vestige
of ridge-like structure. If we rotate the instrument at this par-
ticular level so as to take in the roof, we will find a striking differ-
ence between the distal part of the roof of the pars supramontana
and the vesical portion. Whereas the latter partakes of the same
red color that is so characteristic of the floor of the vesical sphinc-
ter, the distal portion becomes suddenly smoother and paler and a
tendency to transverse folding makes itself apparent. Here there
are no distinct vascular markings and there may simply be a fine
network of vascular channels.
The Montane Region: Let us now turn our attention to the
montane region, which is perhaps the most interesting part of the
posterior urethra. We have already referred to the sub-division
into a floor with its colliculus and the sulci laterales, two lateral
walls and a roof. The colliculus has a summit, a posterior portion
or declive, and an anterior portion or acclive. It is in this region
that we meet with the greatest diversity in the configuration of
the parts, although lesions are no more frequent here than they
are in the supramontane portion. After having examined a large
number of cases, we are soon struck by the fact that the relative
size of the colliculus varies greatly. Not only this, the general
shape of the region is subject to variation, insofar as it may some-
times show a deep concavity, and at others seems to be filled by the
verumontanum and side walls. This fact is in part to be explained
by the great vascularity of the colliculus and its tendency to be-
come turgid upon very slight irritation. This, however, is not al-
ways the cause, and there are undoubtedly cases which present
To Illustrate Dr. Buerger's Article.
Fig. 16 Fig. 17
Fig. 12. Floor of the proximal portion of the supramontane region when
this forms a valley surmounted by prominent side walls.
Fig. 13. Normal colliculus with prominent posterior frenula.
Fig. 14. Normal colliculus viewed from in front (distally), presenting sum-
mit and acclive.
Fig. 15. Normal colliculus with utricle and ejaculatory ducts.
Fig. 16. Normal colliculus with declive (above), and striking orbicular
orifices.
Fig. 17. Pyramidal shaped colliculus with umbilicated utricle.
N. B. — Figure 10 illustrating the empty bladder in the January issue is in-
correctly placed. It should be viewed with the West point looking South
(towards the observer).
American Journal of Urology, February, 1911.
To Illustrate Dr. Buerger's Article.
Fig. 22
Fig. 18. Atypical colliculus with peculiar utricle.
Fig. 19. Junction of pendulous and bulbous urethra. The dark area is the
nont-illuminated bulb; the bright white portion below is the be-
ginning of the floor of the pendulous urethra. If more illumin-
ation be employed the bulb would be clearly visible.
Fig. 20. Juxta-sphincteric portion of the trigone where the mucous mem-
brane shows the continuation of the trigonal markings. Owing to
the declination posteriorly, the upper part of the field becomes
dark. Figure shows a very vascular mucous membrane.
Fig. 21. Normal sphincter; right margin.
Fig. 22. Left margin and part of the roof of the sphincter with reduplicated
marginal fold.
American Journal of Urology, February, 1911.
URETHRA AND NECK OF BLADDER
47
quite an excavation in this region, and others in which consider-
able dilatation is necessary to unfold the parts.
Turning our attention to the colliculus itself, we must point
out that there is no fixed type, since the normal may assume a num-
ber of the different forms that will be now described. In inter-
preting the pictures obtained with the author's cysto-urethroscope.
it must be remembered that only a limited portion of the urethra
is brought into view at once. The size of the field will, of course,
depend upon the distance of the mucous membrane from the fenes-
tra. Thus it is only in cases of small colliculus, or when the pos-
terior urethra permits of considerable dilatation, especially in those
instances where we meet wTith a considerable excavation, that the
whole of the long diameter of the verumontanum is brought into
view in one field. When viewing the fossula prostatica we are apt
to see only the declive possibly with the summit, and the summit of
the colliculus with the acclive can also be made to occupy one field.
Fig. 14 shows a very common type of colliculus seen from above and
in front (distally)i The typical rounded summit is well illustrated,
and one of the forms of utricle orifice is also shown. Not very far
below the top there is a depression, the utricle opening or the
orifice of the uterus masculinus. This leads backward for a dis-
tance of a few millimeters to a centimeter or more. The ejacula-
tory ducts are not to be seen. The slope of the acclive is rather
sudden. Commencing by a fine tapering extremity in the mem-
branous urethra, the urethral crest broadens in a triangular fashion
as it ascends, becoming the acclive of the colliculus. Another not
unusual form of colliculus is shown in Fig. 15, where the ejacula-
tory ducts are prominent and lie to either side of the centrally
placed utricle. Here all three openings are vertical * slits, lying
in mucosa that seems to pout at their immediate site. Frequently
fine tortuous vessels can be seen to cross over the declive and sum-
mit passing between the orifices, as depicted in the figure. A
similar disposition of the ejaculatory ducts and utricle is repre-
sented in Fig. 16, where, however, the prominent orbicular arrange-
ment of the mucosa around the ducts is even more striking. Bemg
seen from a point farther back, more of the declive comes into^the
field, and at the top of the picture several of the frenula make their
*Vertical in the picture, but in fact running more or less obliquely and
sagittally.
48 AMERICAN JOURNAL OF UROLOGY
appearance. Coursing over the surface of the declive we can see
a bifurcating tortuous vessel. Whereas the smooth surfaces shown
in the previous figures are indications of normal structures, we
may at times meet with colliculi whose summit and acclive show
a somewhat bosselated appearance. It is true that bulbous
changes and knob-like hypertrophies are as a rule indications of
pathological processes. This shall be referred to later. In Figs.
17 and 18, however, two varieties of colliculus are shown in which
the rounded contour of the previous type is missing. Although
there was no reason to assume here that this peculiar variation was
due to previous inflammatory process, Fig. 17 shows a pyramidal
type of colliculus that is anomalous, but not pathological. In the
upper part of the field there are indications of the posterior frenula
lying in the darker fossula prostatica. The utricle, too, presents
a rather large umbilicated form. This type of orifice is not at
all common, particularly in those instances where it is difficult to
find the ejaculatory ducts. It would seem that here the ejaculatory
ducts and utricle open into a common receptacle. If we examine
the utricle orifice closely we find in these varieties a marked over-
hang above and a distinct ring-like depression which is somewhat
oval with the long axis vertical. At its center there is a small
bulbous protrusion as in a navel. Another colliculus with irregu-
lar contour and with an odd form of utricle opening is depicted in
Fig. 18. Here the umbilication is still more pronounced, there
being two bulbous bodies instead of one. The ejaculatory ducts
open into a common fossa.
In the contracted and empty state the color of the colliculus
is a pale yellow red. A change in color takes place when upon
artificial irritation or psychical excitation this body becomes con-
gested. Under these circumstances, a deepening of the color at
once takes place. With this there is a corresponding increase in
size.
Under ordinary circumstances, the declive and summit, or the
acclive and summit can be brought into the field at the same time.
It is only in cases of very small colliculus, in prostatic hyper-
trophy, and in the excavated type of prostatic urethra that a
large portion comprising the whole of the colliculus and possibly
a portion of the fossula prostatica can be seen at the same time.
By means of dilatation with fluid we can also bring into view a por-
URETHRA AND NECK OF BLADDER 49
tion of the sulci laterales, although for a perfect examination it is
best to turn the instrument to one or the other side in order
to expose the finer details of the region. It may happen that dur-
ing the examination the colliculus will suddenly become enlarged,
making it necessary to inject fluid under greater pressure in order
to obtain a proper view. As for special markings, it is only the
orifices above described that can be usually seen. In some in-
stances, however, very minute prostatic ducts can be found empty-
ing in the region of the acclive. Normally the declive shows a
pale homogeneous mucous membrane with fine capillary vessels.
The Sulci Laterales. As has already been said, these are best
seen when the colliculus is small and in the excavated type of
posterior urethra. However, the study of these two valleys is
always easy when the instrument is turned somewhat to the side
and the fluid is flowing. Their depth varies considerably in dif-
ferent cases. The transition from the floor to the side walls may
be either in the form of a concave wall or there may be an abrupt
ascent in those instances in which the lateral walls are swollen or
have a tendency to prolapse. It is in these sulci that we find a
number of prostatic ducts varying from two to one-half dozen,
sometimes in the form of tiny slit-like opening and more frequently
having a punctate shape. The mucous membrane here is also of
a pale red yellow and the vascular markings are in the form of
irregularly longitudinal streaks and tortuous delicate vessels.
When there has been no previous pathological process, the mucous
membrane is smooth and apparently thin, without any folds. At
the junction between the floor and side walls we are apt to en-
counter the slit-like orifices, whereas the rounded openings are
more frequently found in the sulci themselves. The tortuous ves-
sels course for the most part in an oblique direction, passing back-
wards and upwards along the side walls. .
As for the side walls, these offer very little of interest. In
most cases there is a fairly abrupt rise from the sulci, and in other
cases there is a concavity which is of a somewhat deeper red than
the floor. When the urethra has been free from inflammatory
process, the delicate vessels seen in the sulci are found to inter-
anastomose with similar vessels on the side walls or continue di-
rectly upward on these walls. Attacks of gonorrhoea cause these
markings to disappear and leave irregular vascular streaks in
50
AMERICAN JOURNAL OF UROLOGY
their st^ad. The roof is devoid of any characteristic markings,
and is usually much paler than the lateral walls.
The Pars Membranacea: As the instrument is withdrawn
from the montane region with the fenestra turned downward, the
acclive can be followed by its tapering crest into the membranous
urethra. The longitudinal markings are very distinct as a rule,
parallel or slightly converging vascular striations passing at the
side of the anterior crest and gradually becoming lost in the floor
of the membranous urethra. The membranous urethra itself is
smooth and the mucosa looks thin, the floor is yellow red, whereas
the roof and sides are somewhat paler, almost gray white.
The delicate median ridge of the acclive, as it becomes lost
in this portion of the urethra, often shows a striking pallor at
its summit or middle, due partly to the pressure effect of the in-
strument and possibly also to an avascular condition of the part.
On either side of the disappearing anterior crest we see the
continuation of the vessels of the sulci laterales, and observe how
they take a longitudinal direction. The roof and sides of this
region present nothing of note and are practically devoid of mark-
ings.
The Bulbous Urethra : Whereas every detail of the sphinc-
teric margin, the pars supramontana, the montane portion and the
pars membranacea can be thoroughly scrutinized without the exer-
cise of special maneuvers, the bulbous region (Fig. 1A)* may offer
some difficulty owing to its distensibility and the depth which it
occasionally assumes. It is in the examination of this part that
some skill is required in the manipulation of the irrigation fluid.
We must be able to displace the mucosa at one time, and at another
produce prolapse in order to obtain a sufficiently clear picture in
some of the cases. Thus the pars bulbosa may be so large that
when distended with fluid its distance from the fenestra and lamp
is considerable, and illumination becomes diminished. This can be
easily overcome by opening the second faucet of the instrument
and evacuating some fluid, or by stopping the flow. The floor of
this part presents a corrugated or folded appearance when in-
completely dilated and the color may or may not be of a some-
what deeper red than the parts above. The roof and sides do
*No attempt was made in the diagrammatic Fig. 1 to represent actual
or even relatve sizes with accuracy.
URETHRA AND NECK OF BLADDER 51
not present the same folded appearance. A useful and interest-
ing distal landmark is afforded by the junction of the bulbous
and penile urethra shown in Fig. 19 (and marked J in Fig. 1).
The transverse margin with the illuminated mucous membrane
below (Fig. 19) presents the beginning of the penile urethra.
On either side the folded lateral wall and part of the floor of
the bulbous urethra are seen, and the central upper dark region
represents the non-illuminated distended bulb. Although the
junction is not always so abrupt, it is usually very well marked.
In a certain number of individuals the proximal limit of the
bulbous urethra is indicated by a distinct transverse ridge or a
few folds that occupy the floor and part of the lateral walls of the
urethra. These ridges may be conspicuous or just barely dis-
cernible. In favorable cases then the boundaries of the bulbous
urethra are sharp, making estimation of its extent easy. The
relative size of the bulb can be determined, as a rule, by a glance
through the instrument.
The Sphincter Margin : In the chapter on the interpretation
of pictures seen with the cysto-urethroscope, we already alluded to
the explanation of the views here obtained. It is not easy to define
the exact limits of what is included in the term " sphincteric mar-
gin." Properly speaking, we should consider three distinct por-
tions. First, the vesical part, which properly belongs to the realm
of the right angled and retrograde cystoscope ; second, the true
margin or ring; and third, the urethral portion. Owing to ana-
tomical conditions it is impossible, in the male, to obtain a satis-
factory view of that portion of the roof of the bladder which ad-
joins the sphincter, namely, the juxta sphincteric part of the
bladder roof. The margin can be perfectly seen throughout its
circumference. Our inability to depress the ocular of the instru-
ment sufficiently makes it impossible to approximate the window of
the instrument and the roof of the bladder near the sphincter
sufficiently to obtain a proper view. In the sides, however, this
is easier, particularly if we allow the bladder to collapse. In ex-
amining the inferior aspect of the vesical portion of the sphincter
we encounter no difficulty, for the transition from trigone to floor
of the vesical sphincter is a gradual one, and there is no sudden
drop or sudden cancavity such as is characteristic for the roof
and sides (Fig. 20). In the female these obstacles do not obtain,
52 AMERICAN JOURNAL OF UROLOGY
the urethra being short and the instrument having prefect free-
dom of motion. An adequate view of all that portion of the blad-
der which adjoins the margin of the sphincter can easily be ob-
tained. In other words, in the female a retrograde cystoscope
can be readily dispensed with when we have a cysto-urethroscope
at our disposal.
In practice it is best to disregard the adjoining bladder from
a consideration of the sphincter margin, and to consider the be-
ginning of this region as being that ring which goes to form the
internal orifice. This is readily brought into view when, in the
slightly distended bladder, the cysto-urethroscope is gradually
pulled out until a sharp illuminated margin appears. The picture
of the floor of this region is so different from that of the sides
and roof that it merits special description. Fig. 6 illustrates well
the normal floor of the sphincteric margin. In the upper part of
the field a dark area is seen which is the non-illuminated bladder.
Below this we see the beginning of the floor of the pars supra-
montana and a slightly convex margin, the internal orifice or floor
of the sphincteric margin. Usually this line is slightly convex or
almost flat and horizontal, but at times we see a central projection
which corresponds to what the anatomists have called the " uvula
vesicae." The color of this part is a fairly deep red admixed
with yellow, and the vascular markings run in a longitudinal direc-
tion with a tendency to converge towards the urethra. In the
normal state, the mucous membrane is smooth without any visible
duct orifices. As a rule the transition from this margin into the
sides is gradual. In a few cases we have noticed an abrupt change
into the side walls, the junction being marked by deep lateral
grooves. It is not alone in color, vascular markings and contour
that the floor of the sphincter differs from the sides and roof.
Whereas the roof, and to a less degree the sides, pass into the
bladder by a sudden concavity, the floor presents a gradual slope
down towards the trigone, and distally, too, there is a gradual
decline towards the fossula prostatica.
Fig. 21 shows the right side of the sphincteric margin. The
absence of vascular markings is striking and the color too is quite
different from that seen in the floor. The red margin is replaced
by a pale pearly line which imperceptibly changes into a deeper
red, the beginning of the supramontane urethra. A slight con-
DESTRUCTION OF URETHRA IN HYPOSPADIAS 53
cavity is the rule. The sides are usually counterparts, but the
roof of the sphincteric margin often presents a more acute angle.
Although a concavity is the rule, a sharp notch is not uncommon.
In rare instances a few tortuous vessels cross along the sphincteric
margin even at the sides and roof. . Sometimes a reduplication of
the sphincteric margin seem to occur (Fig. 22). Close scrutiny,
however, makes it apparent that in such instances we are dealing
with a slight prolapse of the adjoining bladder mucosa.
If we rotate the instrument at the level of the floor of the
sphincteric margin with the border of the sphincter occupying the
middle of the field, we will note that a smaller amount of the lateral
aspect of the sphincter comes into view. As for the roof, this
may just skirt the field or fail completely to come into view. In
this way we ascertain that the annulus urethralis or internal
urethral orifice does not occupy a vertical plain, but has a slight
inclination from above, downward and backward, when the patient
is in the dorsal decubition. The amount of obliquity varies. It is
necessary, therefore, in the examination of the sphincter to draw
the instrument out a short distance as we scrutinize the sides, and
to pull it out still further for the roof. This anatomical peculiar-
ity can be best demonstrated when the bladder is almost empty.
{To be concluded in the March issue)
Contributed by the Author to The American Journal of Urology.
MASSIVE DESTRUCTION OF THE URETHRA AFTER
A SUCCESSION OF ATTEMPTS TO RESTORE
IT IN A CASE OF HYPOSPADIAS
By G. A. DeSantos Saxe, M.D., New York City.
EVERY urologist whose experience is extensive enough
meets in his practice examples of strikingly unfavorable
results after operations performed by colleagues who de-
servedly enjoy high repute. Those whose testimony would be
of great value as first-hand information rarely report such cases,
and so it comes about that many pitiful failures of surgery
remain unknown, unsung, and unseen.
The question arises, is it proper for one who has seen only
the end-result, to report such cases? I submit humbly, that it
Presented to the New York Society of the American Urological Association,
February 1, 1911.
54
AMERICAN JOURNAL OF UROLOGY
is not only proper, but the duty of every surgeon to acquaint
his colleagues with striking examples of operative failures that
may come to his knowledge, especially if a scant number of such
failures have been published in literature. Nothing is of greater
value in checking any tendency towards a furor operandi among
us, than a thorough acquaintance with the reverse side of the
medal commemorating the achievements of urological surgery.
HISTORY OF THE CASE
The patient whom I am presenting to you this evening, H.
B., stock clerk, 28 years old, born in New York, was first seen
by me at one of my clinical lectures at the Postgraduate Hospi-
tal in July, 1910. On examination, he was found to have a mere
stump in place of a penis, the root of the organ and about an
inch of the pendulous urethra being all that remained. At the
free end this stump expanded into a shallow funnel-shaped
structure at the bottom of which the urethral opening could be
seen as a deep-red pit. There was pus exuding from this open-
ing, and on examination this discharge was found to contain
many gonococci. It was for the urethritis that the patient had
applied to the clinic for treatment.
The expansion at the free end of the stump consisted of
wrinkled, shriveled skin, containing harder masses of cicatricial
tissue. There were also in the ear-like flaps of the stump some
remains of what apparently was erectile tissue from the cor-
pora cavernosa, but there remained apparently no vestige of the
glans penis. The urethra, examined at a later date, admitted a
No. 9 F. bougie and was stenosed throughout the entire extent
of the penile remnant. The bulbous and posterior portions
seemed to be of fairly normal calibre.
Upon careful questioning, the patient gave the following
history. He was born with a hypospadias of the penile type,
" The opening from which the urine came," as he describes it>
was situated at about the level of the coronal sulcus. Thence
there was a groove leading upward, a tunneled canal through
the lower surface of the glans, and a second opening, smaller in
size, at the apex of the glans.
At the age of ten, or eighteen years ago, his parents ap-
plied to a surgeon of prominence for the restoration of the hypo-
DESTRUCTION OF URETHRA IN HYPOSPADIAS 55
spadias. A plastic operation was performed, the exact char-
acter of which cannot be vouched for at this time. It appeared,
however, that this operation was not sufficient to restore the
continuity of the canal, and that during the next four years,
or until the patient was fourteen years old, he was under con-
stant observation of this surgeon, who tried his best to complete
the work by three supplementary plastic procedures. The re-
sult at the end of that period was apparently fairly good, at
any rate, the patient received no further attention until four
years later, at the age of eighteen, when he contracted a sore
which he characterizes as " soft," although he is not sure of
this point. The sore, which was situated at the coronal sulcus,
was cauterized by the same surgeon, and three weeks later the
remains of the sore were excised. The patient claims that at
the same sitting the surgeon proceeded to make further attempts
to close the gaping urethra. The healing after this operation
was very unsatisfactory, and the patient remained at the hos-
pital for seven months, during which time the attending surgeon
on eight different occasions cut away sloughing tissue, ap-
parently with the object of saving as much of the organ as could
be rescued. The patient's condition when he left the hospital
was practically the same as at present.
It is impossible to determine definitely the cause of the very
extensive sloughing which took place ten years ago. The pa-
tient is firmly convinced that he had a syphilitic sore, but he
does not give a very clear history of secondary symptoms. Re-
garding the occurrence of a secondary rash he is not very defin-
ite, but claims to have had a scaling, pinkish eruption on chest
and arms some time after the sore had been excised. He as-
serts that his hair fell out while he was in the hospital, — a sign
certainly suspicious in a lad of eighteen. There is, however, no
evidence that he received any regular treatment which could be
construed as antisyphilitic, nor did the surgeon inform him that
he would have to be treated for some years to come.
If the sore was not syphilitic, it must have been chancroidal
in character. The sloughing might have been due to chancroidal
infection, of course, but there is also to be borne in mind the
possibility of gangrene from insufficient blood supply of plastic
flaps, and secondary infection of the wound leading to sloughing
56
AMERICAN JOURNAL OF UROLOGY
of the parts. At all events, the exact etiology of the extensive
sloughing cannot be determined at this late date.
The patient's subsequent history presents some further in-
teresting features. In the first place, his sexual power was not
impaired by the extensive loss of penile and urethral tissue. He
has been able to have normal (?) erections, and satisfactory
intercourse, in spite of the fact that the glans, which is the seat
of end-organs playing an important part in the orgasm, had
been totally destro}'ed. During the erections the penile stump
became several times longer than in the flaccid state, reaching
sufficient length for intromission. It is possible, that the sen-
sory nerves of the urethra have in this case taken the place of
the end organs of the glans, and that thus orgasm occurs with-
out any material change.
Owing to his infirmity, the urethra is naturally exposed to
infection, the funnel-shaped hollow in which it opens lending
itself particularly to the accumulation of secretion. Accord-
ingly, six years ago he acquired a gonorrhea lege art is. The
attack lasted six months and was treated exclusively with inter-
nal medicines. Two years ago he noted another sore upon one
of the flaps of the penile stump. Again he is vague in his de-
scription of the sore, and does not give the history of any sec-
ondaries, nor of any constitutional treatment. About six
months ago, believing that he had syphilis in early youth (at
the time of the disastrous operation) he had his blood examined
by one of the recognized serologists of this city, who found the
Wassermann reaction to be positive. The patient immediately
began a course of mercurial treatment which he has continued
with intermissions ever since. Second Wassermann reaction per-
formed in December, 1910, showed a strongly positive finding,
although the patient has not hand any symptoms of syphilis
since he has been under my observation.
The attack of gonorrheal urethritis for which lie applied for
treatment in July was apparently entirety cured on September
30th. The treatment used by me in his case consisted, in addition
to the use of lacto-santal capsules, of irrigations with solutions
of silver nitrate in increasing strengths, by means of a coude
silk-woven catheter, No. 9 French. The Janet method of irri-
DESTRUCTION OF URETHRA IN HYPOSPADIAS 57
gation could not be used with his deformity, nor did a soft cathe-
ter enable one to irrigate the canal. He was able to use hand
injections of protargol solution (J to -J per cent.) at home, pinch-
ing the flaps over the urethral opening and the tip of the syringe.
SUMMARY
The points of special interest in this case, to my mind, are:
(1) The extensive loss of tissue resulting from a series of
attempts to restore a hypospadic urethra ten years ago.
(8) The fact that the patient's potentia coeundi has re-
mained unimpaired in spite of the reduction of the penis to a
mere stump, with complete destruction of the glans.
(3) The entrance of the syphilitic element, either at the
time immediately preceding the disastrous operation, or since
then.
It is not in a spirit of criticism that I have presented this
case to you to-night. The operator who failed so pitifully in
restoring this man's urethra was a man of such repute that few
of us can say that the patient would have fared better in their
hands, all things being equal. There is one thing, however,
which seems to be inexcusable, if the patient's statement be ac-
cepted,— the excision of the sore at or near the corona, fol-
lowed immediately by a delicate plastic operation. The nature
of this venereal sore could not have been determined ten years
ago (in the absence of knowledge concerning the Treponema of
Schaudinn, and of the serum reaction) without waiting for sec-
ondaries. While the wisdom of excising the sore before waiting
for it to heal might be questioned in the circumstances, the per-
formance of the operation before a definite diagnosis of the sore
was made seems anything but rational. However, in the absence
of medical testimony on this point, even this false step cannot
be held against the operator.
The case is presented chiefly as a warning against ill-con-
sidered interference in the less troublesome forms of hypospadias,
where there is little discomfort or danger. Such cases should
be left alone, if we have any veneration for the principle of non
nocere, which should rule in urological surgery, as well as in all
other branches of the healing art. '
130 West 71st Street.
Contributed by the Author to The American Journal of Urology.
SEXUAL NEURASTHENIA: ITS LOCAL AND HYDRO-
THERAPEUTIC TREATMENT*
By Dr. Moritz Porosz, Budapest.
THE sexual symptoms of sexual neurasthenia often follow a
urethritis or prostatitis. These symptoms are: pollutions,
spermatorrhea, ejaculatio praecox. In the beginning the
features of general neurasthenia are wanting. The patients them-
selves often associate causally the impotence and imperfect erec-
tions with a gonorrhea.
All these symptoms without a previous blennorrhea or pros-
tatitis, may follow masturbation, venereal excesses, especially in
youth, coitus interruptus, prolonged abstinence. Experience
teaches that the prostrate must also be examined in such cases.
Such examinations reveal a diseased conditon which has already
been often described by Porosz under the name Atonia Prostatae.
This muscular atony of the prostate is supposed to weaken
the assumed sphincter of the seminal vesicles and disturb its
function. This sphincter was anatomically demonstrated by
Porosz and confirmed by the anatomical section of the Interna-
tional Congress at Budapest.
These well established facts and the author's clinical and
therapeutic experience have justified his explanations and his pro-
cedure in regard to local treatment.
The treatment of other symptoms of general neurasthenia be-
longs to the domain of balneology and hydrotherapy. The
therapy of sexual neurasthenia belongs to urology and balneology.
Both divisions find a field of activity. While in the milder cases
balneotherapy is not absolutely necessary, in the more severe forms
the recovery of the patient is accelerated.
With hydrotherapy alone one cannot produce definite, invari-
able results, and if in severe cases of sexual neurasthenia the fail-
ure to use hydrotherapy is an error, the failure to use local therapy
— in the author's sense — is a sin committed against the health of
the patient.
*Read at the meeting of the Balneologists of Austria, at Salzburg, October
7, 1910. Author's abstract.
58
SEXUAL NEURASTHENIA
59
It is clear from the author's explanations that local therapy
which is directed against the hyperemia of the caput gallinaginis
is false and useless.
By treating the hyperemia with sounds, various paintings
with astringents, cauterizations with concentrated silver nitrate —
solutions and electro-cautery we can only contribute to the aggra-
vation of the general neurasthenia. These methods have truly no
other effects.
It must be remarked that the hyperemia is by no means rarely
absent so that we sometimes must deal with an anemia of the
colliculus seminalis. Also if a hyperemia is present it is merely a
secondary manifestation which depends upon the prostatic atony.
Svetlin has long ago shown that the venous circulation of the pars
posterior passes through the prostate. The progress of the blood
stream suffers from the atony of the prostatic musculature. If
the hyperemia is done away with by means of the psychrophore the
effect is not permanent. The main cause of the sexual neurasthe-
nia lies in the atony of the prostate. It is here that the root
of the disease must be attacked by a tning up of the prostate
with the foradic current, as the author employs it.
The theoretical explanation of fatigue and irritation of the
centers is not sound, for pollutions and spermatorrhea are present
at the same time. The corresponding central excitations of other
organs, which produce well-known disturbances of function, lead
one astray in assuming an irritation of the genital centers.
The error really resides in the mechanism of the genital func-
tions. After over a decade and a half's experience the author as-
serts that the morbid sexual symptoms of neurasthenia which were
mentioned above can be restored to normal. The increased libido
is diminished, the dribbling of urine is mitigated, urgency of uri-
nation is lessened, erections become normal, sexual pleasure is in-
creased, ejaculation becomes normal and all the general nervous
manifestations "which accompany and precede intercourse dis-
appear, while the subsequent exhaustion was likewise absent.
Contributed by the Author to The American Journal of Urology
CATHETER LEFT IN THE DEEP URETHRA AND BLAD-
DER AFTER OPERATION FOR EXTERNAL
URETHROTOMY*
By Henry J. Scherck, M. D.,
Clinical Instructor of Genito-Urinary Surgery, St. Louis University.
IN Juh*, 1910, J. P. applied at one of the hospitals of St.
Louis for relief. He was suffering from urinary infiltration
due to a stricture of the deep urethra. In as much as it was
impossible to introduce an instrument into the bladder, an external
urethrotomy was performed. He tells me that he remained in the
hospital for about two months and left there with the perineal
wound closed and the urinary function satisfactorily re-established.
About two months ago he began to notice a return of trouble, in-
dicated by a very small urinary stream requiring considerable
effort on his part to evacuate the contents of his bladder. The
trouble gradually increased until there was complete retention,
followed by rather sudden extravasation and abscess formation at
two points, resulting in two urinary fistulae. This was the con-
dition t\at he presented upon admission to our hospital, when I
examined him for the first time. I found evidences of former in-
filtration in the shape of various scars about the buttocks and
scrotum, and two fistulae through which urine was discharged.
All attempts at passing sounds or filiforms failed, so I decided
upon an external urethrotomy.
An incision through the perineum over the old perineal scar
brought me to what I had concluded was the disorganized and
strictured urethra. Upon introducing my finger into the wound
it impinged on a foreign body which gave a rather peculiar sen-
sation to my finger tip. I introduced the forceps in the wound
and attempted to withdraw it. In doing so, I broke off a small
portion of the obstruction, which I found to be part of a large
sized rubber catheter. I then retracted the edges of the wound
and gradually worked the forceps around the catheter, loosening
*Read before the North Central Branch of the American TJ(rologicai
Association, Chicago, January 5, 1911.
60
CATHETER LEFT AFTER OPERATION 61
it up, and withdrawing it. The catheter extended for at least
three and a half inches into the bladder itself, protruding into
the deep urethra for a distance of about an inch and a half.
Surrounding the catheter, for the most part, were phosphatic
deposits. Concretions were also discovered in the fundus of the
bladder, against which the catheter had remained for several
months. After cleansing the bladder thoroughly and removing
from the deep urethra and bladder all deposits, I concluded the
operation in the usual manner. Patient recovered promptly with-
out any ill effects.
Foreign bodies in the bladder, both male and female, are not
uncommon. For the most part these foreign bodies are introduced
through the meatus, either as a result of the individual's own acts
or through accidents on the part of the physician. Ths patient
presented two features which to my mind are rather unique, and
warrant me in reporting this case.
First, here was a foreign body which remained in the deep
urethra and bladder for several months without the knowledge of
the patient or the physician. Second, that so long as the lumen
of the catheter remained open the urinary function was carried on
with comparative comfort, through it. Gradually the lumen be-
came occluded by the deposit of the urinary salts, producing iden-
tically the same symptoms as would be produced by a stricture
gradually contracting and completely obstructing the urethra.
Not only was the lumen of the catheter, which was about an 18
American, occluded, but around the catheter was also a consider-
able deposit of concretions. This catheter had been introduced
through the perineal wound into the bladder upon the completion
of the first operation for drainage purposes, and by some un-
accountable reason had slipped deeply into the wound, had been
forgotten, and the perineal incision completely healed. (The
catheter was passed around). I have not divided it as yet, though
I expect to have the pathologist at the hospital make a report on
the findings of the contents of the catheter, as well as the condition
of the rubber, to determine as a matter of interest the effect of the
urine on it, after having remained buried for several months.
Contributed by the Author to The American Journal of Urology.
SOME REMARKS ON MASSAGE OF THE PROSTATE
By Geza Greenberg, M.D., New York.
THERE seems to be a general opinion, even amongst genito-
urinary specialists, that massage of the prostate should
of necessity follow and complete a cure of gonorrhea.
This idea prevails partly because it is held that an anterior gon-
orrhea invariably invades the posterior urethra and the prostate.
This, however, is clinically and pathologically untrue.
In a large number of cases, the infection does not get be-
yond the anterior urethra ; even in cases of hypospadias with a
small meatus, where one might expect a posterior extension, re-
covery may occur without any complications. Even if there be
an extension into the deep urethra, it does not necessarily follow
that the parenchyma of the prostate must be affected, or if so,
that it does not undergo spontaneous resolution but goes on to
suppuration, as evidenced by gonorrheas with both urines cloudy.
The prostate rebels against indiscriminate massage ; for
vigorous massage in the acute stage of gonorrheal urethritis in-
variably results in some trauma, producing diapedesis of red and
white cells, and the escape of some serum into the open spaces.
This serum is a very good culture medium for micro-organisms
and invites those present in the urethra to invide the prostate,
leading up to a prostatitis which did not exist at the beginning
of the treatment. It is, therefore, apparent that the prostate
should not be meddled with, unless it is affected. This must be
ascertained by careful routine examination. For the determina-
tion of a prostatitis, one must be guided not only by the subjec-
tive signs but by objective symptoms. I do not intend to
enumerate any subjective symptoms, as they are well described
in text books, but merely to emphasize the importance of some of
the objective signs.
By the digital examination of the prostate, at least, some of
the cardinal symptoms of inflammation may be brought out, i. e.,
swelling, heat, pain, which in the acute stage will be more pro-
nounced. Enlargement of the prostate alone is not diagnostic
of inflammation, unless it is accompanied with a certain degree
62
MASSAGE OF THE PROSTATE
63
of tenderness, and if hypertrophy of the prostate be excluded,
taking into consideration the age of the patient, the size of the
organ should be determined both with an empty and a full blad-
der, as a prostate may be normal in size and yet appear to be
enlarged with a full bladder, and the result would be an erron-
eous diagnosis of prostatitis. Furthermore, it must be noted
whether or not the prostate is uniformly enlarged. As to ten-
derness, good judgment is required to gauge the amount of pres-
sure and with the variation of pressure, the degree of tenderness
and whether the tenderness is universal or localized, feigned or
real. Consistency of the prostate is another important factor,
whether hard or soft, or nodular, universal or localized. Heat
can only be felt in the acute stage of prostatitis.
Taking all these signs collectively with the subjective symp-
toms of the patient, they tend materially to arouse the suspicion
of the physician of an existing prostatic trouble, but by means
settle it without further tests.
The next step is the examination of the exuded drop of pros-
tatic secretion at the meatus under the microscope ; for this, two
smears are necessary, one to be unstained and examined with
high power for the number of pus cells, and a second one to be
stained and examined for bacteria. In a good many cases it is
rather troublesome to stain the secretion owing to its too great
fluidity. This can be remedied by incorporating the secretion
with the white of an egg; then it takes up the stain more readily.
In examining for pus cells, due allowance must be made for the
number of pus cells in normal prostatic secretion, due probably
to traumatism caused by the finger. I have seen the field covered
with large numbers of red cells which were evident to the naked
eye in the centrifuged urine after a vigorous massage of a nor-
mal prostate whose owner never had gonorrhea or any disease
referable to the genito-urinary organs.
It is necessary (e. g. when marriage is contemplated) to
have a cultural test made of the prostatic secretion, and if one is
not satisfactory, even half a dozen tests, in order to be perfectly
satisfied that the prostate is normal.
Does the presence of pus in the secretion, without the presence
of gonococci, indicate a gonorrheal prostatitis? Not neces-
sarily. There may be either a catarrhal prostatitis caused by
64 AMERICAN JOURNAL OF UROLOGY
some other agent, or the process may have been started by a
gonococcus which died out. It is not at all unlikely that there
may be an analogy between pus tubes (in women) that are devoid
or organisms, and a similar condition in the prostate in men.
This condition is observed almost daily in treating chronic pros-
tatitis in married men who had their original infection years ago,
without infecting their wives. As a rule, however, if one finds a
large amount of pus cells and a large number of organisms other
than gonococci in the prostatic secretion, the prostate should be
treated in the same way as a case of gonorrheal origin, but less
vigorously.
The next important diagnostic step is the examination of the
urine for shreds. The ordinary two glass test is not sufficient
for an accurate diagnosis. The best method is as follows : Be-
fore the patient urinates, the anterior urethra should be washed
out with sterile water until the return now is clear ; secondly, a
catheter is to be passed into the bladder, the urine withdrawn and
examined for shreds. Withdraw the catheter into the posterior
urethra so that the eye of the catheter rests just beyond the
compressor muscle and the posterior urethra, irrigated gently so
as to wash out the shreds adhering to the posterior urethra.
Then pass the catheter back into the bladder to withdraw the
washings into a third glass. The glass No. 1 contains shreds
from the anterior urethra ; glass No. 2 and No. S contain the
shreds from the posterior urethra. Then instill about 3-5 drops
of 1 % methylene blue solution into the posterior urethra, al-
lowing it to remain in there for about five minutes. Before the
methylene blue is instilled, however, the prostate should be mas-
saged in the following manner. The finger is passed into the
rectum to the apex of the prostate and carried very gently
along the median line to the base of the prostate, stroking it
gently to and fro, but not sufficiently to express any prostatic
or seminal vesicular secretion into the urethra. This manoeuvre
disengages any shreds that are present in the prostatic and
ejaculatory ducts. Then fill up the bladder with sterile water
and allow patient to urinate. The shreds are colored blue and
come from the prostate and the ejaculatory ducts. The methy-
lene blue is not absolutely essential. It merely helps to ex-
clude any possible error and confusion with some shreds of the
MASSAGE OF THE PROSTATE
65
anterior urethra that might have adhered to the wall and not
been dislodged by the anterior irrigations. This latter gener-
ally occurs in a strictured urethra with rigid urethral walls.
The shreds that will be washed out by the last stream from the
anterior urethra are not stained. Hence, in the average case
where stricture is not present, the staining process may be
omitted.
The next step is to massage the prostate vigorously and
examine the drop at the meatus ; if no drop appears, it is best
to fill up the bladder again with sterile water. This will contain
the secretion which flowed backward into the bladder. This
can be centrifuged now, and examined microscopically. It is
more suitable than urine filled with the same secretion.
While I do not intend to describe the treatment, I wish to
mention some of the shortcomings due to faulty technique. Be-
fore one undertakes to massage the prostate, he must bear in
mind the object sought, viz., to improve the circulation and
thereby aid absorption of the infiltrate, and secondty, to ex-
press any macroscopic pus (abscess). It is more important
to bear the first indication in mind and execute the massage
gently, than to do it too vigorously. The procedure should
cause little or no pain to the patient, be kept up for about five
minutes, and not repeated oftener than twice a week, but the
main reliance should not be put upon the massages alone. The
peri-prostatic tissues should be gently massaged as well. The
prostate can be made more accessible by making counterpres-
sure over the symphysis pubis with the disengaged hand. The
prostatic circulation can be more powerfully influenced by the
prostatic vibrator which is even less painful than the finger
massage. When there exists a great deal of interstitial pros-
tatitis, as evidenced by a nodular prostate, the massages do not
influence the prostate, as we cannot hope for any absorption of
organized connective tissue.
63 Second Avenue.
66
AMERICAN JOURNAL OF UROLOGY
Review of Current Urologic Literature
FOLIA UROLOGICA
Volume V., No. 6, December, 1910
1. Clinical and Operative Notes on Seventy-three Cases of Can-
cer of the Urinary Organs. By F. Cathelin.
Functional Renal Diagnosis in the Service of Surgery. By
Paul Steiner.
1. Clinical and Operative Notes ox Seventy-three
Cases of Cancer of the Urinary Organs. Cathelin presents
a summary of his observations in seventy-three cases of cancer
of the genito-urinary organs observed during a period of three
years in his service at the Hopital d'Urologie. Of these there
were eleven cancers of the kidney, thirty-two of the bladder,
twenty-seven of the prostate, and three penile cancers. In the
cases of renal and penile cancer, eleven were treated by opera-
tion, with recovery in ten, and one death. In the other classes
of cases, there were six operations. Death followed, either im-
mediately or later on, in all the six cases. The author concludes
that in nearly every case of renal or penile cancer, operation is
indicated, but he declares emphatically against surgical inter-
ference in cases of cancer of the prostate and in almost all cases
of bladder cancer.
2. Functional Renal Diagnosis in the Service of Sur-
gery.— Paul Steiner reviews the entire subject of the functional
diagnosis of renal affections. The great advances in renal
surgery, which are credited to the last decade, are due, not so
much to perfection in technique, as to improvement in the
methods of examination. We no longer depend upon inspection,
palpation and simple urinary examination. Our aim to-day is
to secure the separate urine of each kidney. The oldest methods
devised for this purpose, consisted of devices for compressing
the ureter on one side through the abdominal tissues, but these
methods proved unreliable. Later, the ureter was exposed in the
anterior vaginal wall and temporarily ligated, but this method
was complicated and unsatisfactory. Simon was the first to
CURRENT UROLOGIC LITERATURE
67
attempt catheterizing the ureter, but he confined his work to
women. Nitze was the first to construct a cystoscope for the
purpose of catheterizing the ureters, and it is from that time
that modern methods of diagnosis may be said to date. The
present author emphasizes the need of a thorough chemical,
microscopical and bacteriological examination of the urine, in
addition to the functional tests. The freezing point of the urine
gives valuable information as to the functional activities of the
kidneys, provided the urines be tested separately on each side.
On the other hand, the freezing point of the blood need be used
only in cases in which the separation of the urine is impossible.
The method of artificial polyuria is theoretically well founded,
but in practice, it does not always work out satisfactorily. A valu-
able test is the determination of the quantity of urea separately
in each kidney urine. The value of the phloridzin test is limited
to the advanced forms of renal disease. It is not reliable in the
early stages of renal insufficiency. The indigo-carmine test is
of no value, as it facilitates finding the ureters. Chromo- cysto-
scopy is only valuable in advanced cases, but even there, is not
equal to the other methods.
All the renal operations performed by the author have been
based upon the principles just enumerated. In no case did the
patient die from renal insufficiency. Tuberculosis of the bladder
and the kidney can be cured only by total nephrectomy. Partial
nephrectomy, in such cases, is of no value. In order to avoid
the formation of ureteral fistulae, it is best to cut the ureter
immediately below the renal pelvis, and to ligate it, instead of
removing as much of the canal as possible. The tuberculous
process in the affected ureter will then heal as promptly as that
in the bladder.
ZEITSCHRIFT FUR UROLOGIE
Volume IV., No. 12, 1910
1. On the Technique of Pyelithotomy. By S. P. v. Federoff.
2. A Bladder Developed Partly within its Ligaments, with an
Interesting Displacement of the Peritoneum, after Su-
prapubic Cystotomy. By J. Voigt.
68 AMERICAN JOURNAL OF UROLOGY
3. Congenital Cysts in the Genito-perineal Region, and their
Relation to the Accessory Ducts of the Penis. By
Carl Gutmann.
1. On the Technique of Pyelithotomy. — Federoff points
out that, of late, pyelotomy has become increasingly popular in
cases of renal stone. The operation of opening the pelvis is a
harmless one when compared to that of splitting the kidney.
Pyelotomy is almost bloodless and has no secondary hemorrhages
as sequels. The only disadvantage of the simpler operation is,
that after opening the pelvis, there had formerly resulted per-
sistent urinary fistulae in nearly every case. To-day this ob-
jection does not hold good, because in every such operation the
surgeon secures a permeable ureter by the use of ureteral cathe-
ters or by attending to the reduction of ureteral kinks by the
fixation of the kidney, if necessary. Even the largest incisions
in the renal pelvis, heal readily without any sutures, while, on
the other hand, the smallest incision in the kidney itself, may re-
main imperfectly healed for months and years, wherever there is
any obstruction to the drainage of urine.
The first thing necessary for a successful pyelotomy, is to
provide room in the operative field, so as to be able to examine
and palpate the pelvis thoroughly, as well as to follow the upper
part of the ureter for some distance. The best way to obtain
this, is to expose the kidney, shell it out of its fatty capsule, and
to inspect the kidney and pelvis after these have been delivered
outside of the cutaneous wound. If it is impossible to deliver
the kidney in this manner, one may conclude usually that the case
is one unsuited for pyelotomy, and consequently, one proceeds
to slit the kidney. This last contingency is apt to be encoun-
tered in a very stout patient, or one with a short renal pedicle,
or in cases in which there are numerous and tough adhesions.
Yet, in such cases, the X-rays sometimes show that there are
stones only in the pelvis, so that pyelotomy is strongly indicated.
Of late, the author has been acustomed to open the pelvis in such
cases, without delivering the kidney. The advantage of this
method is that the kidney is subjected to the least possible trau-
matism. He records eight cases in which he has adopted this
method.
CURRENT UROLOGIC LITERATURE
69
Federoff 's technique is as follows : An oblique lumbar in-
cision is made, or a Guyon's incision. The latter is employed
in those cases in which the X-ray shows that the stone is situ-
ated at or about the twelfth rib. After penetrating through the
muscles and fascial, the fatty capsule is opened over the convex
border and stripped from the posterior surface of the kidney.
An assistant holds the undetached fatty capsule over the anterior
surface of the organ by means of clamps. If this is impossible,
the lower pole of the kidney is freed completely, and the kidney
is held immovable at this point. If the kidney is very high up
and difficult to draw down, the twelfth rib may have to be re-
sected. The upper pole of the kidney and the anterior surface
'thereof, are not disturbed. If there is too much fat behind the
pelvis, it should be pushed aside by blunt dissection or cut away
with scissors. A pair of broad retractors will aid in exposing
quite completely the posterior aspect of the pelvis and the ureter.
An incision is then made into the pelvis, the stone is removed,
and the pelvis and ureter are examined with fingers and probes.
The wound in the pelvis is then sutured. The entire operation
is bloodless, unless there are sharp and multiple stones. Of
course, not every stone can be removed by this method, for when
the stones are in the kidney itself, the latter must be split in
the old way.
2. A Bladder Developed Partly within its Ligaments,
with an Interesting Displacement of the Peritoneum after
Suprapubic Cystotomy. — Voigt reports a case of irregularly
developed bladder, as indicated by the title. The patient had
been treated by Voigt in 1908, for gangrene of the vesical mu-
cosa following an attempted miscarriage. A suprapubic cysto-
tomy was performed, the necrotic mucosa removed, and the pa-
tient made a good recovery. The pregnancy continued to term,
and ended normally. About two years later, he saw the patient
again, and found that she had a hernia in the lower part of the
suprapubic wound. At that time, the hernia was very small, and
apparently contained intestine. The hernial sac gradually in-
creased in size, until it reached the dimensions of a child's head,
and hung over the symphysis. The contents of the sac consisted
of small intestine. The cystoscope showed a fairly normal
bladder, but a diverticulum in the organ was found, which was
70 AMERICAN JOURNAL OF UROLOGY
surrounded by the broad ligament. The anterior wall of the
bladder could be forced into the hernial opening by means of the
cystoscope, but this was done with great difficulty. There was
no urinary fistula into the ruptured parts. The patient con-
sented to an operation, which consisted in closing the hernial
defect. On examining the relations of the bladder to the uterus
and broad ligament, the bladder was found to extend anteriorly
over the fundus of the uterus, and on the right side, a consider-
able portion of it was seen to pass between the layers of the
broad ligament as a diverticulum, reaching close to the right
side of the pelvis. Nothing was done to the bladder itself, but
the uterus was fixed in the usual manner, to the abdominal wall.
The patient made a good recovery, and had practically no vesi-
cal disturbances.
ANNALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Vol. XXVIII., II., No. 23, December (1) 1910
1. Smooth-muscle-fiber Tumors of the Bladder. By M. M.
Heitz-Boyer and Dore. (Continued.)
2. Nervous Reflex Phenomena in the Urinary Organs in Cases of
Appendicitis. By F. De Meo.
2. Nervous Reflex Phenomena in the Urinary Organs
in Cases of Appendicitis. — De Meo points out that there are
cases of appendicitis in which the early symptoms come from the
urinary apparatus, thus leading to doubt in the diagnosis. As
early as 1820, when the term " appendicitis " had not yet been
employed, and when we spoke of typhlitis, Balzer called attention
to the fact that during the acute stage of this condition, there
may be urinary disturbances and even retention of urine.
Strange to say, but very little is said regarding the relation of
urinary phenomena to appendicitis in the modern standard text-
books. The fact that any set of nerves in the body, no matter
where situated, may have a reflex influence upon the bladder, was
demonstrated in 1785 by Troia. A number of cases have been
reported in literature, in which an attack of appendicitis in the
acute stage was accompanied by frequent and painful urination,
tenesmus, etc. But in these cases, there were also sufficient
CURRENT TROLOGIC LITERATURE 71
signs to discover the presence of appendicitis. In a case re-
ported by Giordano, in 1905, the urinary symptoms completely
masked the appendicitis. In 1907, further cases were reported
by Luxardo, and in 1908, still another case by Castiglione. In
1908, the present author reported two cases, while during the
current year, three further cases were recorded by Cassanello.
It seems, therefore, that these important cases have been particu-
larly studied in Italy. In his great work on " Appcndicliis"
Talamon reports a case an appendical colic which was mistaken
for a renal colic, and the true nature of the affection was dis-
covered only at autopsy. This case demonstrates the difficulty
in the diagnosis in such instances. To-day we know that even
when the symptoms are exclusively renal or vesical, there may
be only an appendicitis, and no affection of the urinary tract.
The diagnosis must be made by exclusion, and by a careful exam-
ination of the urinary organs.
The explanation for the renal and vesical symptoms in
cases of appendicitis, lies in the influence which the inflammatory
process in the appendix, exercises upon the nerves of the vesical,
renal, hypogastric, and pudendal plexuses. Therefore, when
symptoms of renal colic, pain on micturition, vesical tenesmus,
pain in the bladder, and burning in the urethra are present,
without any anatomical signs of appendicitis, there is a possi-
bility that these urinary signs are the early manifestations of
an appendicitis which has not yet become manifest. We must be
on our guard, and thus may hope to save many cases of appen-
dicitis which otherwise would prove fatal.
ANNALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Vol. XXVIII, I, No. 1, January (1) 1911
1. Aponeuroses and Periprostatic Spaces. Periprostatic Sup-
purations. By MM. Aversenq and Dieulafe.
2. A New Model of Opaque Ureteral Catheters. By F. Four-
nier.
1. Aponeuroses and Prostatic Spaces! Periprostatic
Suppurations. — Aversenq and Dieulafe contribute an interest-
ing article on the anatomy and surgery of the periprostatic
7£ AMERICAN JOURNAL OF UROLOGY
spaces. This is a subject which has received but imperfect con-
sideration by the majority of authors on prostatic surgery, so
that, clinically, we know well enough that periprostatic suppura-
tions occur, and that they must be dealt with promptly, yet much
confusion exists regarding the topography of these parts. For
this reason, the following abstract is made purposely somewhat
more detailed than is our usual custom.
The prostate gland is surrounded by a connective tissue
membrane which is lined in some places with muscular fibres, and
which adheres intimately to the glandular tissue. This structure
is the connective tissue capsule of the prostate, known more
briefly as the prostatic capsule. In addition to this, however,
the gland is surrounded everywhere from its base to its tip, save
where other viscera come in immediate contact with it, by con-
nective-tissue layers, which are the periprostatic sheaths or
aponeuroses.
The best description of these periprostatic membranous
structures, is that of Denonvilliers : " the prostate and the mem-
branous urethra are lodged between layers of fibrous tissue.
The superior perineal fascia is prolonged anteriorly in the form
of the anterior ligaments of the bladder which are inserted at
the posterior surface of the pubis, and at their opposite ends to
the prostate. Between these, a thin but resistant membrane ex-
tends, known as the pubo-prostatic aponeuroses. This consti-
tutes the upper covering of the prostate."
This upper or anterior periprostatic aponeurosis is some-
times known now. as the preprostatic fascia. This leaflet of con-
nective tissue covers the plexus of Santorini and behind is joined
to the prevesical fascia. The lateral coverings of the prostate
consist essentially, of a fascia which is an expansion of the su-
perior aponeurosis of the levator ani, which is directd upward
towards the prostate and the bladder. This is the pubio-rectal
fascia of the older authors. This lateral periprostatic fascia
incloses a space containing numerous veins which constitute the
lateral prostatic plexus.
The posterior covering of the prostate usually known as
the " aponeurosis of Denonvilliers," or the prostato-peritoneal
fascia, covers the posterior surface of the prostate and the vesi-
cles. Above, it is inserted into the subperitoneal tissue of the
CURRENT UROLOGIC LITERATURE 73
vesicorectal space. Below, its insertion is variously described,
but the present authors have found that it is inserted into the
muscular layers of the membranous urethra, immediately below
the apex of the prostate. Laterally, this aponeurosis joins the
deep surface of the aponeurosis of the levator ani and unites
with the latter to form the lateral periprostatic fascia.
The prostate is therefore surrounded by a series of peri-
prostatic spaces. There is in front the anterior space occupied
by muscles and veins. On either side, are the lateral spaces,
very rich in cellular tissue and veins, while behind the posterior
space is practically empty, but gives occasion for the accumula-
tion of pus in the form of a retroprostatic cavity. This com-
bination of spaces constitutes the " prostatic lodge." Beyond
this lodge, and outside of the aponeurotic walls there are, in
front, the space of Retzius ; on either side, the superior pelvi-
rectal space, while behind is the prerectal space. All these play
an important role in the pathology of periprostatic suppura-
tions.
The experimental portion of the author's work consisted in
the injection of colored gelatin for the purpose of demonstrating
the various periprostatic spaces. These injections demonstrate
quite strikingly that three different cavities may be created by
the accumulation of pus about the prostate; 1, the subcapsular
space, 2, the posterior periprostatic cavity, and 3, the prerectal
space. The subcapsular collections are always rather limited
and diffuse easily into the posterior prostatic space. The retro-
prostatic collections insinuated themselves between the vesicles
and reached upward until they touched the peritoneal cul-de-sac.
Below, these collections of fluid were arrested by the insertion of
the periprostatic fascia into the apex of the prostate. The pre-
rectal accumulation filled the space which bears the same name,
and reached below as far as the median aponeurosis. The rest
of the article is devoted to a discussion of the clinical side of
the subject, with a citation of cases. Finally, a summary is
given, mentioning the role of the various periprostatic spaces in
pathology and the methods of treatment suitable for the differ-
ent varieties. Both experimental studies and anatomical re-
searches showed the existence of spaces on all sides of the pros-
tate within which periprostatic abscesses would accumulate. A
74
AMERICAN JOURNAL OF UROLOGY
study of the clinical side of the subject showed that while each
of the spaces described could furnish a localization for abscesses,
yet these processes were very unequal in frequency. Thus, the
prerectal or posterior extra-prostatic abscesses are very fre-
quent. Posterior periprostatic abscesses are also very frequent,
but the anterior and lateral periprostatic suppurations are rare,
and, if present, are often the result of an extension of a phlebitis.
The intimate connection with lymphatic vessels which character-
izes the periprostatic tissues, accounts for the frequent complica-
tions of periprostatic suppurations with affections higher up in
the pelvis.
As regards treatment, each particular type of abscess de-
mands separate consideration, yet the perineal incision enables
us to reach most of these collections of pus, although the rectal
method is still in favor with some surgeons. The rectal route,
however, proved insufficient in a variety of periprostatic ab-
scesses, for it may not reach retrovesical collections, and the
delay may be fatal to the patient.
2. A New Model of Opaque Catheter. — Fournier de~
scribes a ureteral catheter which is impervious to the X-rays.
This new model is made by Eynard, of Paris, and consists of silk,
coated with a mixture in which is incorporated a metallic powder.
This catheter is made in all sizes, from 4 to 9, French, and its
lumen is as large as that of other catheters of the same size.
This ureteral catheter is very opaque, and shows exceedingly
well upon the radiograph.
The Therapeutic Advantages of Using Mercury in the
Colloid Form. G. Arbour Stephens, (Brit. Med. Journal, Dec. 17,
1910) says that the form of mercury that is worthy of such justifica-
tion is hydrargyrum colloidalis, or colloid mercury. The subject of
colloids is one that has become of great interest during the last few
years, and is one that is worthy of great attention and much study.
In coilloidal mercury we have a very powerful antiseptic. A
1 per cent, solution of hydrargyrum colloidalis is a greenish-brown
transparent liquid, without any smell, but has a faint metallic taste.
It is non-irritant^, non-corrosive, and relatively non-toxic. As a drug
it can be used both externally and internally. Externally it has a
very good cleansing effect on wounds, when applied in solutions of J
to \ per cent.
CURRENT UROLOGIC LITERATURE
75
In ringworm of both the large and small spored varieties, as
well as in two cases of alopecia areata, colloidal mercury has been
very beneficial.
In these cases it is best to remove the grease on the scalp with
petrol before applying the drug, otherwise it has no opportunity of
coming into close enough contact with the disease.
As a mouth wash mercury in this form is very effective in very
filthy states of the mouth, whilst as a spray its effect has been ex-
tremely good. In typical diphtheria cases a few applications of the
spray have produced an effect almost as rapid and satisfactory as that
following the injection of antitoxin. For tonsilar patches of all
sorts it is of extreme value, though for mere redness or inflammation
of the tonsils and pharynx it is not quite so effective.
Administered internally it is of value in acute gastritis, either of
babies, children, or adults. The dose for babies is 3 minims of the 1
per cent, solution to a drachm of water, and for adults 20 to 30 min-
ims. The ease of administration compares favorably with that of,
say, grey powder.
It is in syphilitic cases, however, that the great advantage of
colloidal mercury is seen. The author has not seen any unpleasant
symptoms, such as salivation, sickness, or distaste for food, but in
one patient who was taking 6 drachms daily the bowels were evacu-
ated too freely until the dose was reduced by half.
Organic nervous lesions which fall into the category of syphilides
respond to a certain degree to the internal administration of colloid
mercury, but the other organic nervous lesions do not respond at all.
Chancroids Due to a Peculiar Cause. William J. Robinson,
(Medical Record, Dec. 17, 1910) reports the following case: Mr.
X. Y. applied to me for treatment for chancroids. That was his and
his doctor's diagnosis. It was, according to his statement, a very
bad case and they kept on constantly recurring. The first time he
had them was about a year before he got married, but they were com-
pletely cured. And now they kept on coming back in spite of the
fact that he avoided all extramarital relations, as all good men should.
He had been six years married, had two children, the last three years
old. The first attack since marriage he had over two years ago.
The chancroids would heal in five to ten days, and sometimes they be-
came confluent. The doctor gave him a wash, which from the de-
scription was lotio flava, then he gave him iodoform, but as he ob-
jected to the odor, he gave him some aristol powder. The chancroids
would heal in five or ten days, and would remain well as long as he
76
AMERICAN JOURNAL OF UROLOGY
would keep away from intercourse; but almost invariably after inter-
course with his wife_, the chancroids would break out again. I sus-
pected that the causa peccans was to be looked for in the woman, and
I said so. He rejected this surmise with indignation. His wife was
the purest woman in the world. I told him that I did not at all im-
pugn her purity, but that she might have an irritating vaginal secre-
tion, or leucorrheal discharge. This was also impossible, as she was
very healthy, very clean, and he was sure that he alone was the
guilty party."
" When I examined him I found three small ulcers^ one in the
sulcus, one on the side^ and one near the root of the penis. They
did not look like chancroids to me. They looked like ordinary su-
perficial ulcerations, due to some irritation or a burn. There was no
adenopathy on either side. And careful microscopic examinations of
the scrapings from each ulcer failed to disclose the presence of the
Unna-Ducrey bacillus. Xor were there any strejotococci. In fact,
the field was singularly free from bacterial flora. I cleaned the ul-
cers thoroughly with hydrogen peroxide and gave him the following
ointment to be applied twice a day:
Zinci oxidi -1.0
Bismuthi subnitr 2.0
Bals. Peruviani 1.0
Petrolati albi 20.0
and I told him to abstain from intercourse for two or three weeks.
In five days the ulcerations^ or the chancroids, as he persisted in call-
ing them, were completely healed. A month later the man came back
with the same ulcerations, almost in the same situations. I gave him
the same treatment, but told him that if his " chancroids " broke out
again I would not treat him until I had examined his wife. They did
break out, and reluctantly he agreed to send her to my office. I ex-
amined her. found the vaginal mucosa harsh, dry, and shining, but no
evidence of any disease or any uterine or vaginal discharge. Still I
felt that here was the etiological factor to be looked for. A little par-
leying disclosed the fact that each time before intercourse^ without
the husband's knowledge, she was in the habit of inserting some anti-
septic tablet. She had been doing it for over two years, as she did
not want to have any more children. And she considered it too deli-
cate a subject to speak about to her husband. I analyzed the tablets
and found the principal ingredients to be citric acid and a small quan-
tity of corrosive sublimate. And I consider the latter responsible for
my patient's chancroids. The susceptibility of many people to mer-
CURRENT UROLOGIC LITERATURE 77
curie chloride is well known, some being unable to use it on their
hands without getting an eczematous eruption, etc. I advised her to
leave those tablets alone, suggesting a milder remedy, and since then
my patient's chancroids have not returned. Which is proof positive
that those tablets were the only cause of the trouble."
And in this connection it is not out of place once more to sound
a warning against the use of the highly toxic mercuric chloride as an
anticonceptional remedy and as a vaginal injection. Some druggists
in their ignorance advise the use of the 7.7 grain tablets ! Of course,
several cases of poisoning from the vaginal use of corrosive sublimate
have been reported, some of them with a fatal issue. That more
cases are not on record is a matter of great luck and is to be looked
for probably in the slight absorptive power of the vaginal mucosa.'*
Prostatic Infection. Technique of Examination. E. G.
Ballenger in an article on the Etiology of Prostatic Hypertrophy
(Medical Record, Sept. 10, 1Q10) calls attention to the deficiences in
the existing methods of examining prostatic secretion for microor-
ganisms. He says in this connection:
" For a number of years I have observed patients with sexual
hyperesthesia, or the so-called sexual neuroses, without demonstrable
lesions to account for the persistence of the symptoms. Rarely did
smears of the prostatic secretion show sufficient organisms to lead me
to believe the germs to be the cause of the trouble. In studying the
prostatic secretion of these patients, however, with the Reichert dark
field illuminator, my attention was at once strikingly focussed upon
the large number of motile organisms frequently seen in specimens
free from pus cells. Later I found that a drop of this discharge,
mixed with a 1 per cent, aqueous solution of dahlia, over which was
placed a cover glass, enabled me to see more readily these actively
motile organisms. Since that time about 140 patients have been ex-
amined in this manner to determine if there was a bacteriurio or pros-
tatic infection. In the present report I have not included the patients
where pus was present except in small amounts, as such cases come
under the heading of the inflammatory conditions, which are much bet-
ter understood than are these ' subchronic ' infections."
" In 110 patients with very mild genitourinary irritation or slight
affections of the sexual organs, a large number of mildly pathogenic
organisms were observed in the prostate gland, seminal vesicles, or
in the urine. Cultures of thirty-one of these showed the germs to be-
long to the colon bacillus group, or to the staphylococcus group. A
78 AMERICAN JOURNAL OF UROLOGY
surprisingly uniform and well-defined symptom complex was found
to attend these infections."
Technique. — An irrigation of the urethra and bladder is given
according to the Janet-Valentine method with a normol saline solu-
tion until one to two quarts of the solution has been used. Having
the bladder partly filled with the irrigating fluid, the prostrate is then
massaged and a drop of the secretion which appears at the meatus is
placed on a slide; a drop of a freshly prepared 1 per cent, aqueous
solution dahlia is mixed with this drop of secretion. A cover glass
then placed over it is sealed in place by applying melted white wax
or paraffin around its rim with a camel's hair brush. As a confusing
precipitate forms at times, and especially when the specimen con-
tains urine, it should be placed under the lens of the microscope and
allowed to remain in this position for 15 or 20 minutes or longer, to
allow the precipitate to settle to the bottom and become quiet, other-
wise the Brownian movement of these minute bodies might be mis-
taken for motile organisms.
The germs remain motile for a few days to a week, and a posi-
tive diagnosis may be easily made by a series of subsequent examina-
tions, when their motility differentiates them from the debris which
settles and becomes motionless. If preferred, the specimen may be
viewed with the dark field illumination and the diagnosis thus made.
Fixed smears may also be made and stained in the usual manner, but
these rarely give as accurate an idea of the presence of microorgan-
isms as does the above method.
Sodium Cacodylate in Syphilis. Runnels (N. Y. Medical
Journal, Dec. 3, 19 10) says that other organic arsenic compounds
besides Ehrlich's " 606 " are useful in syphilis. He calls attention
especially to sodium cacodylate in this connection.
From a theoretical standpoint sodium cacodylate has several ad-
vantages over dioxydiamidoarsenobenzol.
First: The latter cannot be obtained in this country at present,
while the former is at hand and it is only necessary to test its purity
before using.
Second: " 606 " will probably be very expensive, while the cost
of the other is merely nominal.
Third : " 606 " causes pain on injection, while the cacodylates
do not.
Fourth: Of the two the instability of the dioxydiamidoarseno-
benzol is the more marked, for while the cacodylates break down in
a few months, giving off poisonous products, it is necessary to ship
CURRENT UROLOGIC LITERATURE
79
the other in hermetically sealed vacuum capsules to prevent imme-
diate decomposition.
Fifth: The maximum dose of the cacodylates. for safety, 0.3
gramme per kilogramme, is twice the size of that of " 606," 0.15
gramme per kilogramme (34), proving that in the experimental ani-
mal it is much more safe.
Sixth: The arsenic content of " GOG " is thirty-four per cent.,
while that of sodium cacodylate is 46.8 per cent.; the latter, therefore,
is capable of delivering, weight for weight, thirty-eight per cent,
more arsenic. Theoretically there seems to be some grounds for be-
lief that sodium cacodylate should be more than a third more effica-
cious.
Seventh: The entire dose of sodium cacodylate is dissolved in
the blood, whereas a large percentage of " 606 " (40) remains unab-
sorbed and therefore unacted upon at the site of injection. Which
means that those who have been treated with " 606 " afterward carry
around in their persons indeterminate amounts of arsenic. This has
in no way had any therapeutic action and is worse than wasted.
It should be said in favor of Ehrlich's compound, however, that
that portion of it which enters the blood possibly breaks down with
more ease and therefore delivers its arsenic content more readily than
does sodium cacodylate.
In the opinion of the author the cacodylates have proved them-
selves worthy of a fair trial. For the only way of determining their
practical value and their worth as compared with dioxydiamidoarseno-
benzol is by the therapeutic application. Those who have the facili-
ties for the Wassermann reaction and spirochsetae determination have
here open before them a field for work. However, neither drug has
had as yet sufficient trial to prove that it is the ultimate specific, but
such results have been reported from both that we have great hope
that the problem of the diseases of animal parasitic origin has been
solved.
But the author, while advising the use of the cacodylates for this
class of disease, must emphasize the necessity for purity and the dan-
ger of deterioration. Use no sample that you have not tested, and if
kept for any length of time retest the purity. Keep in glass stop-
pered or rubber corked bottles and make up all solutions fresh on the
day of use.
Goxococcus Infection of the Kidney. F. R. Hagner, {Med-
ical Record, Oct. 1, 1910) reports a case of pyelitis in which a pure
culture of the gonococcus was obtained. He found sixteen cases of
80
AMERICAN JOURNAL OF UROLOGY
mixed infection of the pelvis, with gonococci. and nine cases of infec-
tion with gonococci alone in the literature. In the majority of cases
the infection seemed to be ascending in origin. The author's patient
was a man aged 35 who had been treated for a long time for a dis-
charge containing gonococci. Although he improved under the usual
treatment the urine continued to contain pus. On cystoscopy worm-
like masses of pus were found escaping from the right ureter. This
ureter was catheterized and pure cultures of gonococci were obtained
from the purulent urine from this source. Argyrol solution was in-
jected into the pelvis and a radiograph was taken, resulting in the
finding of a normal pelvis. Lavage of the pelvis on the affected side
was carried out with 25 per cent, argyrol solution, later with a 1 per
cent, solution of silver nitrate. Gonococcus vaccine was also given
(25 to 30 millions). There were in all five washings of the pelvis.
The patient made a complete recovery and was found with clear kid-
ney urine on the affected side five months after the treatment.
Lactic Bacillus Cultures in the Treatment of Chronic
Specific Urethritis. G. A. Pearson (Medical Record, Sept. 24,
1910) reports 34 cases of chronic gonorrhoea which he treated with
urethral injections of a culture of lactic acid bacilli. Six patients
were not benefited. In the remaining twenty-eight cases the specific
microorganism disappeared, and all clinical symptoms subsided.
Preparation of the Culture — A strain of the lactic acid bacillus,
which coagulated milk at room temperature in twenty to twenty-four
hours, was planted in the following media: Milk. ^0 parts; physiolog-
ical salt solution. 25 parts; nucleanic acid. 5 per cent., 5 parts, and
incubated for twenty-four hours, when plate cultures in agar were
made. The first colonies appeared on the agar plates in from
eighteen to twenty hours; these were selected for sub-cultures in a
media of: Milk. 60 parts; physiological salt solution, 33 parts;
nucleanic acid. 5 per cent.. ? parts, which were grown in the incubator
twenty-four hours, when again plate cultures in agar were made and
the first colonies appearing were transplanted. By this method the
quantity of milk was gradually decreased, the physiological salt solu-
tion and nucleanic acid correspondingly increased, until good growth
was obtained in a media of So parts of physiological salt solution and
1 5 parts of 5 per cent, nucleanic acid, which culture was used as
the urethral injection.
Conclusions — Secretions present in the infected urethra inhibit
the growth of a common strain of lactic acid bacillus. Suspension in
physiological salt solution of lactic acid bacilli grown on slant agar
CURRENT UROLOGIC LITERATURE
81
was injected into the infected urethra and cultures obtained by means
of a sterile platinum loop from the urethra — these cultures were
planted in milk in the following intervals: First culture, one minute
after injection; second culture, five minutes; third culture, ten min-
utes; fourth culture, fifteen minutes; fifth culture, twenty minutes;
sixth culture, thirty minutes. After forty-eight hours' incubation
there was complete coagulation in culture three ; in cultureetaoinetao
there was complete coagulation in cultures one and two; slight coag-
ulation in culture three; in culture four, acidity but no coagulation; in
cultures five and six, no growth.
It was observed that the disappearance of the gonococci bore a
constant relation to the length of time the lactic acid bacilli retained
their virulence in the urethra.
In each of the six unimproved cases the bacilli were killed al-
most immediately after injection and although several different cul-
tures were tried, none proved effective.
Cultures of lactic acid bacilli grown in nucleanic acid media, such
as used in the treatment of the cases here reported, retain virulence
when injected into the infected urethra for a much longer period of
time.
In a number of instances cultures which coagulated milk in
thirty-six hours have been obtained from the urethra of the patients
under treatment ten hours after the injection was made.
Hot Air Treatment of Phagedenic Chancroids. E. W. Rug-
gles (N. Y. Med. Journal, Nov. 26; 1910) reports a second series of
four cases of phagedenic chancroids treated with hot air. The origi-
nal device for applying this treatment was an oven which the author
found unsatisfactory. Hence he constructed a new model. This con-
sists of a box, eight and a half by six and a half inches, and five and a
half inches high, with a detachable cover. A flat iron heater, one and
a quarter inches in diameter and five inches long, is inserted near the
end of one side a little below the center. Extending across the box is
a vertical shield, awo and a half inches wide, its lower edge being one
and a quarter inches from the bottom. This is necessary to prevent
radiation and the consequent unequal heating of the penis. An orifice,
two and a quarter inches in diameter, in the center of the remaining
floor space, six and a half inches square, admits the penis. An aper-
ture,, five-eighths of an inch in diameter, near the bottom of this end
of the oven provides ventilation. The thermometer, extending to
within one half inch of the floor, is inserted through the cover near
one of the distal corners. A rheostat enables the patient to keep the
82
AMERICAN JOURNAL OF UROLOGY
temperature at the required degree by enlarging or narrowing the
aperture.
Both sides of the shield and the entire oven, inside and outside,
are lined with asbestos paper. The oven with a kerosene (incubator)
lamp as heater is also now being made with a detachable cover, since
it facilitates the determination of the position of the penis and
whether the lesions are properly exposed. These ovens can easily be
sterilized without injury in an ordinary cook stove oven. They are
made by the Kny-Scheerer Co.. New York.
An Improved Operating axd Observation Endoscope for
the Anterior Urethra. J. F. McCarthy (Y. Y. Medical Journal,
Nov. 26, 1910) describes his endoscope for the anterior urethra. The
instrument does not differ materially from the ordinary direct vision
urethroscope of the Yalentine-Chetwood type, but in order to make
the urethral lesions more easily detectable, a lens attachment has been
placed at about an inch from the opening of the tube. The author
has also provided an improved handle which carries the electric con-
nection to the lamp. (The use of magnifying lenses in connection
with the ocular end of direct urethroscopes is not a new device. — Ed.)
AMERICAN UROLOGICAL ASSOCIATION
At the special meeting of the Association held in New York
City on February 1, 1911, it was decided to hold the next Annual
Meeting of the Association at a time and place independent of
the meeting of the American Medical Association. It was voted
to hold our next Annual Meeting in Chicago, Sept. 26 and 27.
1911.
Details of arrangements will be announced later.
Members are urged to send the titles of their papers to the
Secretary as early as possible, as the program has been crowded
the past three years. No title will be received after August
1, 1911.
Address : Dr. H. A. Fowler, Secretary, The Cumberland,
Washington, D. C.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII MARCH, 1911 No. 3
A REVIEW OF THE SALVARSAN TREATMENT OF
SYPHILIS.
By Professor E. Tomasczewski.
Chief Physician of the Polyclinic.
(From the University Polyclinic for Skin and Venereal Diseases in Berlin.
Director: Professor Lesser.)
PAUL EHRLICH discovered salvarsan as the result of
many years of indefatigable and purposeful labor. The dis-
covery of this latest remedy for syphilis has been made
possible through a series of other discoveries which we are be-
ginning to appreciate only at this time: The finding of the
spirochaeta pallida, the inoculation of syphilis to monkeys and
rabbits, the discovery of atoxyl, and its application to the treat-
ment of infections due to trypanosomes and spirilla.
Chemistry. — Ehrlich's work began by studying the consti-
tution of atoxyl, which led him to the distinction between the
saturated quinquivalent and the non-saturated trivalent arsenic
compounds He next sought a compound which would combine
the most intense spirillo-tropic properties with the very mildest
possible toxic (organo-tropic) action. In this manner, he pre-
pared, in succession, arsacetin, arsenophenylglycin, and finally,
salvarsan.
In order to show the relation of these compound, I shall
We consider Prof. Tomasczewski's paper the best presentation of the subject
of salvarsan at the present time, and well worth the space we are giving it. — Ed.
S3
84 THE AMERICAN JOURNAL OF UROLOGY
insert here the constitutional formulae of atoxyl, arsacetin and
salvarsan.
XH2 NH . CH3 CO
Sodium p-araidophenylarsinate (Acetyl- Atoxyl= Arsacetin)
(Atoxyl)
As —
XH2 XH-
OH OH
(Dioxydiamidoarsenobenzol= Salvarsan. )
The antisyphilitic action of this last compound was first
noted by Hata in syphilitic rabbits. This investigator noted
the interesting and important fact that when salvarsan was
employed intravenously, the tolerated dose (T) per killigram of
animal, was 0.1 gram, and that the curative dose (C), was very
much lower, i. e., between 0.01 and 0.05, so that the relation
between C and T was ^— =i
The first use of salvarsan in {he treatment of human syph-
ilis should be credited to Alt, and his assistants, Hoppe and
Schreiber.
Salvarsan occurs as a pale yellow powder, becomes speedily
oxidized, and, therefore should be kept in sealed glass tubes
which are filled with an indifferent gas. In its character as an
amin, salvarsan is a base, and forms a hydrochloride with hydro-
chloric acid, having the following formula:
OH OH
In its character of phenol, it is an acid, and forms a sodium
salt with sodium h}'drate, having the formula:
THE SALVARSAN TREATMENT OF SYPHILIS 85
NH2 NH2
ONa ONa
Solutions. — The hydrochloride is the salt which occurs in
commerce, as salvarsan, and is soluble in hot water. A perfectly
clear solution of a greenish-yellow color may be obtained by
dissolving 0.5 or 0.6 gram of the substance in from 6 to 8 c.c.
of distilled water (acid solution). If, to this acid solution,
sodium hydrate be added, a gelatinous precipitate forms, which
upon further addition of the alkali, again disappears, leaving a
perfectly clear solution, yellow in color (alkaline solution).
For this purpose, one requires about 0.7 gram of normal sodium
hydrate (4« per cent.) for each 0.1 gram of salvarsan. If we
add only enough sodium hydrate to redissolve the gelatinous
precipitate, we obtain the so-called " cloudy alkaline solution."
NEUTRAL EMULSIONS
Wechselmann and Michaelis have endeavored to introduce
a "neutral emulsion." Michaelis dissolved the substance in hot
distilled water and added enough sodium hydrate solution to
obtain a perfectly clear alkaline solution. He then added two
or three drops of a \ per cent, alcoholic solution of phenol-
phthalein (red color) to serve as an indicator for the subsequent
neutralization with 1 per cent, acetic acid. When this acid was
added, salvarsan is precipitated in the shape of yellow flakes.
By shaking steadily and adding acetic acid drop by drop, the
red color is made to disappear, showing that the solution has
been neutralized.
Wechselmann dissolves the substance first in one or two c.c.
of 15 per cent, sodium hydrate solution. He next adds glacial
acetic acid, drop by drop, until a fine yellow mud is precipi-
tated. The latter is suspended in one or two c.c. of sterile
distilled water, and then is tested with litmus paper. If the
reaction is acid, it is neutralized with decinormal sodium hydrate
solution ; or with 1 per cent, acetic acid, if the reaction is alka-
line. The neutral suspension is then centrifuged for the pur-
pose of removing the sodium acetate which has formed during
86
THE AMERICAN JOURNAL OF UROLOGY
the process of neutralization. The clear fluid is decanted from
the precipitate in the centrifuged tube, and the remaineder is
suspended in from 4 to 6 c.c. of sterile physiologic salt solution.
OILY SUSPENSIONS
Kromayer, Volk and others have devised and recommended
suspensions of salvarsan in oily media, such as liquid paraffin,
olive oil, oil of sweet almonds, etc. These mixtures are pre-
pared by finely triturating the substance in a mortar with a
little oil, or paraffin. Usually, 5 or 6 c.c. of oil or liquid
paraffin are employed to each dose of salvarsan.
OTHER EMULSIONS
Finally, Citron and Mulzer have recommended an emulsion
prepared by treating the acid solution with 10 per cent, calcium
carbonate, while Jessner makes an emulsion of salvarsan by
adding 8 per cent, of a solution of sodium bicarbonate. Neither
of these last-mentioned modifications have been adopted to any
extent thus far.
HOW TO EMPLOY THE VARIOUS SOLUTIONS
The acid solution is very easy to prepare, but it is very
perishable, and, therefore, must be prepared shortly before
every injection. It is injected intramuscularily into the but-
tocks with the aid of a 10 c.c. " record syringe 99 with a needle
measuring 5 or 6 c.m. in length. The only authors who have
recommended the acid solution, are Taege and Duhot. Alt and
Hoffman warn against its use, inasmuch as it impairs the heart
action. Hoffman reports one case in which the use of the acid
solution was followed by a febrile attack which, in all proba-
bility, was due to a central embolic pneumonia followed by
pleurisy, which originated in a thrombus following the injection
of the acid solution into the gluteal muscles. In Lesser's clinic
the injection of the acid solution was followed by the appearance
of a so-called late exanthem with the threatening general symp-
toms. Hata, moreover, states that the acid solution is very
slowly absorbed, so that it is not therapeutically efficient.
The preparation of the alkaline solution is also simple. It
is not stable, and therefore, must be freshly prepared before each
injection. The technique of injection is the same as that used
for the acid solution. The alkaline solution is recommended
THE SALVARSAX TREATMENT OF SYPHILIS 87
after numerous trials by Alt. And yet, its use has not become
popular. The reason for this seems to be as follows : Salvar-
san at first was difficult to dissolve. A large quantity of water
and of sodium hydrate solution was required. The volume in-
jected, therefore, at first measured from 30 to 4*0 c.c, and the
liquid was markedly alkaline. The result was that extensive and
very painful infiltrates occurred at the sites of injection. Later
on, the preparation was improved markedly, so that now 0.5 or
0.6 gram of salvarsan, as sold in the market, is soluble in from
6 to 8 c.c. of water, and 2.5 or 3.0 c.c. of normal sodium hydrate
suffice for the preparation of a cloudy alkaline solution which
does not give rise to extensive infiltrates nor acute pains, pro-
vided the patient remains in bed for several days after the in-
jection. From our experiences in Lesser' s clinic, I consider the
intramuscular injection of this solution as the most efficient
method of administration which we have yet used with salvarsan.
The neutral emulsion owes its existence to the extensive and
painful infiltrates which followed the injection of the alkaline
solution in so many cases in the earlier stages of the work. It
was apparently necessary to neutralize carefully in order to
avoid the irritant action of the alkali, and also to reduce the
volume injected to the smallest possible amount, in order to make
the injection itself quite painless. These were the principles
that guided Wechselmann in the preparation of his neutral emul-
sion. The method of Michaelis is based chiefly upon the neces-
sity of a neutral reaction.
Both these authors recommend subcutaneous injections into
the scapular or submammary regions. The expectations which
were cherished when the subcutaneous injection of a neutral
emulsion was first employed, have not been fulfilled. Even the
proper execution of a subcutaneous injection is difficult, even in
the hands of experts. Furthermore, the pain at the time of
these injections is very slight, but there is considerable pain
afterwards, for several days.
The most important point, however, is that the conception
that it is necessary to inject a neutral emulsion was based upon
an erroneous premise. It was supposed that the violent local
reactions were due to the acid or' alkaline character of the solu-
tions, and the fact was lost sight of that the real cause of these
88
THE AMERICAN JOURNAL OF UROLOGY
reactions lay in the nature of the remedy itself. Naturally, the
irritating properties of salvarsan must appear very prominently
when a concentrated suspension is introduced subcutaneously, a
method which does not present as favorable conditions for ab-
sorption as the intramuscular. This was, indeed, found to be
the case. After subcutaneous injections of the neutral emulsion
there occurred in from % to 3 per cent, of the cases, and accord-
ing to some authors, even more frequently, areas, of very char-
acteristic softening with extensive tissue necrosis from four to*
ten weeks after injection. At first, a slightly painful, vaguely
fluctuating infiltrate is formed at the site of the injection, with
very little pain. In one place this infiltrate, then, shows a fistula
which secretes some pus. Gradually the skin over a considerable
area becomes necrosed, and a grayish-black, dry, slightly painful
mass is formed, which is often surrounded by a border of skin
which has been undermined by the necrosis. These areas of
necrosis are very slow to heal, are cast off very sluggishly, and
often require excision through healthy tissues, in other words,
an operative method of considerable seriousness. These necroses
are not due to the bacterial infections, but merely to the necrotic
effects of salvarsan. On the other hand, these infiltrates may be
infected secondarily (Martius, Neisser). In the milder cases
there is a more or less extensive solid, scarce^ painful infiltrate,
which may remain unchanged for many weeks or months. The
action is slow, and even in the favorable cases, a deposit remains
for a long time. The subcutaneous administration of the neu-
tral emulsion must, therefore, be abandoned. I should not even
advise the use of this emulsion intramuscularily, because it is
difficult to prepare and because it gives rise to necrotic areas,
particularly readily, on account of its concentration.
The attempts to incorporate salvarsan with oily media,
were intended to make its -administration painless and simple.
Volk and Kromayer were the first to recommend this method.
The oily suspensions have the advantage of keeping much longer
unchanged, provided they are preserved in a dark place. Still, it
is advisable to prepare the mixture freshly in each case, im-
mediately before injecting. Oils seem to be more adapted to
this purpose than liquid paraffin, especially if the entire amount
is injected at once. The injections are given intramuscularily
THE SALVARSAN TREATMENT OF SYPHILIS 89
and are almost painless. In the course of a few days, however,
there appear small or larger, more or less painful infiltrates
which persist for quite some time, as a rule. The therapeutic
effects are not so good as those obtained with the cloudy alkaline
solution, according to the experiences of Lesser's clinic. Kro-
mayer recommends the injection of 0.1 or gram of the sub-
stance at intervals of several days. Isaak and Friedlander
inject 0.1 gram weekly until the symptoms disappear. Both
emphasize the fact that by this method they are able to carry
out the treatment in dispensary patients. To my mind, it is
not a matter for indifference when so many deposits are created
and when the injections are distributed over a period of several
weeks. In using oily or paraffin mixtures, when the entire dose
is injected at once, it is best to employ a 10 c.c. syringe with
asbestos piston. When repeated injections of smaller amounts
are given, a syringe, holding 1 or % c.c. should be used. In both
instances, needles of large calibre, 5 or 6 c.m. in length, should
be employed.
Intramuscular Injections. Local Effects. — The fact that
inflammatory foci which tend to necrose, are formed in the
vicinity of the injected mass, is dependent upon the chemical
constitution of salvarsan. This was made clear by the investi-
gations of Orth, Lbhe, Martius and others, who proved that re-
actions occurred in muscles as well as in the subcutaneous tissues,
with this difference, that in the muscles the conditions for ab-
sorption seem to be more favorable, and therefore, the rule is
that intramuscular injections usually terminate in cicatrization,
while the formation of abscesses which point outward, is exceed-
ingly rare. The intensity of the reaction, furthermore, depends
upon the individual injection. We find the same differences in
employing soluble and insoluble mercurial injections. In this
manner, we can explain the great differences in the local reaction
which occurred in individuals in spite of the fact that the method
of injection was the same in all cases. Naturally, the site of the
injection has also something to do with the intensity of the re-
action. If the injection be made in the neighborhood of the
sciatic nerve, then the formation of the infiltrate which followed
the injection, may give rise to severe pain and even paralysis,
due to the irritation of the sciatic nerve.
90 THE AMERICAN JOURNAL OF UROLOGY
These effects may be discerned in the peroneus and as Mar-
tius states, also in the pudendal nerves. The injections should
therefore always be administered in the upper external quadrant
of the buttocks, and the needle should not be introduced too
deeply in thin persons.
The local manifestations which occur with intramuscular,
and particularly with subcutaneous injections of salvarsan in
doses of 0.5 to 0.6 gm. are certainly great disadvantages. Much
may be gained by abandoning the subcutaneous method entirely,
yet the intramuscular infiltrates also interfere with any repeti-
tion of the salvarsan treatment, as well as with subsequent mer-
curial injections. These points have been gaining importance
clinically, as we have gradually realized the impossibility of ef-
fecting a cure of syphilis with a single salvarsan injection.
Intravenous Injections. — This accounts for the changes in
the technique of administering the new remedy which have been
effected during the past few months, i. e., the gradual transition
towards intravenous injections. These are preferred by an in-
creasing number of workers, not because they act better, but
because they do not give rise to any local reaction, can easily be
repeated, and seem to be especially intensive in their effects when
used in conjunction with intramuscular injections.
Iversen, Schreiber, and Weintraud share the credit of hav-
ing perfected the technique of intravenous injections of sal-
varsan, and having observed the effects of these injections in a
large number of cases. Their technique has now attained a high
degree of perfection. It is not exactly simple, yet it is by no
means very difficult. In Lesser's clinic we employ exclusively the
apparatus devised by Weintraud-Assmy, made by Louis &
Lowenstein (Berlin, Ziegelstrasse) . The use of this apparatus
requires, naturally, a trained assistant, but is much simpler than
the use of Schreiber's syringe. The apparatus consists of a
standard measuring 1 meter in height, bearing supports for two
cylinders, each holding 200 c.c. These cylinders taper to a
coupling-piece to which a rubber tube is attached. Both tubes
are provided with a two-way stopcock, and the latter ends in a
conical tip which fits into a venepuncture needle. Into one of
the cylinders physiologic salt solution at a temperature of 40° C.
is poured. The other cylinder is filled with salvarsan solution.
THE SALVARSAN TREATMENT OF SYPHILIS 91
The latter is prepared by dissolving to a perfectly clear solu-
tion OA to 0.6 gm. salvarsan in the requisite amount of normal
sodium hydrate and diluting to £00 c.c. with normal salt solu-
tion. A rubber bandage is applied to the arm above the elbow.
One of the larger veins is punctured with the needle and the
band is removed. Immediately a small amount of salt solution
is allowed to flow into the vein, to make sure that the needle is
in the venous lumen. The stopcock is next changed to allow the
salvarsan solution to flow in, and finally about 10 or 15 c.c. of
normal salt solution is allowed to flow into the needle. In this
way a venous thrombosis can occur, but very exceptionally.
If the technique has been perfect, no local reaction what-
ever will follow. Experience has shown that these intravenous in-
jections are well borne by persons with intact internal organs,
especially hearts, and that they may be repeated and combined
with intramuscular injections. Jadassohn recommends that the
salvarsan-tolerance of the patient be tested beforehand with a
smaller quantity of the intravenous solution. After the intrave-
nous injection the patient must at once go to bed, where he
should remain about two or three days, inasmuch as the general
reaction takes about that length of time to disappear, and
proper rest materially aids the action of most drugs.
UNTOWARD EFFECTS OF SALVARSAN.
For the present, and perhaps for all time to come, we must
face the necessity of producing unpleasant local effects with
intramuscular injections of salvarsan. Intravenous injections,
however, as we have seen, do not give rise to any local disturb-
ances, provided the technique has been perfect.
The general untoward effects of salvarsan depend, in the
first place, upon its chemical constitution, and partly also upon
its arsenic content, as well as upon the dose injected and, finally,
upon the peculiarities of individual patients.
The general reactive symptoms which are noted usually
after intravenous injections of salvarsan are as follows : Fever,
nausea, vomiting, diarrhea. Rarely there is a total absence of
any temperature elevation. Most patients begin to feel chilly
even during the first hour after the injections. Some of them
get a regular chill. Then the temperature rises, reading 38-39°
92 THE AMERICAN JOURNAL OF UROLOGY
C. — rarely 40° C. and over. Almost invariably the temperature
then sinks to normal after 24 hours. In all probability these
phenomena are due to the intravenous infusion as such, for they
may be observed after the use of ordinary normal salt solution.
Naturally the salvarsan and the alkali in the solution also add
their quota to the effects, but I do not believe the reaction has
anything to do with the disintegration of spirochaetae.
Schreiber found that the second intravenous injections often
pass off without fever. Nausea, vomiting, and diarrhea are al-
most never absent. Sometimes the gastric symptoms are hiore
pronounced, — sometimes the intestinal arsenic is found in the
feces and the vomitus. These phenomena may be interpreted as
local effects of salvarsan, and are to some extent dependent
upon the size of the dose, as Weintraud points out.
In many coses the patients complain of heavy sensation in
the head, headache, or vertigo. Skin eruptions are apparently
rare. On the other hand, the so-called Herxheimer's reaction
occurs with marked intensity. This phenomenon, which had
been previously noted by Welander and Jarisch, consists is a re-
kindling of a faint eruption which appears with greater intensity,
or in an unmasking of a previously latent eruption. The reaction
is noted most intensely in fresh exanthems which had not yet
been treated, especially in the case of the first generalized syph-
ilitic rashes. The reaction occurs in 12 to 24 hours after an
injection of salvarsan. Similar local reactions are noted in
syphilitic lesions in the mucous membranes or in the internal
organs. From our experience with mercurial treatment we can
conclude that this reaction is primarily due to the absorption of
a rapidly acting spirochaeta-killing remedy.
The pulse, which is accelerated during the infusion, and is
often small, usually runs a parallel course with the temperature.
Nearly all the patients feel perfectly well after 24 or 48 hours.
After intramuscular and subcutaneous injections there is
either a complete absence of general reaction, or the general
symptoms occur later or differ from those described above.
Temperature. — On the day of the injection the tempera-
ture usually remains normal, but arises to 38 or 39° C. and falls
again in the following days. Very rarely higher temperatures
have been noted, and very rarely, also, the temperature remains
quite normal throughout.
THE SALVARSAN TREATMENT OF SYPHILIS 93
There seems to be no regular relation between the size of the
dose, the extent and type of the manifestations, and the course
of the temperature. A significant fact is that congenitally
syphilitic children do not show high temperatures usually, in
spite of the large number of spirochaetae which they harbor in
their bodies.
Pulse. — The pulse usually runs parallel to the temperature
curve, yet there may be a tachycardia lasting for days. A slow
pulse, however, seems to be the exception.
G astro-intestinal Tract. — Nausea and vomiting are very
rare, and the same is true of diarrhea. When the latter does
occur, it is usually severe, lasts for days, and may be combined
with annoying tenesmus. Constipation is noted for a few days
in most cases.
Kidneys. — According to Jadassohn, there is frequentlly a
trace of albumin in the urine. In some cases there were tran-
sient symptoms of a hemorrhagic nephritis. Frequently there
is an oliguria of short duration, with a polyuria following.
Bladder disturbances have been noted in a number of cases.
Difficult urination, transient or moderately prolonged urinary re-
tention, vesical tenesmus, — all of which in a number of instances
occurred in conjunction with intestinal tenesmus (Bohac and
Sobotka, Bering, Schlesinger, Polland and Knaur, Eitner, Ma-
linowski, Buschke, Volk-Lipschiitz, Rille). The origin of these
vesical disturbances is still in dispute. In the cases of Eitner
-and Malinowski the salvarsan had been exposed, either as salt
or as solution for days to the air. A crack in the glass ampul
may be a similar cause. As Martius point out, there is also to
be considered the possibility of pressure upon the pudendal
plexus, due to the formation of deeply located infiltrates in the
musculature of the buttocks. None of these explanations suf-
fice to account for all the cases, yet we must not forget that
until now the cases on record are few in number among many
thousands of patients, in spite of the early attention which was
called to these symptoms by the reports of Bohac and Sobotka.
Finally, we must bear in mind that even with these untoward
effects the cases have gone on to favorable results.
Nervous System. — This system deserves particular atten-
tion in connection with salvarsan treatment, because the toxic
94 THE AMERICAN JOURNAL OF UROLOGY
effects of this remedy may assume a stealthy, deceptive manner,
because the impairment of the nervous system often means the
involvement of important organs, and especially because our
previous experiences with atoxyl and arsacetin warn us to be
especially careful in this direction.
It may be said that salvarsan has been watched with espe-
cial care, in regard to its action upon the nervous system. What,
then, has been the experience of the clinicians who have thus far
recorded their observations in this respect.
The central nervous system is not affected by salvarsan,
provided it be intact or the seat of limited secondary or tertiary
lesions. The same holds good for the spinal nervous system.
The peripheral nerves seem to be practically never affected by
salvarsan. Naturally, we must except here the cases in which
more or less severe symptoms have been caused by the injections
of the remedy into the region of the sciatic nerve. These dis-
turbances include sciatic pains which may continue, in some
cases, for days or weeks (Wechselmann and Lange, etc.) radiat-
ing pains (Zieler, Herxheimer, etc.), paralysis of the peroneal
muscles, (Wechselmann and Buschke). All these disturbances
are the immediate effects of the local inflammatory reactions,
due to the injection itself.
In a few cases there was noted the diminution or disappear-
ance of certain reflexes (abdominal, cremasteric, and tendon re-
flexes). The first observations of this sort were reported by
Bohac and Sobotka. Yet, these seem to be very rare and, what
is important, transient manifestations.
The cerebral nerves require a few special remarks. It was
expected that in dealing with an organic arsenic preparation, as
with atoxyl and arsacetin, the effects of salvarsan upon the
optic nerve, would have to be reckoned with. This anticipation
has not been realized, so far as present experience goes. No
organ was so carefully examined before and after the adminis-
tration of salvarsan as has been the eye, and especially the
fundus of the eye. In spite of this, atrophy of the optic nerve
has been noted thus far, only in one case reported by Finger.
Owing to the importance of this question, and the peculiar char-
acter of the case, I shall report its history in detail:
" The patient was 22 years of age, and had been treated
THE SALVARSAN TREATMENT OF SYPHILIS 95
almost constantly during the past two years for malignant
syphilis. In addition to mercury and iodides, this patient also
received in April, 1909, 30 injections of arsacetin and in No-
vember, 1909, eighteen injections of enesol. On July 30, 1910,
he was admitted to the hospital for gummas of the nose and
pharnyx. The fundus of the eye was found to be normal. On
July 6th, he received an intramuscular injection OA gram of
salvarsan, according to Wechselmann's method. On July 13th,
the syphilitic symptoms were considerably improved, and the
patient was discharged. On Sept. 5th, he developed a small
gumma on the septum of the nose. On Oct. 5th, that is, three
months after the injection, the patient came to the clinic, com-
plaining of disturbances of vision. An examination of his eyes
in Dimmer's Clinic, showed a sluggish papillary reaction, aniso-
koria, bilateral narrowing of the visual field, pallor of the tem-
poral half of both papillae, in other words, beginning double
atrophy of the optic nerves.
It is probable that the treatment with arsacetin and enesol,
which had been used in this patient before the salvarsan, may
have had something to do with preparing the optic nerves for
the unfavorable effect.
To sum up all that has been said, it may be stated to-day
that one or two injections of salvarsan, in doses of from 0.5 to
0.6 gram, do not produce any clinically discoverable damage to
the visual nerves. Lately, another important question has
arisen. Fischer found a very severe papular iritis in four cases,
and in another case neuro-choroidoretinitis, occurring as re-
lapses two or three months after the injection of salvarsan.
Wechselmann reports a case of iritis and choroiditis, Kowalewski
noted in one case and Blaschko in two cases, an optic neuritis.
Finger reported a peripheral choroiditis of the right eye, with
central clouding of the vitrous body, a double optic neuritis with
paresis of the ocular-motor. Rille reported a marked choked
disk on the right side, with facial paralysis upon the right side,
accompanied by a unilateral neuritis of the vestibular and coch-
lear nerves. Furthermore, a case of double optic neuritis, with
right-sided paralysis of the facial and the trochlear, has been
reported.
In the majority of these cases, all of which belong to the
96 THE AMERICAN JOURNAL OF UROLOGY
early period, the complications were undoubtedly relapses of
syphilis. In some cases the authors who reported them, left this
question open, but all of them, with the exception of Wechsel-
mann, regard the occurrences as suspicious, and believe it possi-
ble that the seat of the relapses and the manifestations them-
selves are attributable to the salvarsan treatment. This question
must be left undecided, in my opinion, until further clinical ob-
servations have been collected.
Milder or more severe affections of the other cervical nerves
have also been observed after salvarsan injections in the early
period, as, for example, of the facial and the various ocular
nerves (Wechselmann, Spiethoff, Finger, Rille and Stern). The
number of these cases is small, and similar manifestations have
also been noted, though very rarely, as relapses after mercurial
treatment. Yet, it seems certain that, for the present, one must
admit the possibility that salvarsan is responsible for the seat
of these recurrences. According to K. Stern, there was no doubt
that salvarsan was responsible for the untoward effect in his
case of paralysis of the ocular muscles.
The communications of Finger, Rille, Beck and Matzenauer
concerning disturbances of the nerves of the internal ear, as, for
example, difficulty in hearing, disturbances of equilibration, ver-
tigo, vomiting, and nystagmus are even more important. All
these cases belonged to the early stages of syphilis.
In four cases the symptoms appeared very soon after the
injection, after from three hours to three days, and recurred
after ten or fourteen days. In two of these cases the syphilitic
eruption showed a Herxheimer reaction (see below). It is cer-
tainly probable that the disturbances in the labyrinth, in such
cases, may be dependent upon a similar reaction in syphilitic
foci which had previously remained clinically latent (Ehrlich,
Urbantitsch). At any rate, it seems suspicious that such dis-
turbances have not yet been observed with injections of mercury
which, as we know, do develop the Herxheimer reaction quite fre-
quently and intensely.
In two cases the disturbances in the labyrinth occurred in
the fourth and eighth week after injection. In one case, there
was also a double choked disk, and right-sided facial paralysis,
together with a papular syphilide. In the other case there was
THE SALVARSAX TREATMEXT OF SYPHILIS 97
a double optic neuritis and a right-sided facial and trochlear
paralysis. In both cases, the symptoms disappeared under mer-
curial treatment, in one of them very slowly, in the other rapidly.
We are certainly dealing in both cases, with recurrences of
syphilis which have become peculiarly localized.
Finally, we must speak of two cases reported by Finger, in
which labyrinthine disturbances occurred nine and twelve weeks
after injection respectively. The Wassermann reaction was
negative and there were no symptoms of secondary syphilis.
The condition remained stationary. In both these cases, it is
probable that we were dealing with a toxic neuritis of the acous-
tic nerve, due to salvarsan.
Injections of salvarsan quite frequently give rise to skin
eruptions. Usually these eruptions occur in the first days
after injections, are accompanied by rise of temperature and
disappear rapidly. As a rule, these eruptions are erythematous
or urticarious, rarely hemorrhagic. In some cases the eruption
occurs only after a repetition of the injection (Wechselmann,
Jahassohn.)
In is noteworthy, in my opinion, that the skin eruptions
peculiar to arsenic, have been seen but rarely after the use of
salvarsan. Keratosis has never been noted, while arsenical-zoster
has been reported in but a few cases (Ledermann, Bettmann, and
others). Marked pigmentations (melanoses) are also very rare,
but it might be noted that the eruptions of the earlier stages of
syphilis have a tendency to heal with a more brownish discolora-
tion than we are accustomed to see in mercurial treatment.
The so-called late eruptions (Wechselmann, Goldbach) oc-
cupy a special position, and prevent a very characteristic clini-
cal picture. After a chill, the temperature rises to 39° or 40 J
C. and may remain at this level for several days in succession.
At the same time, there appears a measles- or scarlet-fever-like
eruption, frequently accompanied by redness and swelling of the
pharyngeal ring, with or without false membranes. The patients
complain of headache, feel miserable and are sometimes tem-
porarily in a state of depression. The pulse is usually very
small and very frequent. All these cases have thus far termin-
ated favorably. After five or eight days the fever disappears,
the eruption vanishes, often with desquamation, and the patient
98 THE AMERICAN JOURNAL OF UROLOGY
feels well. Abortive cases also occur. For a few days low tem-
peratures are noted and the eruption rapidly fades. In other
cases, the patient merely feels very ill. It has been repeatedly
noted that these late eruptions occur in conjunction with renewed
painful swellings at the sites of injection. Possibly, these erup-
tions may be due to the action of toxic derivatives of salvarsan
which have formed in these deposits. Thus far these late erup-
tions have not been noted after intravenous injections.
The conclusion from all this is that salvarsan is by no
means an indifferent remedy. On the other hand, it has been
shown by the rarity, the mildness and the rapid disappearance
of nearly all the general effects that have been observed thus far,
that the dose of 0.5 or 0.6 gram is relatively non-toxic and that
but very few human beings have a congenital idiosyncrasy for
salvarsan. It is questionable whether this holds good for re-
peated injections. In this respect, we lack sufficient experience.
We know, however, quite surely that one injection does not seem
to produce a specific hypersensitiveness.
THE ELIMINATION OF SALVARSAN.
After intravenous injections the elimination of appreciable
amounts of arsenic in the excreta is terminated within four or
five days. After subcutaneous and intramuscular injections the
elimination is prolonged to six or eight days, (Fischer and
Hoppe), or for fourteen or eighteen days, according to Greven.
Very small amounts of arsenic may be demonstrated in the urine
for a number of weeks, provided a deposit is present, (Fischer,
Scholtz, Stern and others). It is this fact that warns us to be
very careful, — all the more so because we are not obliged to use
repeated injections of salvarsan, save in exceptional cases.
THE MORTALITY OF SALVARSAN : CONTRAINDICATIONS.
Deaths have been reported after injections of salvarsan
(Spiethoff, Hauck, Ehlers, Willige, Mar this, and others). These
cases have led Ehrlich and others to formulate strict contraindi-
cations against the use of the remedy, as follows : Serious dis-
turbances of the circulatory organs. (Even compensated car-
diac lesions are contraindications for intravenous injection).
Cases with degeneration of the blood vessels, aneurisms, transient
cerebral hemorrhages, patients with irritable cardiac and nervous
THE SALVARSAN TREATMENT OF SYPHILIS 99
systems, old persons with advanced degeneration of the central
nervous system, particularly cases of marked locomotor ataxia
and progressive paralysis, cases with fetid bronchitis, with severe
diabetes, even when the urine does not give any acetone reaction,
severe nephritis, gastric ulcers, all forms of cachexia, which are
not directly due to syphilis, and finally, all cases which have
been treated with any of the arsenic compounds mentioned in a
previous paragraph, even when this treatment has been employed
a year or more previously.
In addition, it is not an exaggerated precaution to exclude
from salvarsan treatment, for the present, all cases of specific
affections of the eye, the optic nerve, the eye-muscles, etc. Dis-
turbances in the internal ear, in the acoustic nerve, should also
be contraindications of salvarsan treatment, especially all cases
which have shown symptoms of an affection of the labyrinth after
one injection of salvarsan.
THERAPEUTIC EFFECTS.
The effect of salvarsan upon the manifestations of syphilis,
can no longer be disputed by anyone. Nearly all forms of pri-
mary, secondary and tertiary syphilis yield with remarkable
promptness to this treatment. An enormous mass of clinical
material gathered during the last few months, demonstrates this.
Some forms, however, require further discussion. Thus, the
swollen lymph nodes, especially in the primary stage, diminish
very slowly in size. The large papular eruptions also showed
quite frequently a sluggish respone to treatment, while the acne-
like and small papular syphilides usually disappeared rapidly.
The secondary syphilitic affections of the mouth and throat dis-
appeared rapidly, and without any traces, save in rare excep-
tions. The same is true of the various tertiary lesions. The
tertiary affections of the bones and joints, particularly, are
affected favorably by this treatment. The most brilliant re-
sults, however, are noted in the so-called precocious tertiary
forms, the malignant forms of syphilis, whether they affect the
skin or the nose and throat, as they often do.
At first, it was feared that salvarsan would not be applica-
ble in congenit ally- syphilitic children. The effects of a sudden
destruction of such large numbers of spirochetae in this form of
.syphilis, it was feared, would react unfavorably. Ehrlich him-
100
THE AMERICAN JOURNAL OF UROLOGY
self expressed this doubt. Experience showed, however, that
salvarsan could be employed even in the first weeks and months
of life, and that the results were excellent. The best summary
of this subject was that of E. Lesser: "Of nine children, be-
tween the ages of five and twelve weeks who had been treated by
salvarsan, none died, while in the years 1908 and 1909, there had
been ten deaths among twenty-seven cases between the same ages,
a mortality of almost 40 per cent." The spirochetae disappear,
the symptoms improve and the children develop in a normal
manner.
Of course, some of these children die in spite of this, be-
cause they are unable to live on with the profound changes which
have already taken place in their various organs. Thus, Herx-
heimer and Reinke found that " in two cases of hereditary syph-
ilis no spirochetae were present in any of the internal organs
save in the lungs two and four days respectively after the ad-
ministration of the Ehrlich-Hata remedy. In the lungs the
spirochetae were in a state of agglutination and of a high degree
of degeneration and even disintegration." These investigations
show how rapidly and intensely salvarsan destroys spirochetae,
not only in the skin and mucous membranes, but also in the in-
ternal organs.
It might be noted here how slight a reaction is produced in
the body of an infant when spirochetae perish in it in such
masses. In these infants there are neither symptoms referable
to an intoxication due to the swamping of the body with toxins
which have been set free, nor is there any remarkable high eleva-
tion of temperature.
The successes with salvarsan treatment in older patients
with congenital syphilis with parenchymatous keratitis have been
but slight. According to Igersheimer, the sum total of the ob-
servations made to date by himself, and by Treupel, Neisser and
Kuznitzky, Lindemeyer, Schanz, Sandman, Wechselmann and
Seligsohn, Fehr, Gliick, Frankel and Grouven (and also Jadas-
sohn), is that the cornea is never or almost never influenced with
any degree of certainty by the use of Ehrlich's remedy, no mat-
ter in what form the latter may be administered. When there
is, in addition, beginning labyrinthine deafness, I regard the use
salvarsan as absolutely prohibited.
THE SALVARSAX TREATMENT OF SYPHILIS 101
After the astonishing, sometimes quite remarkable results
obtained with salvarsan in almost all lesions of acquired and con-
genital syphilis, it seemed natural that attempts should be made
to treat with this remedy the so-called meta-sy philitic affections —
tabes dorsalis, and progressive paralysis. Some reason for this
might be traced to the fact that Alt, to whom the credit must be
given of having first applied salvarsan in the clinical treatment
of syphilis in human beings, has reported very early concerning
the action of salvarsan in the early stages of these diseases.
Nobody expected to get any good results in advanced types of
these conditions, and if such cases have been treated at all, it
was usually at the urgent requests of patients or their families.
Experience has demonstrated that such cases may become acutely
worse after injections of salvarsan. All experienced observers
agree upon this point (Oppenheim, Treupel, Willige, etc.). It has
not even been definitely settled whether — undoubtedly good ef-
fects have been obtained in the early stages of these diseases, in
the sense of a specific action upon their lesions. Whenever a
diagnosis of progressive paralysis is made, and when it is found
that antis}7philitic treatment produces remarkable and durable
improvement, there are always some doubts as to the correctness
of the diagnosis. It would be justifiable to regard such improve-
ment after salvarsan as conclusive evidence only if a large num-
ber of cases of paralysis were arrested for a long period or were
improved to a marked degree. Such reports are still lacking.
The value of salvarsan seems to be somewhat more pro-
nounced in locomotor ataxia. It is true, pupils insensible to
light remain insensible and lost patellar reflexes do not reappear.
But all the symptoms which are subject to wide spontaneous
fluctuations often show a remarkable improvement, frequently
after a transient turn to the worse, or, these symptoms do not
recur for a considerable length of time. On this point the ob-
servations of almost all authors appear to be identical. In addi-
tion, according to Alt, the treatment changes the positive
Wassermann reaction in these cases into a negative one, and the
reaction remains negative for a number of months, up to a year
and a half, possibly for a longer time. For these reasons the
injections of one dose of salvarsan is at least permissible in cases,
of tabes dorsalis and paralysis in their early stages.
102 THE AMERICAN JOURNAL OF UROLOGY
RATIONALE OF THE ACTION OF SALVARSAN
The action of salvarsan sets in very rapidly in almost all
cases. In the lesions which are rich in spirochetae and occur in
the early stages, these organisms are first affected. They lose
their mobility, assume bizarre shapes, and disappear entirely.
This process takes from 24< to 48 hours after an injection, but
may last longer, depending chiefly upon the anatomic and
pathologic conditions present. The action of salvarsan must
needs rest primarily upon its bactericidal specific action (spiril-
lotropic effect). It seems, indeed, difficult to understand that
there are still authors who doubt whether the remedy has any
specific action whatever, or who regard such action, as possessed
by salvarsan, as of no special importance." (Ehrlich). The
rapidity of its action, the importance of giving the right dose,
the Herxheimer reaction, the successful influence upon other dis-
eases caused by spirilla in man. Recurrent fever, framboesia,
Vincent's angina, and in animals : Spirillosis in hens and geese,
— all these speak so eloquently, that not the slightest doubt can
be raised now regarding the specific action of salvarsan upon
the spirochetae.
Before the onset of improvement is noted after an injection
of salvarsan, one often sees a so-called Herxheimer's reaction in
the lesions. Usually this phenomenon appears sharply only in
macular or maculo-papular eruptions. The eruption becomes
more distinct, larger, and many new macules or maculo-papules
appear. Similar focal reaction, or phenomena which can be in-
terpreted as such, have been also noted in sclerotic, mucous, or
osseous lesions of the early stage, and even in the tertiary stage.
The general impression is that this Herxheimer's reaction is more
frequently and more intensely noted after the use of salvarsan
than after the use of mercury. The simplest and most plausible
explanation for it is found in the theory that the infective agent
is rapidly destroyed, and that in consequence there is an increase
in the intensity of the local lesions. Many authors regarded this
phenomenon as an unfavorable sign, an expression of an irrita-
tion of the spirochetae due to a too small dose. Later experi-
ence has shown, however, that this assumption was quite un-
founded.
THE SALVARSAN TREATMENT OF SYPHILIS 103
Ulcerating lesions become clean and covered over with epi-
thelia so quickly that some observers have asserted that salvar-
san possesses not only spirillotropic properties but also promotes
the growth of epithelial tissues. This may be so, but of course,
is very different to prove.
The improvement in the lesions is accompanied in very many
cases by a marked increase in weight, and an improvement in the
general well-being which has a marked euphoric note. This is
clinically of great value, for under energetic mercurial treatment
there is usually some loss of weight towards the end of the treat-
ment, as well as an impairment of the general health. The prob-
ability is that the arsenic in salvarsan has something to do with
the improvement noted.
Finally, we must say something about the question of the
formation of antibodies. Taege, Duhot, Scholtz, Meriowski
Grouven, and others, have noted that when a mother is treated
with salvarsan, the hereditary syphiliis of her infant can be favor-
ably influenced. The authors quoted believe that this action is
due to the formation of antigens through the massive destruc-
tion of spirochetae in the mother's body, and that the antigens
are transferred to the child with the milk. In some of these
■cases (in Lesser's clinic also) arsenic was found in the mother's
milk, in others, it was not found. Most important, however,
was Ehrlich's negative result with the feeding of sick animals
with salvarsan, the hereditary syphilis of her infant can be favor-
Blaschko. To this we may answer that the salvarsan in mother's
milk may exist in an easily assimilable form, and that even minute
quantities are sufficient to produce improvement. The question
has, therefore, by no means been solved not even by the experi-
ments of Meirowski, Scholtz, and others, who injected the blood
serum of patients who had been previously treated with salvar-
san, into other patients, and obtained a slight improvement in
some of the symptoms. It is certain, however, that in the case
of infants the treatment through the mother's milk is not suffi-
cient, and that, moreover, similar phenomena have been long since
seen with mercurial treatment.
THE PERMANENCY OF THE EFFECTS '. COMPARISON WITH MERCURY.
The effect of salvarsan upon syphilitic lesions is no longer
doubted by anyone. A single injection of 0.5 — 0.6 as a rule
104 THE AMERICAN JOURNAL OF UROLOGY
removes all the clinical syphilitic manifestations. This is prob-
ably most surely attained with the alkaline solution, and some-
what more slowly with the neutral emulsion and the oil of paraf-
fin mixture. The intravenous injection must generally be re-
peated a second time within ten or fourteen days, in order to
influence all the morbid foci. In fact, I believe that as yet we
do not know the exact value of the intravenous method, and that
further clinical studies are needed to make our experience com-
plete in this direction.
Symptomatically speaking, therefore, a single injection of
salvarsan is equivalent to a course of treatment with mercury
or with mercury and the iodides, only salvarsan in many cases
is more efficient in that it removes the symptoms more rapidly,
but also because it heals lesions often in a short time which are
not influenced by prolonged mercurial treatment, are but partly
influenced by the latter, or else recur in spite of repeated courses
of mercury injections. Naturally, there are, among the cases
cited in support of this, many which cannot stand critical exam-
ination, and in which a course of calomel injections would have
produced the same beneficial effects as salvarsan. This, how-
ever, only proves the superiority of salvarsan, for we cannot use
calomel injections in all patients, nor can we use the chronic
intermittent treatment in all cases.
Most authors cite, as a proof of the superiority of salvar-
san, its action in malignant syphilis. They seem to be right, for
in no class of cases is salvarsan so immeasurably superior to
mercury and the iodides as in these types of the disease. But
it must be remembered that atoxyl also produced remarkable im-
provement and cure in such cases, in spite of the fact that this
remedy had an insufficient symptomatic effect in the ordinary
forms of primary and secondary syphilis. I mean that the so
marked and so striking superiority of salvarsan in malignant
syphilis does not prove, without any further examination, that a
similar advantage exists for all remaining syphilis cases. Only
a prolonged clinical observation of a large number of syphilitics
can solve this question.
The first curative trials with salvarsan were made in experi-
mental syphilis in rabbits. In animals with large primary lesions
rich in spirochetae a single intravenous injection of 0.01 — 0.015
THE SALVARSAN TREATMENT OF SYPHILIS 105
gm. salvarsan per kilogram of the animal's weight suffices to pro-
duce permanent cure. In animal experiments, therefore, Ehr-
lich's ideal — therapia sterilisans magna — has been fulfilled. We
must not overlook the fact, however, that while identical, etio-
logically, syphilis in rabbits is quite different clinically from
human syphilis. In rabbits the disease remains essentially local-
ized, has a tendency to spontaneous cure and but rarely shows
relapses. On the contrary, human syphilis is always generalized ;
and even after apparent cure shows relapses in almost every case,
lasts for years, and is inclined to give rise to after-diseases of a
serious character.
The treatment of human syphilis with mercury and iodine has
not succeeded in arresting the spread of the germ throughout
the system, to change the chronic relapsing character of the dis-
ease, nor to protect against metasyphilitic affections. Does sal-
varsan do more than this, aside from the fact that as a purely
symptomatic remedy it is equivalent to the action of an ener-
getic course of treatment with mercury and in some cases com-
pletely overshadows the effects of mercury? Is the use of sal-
varsan really a therapia sterilisans magna? or at least is salvar-
san able more frequently to prevent the generalization of the
disease, to prevent relapses and after-diseases? No definite an-
swer can as yet be given to these questions.
DOES SALVARSAN ABORT SYPHILIS?
Very early cases of syphilis, with an infection but two or
three weeks old, apparently have been treated with salvarsan in
but a few instances. The literature is very meagre on this point.
The success of the treatment in such cases is indicated by the
absence of local and constitutional symptoms, generalized glandu-
lar swellings, and lesions of the skin and mucous membranes,
together with a negative Wassermann reaction. Naturally the
patients must be observed and their serum tested for months, and
even then it is doubtful whether a permanent cure has been
effected. Wechselmann, Neisser, E. Lesser, Finger, and others
have reported such cases. From the reports which have thus
far appeared it seems clear that salvarsan acts very well in the
very early cases of syphilis. At any rate we must admit the
possibility that in these cases the disease has been successfully
106 THE AMERICAN JOURNAL OF UROLOGY
aborted, by means of a therapia magna sterilisans. An energetic
salvarsan treatment should be inaugurated in every case in which
the disease has been discovered at its earliest stage. Accord-
ing to Alt this is best done by giving an intravenous injection of
salvarsan, then following with an intramuscular injection, and
excising the chancre if situated so that it can be reached.
Cases in which first syphilitic infection has occurred a short
time after a salvarsan treatment also speak in favor of the
abortive action of the new remedy when applied early enough.
Schreiber and Milian each have reported one such case. In my
opinion, however, the lesions in these cases were so called " Thal-
mann's chancres " which are merely expressions of an incomplete
abortive treatment.
One of the principal tasks of the future will be to gather
material for the solution of this question. This problem is of
great practical importance, and if the abortive effect of salvar-
san be demonstrated, the remedy will be undisputably placed far
above all other antisyphilitics hitherto employed.
SALVARSAN IN THE PRIMARY STAGE.
Many cases of chancres with regional glandular enlarge-
ment, without generalized symptoms, have been treated by means
of salvarsan. It is as yet impossible to say whether a large
percentage of such cases remain free from symptoms clinically
and serologically. One thing seems certain, however, namely, that
nearly every author with considerable experience has seen recog-
nizable clinical symptoms develop sooner or later in these cases,
in spite of the fact that the chancre and the adenitis had dis-
appeared. These observations seem to be of great importance
for they show that salvarsan treatment, in the sense of a therapia
sterilisans magna may fail, even when the clinical conditions are
favorable for its success.
SALVARSAN IN THE SECONDARY AND TERTIARY STAGES.
No one can deny at this time that salvarsan acts very favor-
ably in the majority of cases with secondary and tertiary lesions.
And yet it must be admitted that the number of " failures," i. e.,
of cases which remain entirely uninfluenced or only insufficiently
influenced, is far larger than might be expected from the first,
and from many of the later reports. In some of these cases the
dose of salvarsan might have been too small, in others the ab-
THE SALVARSAN TREATMENT OF SYPHILIS 10T
sorption may have been insufficient. In a small number of cases
we must also admit the possible presence of " arsenfast " spiro-
chetae, for some " failures " remain uninfluenced even by a second
injection of salvarsan in larger dose.
THE PERMANENCE OF THE EFFECTS IN THE FAVORABLE CASES.
Even in those cases of secondary and tertiary lues in which
injections of salvarsan produce rapid and complete disappear-
ance of the lesions, it is difficult to judge of the permanence of
the effects. We know that tertiary cases treated with mercury
remain free from relapses even when the Wassermann reaction is
positive. It is not astonishing, therefore, that the cure in some
cases of tertiary syphilis remains permanent after salvarsan
treatment. On the other hand, relapses are of special import-
ance in this stage of the disease. One or more such cases are
recorded in almost every more important report.
The chronic-relapsing character of syphilis is particularly
noted in the earlier stages, and especially the first eruptions
which very frequently recur even after energetic mercurial treat-
ment,— according to Bruhn's in 75 per cent, of cases. There is
even a regular interval for the recurrence of these lesions, —
usually 2 or 3 months. We know now that after salvarsan treat-
ment there may also be recurrences of the early eruptions. It
is a question whether the frequency of these recurrences is greater
with mercury treatment than with salvarsan. It is remarkable
that the number of recurrences of the early eruptions is greater
in proportion to the length of observation to which the various
series of cases have been subjected. Some authors, e. g., Wechsel-
mann, emphasize the mild character of the recurrences, and their
locally limited extent. It is still an open question as to whether
the opinions of these authors deserve general acceptance. Other
writers have pointed out that the relapses frequently affect the
eyes and the cranial nerves. (See above.)
THE INFLUENCE OF SALVARSAN ON THE WASSERMANN
REACTION.
Naturally, the behavior of the Wassermann reaction has been
studied with special care in the cases treated with salvarsan. A
number of striking facts have developed in the course of these
investigations. In the first place, it was found that, like in cases
108 THE AMERICAN JOURNAL OF UROLOGY
treated with mercury, the disappearance of clinical symptoms
and the negative Wassermann reaction do not occur simultane-
ously. The symptoms disappear first, then the serum reaction
becomes negative. The only difference is that in the use of sal-
varsan the difference in time between the clinical disappearance
of symptoms and the vanishing of the positive Wassermann test
is greater, simply because the symptoms disappear more promptly
than under the use of mercury; while the Wassermann reaction
usually takes about the same length of time to become negative.
Thus C. Lange reports 250 cases of syphilis with positive
Wassermann's in which salvarsan was used. Of these 153 showed
negative reactions within from four to five weeks. In 97 the re-
action remained positive, and in 54 the reaction, which was
watched for a period of three weeks, did not diminish in intensity.
These figures correspond to those of nearly every other author.
The reaction seems to remain positive for a longer period, or
even permanently in tertiary cases, just as in patients treated
with mercury. This is especially the case in patients who had
no treatment for many years after infection. We may also note
here that, as Lange, Neisser, Stern, Citron, and Blaschko, and
many others have reported, a reaction which had been negative
during the primary stage may become positive some time after
the injection of salvarsan. Similar events were noted also in
cases of secondary and tertiary syphilitic affections where the
reaction had been negative before the treatment. The most
plausible explanation for this apparent paradox is that the
" positive phase " is accelerated by the sudden destruction of
many spirochetae.
The diagnostic value of the Wassermann reaction is firmly
established at the present time. The reaction is therefore an
indispensable part of the control of cases in which the disease is
supposed to have been aborted, and which have remained free
from symptoms, — and also of cases in which no treatment has
been used after the first two or three years but which showed no
symptoms. On the other hand, it may be said that the value of
the Wassermann test as a criterion if an antisyphilitic treatment
has been exaggerated, save in cases in which repeated negative
results are obtained and in which clinical symptoms are also
absent. // we use the Wassermann reaction as a criterion for
THE SALVARSAN TREATMENT OF SYPHILIS 109
each course of treatment, then salvarsan does not present any
superiority over an energetic mercury treatment.
SUMMARY AND CONCLUSIONS.
An enormous amount of work has been accomplished in
order to determine the value of salvarsan in the treatment of
syphilis. In spite of this we have reached only the very earliest
stages of clinical experience in this direction. And yet, many of
our expectations which were legitimately aroused by the genial
discovery of Ehrlich, have already been shown to have been vain,
expectations which were fostered by an unbounded, often incom-
prehensible optimism by many experienced clinicians. (Italics
translator's.)
It may be stated to-day:
1. That a single intramuscular or subcutaneous injection,
possibly a repeated intravenous injection, certainly a combined
intravenous and intramuscular injection of a sufficient amount
(0.5 to 0.6 gm.) of salvarsan produces marked symptomatic ef-
fects in cases of malignant syphilis, often effects of very long
duration, and not infrequently saves life in these cases.
%. That salvarsan treatment attains the value of an ener-
getic mercurial course (calomel injections) in all other types of
syphilis, with relatively rare exceptions.
3. That it is possible that a permanent cure, a therapia
magna sterilisans may be effected early in the primary stage,
but that undoubtedly most of these cases remain clinically and
serologically free from symptoms for a long period.
4>. That in cases of syphilis in any stage in which mercury
was not tolerated, or very badly borne, or in which new recur-
rences appeared in spite of repeated courses of mercury, salvar-
san almost invariably produced excellent results, — if not per-
manent cures, at least cures lasting a long time.
5. That salvarsan produces certain local more or less severe
tissue changes in all cases save when used intravenously, and that
it gives rise to a series of untoward general effects, no matter
what mode of administration be used. These untoward effects
vary greatly in character and intensity in different individuals.
Untoward effects of serious nature have thus far been noted in
a very small proportion of cases after a single injection, and in
some of these cases they were referable to faulty technique or
some other preventable cause.
110 THE AMERICAN JOURNAL OF UROLOGY
6. That we must continue to employ the chronic intermit-
tent treatment of s}rphilis and must maintain as before the neces-
sity for a complete course of treatment in deciding such ques-
tions as transmissibility, consent to marriage, etc., in every case.
7. That all our experiences thus far (indications, contra-
indications, etc.), are essentially based upon single salvarsan in-
jections, and that we as yet know practically nothing of the
action and untoward effects of a chronic intermittent salvarsan
treatment.
8. That neither an injection nor an infusion of salvarsan
excludes a simultaneous or subsequent course of treatment with
mercury and iodides, but, on the contrary, the special therapeutic
effects of these three remedies may be happily combined.
THE NORMAL AND PATHOLOGICAL POSTERIOR
URETHRA AND NECK OF THE BLADDER*
A STUDY WITH THE CYSTO-URETHROSCOPE
By Leo Buerger, M.A., M.D.
Assistant Adjunct Surgeon and Associate in Surgical Pathology, Mount
Sinai Hospital; Associate Surgeon, Har Moriah Hospital, N. Y.
PATHOLOGICAL LESIONS.
IT is not my purpose here to give a comprehensive account of
the pathological lesions found in the neck of the bladder and
posterior urethra, for the material examined up to the present
writing is not sufficient to explain all the doubtful findings,
nor have I been able to satisfy myself regarding the nature
of all of the lesions encountered. It seems best, therefore, to
allude only to those changes which were seen often enough to
leave no doubt as to their nature. The superiority of the cysto-
urethroscope in diagnosticating the finer and more minute lesions
of the trigone, especially near the sphincteric margin, has already
been referred to elsewhere. The so-called cystitis colli gives a
most remarkable and beautiful picture. Fig. 23 shows the mucous
membrane of the bladder just beyond the sphincter margin, with
the cysto-urethroscope turned sligtly to the right side of the pa-
tient. The small bulbous excrescences are well depicted. With
the cystoscope these bodies are markedly enlarged and the picture
* Continued from February.
Fig. 26
Fig. 27
Fig. 28
Fig. 29
Fig. 30
Fig. 31
Fig. 23. Juxta-sphincteric region to right of median line, at the floor of the
bladder in one type of cystitis colli.
Fig. 24. Papilloma at the left margin of the internal sphincter.
Fig. 25. Large (pathological) crypts in roof of pars supramontana with
purulent contents.
Fig. 26. Solitary cyst at the roof of the internal sphincter.
Fig. 27. Small cysts in roof of the pars supramontana.
Fig. 28. Cyst on left side wall of prostatic urethra; knife is piercing the
cyst; drawn with knife in situ.
Fig. 29. Collection of cysts in the right margin of the internal sphincter.
Fig. 30. Conglomerate cysts in the left margin of the sphincter.
Fig. 31. Symmetrical cystic bodies at margin of roof of the sphincter. The
cysts encroached upon the internal urethral orifice, obstructing it.
American Journal or Urology, March, 1911.
Fig. 38 Fjg. 39 Fig. 40
Fig. 32. Fossula prostatica and declive of same case as shown in Figs. 29-31.
Above, in the figure, is seen the bulbous degeneration of the
frenula; on the left, the deep cleft is an enlarged prostatic duct.
Fig. 33. Cystic degeneration of the colliculus.
Fig. 34. Turgid colliculus with irregular contour, in subacute urethritis.
Fig. 35. Inflammatory excrescences on the colliculus.
Fig. 36. Crater-like distortion of the summit of the colliculus, the result of
chronic inflammation.
Fig. 37. Colliculus as seen without the telescope, with an endoscopic light
carrier.
Fig. 38. Left sulcus lateralis contains an oval scar. On the left, in the figure,
is seen the bulbous left margin of the enlarged, distorted colliculus:
case of atrophy of left testicle.
Fig. 39. Enlarged prostatic duct in depressed scar tissue in the right sulcus
lateralis; displaced and distorted colliculus.
Fig. 40. Papilloma arising from the summit of the colliculus; common variety
at the usual site.
American Journal of Urology, March, 1911.
To Illustrate Ok. Buerger's Articlk
Fig. 41
Fig. 42
Fig. 43
Fig. 44
Fig. 45
Fig. 46
Fig. 41. Small papilloma lying against colliculus and arising by a slender
pedicle from the foot of that body.
Fig. 42. Stricture of the bulbous urethra, showing a tear after dilatation to
Charriere 24.
Fig. 43. Floor of the sphincter in hypertrophy of the prostate showing en-
larged lateral lobes.
Fig. 44. Left side of the sphincter in prostatic hypertrophy.
Fig. 45. Floor of pars supramontana in prostatic hypertrophy.
Fig. 46. Montane region in prostatic hypertrophy; note prostatic lobes and
small colliculus.
American Journal or Urology, March, 1911.
To Illustrate Dh. Buerger's Artical.
Fig. 49 Fig. .50
Fig. 47-50. Series showing excavation left after perineal prostatectomy.
Consecutive fields taking in the floor of the prostatic urethra
are represented, beginning with number 47 as the field nearest
the bladder.
American Journal of Urology, March, 1911.
URETHRA AND NECK OF BLADDER 111
is very dark and distorted. We have here a very good example of
cystitis proliferans or papillomatosa if we so wish to designate it.
We occasionally encounter papillomata at the margin of the
vesical sphincter. Such a tumor is represented in Fig. 24. This
papilloma springing from the left margin of the sphincter fol-
lowed the removal of a very large villous tumor of the bladder
by suprapubic cystotomy. Owing to the fact that the larger num-
ber of its villi were lying in the posterior urethra, it appeared only
as an irregular shadow through the observation cystoscope. It
was completely destroyed by means of the high frequency current *
through the author's operating cystoscope. f
Inflammatory processes involving the floor of the sphincteric
margin showed themselves not only in the effacement of the longi-
tudinal markings, but also in an increase of the depth of the red
color, as well as in a general velvety appearance of the mucous
membrane. Chronic inflammatory processes leave their traces in
a hypertrophic condition of the mucous membrane, and in the pro-
duction of folds which evidently represent sub-mucous infiltration.
Here, too, as well as in the supramontane region we encounter a
bulbous hypertrophy of the mucous membrane which may simulate
true cysts.
Although we not infrequently meet with a slight protrusion
of the central portion of the floor of the sphincteric margin, it
would seem to be either an anomalous development or a pathological
lesion which would cause this part to be unduly prominent. This
hypertrophy, if such we may call it, may be so marked that a be-
ginner would be apt to take it for a hypertrophy of the middle lobe
of the prostate. When it is present we can recognize it by the
fact that the trigone takes a sudden drop downward from the
sphincter, leaving almost an excavation behind the sphincteric mar-
gin. At the present writing I am unable to say what the signi-
ficance of this hypertrophy is, for it seems to be due rather to a
hyperplastic condition of the sphincteric muscle than to a thick-
ening of the mucosa. Perhaps it is only an anomaly of the so-
called uvula vesicae.
* Reported by Buerger and Wolbarst: New York Medical Journal, Oct.
29, 1910.
fThis instrument will be described in a future publication. See reference
to it in the American Journal Dermatology, Jan., 1911.
112 THE AMERICAN JOURNAL OF UROLOGY
Small white patches of mucous membrane indicate the sites
of old scars. Such mucous membrane is very thin and is evidently
bound by scars. The cicatrices may cause such rigidity that the
passage of a sound causes distinct linear tears or cracks compar-
able to those seen in the cases of hard infiltration of the anterior
urethra.
Supramontane Region : The sphincteric margin and begin-
ning of the supramontane urethra is a favorite site of that pro-
liferative condition of the mucous membrane which we may desig-
nate as urethritis proliferans or bulbous hypertrophy. Beginning
at the sphincteric margin and extending for varying distances into
the posterior urethra, we find hypertrophic folds of velvety mucous
membrane, with bulbous vesical knobs, the nodular thickenings re-
sembling cysts very closely. The most common site for this rugous
condition of the mucous membrane is at the roof and lateral walls
of the sphincteric margin.
A very interesting sequela of the gonorrhoea is the presence
of widely dilated crypt orifices, either in the roof or in the floor
of the supramontane region. We have not met them in the region
of the side walls. Fig. 25 illustrates three such openings, and
shows a peculiar cribriform appearance of the largest one with a
flake of pus exuding from it. In the floor, particularly in the
neighborhood of the colliculus these openings may be considerable
in size and sometimes represent the perforations of small sub-
mucous or prostatic abscesses.
In a paper on urethritis chronica cystica, * the subject of
cysts formation was discussed in detail. Cysts were found in about
twenty cases of my series but accurate notes were obtained in only
fourteen of these. Although all the patients had had either one or
more attacks of gonorrhoea, I gained the strong impression that
there are two types of cystic disease of the neck of the bladder
and posterior urethra. The first and most common of these is
undoubtedly an inflammatory process, the end result of a gonor-
rhoeal inflammation, and the second presents itself in the form
of simple lesions of retention such as belong to the involution
changes of the senile period. The inflammatory type (namely,
those cysts that belong to true urethritis chronica cystica) are
most frequently found in the pars supramontana, although they
* Folia Urologica, Nov., 1910.
URETHRA AND NECK OF BLADDER 113
are often seen in the montane portion, and may even involve the
colliculus itself. The supramontane region was diseased in all
of the cases, whereas the pars montana only in six instances. The
verumontanum was found markedly diseased in two of the patients.
The cysts vary considerably in size, the smallest measuring about
a millimeter in diameter, the larger one 3, 4 and 5 millimeters or
more. At times we meet with a confluent form that may take on
considerable dimensions. The simple discrete variety is the most
common (Fig. £6), tiny hemispheres or ovoid bodies occurring
frequently near the sphincter margin, In order to appreciate
their color properly it is important to regulate the amount of
light so that the illumination is sufficient. When the light is
adequate, their surface seems to be made up of a fine pearly veil-
like membrane, over the surface of which very fine oborescent ves-
sels ramify. The mucous membrane upon which they lie, or more
properly in which they are imbedded, is usually found to be thick-
ened and velvety, but the fine vessels as a rule become lost as
they are traced into the neighboring mucous membrane in which
they undoubtedly arise. When the illumination is insufficient the
true milky surface becomes a pale yellow and the cystic nature of
the body is not easily detected. They then appear to be solid
bodies or bulbous hypertrophies. In the region of the pars supra-
montana the larger more sessile, less prominent oval cysts were
more frequently encountered lying on either side of the colliculus
at the junction of the supramontane and montane region. These
are more apt to be solitary although at times such large oval cysts
may be surrounded by smaller satellites. I have often seen single
cysts near the sphinteric margin in the roof of the pars supra-
montana. Fig. 27 shows the typical tendency of the small cysts
to aggregate in one locality. Here the mucous membrane showed
marked disease, and in the figure the small areas represent de-
pressions in the mucous membrane giving a cribriform appearance.
This is probably produced by scarring consequent upon a pre-
vious inflammatory process. It is the roof of the pars supra-
montana which seems to be the favorite site for the lesions just de-
scribed. Fig. 28 shows a larger cyst that is being incised by the
endoscopic knife. At the junction of the pars supramontana and
montane region we encounter the larger, more elongated cysts that
114 THE AMERICAN JOURNAL OF UROLOGY
seem to have a predilection for the side walls. The small cysts are
seen in the fossula prostatica, where tiny bodies are found in de-
pressions between the posterior frenula and may even ride upon the
frenula themselves. Although we would gain the impression that
the changes thus far described are rather insignificant, experience
teaches us that the same type of pathological change may become
very extensive and profound in some cases. In eleven out of fif-
teen patients the cysts were few in number, and the evidences of
an old inflammatory process in the mucous membrane was not very
striking, although they were definite enough to be diagnosticated.
The more severe type of lesion presented itself in three cases, and
could be regarded as of sufficient magnitude to warrant the appella-
tive, urethritis chronica cystica. In one case both the roof and the
floor of the vesical sphincter, the roof of the pars supramontana,
the fossula, the left wall of the junction and the colliculus itself
were beset by small cysts. The picture presented here was one of
intense cystic degeneration of the larger part of the posterior
urethra. A still more striking instance was afforded by a patient
in whom the confluent, large type of cysts was encountered. Here
the roof and sides of the sphincteric margin were converted into
a mass of grape-like bodies, some composed of tiny cystic patches,
others being lobulated. The latter may be bilocular, trilocular, or
somewhat sausage-shaped cysts. All of these have the typical
glistening pearly surface, with large arborescent vessels which can
be traced here and there into the surrounding mucous membrane.
Fig. 29 shows a collection of cysts at the right side of the sphinc-
teric margin, the mucous membrane being much thickened espe-
cially below where two cysts are seen to lie in a granular or follicu-
lar mucous membrane. Fig. 30 shows the opposite side of the
sphincter, the upper part of the illustration showing a portion of
a lobulated cyst which was found upward and inward almost to
the median line. In Fig. 31 we can see the continuation of the cys-
tic bodies on the roof of the sphincter. There is only a small space
free above, where the cribriform and granular variety of mucous
membrane is found. Although these pictures give one an idea of
the condition at the annulus urethraUs, or at the beginning of the
posterior urethra, in the case under consideration it gives no con-
ception of the extent of the process in the supramontane portion
and the region of the colliculus. On the right, cysts could be
URETHRA AND NECK OF BLADDER 115
traced along the side walls down into the fossula prostatica, where
numerous bead-like hypertrophies of the posterior frenula were
seen (Fig. 32). The colliculus presented the remarkable picture
shown in Fig. 33. The utricle was plainly evident at the summit.
There was a thin strip of red mucous membrane in the center of
the colliculus, but on either side, this body was converted into a
number of cystic masses.
The Montane Region: Inasmuch as our observations were
confined to the post-gonorrhoeal stage, we but rarely met with
instances of acute inflammation of the colliculus. Hyperemia of
the colliculus was frequently encountered. Those cases of acute
and sub-acute inflammation of the posterior urethra which we had
the opportunity of observing, showed considerable enlargement of
the colliculus, a velvety condition of its mucosa, an absence of all
vascular markings, the utricle still visible but the ejaculatory ducts
being buried and unrecognizable in the swollen mucous membrane.
As a result of a posterior urethritis, the mucous membrane of the
colliculus loses its smoothness, the outlines of this body becomes
rough as is shown in Fig. 34, and in many cases we find the de-
velopment of cock's-comb-like vegetations at the summit or over
the declive. Fig. 35 shows a turgid colliculus with inflammatory
excrescences, two enlarged prostatic ducts appearing on the left
side of the field. After treatment the villous condition of the
colliculus may become considerably reduced, but as a rule a close
scrutiny of the mucous membrane at close range will reveal pale,
pointed, finger-like bodies over the declive even after all evidences
of inflammation have disappeared.
In cases of chronic prostatitis we have met with evidences of
previous involvement of the colliculus. Fig. 36 illustrates an in-
stance in which the summit of this body has been converted into a
veritable crater surmounted and bounded by a series of polyp-like
excrescences in the form of an irregularly shaped crown. Fine
vessels were discernible even on the surface of the individual tufts,
but the mucous membrane had lost the smooth appearance char-
acteristic of the normal picture. The polyp-like excrescences, it
seems to me, are but the lobulations produced by a cicatrizing
process. In this case we were dealing with the result of a pros-
tatitis of long duration.
116 THE AMERICAN JOURNAL OF UROLOGY
We wish to emphasize here that in our experience enlargement,
hyperemia and inflammation of the colliculus are not as frequent as
one would suppose from the writings of those who have relied upon
direct endoscopic examination. In the cysto-urethroscope we have
at our disposal a reliable means of detecting the slightest increase
of size, and the most minute changes in the colliculus. The
turgescence of this body during erection could be frequently
seen and its varying size under different conditions was made the
subject of thorough study. Although it may be urged against
this method of urethroscopy that the presence of the irrigating
fluid may cause a considerable reduction in the size of the colliculus,
experience shows that with the proper manipulation of the flow we
have within our control an effectual means for overcoming this ob-
jection.
In order to control the apparent size of the colliculus under
the conditions that obtain in " irrigation urethroscopy " by a
direct view in air medium, we frequently removed the telescope,
aspirated the fluid in the sheath and examined the colliculus with
the aid of an endoscopic lamp. Fig. 37 shows the picture that is
thus obtained. Often the utricle can be recognized, especially if
a magnifying lens1 is used.
Varying degrees of cystic disease of the colliculus were also
encountered. An extensive degree of cystic degeneration of the
colliculus is show in Fig. 33, where the summit and a small strip of
mucous membrane in the center are alone unaffected by the degen-
erative process.
Argyria occurs in cases of chronic urethritis that have re-
ceived a great deal of treatment with silver nitrate. It was usually
found affecting the summit and declive of the colliculus, more
rarely the acclive. In a number of instances the fossula pro-
statica was also markedly pigmented. The declive is apt to be
rough and stippled, covered by minute black dots ; or the whole of
the declive may have a blue-black appearance. It is not difficult
to differentiate this condition from prostatic sand. The granules
of prostatic sand are much larger, are not confined to any par-
ticular portion of the colliculus, are very often encysted, and are
more frequently seen in the region of the acclive and sulci laterales.
In the pars supramontana, larger collections of gravel-like ma-
URETHRA AND NECK OF BLADDER
117
terial are often deposited between the frenula. The bulb is also a
favorite site for silver nitrate discoloration.
It would take us too far to go into a detailed description of
the anomalous conditions that were encountered. As a result of
repeated instrumentation traumatism, or chronic urethritis, con-
siderable distortion of the colliculus may be produced. Thus we
have found these bodies to be converted into a number of knob-like
masses ; peculiar bands have been seen to divide the colliculus into
irregular portions, and an atrophic condition writh considerable re-
duction in the size of the colliculus was encountered. These are
some of the peculiar types of disfigurement amongst the many in
our series.
Fig. 38 shows the left sulcus lateralis and a small portion of
the colliculus in a most interesting case. The patient consulted
me because of atrophy of the left testicle. He had received an in-
jury about eight years previously, having fallen astride on the
perineum. As a result of this trauma the urethra was ruptured,
and two operations for the restoration of the canal had been since
performed. At the time of examination the urethra admitted a
No. 27 Charriere sound and showed a peculiar lesion in the
prostatic urethra. The colliculus was scarred and much enlarged,
showing a number of bulbous bodies represented in the figure. In
the left sulcus lateralis there was an oval depressed cicatrix, at the
bottom of which there were smaller scars and deep pits. There
seems to be little doubt but that this lesion represents a connective
tissue change in the prostatic urethra and in the prostate, possibly
involving the ejaculatory duct on that side and in all probability
the cause of the atrophic condition of the left testicle.
As the result of repeated infections with gonorrhoea and (as I
have interpreted the pictures) following the evacuation of purulent
collections on the prostate, certain prostatic ducts on either side of
the colliculus may become permanently enlarged. Their orifices
are oval and usually lie in depressions that are probably the seat
of scar tissue. Fig. 39 shows the right sulcus and the colliculus in
such a case. The colliculus is somewhat distorted, is elongated and
carries enlarged vessels. The sulcus is pale where it lodges a fossa
whose wall is lined by pearly ridged mucosa. At the bottom of
this oval depression a duct opening is the most striking feature of
the picture.
118 THE AMERICAN JOURNAL OF UROLOGY
Papillomata of the prostatic urethra are not uncommon. A
favorite site is a point near the summit of the colliculus, to the
right or left of the utricle orifice. Usually there is a long slender
pedicle bearing a swollen bulb-like extremity, as depicted in Fig.
40. This particular case was treated by the fulguration method
through the cysto-urethroscope, a number 5 Charriere, fulguration
wire being employed. Sometimes the bulbous end is absent and a
number of delicate villi radiate from a slender stalk in sceptre-
like fashion. An interesting finding is illustrated in. Fig. 41, where
there was a small villous tumor arising from the foot of the acclive.
We must be careful to recognize the minute, conical, coxcomb
excrescences that beset the declive, and less frequently the acclive
of the verumontanum, in the healed stage of a severe posterior
urethritis and prostatitis. These are not true papillomata. The
differential diagnosis may be diffcult when the outgrowth is small
and when it simulates the broken pedicle of a true papilloma. I
had the good fortune to verify the urethroscopic diagnosis of
papilloma in one case by microscopic examination of the tumor
after it had been removed through a straight tube by means of a
forceps.
Less striking lesions, such as follicular hypertrophy and scars,
were seen now and then. My material is not large enough to
describe these in full, and I shall therefore refer to them in a
future publication. My conception of the lesions in the membrane-
ous and bulbous urethra, as seen with the cysto-urethroscope, is
also not complete enough as yet to warrant a description of them
here. A thorough study of this region is now in progress.
At the time of the present writing I have had occasion to
examine but a very few cases of stricture of the urethra.* I can
not refrain, however, from citing one instance, because it per-
mitted of such satisfactory inspection of the site of the lesion. In
the bulb not far from the bulbo-pendulous junction depicted in
Fig. 42, there was a shelf-like or ridge-like band which projected
above the surrounding mucous membrane and was slightly torn by
the passage of a sound.
In prostatic hypertrophy the cysto-urethroscope affords us
an excellent means of diagnosis, as well as of estimating the exact
*Since writing the above a number of additional cases have been examined,
some of which have been treated by fulguration through the cysto urethroscope.
URETHRA AND NECK OF BLADDER 119
extent of the intravescial and endo-urcthral enlargement. In the
series of illustration 43 to 46 inclusive, we have pictures which
demonstrate clearly the changes produced by hypertrophy of the
prostate. Fig. 43 shows the prominence of the lateral lobes at the
floor of the sphincteric margin. Comparing this figure with the
illustration of the normal sphincteric floor, we note a total absence
of the tranverse line, and the presence of two rounded bodies sep-
arated by a V-shaped incisure. The tortuous blood vessels are
plainly visible. A lateral view of the sphincter is seen in Fig. 44.
where the typical concave margin is absent, and the left lateral
lobe overlaps the sphincter. With the fenestra of the instrument
still looking downward and including a portion corresponding to
the supramontane urethra, a picture illustrated by Fig. 45 presents
itself. The prostatic lobes look like two large vocal chords sep-
arated by a deep cleft. Evidently the shaft of the instrument
rides upon the prostatic lobes whose rigidity prevents contact with
the region of the fossula, and effectually masks this part of the
urethra. By increasing the force of the irrigating flow we can
make the two lobes separate, the telescope looking down into a deep
cavity, the bottom of which remains dark. The montane urethra
and the distal portion of the montane region of the same case are
shown in Fig. 46. The peripheral termination of the lateral lobes
is seen to lie somewhere near the junction of the montane and mem-
branous urethra, and the small size of the colliculus becomes evi-
dent. This is a feature which is frequently encountered in hyper-
trophy of the prostrate and is of some diagnostic value.
There are cases of prostatic hypertrophy in which there is
little or no distorsion of the sphincteric margin. In these there
may be very marked endo-urethral changes. Beginning our ob-
servation with the floor of the sphincteric margin in such instances,
and drawing the instrument outward, we soon meet with projections
of the lateral lobes which form a V-shaped cleft in the supramon-
tane region. Distally, these become more prominent and form two
ridges such as are seen in Fig. 45. The prostatic lobes have a
tendency to overshadow the distal part of the supramontane region
and the fossula prostatica. They separate as we approach the
region of the colliculus, but even this body may be shadowed, as it
were, and elude the unpracticed eye. I have frequently resorted
to the following maneuver in demonstrating the colliculus to stu-
120 THE AMERICAN JOURNAL OF UROLOGY
dents in such cases of prostatic hypertrophy. The ocular of the
instrument is raised somewhat with the right hand and the shaft of
the instrument is pressed downward towards the perineum with the
left. In this way the shaft descends between the rigid lobe upon
which it tends to ride, and the fenestra approaches the fossula
prostatica and colliculus. What would otherwise appear as a
deep chasm, the bottom of which is imperfectly illuminated, now
becomes bright and distinct.
We have already elsewhere referred to the fact that after the
age of forty-five we may meet with small cysts of the prostatic ure-
thra, sometimes enclosing prostatic sand: an evidence of senile
change. Although such cysts usually occur in the fossula pros-
tatica, they are not strictly limited to this region. And so we also
find them on hypertrophied prostatic lobules. In those cases of
prostatic hypertrophy where we have to deal with an added chronic
cystitis, we may meet with an interesting lesion. The cystic bodies
become enlarged by virtue of edema, and we see a collection of such
cysts on one or both prostatic lobes, some pedunculated, forming
small pyriform masses with milky contents.
In a case of perineal prostatectomy followed by the establish-
ment of a perineal fistula that came under my observation, the cav-
ity left by a somewhat incomplete removal could be completely
mapped out and the opening of the fistula in the prostatic urethra
could be detected after the injection of methylene blue. Fig. 47 to
50 inclusive, show the irregular somewhat ragged oblong cavern as
it could be traced from the supramontane urethra towards the mem-
branous. The central and distal terminations of the cavity are
shown in Figs. 47 to 50 respectively. The region seen in Fig. 49
contained the orifice of the fistula which is not indicated in the
drawing, inasmuch as it could be only seen upon considerable dila-
tation, being hidden by the ragged left residual lobe of the pros-
tate. Two small lobulated masses, somewhat pyriform in shape,
also occupy this region. For a study of the endo-urethral and
sphincteric aspect of the hypertrophied prostate, in those cases
where but slight enlargement can be felt per rectum and particu-
larly in the early cases, the cysto-urethroscope gives most reliable
information.
THE UROLOGISTS OF THE MIDDLE AGES 121
THE UROLOGISTS OF THE MIDDLE AGES
DURING the Middle Ages, that interregnum of science dur-
ing which a damper seemed to have been put on all intel-
lectual activity and the progress of the earlier centuries
seemed to have remained at a standstill, or, indeed, to have retro-
graded, the word " Urology " was first used to designate the art
of examining the urine. The term urology came to be applied to
urinary surgery very much later; in fact, this term has been in use
extensively only within the past quarter of a century. A number
of treatises upon the so-called urology of the Middle Ages are
extant. The earliest of these was published by a certain Theoph-
ilus in the seventh century. Other works of this sort were the
treatises of Isaac, translated by Constantine, and the quaint book
of Gilles de Corbeil, physician to Philippe-Auguste, which was
written at the end of the twelfth century in Latin verse. The
examination of the urine in the thirteenth century became the chief
diagnostic measure practised by physicians, and the importance
of this procedure at that time might be surmised from a reference
in a popular collection of fables published under the title " Roman
du Reynard " (The Story of the Fox). The sick lion consults
the fox, who is pictured as a sagacious physician, and in order to
make his ailment plain, the lion says :
" Bring unto me a urinal,
And you shall see therein my trouble."
The fox thereupon examines the precious fluid and gives the lion
a potion intended to cure him. In the beautiful works of Richer
and Meige there are numerous reproductions of paintings, en-
gravings and drawings, dating from the thirteenth to the eigh-
teenth century inclusive, dealing with " Urology," i. e., the art of
inspecting and examining the urine. We reproduce two of these
cuts, showing that the attention of artists was directed to a con-
siderable extent toward the depiction of the mystic process of
making a diagnosis by the mere inspection of receptacles contain-
ing urine.*
'The figures reproduced herewith are taken from a lecture by Professor
Albarran, which appeared in La Presse Medicale, November 17, 1906, and to
which we refer for further data upon the early history of urology.
THE AMERICAN JOURNAL OF UROLOGY
In most of the pictures of that period the physician was repre-
sented as holding a urinal in one hand, raising the receptacle to
the light in order to judge of the character of its contents by
inspection. Sometimes this examination is pictured as taking
place at the bedside, at other times the patient is absent and the
urologue has nothing but the urine to base his diagnosis on and
Fig. 1
to give a clue as to the necessary treatment. The Flemish school
of painters, with their passion for realism and for exactness of
detail, is particularly noteworthy for the illustration of the
methods of the mediaeval " urologists." Thus, in Gerard Dow's
famous painting which hangs in the Louvre, La femme hydro pique,
the physician examines the urine of a woman who probably has
Bright's disease.
In the treatise upon urology published by Montagnana, in
1487, the frontispiece of which is reproduced here (Fig. 1), there
THE UROLOGISTS OF THE MIDDLE AGES 123
is a colored plate showing twenty-one urinals containing urine of
the greatest variety of colors. This plate was intended as a guide
to the diagnosis of disease by the color of the urine.
Just as in these days we have always with us the host of
quacks who pretend to be omniscient and omnipotent, so in the
Middle Ages there was, in addition to the urologues, who repre-
sented the honest " scientific " medicine of that day, a numerous
class of pretended experts on the urine known as " uromants "
Fig. 2
or " uromancers 99 who, like all other charlatans, exploited the
credulous public by pretending that they could see everything
and even predict the future by examining the urine.
The pictures representing the doing of the " uromancers 99
are even more interesting and amusing than those showing the
methods of the " urologues." The fake urologists seem to have
flourished as late as the end of the eighteenth century. One of
the popular superstitions, traces of which survive to this day,
was that one could diagnose pregnancy by looking at the urine.
Thus in one picture Schalken shows a " urolomant " holding up
the urinal which had just been handed to him by a young woman.
121
THE AMERICAN JOURNAL OF UROLOGY
In the fluid one can recognize quite distinctly the shadowy shape
of a child. Bilcocq, in a painting which we reproduce herewith
(Fig. 2), shows another characteristic scene. A venerable physi-
cian with a long beard is sitting in his study with the parapher-
nalia of his calling about him, and with a young assistant — the
^Ltfyu>c,UzJe d^sCiUs
Dn.Urologue au xixc_siecle
mediaeval prototype of the modern office boy — in the back-
ground. In an adjoining room one sees through the open door
a mother and daughter, and the embarrassed attitude of the latter
shows plainly her fear of the indiscreet situation that might be
revealed by the examination of the bottle.
For centuries mediaeval " urology " continued to be a mixture
of guesswork and charlatanry, and it was not until the spirit of
exact logic and of exact biological and mechanical principles,
fathered by Bellini and Boerhaave. had entered medicine that the
old urology began to be discarded in order to give place to the
earliest data of modern urology.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII APRIL, 1911 No. 4
Contributed by the Author to The American Journal of Urology.
CONTRIBUTION TO THE STUDY OF PHENOLSUL-
PHONEPHTHALEIN AS A TEST FOR RENAL
FUNCTION BEFORE OPERATION
By E. L. Keyes, Jr., New York.
THE following cases are cited to illustrate both the difficulty
of drawing any accurate conclusion from any one test of
renal function, and also the general accuracy of the
phenolsulphonephthalein test.
In the first case this test declared that the patient would die
whether operated upon or not, though the urea output was fair,
and operation certainly hastened his death.
In the second case the test agreed wTith other tests of the
kidney function, and suggested that any grave, operative inter-
ference would probably be fatal; yet careful preparation and
operation avoided a fatal issue. Prostatectomy was performed
by the method of Young in both of these instances. Both because
it seemed probable that the wound thus produced would be less
liabe to grave infection than if the suprapubic prostatectomy was
done, and also because this test has been used chiefly in reference
to this method of prostatectomy, and it seemed interesting to
continue this comparison.
It is by no means evident that the operation in case II did
the patient any good. He still carries his suprapubic tube.
Yet his clinical history, both before and after operation amply
attests the accuracy of the phenolsulphonephthalein diagnosis.
The third case seems interesting in that it illustrates the
impossibility of prophesying with absolute accuracy the func-
125
126
AMERICAN JOURNAL OF UROLOGY
tional reaction of any organ to a given set of circumstances,
until the actual circumstances arise.
The test in this case asserted that the patient's left kidney
was competent to sustain life ; actually the failure in function
of this kidney was the cause of death, as proven by pathological
examination ; yet Dr. Symmers was unable to find in this kidney
any evidence of abnormality antedating operation. The test was
accurate enough pathologically, but not clinically.
In short, these three cases illustrate (though of course they
do not prove) the accuracy of the phenolsulphonephthalein test
and the fact that while it is by no means infallible, its fallibility
lies more in the difficulty of interpreting the findings than in
any inaccuracy in the test itself.
Case 1
G., 65 years of age. At St. Vincent's Hospital.
Denies syphilis. Frequent urination two years. Catheter
life six months. Has lost 30 pounds, and now weighs 150 pounds.
Dr. Fisher finds Argyll-Robertson pupil, static ataxia, and
increased reflexes.
The patient passes daily from thirty-five to fifty ounces
of urine containing a trace of albumen, no casts, 0.8 c/c to 0.9 f %
of urea, and pus. Prostate feels long, but not large by rectum,
and the cystoscope shows a moderate, general prostatic enlarge-
ment.
November 9, 1910.— -Dr. G. D. Stewart drains the bladder
suprapubically, using local anesthesia.
Xoi'ember 11, 1910. — 1 c.c phenolsulphonephthalein in-
jected. It appears in thirty minutes, and in two hours thereafter
only traces of the color are passed. The patient has been very
weak, and cold, and is apparently losing ground.
November 16, 1910. — Four cmc. of stovaine injected into
the lumbar spine. Anesthesia not quite complete.
Prostatectomy by Young's method in twenty minutes.
After operation saline enemata. The patient remained per-
fectly comfortable and afebrile, but the tongue became absolutely
dry, and he hiccoughed quite constantly. No difficulty with the
bowels.
* November 20, 1910. — He passed 1035 c.c. of urine, contain-
ing 0.9 % urea.
PHENOLSULPHONEPHTHALEIN TEST
127
November 22, 1910. — Delirium. Temperature dropped to
97° F. Great hyperesthesia. Hiccough and dry tongue con-
tinued.
November 23, 1910. — Patient died at 1 a. m. -No post mor-
tem.
Case 2
W., 55 years of age.
June 2, 1910. — The patient complains of frequent urina-
tion, anemia, and loss of weight. Last winter he had repeated
chills and vomiting. This was called malaria. He still has
occasional chills, urinates every two hours, and is said to have
cancer of the bladder. His weight has fallen from 176 to 162
pounds.
He is feeble, slightly jaundiced, and utterly pale. The feet
are considerably swollen. He is wet from incontinence of urine.
The prostate is moderately large by rectum. I draw off a pint
of moderately purulent urine of very low specific gravity. There-
after, he is introduced into catheter life by his own physician.
July 15, 1910. — In six weeks he has lost 19 lbs. The jaun-
dice is less. The feet no longer swell, and he feels much better.
October 7. — Under tonics, urotropin, and regular catheter-
ism, he feels much better, and has regained 6 lbs., but has had a
chill, and is still so white and weak that it seems wise to attempt
operation, for fear of the catheter.
October 28. — Cystoscopy reveals general hypertrophy of
the prostate, and a sacculated bladder. One c.c. of phenolsul-
phonephthalein injected, does not come down in forty-five min-
utes, but the specimens are lost.
November J±. — Passes in 24 hours 1450 c.c. of urine, con-
taining 0.5 % albumen by weight and 0.9 % urea. Other 24-hour
specimens show 0.8 % and 0.7 % urea.
November 6. — 1 c.c. Ph. injected appears in fifty minutes;
2 % in the first hour, 4 % in second hour.
November 7. — Suprapubic drainage under cocaine.
November 11. — Passes 3500 c.c. containing 0.3 c/c albumen,
1.1 % urea and no casts.
1 c.c. Ph. injected. Delay 50 minutes: 2.5 c/c in first hour,
and between 5 % and 6 % in second hour.
128 AMERICAN JOURNAL OF UROLOGY
November 17. — Spinal anesthesia. Prostatectomy by
Young's method. No bad post-operative reaction whatever.
November 19. — Packing withdrawn from perineal wound,
after which the patient became drowsy, temperature went to
104?° F., tongue became dry, and in twenty-four hours he passed
but three ounces through the suprapubic tube. Treatment by
saline enemas, hot pack, and stimulations. In the following
twenty-four hours he passed fifty-four ounces of urine, and all
was well.
November 26. — Fistula closed. Passes 45 to 60 ounces a
day, with about 1 % urea. 1 c.c. Ph. injected, and experimental
polyuria by drinking three glasses of water at the beginning of
the second hour. The color came in 25 minutes. During the
first hour he passed 10T c.c. containing 9 % urea and but a trace
of color. Second hour 99 c.c. 1 °/o urea, and 16.6 % color.
December 12. — Fistula almost closed, but no attempt at
urination. I passed a catheter, and he had a chill, and tempera-
ture of 104°, but no suppression. Accordingly, I reinserted the
suprapublic tube, and a week later sent him home with this.
He is now in about the same physical condition as before
operation, but wears a suprapubic tube, and has had no further
chills.
Case 3
H., 45 years of age.
December 26, 1910. — In 1889 he had colic on the right side,
and thereafter passed bloody urine, but no stone. Numerous
colics since, but he never passed stone.
In 1896, straddle injury to perineum, followed by perineal
abscess, and a year later by another abscess. No sounds passed
for a week, then gradual dilatation to 28 F. Internal urethrot-
omy was also performed.
In 1907 he was in bed 22 weeks with what was called a " right
kidney abscess." This emptied through the natural passages,
and since that time his urine has been extremely purulent, and
its odor most offensive.
In 1908, Dr. Ayres found that the right kidney pelvis was
the source of the pus, and would contain " two and a half ounces
of fluid," while the left kidney was normal. Since then no
treatment. Early in the Fall he had a number of chills, and
PHEXOLSULPHOXEPHTHALEIX TEST 129
since then has felt very badly. His weight has fallen from 170 to
159 lbs. He urinates every two hours, night and day, with diffi-
culty, and has a great deal of pain in the perineum.
Urine very foul, acid, sp. gr. 1015, 0.5 c/o albumen, 1 %
urea. Prostate by rectum a little large. Stricture in bulbous
urethra dilated with Banks bougie, and 14 and 16 F. sounds.
He empties the bladder. Liver enlarged (he has been a heavy
drinker). Kidneys impalpable and insensitive. He is kept on
helmitol since urotropin irritates.
In two weeks the stricture was dilated at 27 F., the last
passage of sounds causing a chill in spite of helmitol and bladder
wash.
January 5. — 1 c.c. Ph. injected, appeared in 13 minutes,
and in the first hour he passed 38.4 %, in the second hour 16.6 9c.
January 7. — Cystoscopy revealed cystitis of the base, dilata-
tion of right ureter orifice, and much pus from the right side.
A 6 F. catheter introduced 20 cm. into the right ureter
drew 27 c.c. of urine in 20 minutes. This contained 0.4 % urea,
and during the same period 10 c.c. containing 1.3 % urea, were
collected from the bladder. The ureter catheter then became
plugged, and thirty minutes later, 10 c.c. containing 1.5 %
urea were obtained from the bladder. All the specimens were
purulent (on account of extra-catheter flow), but only that ob-
tained from the right kidney was stinking.
January 13. — Xegative X-ray by Dr. Caldwell. In 24
hours the patient passed 1650 c.c. of urine containing 1 % urea,
0.5 % by volume of albumen, no casts, and many acid fast bacilli.
January 1J±. — Right nephrectomy in 50 minutes. Kidney
was a pyonephrotic sac, densely adherent about the hilum.
Clamp left on vessels. Kidney ruptured in removal.
Patient left the table in good condition, and saline enemas,
q. 2. h., were ordered. Later these were made q. 4. h. He had
a good night, except for occasional vomiting and great thirst. He
passed in the first 24 hours about 10 ounces of urine, and his pulse
and temperature did not rise above 100. Enemas were then dis-
continued, and he was given three ounces of water, q. h., by mouth.
He vomited three or four times during the day, and passed only six
ounces of urine in 12 hours. Pulse rose to 120, and tempera-
ture remained at 100°. The stomach was then washed, nitro-
130
AMERICAN JOURNAL OF UROLOGY
glycerine, gr. 1-50, given q. 3. h., and saline enemas resumed.
A specimen of urine at this time contained 3.3 % urea and only
a faint trace of albumin. At the end of the second day he had
only passed 20 ounces of urine since operation, and his pulse
suddenly went to 160. The vomiting continued in spite of re-
peated stomach washing, and although the bowels had moved
freely, and there was no abdominal distension. The respiration
was very labored, and the patient failed rapidly, and died three
hours later. He did not hiccough. An hour before his death
his tongue was perfectly moist, and he remained entirely rational
to the end.
The remaining kidney was removed post-mortem and exam-
ined by Dr. Symmers, who reported, as follows :
44 Specimen consists of a kidney 10 cm. in length. Capsule
is thin and surface is smooth, except for a few retained fetal
lobulations. The organ is diffusely bluish-red in color, and on
section cuts readily. Cut surface is smooth, deep bluish-red in
color and drips blood on pressure. The consistence is that of a
normal kidney. The cortex and medulla are well proportioned
and well differentiated. The cortex does not bulge markedly be-
yond the cut edge of the capsule. The cortical markings are
distinct, especially the vascular apparatus, in which the Mal-
pighian bodies are unusually prominent, standing out as minute
bright red points. Microscopically, the vascular apparatus
throughout is deeply engorged. The inter-tubular capillaries
are widened and tortuous, and the red cells in them are closely
pocked and show marked effect of reciprocal pressure, or are even
fused. The epithelium in the convoluted tubules is in a state of
advanced granular degeneration.
''Note: The histological changes in this kidney correspond
entirely with those occasionally encountered in athletes who.
after severe exertion, have suddenly subjected the overheated
body to the effects of cold, in which event contraction of the
peripheral vessels is followed apparently by loss of vasomotor
control in the kidneys. The vessels dilate and become tortuous
and the red cells in them fuse. At the same time, stagnation of
blood results in nutritional changes in the lining epithelium of
the tubules and granular degeneration occurs. Very similar
changes are met with in the kidney in subjects dead of tetanus,
INFECTIONS OF THE URINARY TRACT 131
of hydrophobia, or of certain irritant poisons. The condition is
relatively rare, but by no means unknown, as a sequence of simple
ether anaesthesia and sometimes follows nephrectomy of the op-
posite kidney. In the latter circumstance, the combination of
anaesthesia and suddenly increased functional demands upon the
remaining kidney consequent upon the removal of its fellow, is
possibly the best available explanation. Death usually succeeds
upon complete anuria and may occur within a few hours or be
delayed for days ; thus in one patient death occurred on the
twenty-first day after an operation for epithelioma of the penis."
No evidence of tuberculosis could be found in the pyonephrotic
kidney.
Contributed by the Author to The Americas Journal of Urology.
VALUE OF VACCINES IN THE TREATMENT OF
INFECTIONS OF THE URINARY TRACT1
By Hugh Cabot, M.D., Boston,, Mass.
THIS report is based upon the study of cases seen at the
Massachusetts General Hospital and in private practice.
One case, No. 22, was a patient of Dr. A. T. Cabot. The
bacteriology and preparation of vaccines has been done largely
by Dr. H. F. Hartwell and E. C. Streter, to whom my best
thanks are due.
In looking over the material it seemed best to exclude the cases
of tuberculosis treated with tuberculin and infections due to the
gonococcus, as the number of cases of the former class is as yet
too small to warrant conclusions and our results in the treatment
of gonococcus infections were reported last year in a paper by
Hartwell.
This report will, therefore, be confined to infections due to the
colon bacillus and the pyogenic cocci. The cases dealt with in this
report have been rather carefully selected, with the view to utiliz-
ing only such as have been thoroughly studied for a considerable
period of time. Practically all the cases have been examined by
means of preliminary cultures from the urine, guinea pig inocula-
#
1 Read before the American Association of Genito-Urinary Surgeons, at
the Eighth Congress of American Physicians and Surgeons, 1910.
182 AMERICAN JOURNAL OF UROLOGY
tions to exclude tuberculosis, examination with the eystoscope
and ureter catheter where indicated, X-ray and finally cultures
from the urine at a considerable period after cessation of treat-
ment. They may therefore be regarded as showing the end re-
sults.
In estimating the therapeutic value of vaccines, or bacterins
as they are now commonly called, surprisingly different results may
be obtained, according to the point of view of the investigator.
Thus the general practitioner who is particularly interested in the
relief of symptoms will be impressed by the success or failure in
the relief of symptoms, while at the other end of the line the
clinical bacteriologist will be interested in the ability of this form
of treatment to rid the urine of bacteria. The very varied con-
clusions .of different observers have been largely due to this dif-
ferent bias. In fact, several cases in this series have already
been reported as cured, by other men, though their urine still
contains bacteria. Without attempting to reconcile this differ-
ence in viewpoint, it should be borne in mind that the persistence
of bacteriuria undoubtedly renders the patient liable to a re-
currence of the symptoms.
RESULTS.
Site of Infection in the Urinary Tract. It is not easy
to determine at what point the disease is primary, but it is
generally possible to locate it either in the upper (kidney and
ureter) or lower (bladder, prostate and urethra) urinary tract.
The upper urinary tract was definitely involved and was believed
to be the primary focus in fifteen cases. Of the remaining
fifteen, seven had obstructive lesions of the lower urinary tract,
prostatic or urethral, while the remainder are cases of chronic
cystitis in which the origin of the infection is not clear.
Of the three cases showing sterile cultures all were infections
of the upper urinary tract, one of which may have been associated
with stone.
Bacteria. In the thirty cases here considered, the colon
bacillus was the infecting organism in twenty-two. The colon
bacillus mixed with the streptococcus or a staphylococcus was
found in three. The streptococcus in two. The staphylococcus
INFECTIONS OF THE URINARY TRACT 133
albus and streptococcus in two. The staphylococcus albus in one.
The great predominance of the colon bacillus in these infections
is about the same as that reported by other observers.
Operative Cases. fIn thirteen cases vaccines were given after
operation in order to help eliminate the remains of the infection.
In eight the symptoms were relieved, in five not relieved. The
bacteriuria was cured in one.
Sex. Of the thirty cases, thirteen were males, seventeen fe-
males, so that the basis of comparison is fairly equal. Of the
thirteen males, eight were relieved of symptoms. Of the seven-
teen females, eleven were relieved.
Duration of Vaccine Treatment. The duration of the treat-
ment by vaccines varied from two months to two years, the
average being ten months minus. All of the cases were under
observation for a considerable time, both before and after treat-
ment by this method, so that a sound estimate of the effect on
the symptoms can be given.
Effect on Symptoms. In nineteen cases there was a definite
relief of symptoms, varying from marked improvement to com-
plete symptomatic cure. In the remaining eleven cases there was
no definite or permanent relief, though many of them showed
transient improvement which may or may not have been due to
the treatment.
Effect on Bacteria. In all cases the culture has been ob-
tained from two months to two years after the cessation of the
treatment. Three are and have remained free from bacteria, the
remaining twenty-seven all showed bacteria and were therefore
not benefited as to the presence of bacteria.
Conclusions. The study of these cases seems to warrant the
following conclusions :
1. The use of vaccines is followed by improvement of the
symptoms in more than half the cases.
2. Vaccines have little effect on the bacteriuria.
3. The results are practically the same whether the lesion is
in the upper or the lower urinary tract.
THE TIME AND METHOD FOR PROSTA-
TECTOMY1
By Benjamin Tenney, M.D.,
Surgeon to the Boston Dispensary and the Berkeley Infirmary; Instructor
in Surgery, Tufts Medical School.
WITH all that has been written and demonstrated of the
operation of prostatectomy and its results there is yet
too large a part of the profession and the public who
look back to the early days of surgery for their decision. Ab-
dominal surgery has not offered safe treatment for much more
than twenty years, and prostatectomy is a later operation to
"be put on the safe list. In 1906 Dr. Chase and I published
a paper on the mortality from prostatectomy,2 its fatal periods
and its causes. Among other records we looked up the mor-
tality in public hospitals from 1895 to 1905 and found it re-
markably high. In one splendid institution one case in three
had died, and in another one case in five. During that period
thousands of house officers, students, dressers, nurses, ward men
and members of the medical staff had seen a few of these cases
and decided that the risk was too great to justify the operation
on their patients and friends, and that impression still clings
to them and influences their advice. It is with the hope of al-
tering this impression among some of my medical friends that
this paper is written.
There are few classes of men over forty who consult a physi-
cian for symptoms which may be due to prostatic obstruction.
First, those with residual urine, without cystitis, whose com-
plaint is of frequent urination, night urination, difficult urina-
tion or albuminuria. Second, those with residual urine and in-
fected bladders. Third, those more or less dependent on
a catheter.
With all these patients the same fact applies. It is not
the hypertrophy of the prostate that makes the patient suffer;
it is the obstruction. I have removed a nodule the size of the
end of my thumb from a man who had passed no urine without a
1 Read before the Maiden Medical Society, Jan. 14, 1911. Boston Med.
and Hwrg. Jour.
2 Jour. Am. Med. Asso., May 12, 1906.
134
TIME AND METHOD FOR PROSTATECTOMY 135
catheter for more than a year, and a huge prostate weighing
256 gm. from a man who had used a catheter but three times
and had but 2 oz. of residual urine. Both men were uncom-
fortable, and the man with the larger prostate was the more so,
but the first had complete obstruction, while the man with the
big prostate could still urinate and had but two or three night
urines.
The number of men over forty who complain of frequent
urination, night urination, difficult urination or albuminuria is
very large and includes some who have no prostatic obstruction,
but the important thing is that it does include all those who do
have prostatic obstruction in the early stage. There must be
many such now under treatment or neglect with a diagnosis of
cystitis, pyelitis, pyelonephritis and even Bright's disease who
are suffering from prostatic obstruction. A simple catheter
is usually enough to settle the diagnosis. If the catheter will
not go in with ease there may be some other form of obstruction
which will keep the urine from flowing out, but if the catheter
passes easily and residual urine is found, the diagnosis of pros-
tatic obstruction is made.
Should we operate on these early cases? If we can relieve
the obstruction by massage, sounds, dilators, the answer is, No.
So long as a man can empty his bladder there is no good reason
for removing an organ which may trouble him later but does
not now. If the measures suggested are not successful, there is
still opportunity for a difference of opinion. To me the fact
that there is residual urine proves that the bladder is working
harder than it was intended'to, and the compensatory thickening
of the bladder wall is a warning of a contracted bladder to
come later. Operating through a thick bladder wall is less easy
than through the normal, but that is a small matter beside the
fact that a contracted bladder is exceedingly slow to resume
normal capacity after a removal of the obstruction. The dis-
appointing operative results are found among the patients whose
bladders will hold but two or three ounces before they have been
operated. They continue to have night urination and daily
frequency for a long time after they leave our hands.
The comparative risk of operating on men with clean blad-
ders and septic trabeculated bladders is to be considered as
136 AMERICAN JOURNAL OF UROLOGY
well as the chance of ascending and general infections. Per-
sonally I do not think the increasing age of the patient is of
great consequence except as these progressive results of obstruc-
tion appear.
My youngest patient was forty-six, and I was able to
sew up the bladder and send him home at the end of ten days
with a tight bladder. I have not felt justified in trying it with
my others, all of whom have been above sixty with one exception,
but the contrast between the rapid convalescence of this patient
and that of the patients with infected bladders was almost as
great as that between patients with interval and drainage opera-
tions for appendix inflammations. I believe the time has come
to advocate early operation, that is, operation as soon as pros-
tatic obstruction can be demonstrated by the presence of con-
stant residual urine, because there is present an anatomical
condition which will by no possibility disappear and which will
probably increase ; because this condition will produce patho-
logical changes in bladder, ureters and kidneys ; because as a
result of these changes general health will suffer, discomfort will
increase and the period of usefulness be shortened ; and because
at this time the operation is less of a shock, practically without
danger if properly done, and the convalescence is comfortable
and short.
Recent statistics as to the frequency of malignant disease
in hypertrophied prostates furnish another argument for early
and complete removal.3
The second class of patients includes the majority of all
who call for help. They have not begun to use a catheter and
they are often ignorant of the condition which sends them to a
physician. They are slowly going down hill, losing sleep, los-
ing strength, growing old faster than their years warrant. Their
urines are alkaline, contain a little albumen, often a few casts
and white and red blood corpuscles. They rise two or more
times at night to urinate and pass urine every two or three hours
by day. Many of them think they have a "little kidney
trouble " and have gone the rounds of physicians and proprie-
tary remedies. It is unfortunately true that they can find a
sCohn: Dent. med. Wochenschr., Berlin, April 1, 1909. Young: Ann.
Surg., January, 1910.
TIME AND METHOD FOR PROSTATECTOMY 137
large number of physicians who will accept this ready-made
diagnosis when confirmed by the albumen findings in the urine
and who will try to work the miracle of curing them of a me-
chanical difficulty by pill and potion. For these patients we
have but two alternatives ; we can put them into the third class
and let them use a catheter more or less frequently, or we can
operate. There is no other alternative if they are to live with
any comfort. The first alternative is often chosen from fear
of death from the operation and sometimes from the knowledge
of some one who has been operated and has incontinence or the
need of using a catheter after the operation. For four years I
have had the opportunity of watching the progress of such a
case living under the most favorable conditions. He had a
stone crushed and evacuated in 1901. Symptoms of obstruc-
tion appeared in 1904. In 1906 he had three ounces of residual
urine, alkaline and cloudy. He rose every hour to urinate by
night and was called to the same function every hour or hour
and a half by day. After a few weeks of treatment his residual
dropped to one ounce and his nights were disturbed but two or
three times. Gradually the residual increased to four and five
ounces and his night urines to three and four in spite of the
best non-operative treatment that I could give him. He has.
been comfortable all the time except on one occasion when his
plans were interrupted by another physician who was alarmed
at the amount of pus in the urine and sent him home from a
vacation trip. The case has taught me much that can be done
for the patients who utterly refuse to consider any operative
procedure. I did not suppose they could be kept as comfort-
able for so long a time. On the other hand, this man is now
seventy-nine and the chance he once had of a comfortable con-
valescence and a prompt recovery is growing more remote, and
he requires the constant attendance of a nurse.
For a man who can have every comfort and care, the prob-
lem is different from the one whose care is fitful and not of the
best. Such a patient is likely to suffer much and die within a
year or two unless he can be taught to use a catheter cleanly
and regularly or have unusual powers of resistance. One of
my patients who had frequent attacks of cystitis in spite of
much washing of hands and boiling of catheters used to mourn
138 AMERIC AN JOURNAL OF UROLOGY
his hard luck when he had a neighbor who carried his catheter
in his hat band and lubricated it with saliva with no unpleasant
results.
Even the man who is most comfortably situated is better
off with a bladder that empties itself than he can be with the
most minute care possible.
One of my patients had depended on a catheter for six
years, during which time he had been operated for hemorrhoids
and had perineal section for stone. After the enucleation he
was two months in recovering perfect control of his sphincter,
which had not been exercised during his catheter life. The
change in his general condition and his delight in nights of un-
disturbed sleep were as striking as his regret that the prostatec-
tomy was not done earlier.
I believe in operating on prostates with cystitis because the
operation will cure the cystitis and guarantee against a return ;
because, with relief from the discomfort and opportunity to get
their sleep, they will gain in general health and usefulness ; and
because it allows proper drainage of the ureter into a clean
bladder instead of keeping its orifice submerged in a pool of
purulent urine.
I do not see room for a difference of opinion about the de-
sirability of operating on these cases. The danger and discom-
fort of the operation is less than the danger and discomfort of
going without, and the successful removal of a benign hyper-
trophy promises absolute and permanent comfort so far as the
bladder is concerned.
The third group will include all who use a catheter one or
more times daily. If they are entirely comfortable using a
catheter four or six times in twenty-four hours they may safely
be allowed to continue if they prefer it, but they should have the
option of the operation and freedom from such annoyance.
Such cases are ideal for operation because of their proved re-
sistance to infection, their toleration of urethral instruments,
their normal bladder capacity and the probability of a definite,
easily removed obstruction. Just as soon as the frequency of
catheterization begins to increase there is proof of beginning
infection, and unless a short course of antiseptic washing re-
TIME AND METHOD FOR PROSTATECTOMY 139
stores the normal intervals, operation should be prompt. They
go from bad to worse more rapidly than any of the others
here described, and the risk of the operation increases just as
fast until a point is reached where the prostatectomy must be
preceded by a long drainage period to be safe.
I believe in operating on both classes of catheter patients
— ■ those who are comfortable because of the slight risk and the
guarantee against future trouble offered by the successful opera-
tion, and those with painful cystitis because there is nothing
else to do to save life and comfort for their remaining days.
THE METHOD
Castration and the cautery knife are now historical. The
literature of to-day refers only to the perineal and suprapubic
operations.
Of the former there are two variations, the urethral and the
transcapsular, and in operating by the suprapubic route some
prefer removal in one or at most two portions, while others
enucleate as happens to be most easy.
Anatomically almost all hypertrophies of the prostate are
in part at least intravesical. This may be denied by some
whose knowledge is limited to cystoscopic views and perineal
operating, but I am positive of its truth from the cases I have
operated, from autopsy specimens, from the lengthening of the
urethra in most cases and from the fact that the mucous mem-
brane and internal sphincter of the bladder offer less resist-
ance to upgrowth than is found in any other direction. There
is probably no hypertrophied prostate which cannot be removed
through a perineal incision, but no large one can be dragged
out through the urethra without injury to ejaculatory ducts
or sphincter unless in small pieces, and the same must be in less
degree true of the transcapsular operation.
If twenty per cent, of hypertrophied prostates are in some
degree cancerous, the objection to morcellation is evident. If
the wound be left entirely open, or a large tube be left from the
bladder to the dressing, an ideal drainage is provided, but the
importance of this may be overestimated. In gross, recovery
from operations through the perineum has been a little better
140 AMERICAN JOURNAL OF UROLOGY
than from the suprapubic operation, but as Dr. Chase and I
have before pointed out, there is a much greater difference in
mortality reported among men doing the same operation than
there is between the gross statistics of the two operations, and
these gross statistics are coming nearer together each year.
It is generally admitted that the late results of the suprapubic
operation are more satisfactory.
The reported higher mortality of the suprapubic operation
is really the only one argument against its adoption as the
general rule, and the perineal operation for occasional use. The
preference of men already experienced, in other perineal operat-
ing, for perineal prostatectomy may partly account for a differ-
ence in results. Another explanation has occurred to me. The
tables previously referred to show an admitted mortality due
to " shock and hemorrhage " nearly three times as large in the
suprapubic as in the perineal results. Most of these cases
really mean hemorrhage, and the source of the hemorrhage be-
comes important. It is mostly venous and the veins are most
numerous where the hypertrophied prostate is in contact with
the internal sphincter.
In urethral perineal prostatectomy the separation is down-
ward, the finger is hooked over the top and the masses are
dragged out. The same result is accomplished by the retractor
and traction forceps in the transcapsular operation. In doing
a suprapubic enucleation the natural movement is to use the
same hooked finger before the prostate has been fully separated
from its upper attachments all around. Doing this, one is likely
to peel up a strip of the bladder wall itself and open into the
rich plexus of veins. I have seen strips of mucous membrane
and even portions of a seminal vesicle in the material removed
by premature "hooking."
A suprapubic enucleation should be done with a straight
finger until the hypertrophied gland is entirely separated from
all its lateral attachments. I cannot help thinking that the
enucleation downwards which is a feature of the perineal work
has been one of the reasons for its better operative record, espe-
cially in the matter of " shock and hemorrhage."
I have had one death two days after operation on a cardiac
TIME AND METHOD FOR PROSTATECTOMY 141
case whose removed and remaining tissue showed extensive carci-
noma, and no other mortality in the seven years Dr. Chase and
I have been doing suprapubic prostatectomies. We have had
no case of incontinence, injury to rectum or peritoneum. We
have had one case showing infection of the prevesical space, five
cases of epididymitis, and one patient who has developed cancer
and resumed the use of his catheter four years after operation.
One case took forty-three days to close his suprapubic
bladder wound, another twenty-seven days, and one was sewed
up tight at time of operation. The rest have been tight in
from fourteen to twenty-one days. The flexible metal catheter
as perfected by Dr. Chase is an improvement over the gum
elastic tube previously used, because it will not kink, rarely
stops up, empties into a urinal without any extra piping, and
gives all the " drainage " necessary.
We use no suprapubic tube and many of our patients keep
their dressings practically dry after the first twenty-four hours.
The statistical difference in fatal results between the high
and low methods of approach is steadily growing less. Either
method well carried out if preceded and followed by minute and
unsparing care will have a low mortality. Carelessness in tech-
nic or average after-care will send the mortality up with either
operation. A prostatectomy is not a completed piece of work
when the surgeon has washed his hands. The results of a per-
fect operation may be lost or a less perfect operation turned
into a success by careful preparation of the patient for the
ordeal and equally careful watch for and prompt action on dan-
ger signals after the operation.
I believe in the suprapubic prostatectomy because we are
dealing with a tumor which is partially intravesical at least ;
because even the largest prostates can be removed entire or in
two pieces without injury to rectum, sphincter or ejaculatory
ducts ; because recent studies of hypertrophied prostates show
cancer formation to be comparatively frequent and morcellation,
therefore, undesirable; because the slight excess of mortality
does not seem necessary if enucleation be downward and the
after-care correct; and because it has given results satisfactory
to my patients and to me.
SOME UNTOWARD CONSEQUENCES OF PHIMOSIS
AND OF CIRCUMCISION
By George H. Edixgtox, M.D., F.R.F.P.S.G.,
Professor of Surgery, Anderson's College Medical School; Assistant Sur-
geon, Western Infirmary, Glasgow, &c, &c.
IN the practice of medicine and surgery one cannot but be
struck with the way in which it becomes the fashion from
time to time to attribute various morbid conditions or symp-
toms to disease of a particular organ. One of the most recent
examples of this is the so-called " Appendix-dyspepsia," concern-
ing which there has lately been so much discussion. Another
example, by no means recent however, is the fact of phimosis
having been looked upon as the cause of a variety of more or
less remote ailments, such as spastic palsies, simulated hip-joint
disease, muscular inco-ordination, convulsions.1 The perform-
ance of circumcision was not, however, universally followed by
relief from the symptoms supposed to depend on the abnormal
tightness of the prepuce, and opinion as to the etiological re-
lationship of phimosis to the ailments in question underwent a
change, or at least a modification. Surgeons continued to per-
form the operation ; but they were more chary of giving a
glowing prognosis. In his recent work on the Surgery of Chil-
dren, Kirmisson,2 referring to Sayre's view that phimosis may
cause reflex contractures and even parahrsis, states that he
has not seen any case which has convinced him of the truth of
this statement. I may add that my experience is in agreement
with that of the French surgeon.
No one can deny that there are some conditions which un-
doubtedly result from phimosis, and that in these cases circum-
cision will effect a cure on the principle " causa sublata, tollitur
effectus." I do not intend to deal with all of these condi-
tions. I wish merely to mention two cases in which phimosis
caused obstruction to micturition, and in which surgical inter-
ference became a matter of utmost necessity. In recording these
1 White and Martin's Genito-Urinary Surgery and Venereal Diseases.
Fifth edition. London. 1902. Pp. 8.
2 Handbook of the Surgery of Children. Translated by J. Keogh Mur-
phy. London. 1902. Pp. 141.
142
UNTOWARD CONSEQUENCES OF PHIMOSIS 143
cases I would expressly state that such examples, are by no means
common.
Retention of Urine. — In March of this year (1910) I was
asked by his medical attendant to see a gentleman aged eighty-
four. The patient was the subject of congenital phimosis, and
occasionally suffered from retention of urine during attacks of
balanitis. On these occasions his doctor was in the habit of
relieving him by the passage of a No. 4 rubber catheter. The
present attack of retention commenced in the morning, and when
the medical man saw him in the evening it was found that the
catheter could not be introduced into the meatus.
There was no redundancy of the prepuce, but phimosis
existed to an extreme degree, and the bladder was greatly dis-
tended. The preputial orifice was so tight that I could not get
the point of a scissors-blade through it. After subcutaneous
injection of novocaine and suprarenin, access to the glans was
obtained by cutting down in the medial line of the dorsal surface
of the prepuce. When the mucous layer had been penetrated
some urine retained in the preputial sac escaped. The incision
was then extended forwards and the orifice of the prepuce laid
open. At first no appearance of a meatus could be seen, but
very soon urine was ejected with considerable violence from a
minute orifice, the stream continued till the patient had emptied
his bladder, and his groans were exchanged for expressions of
relief.
It was difficult to recognise the preputial orifice on account
of its small size. Its edge was hard and gristly, but did not
seem to be near the seat of any acute inflammatory change.
There was dense adhesion between the mucous layer of the pre-
puce generally and the glans, extending forwards on the dorsum
and on the right to quite close to the meatus : the corona could
be exposed only in the ventral portion of the left half of the
glans, and the prepuce could not be stripped back. The mucous
layer was stitched to the skin at the margins of the incision.
Recovery was uneventful.
Phimosis may cause considerable difficulty in urination, and
the difficulty may be greatly increased by the swelling accom-
panying balanoposthitis ; but it seems to me that actual re-
tention of urine occurring in the absence of marked inflamma-
144 AMERICAN JOURNAL OF UROLOGY
tory swelling of the parts is distinctly uncommon. At any rate,
I had not before seen an instance of it. The condition of affairs
is comparable to what one is familiar with in the case of urethral
stricture.
Perineal Peri-urethral Abscess. — In March, 19.05, a lad aged
twelve, the subject of very tight phimosis, was admitted to the
Western Infirmary under the care of Sir Hector Cameron, to
whom I am indebted for permission to record the case. There
was a history of pyuria and elevated temperature of four days'
duration. There were signs of extravasation in the perineum,
extending forwards into the posterior part of the scrotum. Cir-
cumcision was performed, and the perineum was incised in the
median line, giving vent to pus, but without opening the urethra.
The meatus when exposed by circumcision was seen to be atresic.
After his return to bed he micturated before he had recovered
consciousness, and at the close of the act pus was observed to
come away in the urine. He made a good recovery, and when I
saw him about a year ago he had no trouble with his urinary
organs.
These two cases are interesting as extreme results of ob-
struction. In the second the obstruction was not complete ; but
it had been sufficient to act on the wall of the urethra in a way
similar to what occurs in the case of tight stricture of the
urethra. In both cases there was some atresia of the meatus ;
but in neither was this sufficient to produce complete obstruc-
tion, and in the first it was quite evident that the retention was
due entirely to the condition of the preputial orifice.
Circumcision. — The frequency with which circumcision is
performed on the children of non-Jewish parents has almost
ceased to be a matter for comment. Infants are being constantly
brought to the out-patient department of the Royal Hospital
for Sick Children in Glasgow for circumcision, although there
may be no phimosis, and the extent to which the custom has
spread may be appreciated from the remark made by a young
mother when I told her that her child did not require the opera-
tion : " I thought," said she, " all boys were circumcised." It
is well, in view of this frequency, to bear in mind a post-operative
condition which I do not think has received sufficient attention.
I refer to acquired stenosis of the urethral meatus.
UNTOWARD CONSEQUENCES OF PHIMOSIS 145
Post-operative Me at at Stenosis. — Such stenosis is the result
of superficial ulceration of the lips of the meatus, the ulceration
being caused by irritation of the exposed meatus by the child's
clothing. The fact that it is hardly ever observed in the chil-
dren of well-to-do parents shows that with care it may be pre-
vented; but in the majority of hospital cases cleanliness is not
an outstanding virtue, and it is in these cases usually that this
troublesome result is found.
The usual sequence of events is that the patient is brought
back to the hospital, in the course of two or three weeks after
circumcision, with the story that he seems to have pain and diffi-
culty in passing urine. Examination of the glans shows moist
scabbing occluding the meatus, the lips of which are more or less
ulcerated. Ultimately healing is followed by contraction of the
meatus.
In circumcision cases treatment may be directed to prevent
this ulceration. Such treatment consists in frequent bathing
and in covering the part with vaseline or some unirritating oint-
ment. If ulceration has occurred, the same treatment may be
adopted, and when the ulcerative condition has been cured the
meatus may be slit downwards into the fraenum, and the cut
edges of the urethral mucous membrane united by suture to the
skin of the fraenum. It may be objected by some that the con-
dition is really a congenital stenosis which, as is well known, not
infrequently accompanies phimosis ; but if the precaution be
taken of inspecting the meatus at the time when circumcision is
done, it will be found that narrowing of a previously normal
meatus may occur in the way I have mentioned.
Constriction of Post-Coronal Sulcus by Hair. — I have quite
recently observed a case in which, from want of attention, this
unusual condition was present. I record it as a curiosity.
Baby C, aged six months, was brought to the out-patient de-
partment of the Royal Hospital for Sick Children in November,
1910, on account of great swelling of the glans of one day's dura-
tion. He had been circumcised at the age of three weeks, and
no trouble had ensued till the present. The glans was enlarged
to about the size seen in the adult. It was quite pale and
showed no signs of venous congestion. A deep furrow was pres-
ent behind the corona, and on retracting the skin of the penis
U6 AMERICAN JOURNAL OF UROLOGY
there was observed in the furrow what looked like dark hairs
wound round the organ. Examinations under an anaesthetic
confirmed this, and showed further that the hair, two or three
ply, had actually produced a ring of ulceration, which on the
ventral aspect had extended right through the fraenum. The
constricting hairs were divided with scissors and removed, and
the mother was directed to bathe the parts frequently and to
annoint with vaseline.
That this condition may arise independently of circumcision
was demonstrated a week later, when a boy aged 7 was brought
to the hospital on acount of soreness of the penis of one week's
duration. This boy was uncircumcised, but he had retracted
the prepuce, which was shorter than usual, and in the exposed
post-coronal sulcus was a constricting wisp of hair and wool.
The constricting material had produced a ring of ulceration
which extended round behind the corona and involved the frae-
num. The treatment adopted was the same as in the former
case. In neither of the cases was there any suggestion of in-
tentional ligation of the penis. The nature and bulk of the con-
stricting material pointed rather to its having come either from
the patient's clothing or from towels in common use. I men-
tion these conditions of meatal stenosis and post-coronal con-
striction as examples of dangers to which the exposed glans is
liable. Their prevention depends on proper care and cleanli-
ness being seen to by the child's mother or nurse.
PERINEAL PROSTATECTOMY1
By Alex. Hugh Ferchsox. M.D.. Chicago.
DIFFERENT surgeons employ different incisions of the
skin and subcutaneous structures to gain access to the
enlarged prostate. The median incision is the one of
choice in the vast majority of cases, because through it rapid
and efficient work can be executed with excellent results, espe-
cially by a man whose hand is not too large and who is dextrous.
Some excellent surgeons have such large fingers that they are
practically excluded from attempting perineal prostatectomy.
While a short slender finger is at a disadvantage as compared
with a long slender digit, still, with the aid of instruments which
i Read at a meeting of the Chicago Medical Society, March 16, 1910.
PERINEAL PROSTATECTOMY
drag the gland down into the perineum, the former can do satis-
factory work. As one surgeon has aptly said, " A short finger
becomes longer by experience," but I might add that a stout
finger acts as a cork.
Incisions: Median, transverse, Y-shaped, T-inverted, semi-
lunar and modification of these.
From a sufficient number of cases to enable me to have an
opinion, I am compelled to say that the median perineal incision
is my preference. In a very limited number of cases the entire
prostate can be removed without injury to the prostatic or mem-
branous urethra (Mace-wen and Ferguson). This can never be
done suprapubically. Nearly all the operations by the perineal
route open the membranous and prostatic urethra ; the one for
the purpose of introducing instruments which aid in the opera-
tion; the other to afford ample room for the enucleation of the
gland. In the intracapsular method the capsule must be opened
to find cleavage for the finger to separate the gland from its
capsule.
While this is true, we must admit that some cases are more
suitably dealt with by the suprapubic route. In my opinion,
they are vastly in the minority. From my experience I would
advise that almost all cases should be first explored through the
perineum. If certain portions of an hypertrophied prostate
cannot be removed through the perineum, it does not compromise
either the surgeon or the patient to open suprapubically and
complete the operation. It seems to me that this is much safer
than suprapubic prostatectomy alone, or the combination opera-
tion reversed. More knowledge can be gained of the size, shape
and extent of prostatic protrusions into the bladder by the
finger in the perineal wound than by cystoscopy before opera-
tion.
Operation. — The bladder is washed out with an antiseptic
solution. Six or eight ounces of the fluid is then left in the
viscus. A plug of gauze is next inserted into the rectum. A
grooved staff is passed per urethram into the bladder. Then
the patient is placed in the extreme lithotomy position and held
by assistants.
Now pass the middle finger of the left hand into the rectum.
Split the perineum in the median line from behind forward.
Open the membranous urethra and prostatic urethra as far back
148
AMERICAN JOURNAL OF UROLOGY
as the sinus pocularis, and pass the index finger of the left hand
into the wound as the staff is withdrawn. In exposing a mem-
branous urethra to median incision it is probably better to
teach that the skin be cut first and careful dissection made
through the other soft structure down to the urethra in order
to insure against injury to the bulb. Remove the finger from
the rectum and pass the prostate depressor into the bladder as
the finger is withdrawn.
Remove the glove from the left hand and reinsert the finger
into the wound and search for a line of cleavage within the cap-
sule of one or both lobes of the gland. LTsually the cleavage
can be found near the apex of the prostate and to the left, be-
cause the knife generally cuts a little to this side as it opens the
prostatic urethra. If cleavage is found, a small transverse in-
cision is made alongside of the finger through the capsule. By
means of the prostatic depressor the gland is pulled down as it
becomes enucleated by the finger, sometimes in less time than it
takes to describe the process. It will be found that the separa-
tion of the gland is interfered with where it is covered with
vesical and prostatic urethral mucosa. Pulling and tearing
should be avoided here ; large portions of prostatic tissue may
be grossly cut away by means of my prostatic cutting forceps.
Both lobes being removed, the interior of the bladder may be
readily explored by the finger. If there are protrusions of pros-
tatic tissue in the shape of a pathologic middle lobe, or pro-
longations from either or both lateral lobes, the first thing to
determine is whether the growth is sessile or pedunculated. If
the former, it is an easy matter to enucleate it with the finger
or remove it by morcellement. If the growth is pedunculated
and cannot be delivered through the perineal wound, then the
operation should be completed suprapubicallv.
Where enucleation is easy and the bladder is not septic,
deep sutures (No. 0 chromic catgut) are employed to close the
urethra and bring together the edges of the levator ani muscles.
A small cigarette drain is employed to take care of the discharge
from the perineum alone, and the skin is closed by horse-hair.
In septic cases and in very old men with marked prostatic
deformity, the gland must be removed as rapidly as possible.
The safety of the rectum from injury and the rapidity of the
operation may be increased by the use of a double-edged gouget
PERINEAL PROSTATECTOMY
149
with a beaded point which strikes the groove in the staff and the
knife is passed through the prostatic urethra in a firm, gentle
curve. The gouget splits the prostatic urethra laterally, its
flat posterior side is toward the rectum and protects it from
injury. This is not the operation of choice.
Total enucleation of the prostate gland by Freyer has
taught us one thing, viz. : that the preservation of the prostatic
urethra is not of so great importance as the advocates of peri-
neal prostatectomy believed. With this in mind we can attack
the enlarged prostate without regard to the prostatic urethra
and rip it from its bed where all the structures are in reach of
the finger. One type of gland, the chronically inflamed pros-
tate, usually atrophied, can only be removed piecemeal. A
chronically inflamed prostate cannot be removed suprapubically
at all. This is also true of prostatic abscess and calculi, and
recent experience of Young demonstrates that a malignant pros-
tate can be best removed through the perineum.
In my opinion, it seems unsurgical to attack a contracted
bladder from above, except possibly in two steps. Bilateral in-
cisions of the capsule as devised by Proust and exploited by
Young, in order to save the ejaculatory ducts, is not considered
by decent old men. While the many tractors and depressors
are often clumsy and inefficient, though not all immaterial, I pre-
fer my own.
Practically all the sequelae formerly obtained in perineal
prostatectomy in a small percentage of cases are now prevented
by the experienced operator. The worst result that can be ob-
tained in prostatectomy is death. " While old age waits to
hear the keel upon the other shore " and the old man welcomes
death to misery, still life is dear and endurable even though it
be almost intolerable.
It is interesting to note that for years the mortality of
suprapubic prostatectomy (McGill) when combined with lith-
otomy has been less than when no calculus was present.2 Burck-
hardt gives 13.8 per cent, mortality (4 deaths in 29 cases) for
the former operation, and £0.8 per cent. (16 deaths in 77 cases)
for the latter. This difference can only be explained on the
assumption that the presence of the stone necessitated operative
interference earlier, and while the patients were better able to
endure an operation than when no calculus existed. . . . The
2 Deaver's Enlargement of the Prostate, pp. 210-212.
150 AMERICAN JOURNAL OF UROLOGY
death rate from McGill's operation (partial suprapubic pros-
tatectomy) has always been higher and always will, it seems.
Belfield collected 88 cases of McGill's operation with 12
deaths, a mortality of 13.6 per cent. ; Moullin in 1892 collected
94 cases, with 19 deaths, or 20.2 per cent/mortality.
Watson collected from various sources 243 cases of total
suprapubic prostatectomy, with 28 deaths, a mortality of 11.5
per cent., while among perineal operations he found 33 deaths,
a mortality of 6.2 per cent. . . .
I have now had 185 consecutive cases of perineal prosta-
tectomy with seven deaths as recorded, a mortality of 3.7 per
cent. This includes all of the early cases, when the operation
was in a developmental stage and much less satisfactor\T — the
patient being confined to bed and the drainage not removed for
much longer periods. It certainly does not represent the true
mortality. " During the past two and one-half years there have
been one hundred cases with only two deaths, a mortality of 2
per cent. But the most convincing evidence of the benignity
of the operation is the fact that in the last sixty consecutive
cases there has not been a single death or bad result."3 (Young.)
4 Si My experience, then, has been that the restoration of
function is more complete and lasting after the perineal than
after the suprapubic. ... In the past four years I have oper-
ated on 35 cases of perineal prostatectomy. Two cases have
died, one three days after operation, the other at the end of
a month."
5 A study of 485 cases of prostatectomy for hypertrophy
of the prostate, occurring in the practice of 13 different opera-
tors, wherein the cause of death is given, shows in all 33 deaths.
Of these deaths ten were due to such causes as cancer of the liver,
pulmonary tuberculosis, etc., in no way connected either with the
operation or the pathologic condition for which the operation
was undertaken. Eight of the deaths were due to exhaustion,
pneumonia, pulmonary embolism and sepsis, conditions caused
by the operation itself or the anesthesia. It would be nearer
3 Johns Hopkins Hospital Report, 1906, iv, 115. Hugh H. Young, Study
of 145 Cases of Perineal Prostatectomy. Final Note as to Mortality Jan.
7, 1907.
4 Cabot, A. T.: Modern Operations for Complete Removal of the Pros-
tate, 1907.
5 Porter, Miles F.: Jour. Am. lied. Assn., May 23, 1908.
PERINEAL PROSTATECTOMY
151
the exact truth, perhaps, to say of the deaths due to sepsis, that
most of them were due to conditions existing before the opera-
tion was done, but for the present, at least, we will consider them
as deaths due to the operation per se. The remaining 15 deaths
were due to pyelitis, pyelonephritis, and other conditions second-
ary to and caused by the hypertrophy of the prostate, and exist-
ing at the time of the operation. Miles F. Porter.
The total death rate in this series of cases then, is less than
7 per cent. £< The death rate of the operation is less than 2
per cent., while the conditions secondary to and caused by the
enlarged prostate is 3.5 per cent. In other words, half of all
the deaths following prostatectomy are due to conditions set up
by the enlarged prostate. The deaths from these conditions
outnumbered the deaths from the operation per se, two to one.
This means that the death rate in hypertrophy of the prostate,
treated without operation, is about 4 per cent., while timely
prostatectomy will yield a death rate of 2 per cent, or less. If
there is any error in these statistics, it consists in attributing
to the operation itself, too many deaths, and charging to the
pathologic conditions secondary to the enlarged prostate, too
few. Fuller, speaking of his personal experience with prosta-
tectomy in over 300 cases, says : " I feel that if cases complicated
with very marked uremia are excluded I can operate with an
average risk to the patient of not more and probably under 5
per cent. Death from the operation itself is practical!]) nil."
(Fuller's cases are not included in the 485 cases studied.)
Goodfellow has done 105 prostatectomies with but two
deaths. Watson gives the death rate in enlarged prostate
treated by catheterization as 7.7 per cent.
C. H. Mayo, including his brother's cases with his, says :
" In two hundred and ninety-one cases, including 26 for carci-
noma, we have had 28 deaths."
Willy Meyer writes as follows : " I have done, outside of
some 85 Bottini operations for prostatic enlargements, 41 supra-
pubic and 8 perineal prostatectomies. . . . Personally I prefer
the suprapubic to the perineal operation."
Crile says : " In my experience in about 25 operations for
prostatectomy the patients themselves were pleased with the re-
sult."
My own experience (Porter) is limited to 25 cases. There
152
AMERICAN JOURNAL OF UROLOGY
were three deaths, all due to septic conditions (pyelonephritis
and cystitis) which existed at the time of the operation and be-
cause of which condition the patients finally asked for relief. . . .
The fatalities following prostatectomy are largely due to condi-
tions resulting from the hypertrophy and existing at the time of
operation. Prostatectomy, in the absence of serious complica-
tions, entails a risk of life of less than 2 per cent. The death
rate in enlarged prostate treated by catheterization is only five
per cent. (Miles F. Porter.)
6 Dr. Stanley Stillman of San Francisco referred to the cus-
tom of Sir William Macewen, of performing the suprapubic oper-
ation in all cases in which the urine could be rendered fairly
healthy, but when this could not be done he performed a double
lithotomy incision for drainage purposes, followed by an inter-
val of a week or ten days, during which time granulation tissue
lined the incisions which were made, and the capsule of the pros-
tate retracted ; in that time the cut surface of the prostate
protruded from the wound, the prostate itself was reduced in
size as the result of complete dissection, and ten days later he
would shell out with his index finger each lobe of the prostate,
with no bleeding, and little danger of infection, inasmuch as
the urine had become fairly healthy in the interval. Dr. Still-
man had followed this plan himself for two years with much
better results than he ever obtained from our methods of prosta-
tectomy. His preference is distinctly for the suprapubic methods
of operation where the urine is healthy and for Macewen's
method where the urine cannot be rendered healthy prior to the
operation.
7 Percentage of Mortality. — Including cases of cancer of
the prostate in which the typical operation of conservative peri-
neal prostatectomy was employed, 13 recent cases which have
not been tabulated above, 20 cases in which operation has been
performed since the above paper was written some months ago,
and a few cases in which the technic was not the typical one
and which had not been tabulated above, there have been 400
cases of perineal prostatectomy, with 13 deaths, a mortality of
3.25 per cent. . . . During a period of two years and eight
sJour. Am. Med. Assn., July, 1909.
'Young, H. H.: Perineal Prostatectomy, Jour. Am. Med. Assn., March 5,
1910.
PERINEAL PROSTATECTOMY
153
months 128 consecutive cases were subjected to the operation
of conservative perineal prostatectomy without a single fatal
result; 43 of these 128 patients were over 70 years of age and
two were over 80 years of age.
8 Suprapubic enucleation of the prostate. In Freyer's
series of 641 operations of enucleation of the prostate to date,
there have been 18 octogenarians, and nine bordering on this
period, with six deaths. ... In connection with these 611 oper-
ations there have been 39 deaths in periods varying from six
hours to thirty-seven days after operation, or a mortality of
6.05 per cent. The mortality has been gradually diminishing
from 10 per cent, in the first 100 cases, to 1.21 per cent, in the
last 200. Freyer mortality 6.05 per cent.
0 M. Tuffier believes that the suprapubic operation is easier
and quicker to perform than the perineal. When the gland is
very small and the abdomen very fat, he selects the perineal
operation, and quotes from Proust, Watson, Horwitz, Leque,
Hartman, Pauchet, Rafin, Young and Albarran, to the effect
that there were 2,222 cases, the average mortality being 6.23
per cent. ; out of the total number of cases operated on the per
cent, of deaths is about the same in both operations (35 per cent,
perineal and 33 per cent, suprapubic). Shock is given as the
cause of death in 17.8 per cent, operated on by the suprapubic
method.
The general mortality is about 4 per cent, in perineal pros-
tatectomy. Re-establishment of spontaneous urination and re-
lief of vesical infection are the rule. The genital loss is habitual.
The age of the patient and the lesions are not contraindications.
The relative integrity of renal activity is necessary. Patients
with grave organic- deficiency, such as diabetes and albuminaria,
succumb to pretended shock. The two methods have their ad-
vantages and disadvantages.
Mortality. — Mortality after prostatectomy is the subject
of a paper by Drs. Tenney and Chase,10 in which they accept
sRicketts: Jour. Am. *Med., Assn., Jan. 29, 1910.
9 Ferguson, Alex. H.: Jour. Am. Med. Assn., 1906.
10 Ann. des Mai. G. U., October, 1902; Jour. Am. Med. Assn., Oct. 25,
1902; Centralbl. f. krankh. d. Harn. u. Sex.-Org., 1901, p. 571; Philadelphia
Med. Jour., June 8, 1901 ; " Treatment de l'Hypertrophie de la Prostate,"
Report au xv, Cong. Intern, de Med., 1905.
154
AMERICAN JOURNAL OF UROLOGY
as possibly due to the operation every death reported as occur-
ring within six weeks. From their table we find that 2,342 pa-
tients were operated on through the perineum, and 667 supra-
pubically. It will be seen that the average mortality by the
peritoneal route is 7.9 plus. The average mortality by the
suprapubic route is 13.2 plus, nearly twice the mortality of the
operation through the perineum.
In my own cases I had no deaths in the first series of 21.
Following that I lost three cases, one from renal insufficiency in
48 hours. This was considered a very unfavorable case for any
operation. Another patient died in twelve hours from an over-
dose of morphin, and the third succumbed on the third day, an
unfavorable case because of old age and emaciation. This makes
my mortality between 3 and 4 per cent, in 103 cases, and does
not include five deaths following prostatectomy, three from
carcinoma and two from acute tuberculosis.
There have been no permanent fistulae seen in those with
pus-furnishing bladders, which were inflamed, trabeculated and
with stones, pouched or diverticulated. The natural tendency
of the perineum is to close spontaneously, but, so long as pus
emits, a fistula is likely to persist or recur. I had two of these
cases. Injury to the rectum during operation is more of a
blunder than an accident, and secondary rectal fistulae are
caused most frequently by rough treatment from the eighth to
the twelfth day, when granulation is profuse. This latter has
occurred in the case of two of my patients in whom the after-
treatment was not carried out by myself. Three patients were
wearing urinals on account of partial incontinence, which was
more acceptable to them and to their relatives than death. One
of these, aged 70, accepted the operation only when life became
unendurable from pain due to cystitis, etc. Considerable slough-
ing at the seat of operation from the skin inward occurred.
There was one man, with impotence following, who avers he proved
his vigor two nights previous to the operation. One case of
stricture secondary to operation was cured by perineal section.
Five patients had epididymitis. One had unilateral intraneph-
ritic and extranephritic abscess developing three weeks after
operation. I cured him by incision and drainage. Stone in the
bladder was present in six cases.
CURRENT UROLOGIC LITERATURE 155
Review of Current Urologic Literature
FOLIA UROLOGICA
Vol. V, No. 7, January, 1911
1. A New Case of So-called Primary Actinomycosis of the Kid-
ney. By J. Israel.
2. Four Cases of Distended Bladder Due to Diabetes Insipidus.
By H. Strauss.
3. Urethral Pain Occurring in Completely Cured Urethritis. By
G. F. DeMeo.
4. Contribution to the Study of Syphilis of the Bladder. By G.
Von Engelmann.
5. The Treatment of the Urethra by Means of Hot Sounds for
1. A New Case of So-caleed Actino Primary Actinomy-
cosis of the Kidney. — J. Israel reports a case of primary actino-
mycosis of the kidney, involving also the tissues immediately about
the organ. After nephrectomy, a small fistula persisted which had
not healed ten months after the operation. The author calls at-
tention to certain similarities between actinomycosis of the kidney
and tuberculosis of this organ, principally as to the mode of in-
fection, the clinical appearances and the anatomical distribution.
2. Four Cases of Distended Bladder Due to Diabetes
Insipidus. — H. Strauss reports four cases of diabetes insipidus
in young persons in whom he noted markedly distended bladders.
The disease was always characterized by a positive result with the
alimentary sodium chloride excretion test. The author believes
that distended bladders are more common a feature of diabetes
insipidus than is generally believed. His four cases represent a
larger number than have been reported by other authors. In one
of the cases, he was able to examine the bladder with the aid of
the cystoscope and found that the organ was somewhat trabecu-
lated. The origin of these dilated bladders in diabetes insipidus
resembles that of bladders in chronic retention of the urine, al-
though this question is still unsettled. For the purpose of a
functional diagnosis of diabetes insipidus itself, the author rec-
ommends the alimentary salt excretion test. The absence of fer-
156 AMERICAN JOURNAL OF UROLOGY
ments in the urine, may also be possibly a useful means of diag-
nosis.
3. Urethral Pains Occurring in the Completely Cured
Urethritis. — G. F. DeMeo remarks that there are urethral pains
occurring in completely cured urethritis. The pain may be the
only symptom of the affection, or some other trouble might ap-
pear with it after the cure of the urethritis. The beginning, the
duration, the intensity, the localization and the irradiation of the
pain differ widely. The pain indicates alterations in the deeper
layers of the mucous membrane of the urethra. The cicatriza-
tion of the mucous membrane after the cure of the inflammation
causes an alteration of the nerve-ends within the mucous membrane.
The physiological and anatomical lesions of these nerve endings
cause irritation and pain. By cicatrizations in the urethra neur-
algic crises may be produced, due to congestion compressing the
anatomical elements, nerves included. Medicinal treatment alone
does not favorably influence the pain ; but gradual dilatation
and gentle massage of the infiltrates over a metal sound will im-
prove the circulatory and anatomical conditions of the mucous
membrane and indirectly also influence the nervous elements.
These procedures facilitate nerve metabolism and stretch the sen-
sible nerve fibers. This is the best way to treat persistent neural-
gias. In the more severe cases the effect of the mechanical treat-
ment can be increased successfully by a moderate hyperemia of
the perineum and by large irrigations of the urethra and bladder
with antiseptic and anesthetic remedies;
4. Contribution to the Study of Syphilis of the Blad-
der.— G. Von Engelmann reports 3 cases of pronounced gum-
matous lesions of the bladder which he has treated with the aid
of the cystoscope during the past 3 years. Syphilitic affections
of the urinary bladder are very little known and are scarcely
mentioned, or their existence is even denied in the text books. A
number of cases are on record, however, in which syphilitic ulcers
of the bladder have been found postmortem. A few cases have
also been reported in which the disease was discovered through
the c}Tstoscope. The patients whose histories are here related,
two women and one man, gave histories of syphilitic infection
many years previously (15 or 20 years). Hemorrhage was the
chief symptom. There were but a few subjective symptoms in
CURRENT UROLOGIC LITERATURE 157
the two uncomplicated cases, while in the third case, complicated
with intense cystitis, there were severe pains and frequency of
micturition.
Cystoscopic examination showed multiple ulcers covered with
crusts in the case with general cystitis. In the two other cases
there were tumor-like growths with ulcerated surfaces surrounded
by areas of inflammation in the region of a ureter. In two of
the cases there were no other syphilitic symptoms except the
affection of the bladder, while in the third, an involvement of the
spinal cord was noted as well as some ulcerated papules in the
genital regions. In all cases, the treatment with mercury and
iodides effected a complete cure, with distinct cicatrization of the
ulcers.
5. The Treatment of the Urethra by Means of Hot
Sounds for the Purpose of Producing Hyperemia. — M.
Porosz contributes an article on this subject, a translation of
which has appeared in the January issue of the American Jour-
nal of Urology.
ANNALES DES MALADIES GENITO-URINAIRES
Vol. XXIX, I, No. 2, January 2, 1911
1. Operations Upon the Kidneys, and Pregnancy, By Prof. Hart-
mann.
2. Operations Upon the Kidneys and Pregnancy. By Prof.
Pousson.
3. Reflex Calculous Anuria. By Henri Eliot.
4. The Treatment of Chronic Urethritis by Aspiration. By Dr.
Bronner.
5. Calculous Anuria in a Single Kidney Treated and Cured by
Ureteral Catheterism. By Dr. Audre.
1. Operations Upon the Kidneys and Pregnancy. — Pro-
fessor Hartmann remarks that many physicians do not like to
see pregnancy in a woman who has had an operation upon her
kidneys, especially in one who has had a kidney removed. He
asks whether this fear is justified. Some believe that it is, basing
their opinion upon purely theoretical grounds. As a matter of
fact, patients with one kidney have as much chance to go through
pregnancy without any mishaps as any other patients. Hart-
158
AMERICAN JOURNAL OF UROLOGY
mann has watched seven of his women patients who have had
operations upon the kidney through pregnancies, which did not
seem to be influenced by the previous operation. In another case,
Hartmann was consulted regarding the advisability of marriage
for a woman who had had one kidney removed for renal tubercu-
losis. After having found that the urine of this patient was normal,
and that guinea pigs inoculated with its sediment did not develop
tuberculosis, the author gave his consent. In addition to the eight
cases thus observed, Hartmann summarizes 16 additional cases
which had been communicated to him, making, in all, 24? cases of
nephrectomy in which the operation seemed to have no influence
upon subsequent pregnancy. In addition to these unpublished
cases, the author collected 89 cases previously published, thus
making a total of 113 operations accompanied or followed by
pregnancy. A study of these cases leads him to the conclusion,
that after operations upon the kidneys, particularly after ne-
phrectomy, pregnancy goes on normally, labor is accomplished with-
out incidents, and lactation is possible. These conclusions may
seem contradictory as compared with the ideas of some physicians,
but they are based upon facts, which Hartmann collected and
they agree with the opinion of Israel. We are therefore justi-
fied in authorizing the marriage of young women, who have had
a nephrectomy performed, even if this operation had been done
for the presence of tuberculosis of the kidney. If the urine is
examined carefully, and if it is found, especially after inoculating
animals, that it docs not contain any tubercule bacilli, it is quite
safe to allow such women to marry.
2. Operations Upox the Kidney and Pregnancy. — Pro-
fessor Pousson, remarks in connection with the same subject that
nephrectomy is nowadays such a common operation that we must
consider seriously the various social problems which arise in
patients who have been thus operated. The questions which come
up, in this connection, include the indemnity for accidents re-
quiring the removal of a kidney, accident insurance, military
service and marriage. It is this last point which the author
considers in connection with a study of 66 cases, which he has
been able to collect. Life is certainly not impossible with a
single kidney. It has been found that an animal could be de-
prived of three-quarters of the total weight of both kidneys with-
CURRENT UROLOGIC LITERATURE 159
out causing any fatal results. Whenever the tissues of the kid-
ney are so reduced in quantity, they begin to hypertrophy, and
this takes place both in animals and in man. Moreover, provi-
dentially, the healthy kidney often has already become hyper-
trophied when the operation is undertaken. This hypertrophy
usually persists and continues to assure the sufficient secretion of
urine. The remaining kidney, may however, sustain serious
changes, which would have to be considered in connection with
the question of marriage for women in whom one kidney had been
removed.
Among 66 women who had become pregnant after varying
intervals had elapsed after nephrectomy, seven had miscar-
riages. The remaining 59 passed through their pregnancies
without any disturbance, and were delivered at term. Of these
women, 46 were pregnant but once, 8 twice, and five three times
after the operation. In all of them, the confinements were free
from all complications, even in those cases in which instrumental
delivery was found necessary. Most of the women nursed their
infants. All these patients were living at the time of writing,
except five, who died long after delivery, so that their deaths could
not be connected with the pregnancy.
The results above recorded ought to set at rest the fear that
women who had lost one kidney by operation, were incapable of
bearing the strain of maternity. This does not mean, however,
that we must allow such women to marry in every case, without
thoroughly investigating their general health, the functions of
their various organs, and especially the condition of the remain-
ing kidney. Functional tests may show that the remain-
ing kidney is intact, and that marriage can be authorized with-
out hesitation. If the urinary secretion is not normal, permission
to marry should be given only after a thorough examination of
the patient and of the renal secretions. In a third class of cases,
marriage should be prohibited, if the kidney is found markedly
altered. The character of the affection which had lead to the re-
moval of the first kidney is not of such importance in this con-
nection as might be supposed. Thus, of 32 patients in whom
nephrectomy had been performed for tuberculosis, the author
noted but three in whom miscarriages occurred, while the remain-
ing 29, with one exception, pregnancy went on to term, and the
160 AMERICAN JOURNAL OF UROLOGY
child was living. Of these women, two died a considerable time
after labor. Of ten women operated upon for stone in the kidney,
only one had a miscarriage. .
S. Reflex Calculous Anuria. — Eliot, discusses the ques-
tion of reflex anuria, due to the obstruction of one ureter by
stone. In France, Guyon and Albarran, have been the advocates
of this theory in certain cases of stone. On the other hand,
Legueu, has combatted this idea. It is curious to note that,
while the possibility of a reflex anuria, due to the obstruction
caused by stone, has been strenuously opposed, yet every one
agrees that the same reflex process can produce anuria, in cases
without any stone; as for example, an injury to one kidney, etc.
The author examined critically the literature and clinical records
of cases of calculous anuria. He cites 20 cases which he believes
are eloquent witnesses for the cause of reflex calculous anuria.
In most of these cases, modern methods of renal diagnosis alone
permitted the recognition of the fact that the opposite kidney
did functionate, although imperfectly. If these methods of ex-
amination were more universally adopted, there is no doubt that
a larger number of cases of reflex calculous anuria would be
recorded.
As regards the path pursued by the inhibitory reflex and as
regards its mode of action, we are as yet unable to make any
positive assertions. One thing is evident ; namely, that the kid-
ney in anuria is always congested, purple, and bleeds readily.
This does not seem to favor the idea that the secretion of urine
is arrested by a spasm due to the action of vaso-constrictors. As
regards the explanation for the persistence of the reflex, the au-
thor points out that it is well known that the inhibitory reflex is
especially noted in kidneys already diseased. Normally, the kid-
ney is able to furnish a certain amount of resistance against the
toxic agents which give rise to uremia. The diseased kidney, on
the other hand, is unable to furnish this resistance. In reflex
calculous anuria, the symptoms of uremia occur quite promptly,
as a rule, although they may remain latent for a time. The per-
sistence of the reflex therefore, in Eliot's opinion, is probably due
to the presence of latent or active uremia.
4. The Treatment of Chronic Urethritis by the Aspi-
ration Method. — Bronner, in a preliminary note, announces the
CURRENT UROLOGIC LITERATURE 161
results which he has obtained with a method of treatment which
he calls, " aspiration," in cases of chronic urethritis. The ap-
paratus constructed for this purpose by Lowenstein, of Berlin, is
composed of a straight metallic sound, hollowed in its interior and
pierced by a number of openings over its entire surface. The
upper end divides into two arms, to which are attached two rub-
ber bulbs provided with metallic stop cocks. One of these bulbs
is intended for aspiration, the other for irrigation. The appara-
tus is used as follows : After having irrigated the entire urethra,
and filled the bladder, the sound is well lubricated, and is intro-
duced without its bulbs. The glans is then surrounded with a
thin layer of cotton, and the latter is held in place by a few
turns of thread, thus preventing the entrance of air. One of the
bulbs is filled with the solution intended for the irrigation. The
air is expressed from the other bulb, and the stop cock is closed.
The two bulbs are then adjusted upon the apparatus. Holding
the glans with the left hand, the stop cock of the aspirating bulb
is opened. The aspiration begins and lasts from ten to fifteen
minutes. The stop cock of the aspirating bulb is then closed,
that of the opposite bulb is opened and the canal is irrigated.
In order to obtain a more powerful aspiration and at the
same time to regulate its force, the author has substituted a
syphon pump provided with a monometer. Instead of using the
bulbs, the branches of the sound can be connected with a syringe.
The author reports having treated by the method of aspiration,
12 cases of chronic urethritis, during a period of four weeks. He
found that all the patients bore the treatment very well and that
aspiration never gave rise to bleeding. In the aspirated liquid,
he was always able to find numerous pus cells and sometimes true
pus shreds. In cases in which the lining of the urethra had be-
come changed to a horny state, a large number of the horny epi-
thelia were found in the aspirated fluid. In some cases, the
dilating influence of the aspirations was clearly demonstrated.
The condition of the patients before the treatment was begun,
showed that a great variety of other methods of treatment had
been used without success. After the use of aspiration, marked
improvement occurred. The effect of this method of treatment
is twofold: First, it performs a sort of curettage of the urethra,
and also aspirates the secretions of the glands by a method which
162 AMERICAN JOURNAL OF UROLOGY
seems superior to massage. Second, it produces hyperemia act-
ing" in the shape of a dry cup and thus has the same effect as
Bier's method. The author is continuing his observations and
promises to report further progress with his method.
5. Calculous Anuria in a Single Kidney Treated by
Means of Urethral Catheterism. — Andre reports a case, the
character of which is described in the title. The patient was 42
years of age, and presented himself at the hospital because he had
been unable to urinate for 48 hours. Six years previously he had
an attack of renal colic on the left side, which was repeated after
two months. During the second attack, he passed a number of
small yellowish stones. He had not suffered at all for six years.
A third attack of renal colic occurred just before admission.
Complete anuria had been present in this patient for 48 hours.
The left kidney was painful and evidently the anuria was due to
the blocking of the left ureter.
The left ureter was accordingly catheterized, a 7 F catheter
entering and passing up to the pelvis. Immediately a stream of
urine began to flow, showing that this fluid had been retained in
the pelvis in a state of tension. At first, 70 grams flowed out of
the catheter at one time ; then the flow continued drop by drop.
The catheter was allowed to remain in place for 48 hours. Dur-
ing the first 24 hours, 1800 grams of urine were voided. During
the next 24 hours, 2600 grams were passed and after that the
patient secreted urine continuously. During the following days,
large quantities were secreted. Examination of the region of the
right ureter failed to show its presence, and although every ef-
fort was made to find a second opening, it could not be discov-
ered. The patient recovered completely and never passed any
stones. X-ray pictures were negative, but this may not mean
much, as the stone may have been very small.
ANNALES DES MALADIES VENERIENNES
Vol. VI, No. 1, January, 1911
1. Is Early Malignant Syphilis Really Syphilis? By Dr. Carle,
of Lyons.
1. Is Early Malignant Syphilis Really Syphilis? —
Carle discusses this question, which was first asked by Queyrat
CURRENT UROLOGIC LITERATURE 163
in 1908. It raises an interesting problem. There is scarcely a
specialist who does not see several times a year, cases which are
called precocious malignant syphilis, and which are characterized
by a remarkable rapidity, intensity, and tenacity of the lesions.
In spite of very careful treatment, these lesions do not improve,
and the question frequently arises whether we are really dealing
with syphilis in such cases. The author proceeds to report a
case of what he thought was precocious malignant syphilis, in
which after a year's comparatively unsuccessful treatment, the
Wassermann reaction was found to be negative. The patient re-
sumed his usual mode of life and did not present any symptoms
whatever after that. In this case, and in similar cases, the ques-
tion may be asked, whether precocious malignant syphilis has the
same origin and the same character as normal syphilis ; whether
the symptoms of this special type differ from the normal type,
and if so, to what extent ; and finally, whether or not the same
treatment is applicable to the malignant form. The author con-
cludes from a study of this subject, that precocious malignant
syphilis is true syphilis, because in authenticated cases, the spiro-
cheta was found. In general, it might be said that the malignant
form reduces itself to one or two attacks of ulcerated lesions
accompanied sometimes by a more or less impaired general con-
dition. The absence of the classical symptoms of the secondary
period, as well as of the later complications, is characteristic of
these cases, even in instances in which the disease had never been
treated specificially.
The treatment in these malignant cases does not have the
rapid effect which we are accustomed to see in cases of the normal
type ; in fact, the treatment does not seem to have any appreci-
able effects upon the malignant lesions and it is even possible that
mercury in these cases is dangerous. In such instances, we should
try the arsenical preparations, although the best results up to
date have been obtained with potassium iodide in large doses. At
the same time, it is necessary to combine a medication which would
be both tonic and sedative. All local treatment should be avoided,
except the necessary dressings and washes, which should be as
anodyne as possible.
164 AMERICAN JOURNAL OF UROLOGY
RIVISTA UROLOGICA
Vol. I, No. 9, November 15, 1910
1. A Case of Double Ureter. By Quirino Sergi.
2. Consideration on a Case* of Rupture of the Urethra. By E.
Cibrario.
1. A Case of Double L'reter. — Quirino Sergi reports a
case of double ureter on one side. This anomaly is not very rare,
and has been known since the publication of Bartholin's " Anat-
omy " in 1655. The question is, to what is this anomaly due?
Embriology teaches us that the ureter does not descend from the
kidney towards the bladder, but that it ascends from the bladder
upward. Thus, in cases of incomplete double ureter we find that
there are two distinct canals at the lower end which merge into
one further upward. The ureter is but a prolongation of the
cloacal extremity of the diverticulum of the kidney.
The specimen obtained postmortem and reported upon by the
present author, showed a double ureter which was discovered ac-
cidentally during a careful dissection of the abdominal organs.
The right kidney was normal, while the left was large, and irregu-
lar in outline. The renal sulcus was large and gave issue to two
pelves, each terminating in a separate ureter. Each pelvis
drained a number of calices. The organ seemed to be composed
of two distinct kidneys, superimposed and fused together. The
lower kidney was turned slightly towards the left upon its long
axis, as well as upon its horizontal axis. The upper kidney,
however, seemed to be fairly normal in position. The anomaly
described, therefore, represented a complete double ureter on the
left side. The trigone showed an irregular arrangement, owing
to the presence of three ureteral mouths, and to the scarcity of
the inter-ureteral muscle fibres. Upon microscopical examination
of the two urethral mouths on the left side, a sheath was dis-
covered which surrounded the extremities of both ureters, thus
confirming the theory of Versari upon the origin of the intra-and
extra-mural fascia described by this author.
2. A Case of Double Rupture of the L'rethra. — Enrico
Cibrario, reports an interesting case of rupture of the bulbous
and prostatic urethra. The patient was a young man of 19, a
plasterer, who sustained a fall from a scaffold, his bod}' falling
forward. On examination immediately afterward, a lacerated
wound was found upon the internal surface of the thigh on the
CURRENT UROLOGIC LITERATURE
165
left side, near the root of the limb. This wound was carefully
dressed and sutured. A small quantity of blood issued from the
meatus at this time. The patient refused to go to the hospital,
believing that his injury was not severe enough. Towards even-
ing he felt an intense desire to urinate, and a physician who was
called tried in vain to cathetcrize him. A moderate swelling
formed in the perineum. When seen 24 hours after the accident
he was able to urinate, and had fever, with a frequent and small
pulse and a coated tongue. The swelling in the perineum had
greatly increased, ocupying the entire scrotum and extending
laterally towards the thighs. The skin which covered this swell-
ing had become bluish black. There was only one thing to do ;
namely, to cut into the perineum at once and perform external
urethrotomy, for the purpose of emptying the bladder and coun-
teracting the septic process.
Accordingly, a Syme's guide being introduced down to the
bulb which had become ruptured, an incision was made extending
from the scrotum along the median line to within 1 cm. from the
anal orifice. The dissection was carried through the very much
infiltrated tissues to a depth of about 4 to 5 cm. until a cavity
with necrotic walls was reached, containing a small quantity of
foul smelling liquid mixed with blood clots. This, then, was the
location of the rupture in the bulbous portion. A careful cleans-
ing of the parts was carried out, a stream of hot water being
directed against the necrotic tissue, thus removing the clots and
debris. It was found that the upper wall of the urethra had en-
tirely disappeared, and that there was a complete rupture of the
canal. Attempts were therefore made to find the central end of
the urethra, and when this was accomplished, a sound was intro-
duced into the bladder. The central end of the urethra was at-
tached to the skin by means of two silk sutures and drainage was
established through the perineum. The patient improved appar-
ently for a few hours, but contrary to expectations he did not
urinate through the perineal drain. The bladder was enormously
distended, the fever rose, and the patient became restless. The
bladder was then drained by means of a hypogastric puncture
and the patient was taken to the hospital. Under chloroform, a
sound was introduced through the urethra and through the upper
segment of the canal, which had been fixed to the skin, but after
passing upward for a short distance, the instrument was arrested.
The presence of a second rupture was then thought of, and rectal
166 AMERICAN JOURNAL OF UROLOGY
exploration was practised. The membranous urethra was unin-
jured, but in the prostatic portion, the finger felt a large swell-
ing of the size of a small orange, which seemed to contain fluid.
The conclusion was, that there was a second rupture, situated
in the prostatic urethra. Two ways now presented themselves
for the relief of this condition. The first was the classical method,
namely, that of retrograde catheterization through a suprapubic
incision, and the second, through a perineal incision, as recom-
mended by Riche.
The first of these methods, while simple of execution would
probably have been insufficient in this case to establish the continu-
ity of the canal. The perineal method was therefore preferred
as giving better drainage, the only difficulty being the extreme
delicacy of working in the prostatic region, when the tissues were
in a state of such marked infiltration.
A transverse incision was made as customary for perineal
prostatectomy, and after dividing the recto-urethral muscle the
space between the rectum and the urethra was reached. After
separating these organs, a cavity of considerable size was readied
in the upper wall of which the finger discovered an aperture in
the beak of the prostate. After the clots and fluid contents of
the cavity, had been removed by irrigation, an unsuccessful at-
tempt was made to enter the bladder with a sound. The operator
then made a longitudinal incision along the posterior wall of the
prostatic urethra. Through this incision a drainage catheter
was introduced through the bladder, and allowed to remain in
place. Strips of gauze were packed around the catheter, and a
smaller drainage tube was introduced, alongside the larger for the
purpose of draining whatever urine might escape between the
catheter and the urethra. The drainage catheter was attached to
the skin by means of a few stitches. The patient made a good
recovery. The gauze was removed on the fourth day and the
drainage tube on the fifth. On the eighth day, sounds were
passed, and this was repeated every day, gradually increasing
the size of the sound. The patient was discharged on the eight-
eenth day. A year after the operation, the patient was in good
condition, and his urethra admitted a good sized sound. The
author emphasizes the value of removing the drainage tube after
a period not- exceeding six or seven days. If allowed to remain
longer, the drainage tube favors the formation of traumatic
strictures.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII MAY, 1911 No. 5
Contributed by the Author to The American- Journal of Urology.
VESICAL STONE AND ITS MANAGEMENT WITH
SPECIAL CONSIDERATION OF LITHOLAPAXY 1
By F. Kreissl, Chicago.
IN accepting the honor of addressing your distinguished so-
ciety I was fully aware that I could not appear before you
with a subject which has been worn threadbare in the course
.of years, nor was I in a position to deliver a new and startling
message. I therefore, selected a topic, which, while not new
seemed to me to deserve much more attention than it has re-
ceived from our profession in America, namely, " Vesical calcu-
losis and its management with special reference to Litholapaxy."
By a circular letter sometime ago sent to a large number of
surgeons especially to those engaged in Genito-urinary work I
have endeavored to obtain a definite answer to the following
questions :
I. Is your operation of choice for vesical stone, Lithotomy
or Litholapaxy?
II. If any, what is the mortality after your operations for
vesical stone?
III. If any, what is the percentage of recurrence?
IV. In how many cases was marked cystitis present at the
time of operation?
V. Did the cystitis always receive attention after the opera-
tion?
VI. What, in your experience, is the percentage of stones
of renal origin that caused vesical calculosis?
1 Read by invitation at the meeting cf the St. Louis Medical Society
March 4th.
167
168 THE AMERICAN JOURNAL OF UROLOGY
VII. If so disposed, can you give me the number of opera-
tions for vesical stone performed by you?
The replies were mostly incomplete and unsatisfactory
which is regretable since there is no consensus of opinion yet on
most of these points and since exact clinical work and harmon-
ious co-operation of those engaged in this branch of surgery
would help a great deal to throw much light on very important
questions such as : The Etiology of Vesical Calculi, the indica-
tions for the different operative methods for their removal and
the prevention of recurrence of the same.
But many surgeons seem to be satisfied to record the diag-
nosis and the operation and sometimes the size and weight of the
stone if it happens to be unusually large and heavy.
It is not the purpose of my address to annoy you at length
with a more or less dry lecture on vesical stone and its treat-
ment. I merely submit to your consideration a few points which
appear to me of sufficient importance since they are not gen-
erally appreciated.
It is therefore hardly necessary to mention that a large
proportion of vesical stones are of renal origin although the
proportion may not be so large as is commonly believed. While
I have been unable to receive a satisfactory reply to this question
from other surgeons, I have in the large number of my own cases
always tried to ascertain this point by inquiring of my patients
if symptoms of lumbar pain or renal colic had preceded those of
the vesical disorder at any time. In my own cases the percent-
age of vesical stone of apparent renal origin is very small, ex-
pressed in figures not over fifteen percent.
The majority of my patients exhibited evidence of infection
of the lower urinary tract — urethra and bladder — or at least of
the latter, some also of the upper urinary tract. Many of them
had gonorrhoea in former years, had been treated with bougies
and metal sounds and stated that at times these instrumenta-
tions were followed by more or less bleeding. Frequently I
found a still active prostatitis and oftentimes urethral strictures.
In examining concrements which had been removed by Litho-
tomy I have several times discovered blood as the nucleus of a
stone. From this I would conclude that careless and forcible
instrumentation will eventually lead to injuries and repeated
VESICAL STONE AND ITS TREATMENT 169
bleeding of the prostatic urethra and bladder, which under favor-
able conditions might lay the foundation for a vesical stone.
Such favorable conditions are furnished by inflammation, cystitis,
urine retention a trabeculated bladder, a diverticulum or a eysto-
cele in woman.1
Under similar conditions, vaseline used as a lubricant might
form the nucleus of a stone and for this reason it has been pretty
generally abandoned for the above purpose.
In former years when medicated bougies containing bees-
wax as an excipient, were freely used in the female urethra I had
several times occasion to remove vesical concretions, the nucleus
of which consisted of a fragment of the urethral bougie. With
the introduction of the soluble gelatine-bougie this sort of vesical
calculi has become quite rare.
In one of my cases the stone had formed around a lump of
paraffin which was previously employed in a periurethral injec-
tion for incontinence. Apparently a part of the paraffin es-
caped through a puncture into the bladder. Since this method
is still practiced without any guide except the index finger intro-
duced mto the vagina I would suggest that a cystoscopic inspec-
tion of the bladder should follow such applications.
Another source of vesical calculus are silk-thread loops im-
migrating into the bladderwall after operations on the abdominal
and pelvic viscera. Rut at this date they are more of historical
interest since catgut or tendon has replaced non-absorbable
material as ligature and suture material.
The small proportion of women afflicted with vesical stone
— about five per cent. — is rather surprising especially in the
light of the generally accepted theories of lithogenesis which
should hold good for both sexes. I believe this small percentage
may be partly explained by the shortness and dilatability of the
female urethra which permits the spontaneous expulsion of
stones of a size too large to pass through the male canal. Rut
I also believe it to be due to the fact that women are yet much
less than men subjected to urethral and vesical instrumentation,
which as I previously suggested is etiologically responsible for a
certain number of vesical stones.
1 But this might be an. incident, since most of my patients were of ad-
vanced age and presented urinary lesions which apparently were directly or
indirectly responsible for the formation of vesical stones.
170 THE AMERICAN JOURNAL OF UROLOGY
Very strange is the endemic existence of vesical stone in cer-
tain localities and still stranger and confusing are the reasons
sometimes quoted for this phenomenon. The climate, the condi-
tion of the soil and the water have been utilized for an explana-
tion, but undisputable proof has not been furnished for any of
them.
In one instance, at least, the theory of the influence of
climate and the conditions of the drinking water has received a
setback. I refer to the prevalence of vesical calculus in Egypt,
which was demonstrated beyond doubt by Bilharz to be due to
distoma hematobium, the latter causing a more or less severe
cystitis and itself forming the nucleus of the stone.
It seems to me that in other districts perhaps faulty meta-
bolism might be the cause of the prevalence of urinary calculus
may be due to certain habits or the preference for certain food
products rather than the climate or the water supply. In all
probability the Bacterium coli contributes its share to the forma-
tion of vesical calculus in the same proportion as it is guilty of
many other offences in and outside the urogenital tract.
Vesical stone in infancy and childhood is perhaps largely
due to uric acid infarct of the kidney. This condition at least
is of particular frequent occurrence in districts in which vesical
calcinosis is an endemic disease. However, this theory would
only explain the formation of uric acid stones, while no doubt,
purely phosphatic concrements owe their origin to vesical irrita-
tion and infection. Perhaps the pyelitis of infants which occa-
sionally induces so-called enuresis plays an important part in this
respect.
Heredity also seems to have some influence inasmuch as uric
acid diathesis and eystinuria with subsequent vesical calculosis
can be observed in several generations of the same family.
The symptoms of vesical stone are sometimes typical and
unmistakable at others not sufficiently pronounced to suspect
the disorder particularly so in women.
There is usually a phase of toleration which extends from
a few weeks to several years. Ultimately, the bladder reacts
with hematuria, pain, polakiuria, interruption of the stream of
urine, retention or incontinence and finally a very painful try-
ing cystitis.
I do not need to go into details on these symptoms, except
VESICAL STONE AND ITS TREATMENT 171
to mention that most of them are by far not so pronounced in
women because of the different shape and position of the female
bladder. So for instance, do we not observe the interruption of
the stream of urine, which in the male bladder is produced by
the rolling of the stone over the vesical outlet acting there like
a valve. On account of the spacious lateral pouches of the fe-
male bladder stones are always located away from the vesical
sphincter. For the same reason vesical stones in the female
bladder are not so apt to change their position as in the male
and therefore pain and hematuria is less often observed and less
pronounced than in the male sex.
Indeed frequently, the discomfort is referred to the genital
organs and women are treated gynaecologically or rather
gynaeco-illogically until a subsequent cystitis directs attention
ip the real nature of the trouble.
Another symptom the incontinence if occurring in children
— and vesical stone is much more frequent in children than in
adult women — is oftentimes mistaken for enuresis and treated as
such, of course without result except perhaps that we wrong-
fully attribute the failure to the difficulty of managing enuresis.
While the blocking of the vesical outlet by a stone is partly re-
sponsible for urine retention it is not the only cause of it. If
cystitis has set in the pain is most marked when the bladder be-
comes empty and soon the latter learns to cease contracting
before complete evacuation occurs. This can be readily proven
by urging the patient to urinate while lying on his back. In
this position the stone rolls away from the vesical outlet, there
is no blocking of the free escape of the urine and yet immediately
after urination, residual urine will escape through a catheter in-
troduced into the bladder.
If not removed in due time, extensive ulceration of the blad-
der wall takes place leading in extreme cases to perforation
mostly into the rectum, or the vagina, rarer in the prevesical
space. Another and serious complication is the extension of
the infection into the renal pelvis and the kidney proper, which
renders subsequent surgical interference for the removal of the
stone, a rather dangerous procedure.
The diagnosis of vesical stone from the symptoms enumer-
ated is not always easily made; since hematuria, terminal tenes-
mus and sudden interruption of urination are observed in other
disorders of the urinary tract. Particularly in the presence of
a cloudy urine such symptoms might readily be attributed to
172 THE AMERICAN JOURNAL OF UROLOGY
a cystitis of other origin than of calculosis and the stone either
as the cause or the result of the cystitis is not thought of. Very
characteristic for stone, however, is the pain radiating into the
glands in the male and the rectum which is most pronounced
when the patient is on his feet or being shaken up when riding
in a vehicle, while he or she is comparatively comfortable when
resting in the recumbent position. But even this symptom is
absent in patients whose bladder has lost its sensitiveness on ac-
count of some spinal disease for instance, in tabes and poly-
omyelitis.
Thus, it is seen that we have to resort to local inspection of
the bladder in order to get a clear idea of the conditions exist-
ing therein. In the precystoscopic time we had to rely upon
the deceptive rectal or vaginal palpation of the bladder and the
examination with metal sounds. This was not always satisfac-
tory since excessive fat on the abdomen or the small size of a
stone would not permit it to be felt and calculi escaped detection
by the sound either because they were located in a diverticulum
or wedged in between a large lobe of the prostate and the blad-
der wall or because the bladder being extremely sensitive would
contract pouchlike around the stone so that the metal searcher
could not come in contact with the latter.
With the advent of the cystoscope the diagnosis of vesical
stone has been simplified and errors are almost impossible, fail-
ures rare. It should therefore be employed wherever circum-
stances, the condition and the age of the patient, permit to do
so. Only unusual enlargement of the prostate, excessive hemor-
rhage from the bladder a urethral stricture of a very small cal-
iber or the extreme youth of the patient interfere with this
method. In these cases we possess in the shadowgraph a valua-
ble aid to establish the presence or absence of vesical stone.
However, it must be remembered that with the latter method
errors are unavoidable which are not without consequence when
indications for therapeutic procedures have to be considered.
I have reference to the incrustations of vesical ulcerations and
of tumors which in the X-ray picture cannot be differentiated
from veritable stones. Even with the cystoscope the deception
is sometimes complete when a tumor with a slender pedicle be-
comes covered with a phosphatic shell. Many years ago I en-
countered such a growth and incidentally touching the same
w'th the beak of the cystoscope fractured the thin phosphatic
shell, pieces of which separated from the tumor exposing its red
VESICAL STONE AND ITS TREATMENT 173
surface. Since then it is my practice whenever possible, to move
the stone from its bed with the beak of the cystoscope, which
could not be done if it was an incrustated growth. Owing to
this practice, I also diagnosed the rare case of a so-called hour
glass shaped diverticle-stone, one-half of which was enclosed in
the diverticulum, the other half protruding into the bladder and
its narrow centerpart or neck being closely surrounded by the
vesical opening of the diverticulum. In a case published in the
Journal of Urology last year I saw a stone apparently lying
free in the retroprostatic pouch behind a very large gland. It
could not be reached with the beak of the cystoscope on account
of the large size of the middle lobe. Upon opening the bladder
in the subsequent suprapubic prostatectomy this stone was found
to be emanating from the narrow neck of a very large diver-
ticulum from which I removed sixteen more stones of like size.
An X-ray picture would have shown the condition before the
operation and these pictures should be taken in all unclear cases
of vesical distress in which only diverticula are found, because
stones are oftentimes located inside of them without being visible
through the cj'stoscope. The X-rays will also demonstrate
stones which are wedged in behind and covered by enlarged
prostate lobes, and therefore cannot be palpated with a metal
sound or seen through a cystoscope.
Treatment : — The presence of stone in the bladder ascer-
tained, its early removal becomes necessary. This can only be
accomplished by surgical means. The problem of dissolving a
concrement by injections of solvent drugs or by internal medica-
tion has remained a problem up to the present time and doubtless
will so continue. Where such results have been observed the so-
called solvents did not act on real stones, but on gravel (min-
eral deposits of minute size). Since all solvents are adminis-
tered with large quantities of water the good results obtained in
this way should be credited to the water and not to the drug.
We have been taught that in the choice of the method of
removing vesical stones, the bladder, the stone and the general
conditcn of the patient are to be considered. You may add to
it "the experience of the surgeon in and his preference /or, a cer-
tain method." But the latter should not count because there is
no one method for every case and while it might be true that all
roads lead to Rome, there are shorter and longer ones and there
are smooth and rough roads.
We possess two established methods for the removal of vesi-
cal stones :
174 THE AMERICAN JOURNAL OF UROLOGY
LITHOLAPAXY AND LITHOTOMY
The former, as the name indicates, aims at the crushing of
the stone and the removal of all the fragments by aspiration in
one sitting. It is performed with instruments which are intro-
duced into the bladder through the urethra.
It is not the purpose of this address to give a description
of the instruments required or the technique of the operation,
but it may be said that the surgeon, who performs litholapaxy, is
supposed to possess a well developed tactile sense and great dex-
terity in intravesical manipulations. Maybe this is one of the
reasons, if not the only one, why a majority of surgeons are, so
to say, addicted to Lithotomy and opposed to Litholapaxy.
The operation is indicated in free stones of small and
medium size, of not more than five centimeters diameter. This,
however, is said with reservation, as even somewhat larger con-
crements, chiefly consisting of phosphatic material, can be readily
crushed, while very hard stones of less than five centimeters will
resist even the toughest Lithotrite. I personally take into ac-
count in these cases rather the condition of the bladder, it's sensi-
tiveness and distensibility.
Litholapaxy can also be performed in certain fixed stones,
that is, in stones which have formed around ligature-loops im-
bedded in the bladder wall provided one be reasonably sure of
this condition and the possibility of an incrustated tumor can be
excluded.
The operation is not indicated when stones are wedged in
between prostate and bladder wall or lodged in a diverticulum.
The multiplicity of stones is for me not a strict contraindication
for Litholapaxy. To my mind it is not the number of stones,
but the total diameter of all of them taken together that should
determine the method of operating. If the total size of all these
stones should exceed the limits mentioned above Lithotomy
should be performed for the identical reason for which the latter
would be indicated for a single stone of the same size.
If, however, the total diameter lies below this limit these
stones represent to me the same as the fragments of one large
stone dropped to the floor of the bladder during the crushing
operation. These have to be seized and crushed into the smallest
possible pieces and made ready for the aspiration, and the same
process will reduce multiple concrements. Thus you might per-
form Litholapaxy in a bladder containing perhaps a half a dozen
VESICAL STONE AND ITS TREATMENT 175
stones of an average diameter of one ctr., while in another case
of but two stones of three and four ctr. diameter respectively
you will be compelled to do a Lithotomy.
Litholapaxy is also not indicated in an ulcerated bladder
when the ulcerations have passed beyond the mucosa, and re-
duced the tensile strength of the muscular coat.
Enlargement of the prostate gland if not excessive does not
ccntra'ndicate the operation. The difficulty of passing metal
instruments over the obstructing parts in these cases is readily
overcome by leaving a retention catheter in the bladder for a day
or two preceding the operation. This also prevents excessive
hemorrhage subsequent to the urethral trauma of the operation.
Difficulty, however, may be experienced in the evacuation of the
fragments by the depth of the retroprostatic pouch.
In very large prostatic obstructions Litholapaxy is not indi-
cated, because of the difficulty of seizing the stone and the frag-
ments, which necessitates prolonged manipulations and undue
traumatisms to the gland. Inasmuch as there is always more or
less infection present in these cases prostatic abscess is the usual
result, and passi paru, Lithotomy has to be considered the milder
procedure. But aside of this consideration very little is to be
gained by Litholapaxy in such a case, since the large prostate
and the subsequent urine retention are at least partly if not alto-
gether responsible for the formation of the stone, and nothing
but the removal of the gland will give a fair prospect of prevent-
ing the recurrence of the vesical trouble. On the other hand
one should remember that an enlarged prostate does not always
cause retention and that where both conditions, large gland and
vesical stone are found together, the latter might be the sole
source of the trouble.
Litholapaxy should not be performed in a diverticulated
bladder, not so much on account of the danger of rupturing its
walls, but chiefly because fragments and stone dust are likely to
drop into the diverticulum, from where their removal is not only
difficult but most likely impossible. The inevitable result then
would be the early formation of diverticle stones, which will put
the patient in a condition just as bad if not worse than he was
before the operation.
Litholapaxy in the female bladder is very difficult for
anatomical reasons, such as lack of support for the lithotrite
as it is rendered by the prostatic urethra, the greater distensi-
bility of the posterior wall and the irregularities in contour.
176 THE AMERICAN JOURNAL OF UROLOGY
Smaller concrements ma}r be easily extracted through the dilated
urethra.
Litholapaxy under general anaesthetic is contraindicated
in all cases in which any other major operation would not be
permissible. However, seme of these patients can be safely and
painlessly operated under local cccain or spinal anesthesia. I
have repeatedly performed Litholapaxy under similar conditions
by cocainizing the urethra and bladder and injecting into the
rectum one ounce of water containing thirty grains of antipyrin
and one-fourth grain of morphine. Of course, this mcde of
anesthetizing will only be applicable in a bladder which is very
tolerant and not inflamed or ulcerated.
A cystoscopic examination should immediately follow the
operation in order to determine if fragments have been left be-
hind. There is no excuse for not doing this, because if properly
and skillfully performed there is hardly any bleeding observed
which could interfere with a clear view of the bladder cavity.
There is sometimes a little more bleeding if the bladder be ulcer-
ated, but it is not so profuse that it could not be checked by
irrigations with hot boric solution to which a few drops of
adrenalin may be added. Neglect of this rule will oftentimes be
followed by forming of new stones around the fragments as a
nucleus and the operation loses its chief characteristic and pur-
pose, the removal of the stone in one sitting. Instead of re-
lieving the patient he is then left in a possibly worse condition
because, where he previously carried a rather smooth concre-
ment, his bladder is now injured by one or more sharp-edged
fragments.
The practice of leaving a retention catheter in the bladder
after Litholapaxy should be discouraged. It is unnecessary and
irritating, and in an infected bladder the vesical part of the
catheter readily becomes coated with phosphatic deposits and in-
fectious debris which increases the symptoms of cystit's instead
of reducing them and renders the ultimate removal of the instru-
ment very painful and bloody.
It is true frequently complete retention follows the opera-
tion for a day or two which is due to the distension of the weak-
ened bladder wall unavoidable in Litholapaxy. But whether the
bladder be infected or not it suffices to empty the same at regular
intervals. Litholapaxy as an office operation has to be con-
demned. It is impossible to render an office as aseptic as an
operating room should be, and accidents making it necessary to
VESICAL STCNE AND ITS TREATMENT 177
discontinue the operation and finish by suprapubic cystotomy
might occur.
Postoperative attention to the bladder is also one of the
requirements, lest recurrence should appear socn afterwards.
If we bear in mind that the majority of vesical stones are the
product of or complicated by cystitis it is at once apparent that
unless the bladder be restored to normal condition recurrence
of stcne will be inevitable. In some cases a short treatment
will suffice, while in others the etiology of the vesical infection
requires prolonged or even perpetual attention. Such is par-
ticularly the case when we have to deal with chrcnic pyelitis
and pyelonephritis prostatic obstruction or paralysis of the
bladder as the source of the cystitis.
Prophylactically we may here employ such remedies which are
recommended as solvents. No dcubt the drinking of copious
quantities of water with or without the addition of mineral drugs
will dilute a concentrated urine, will keep certain urinary salts in
solution and mechanically flush the urinary tract. Urotropin,
a specific for coli infection, unquestionably is of great value in
cases of vesical stone of renal origin in which the bacillus is the
sole cause of the trouble. Regulations of the diet and elimina-
tion has its place where faulty metabolism is an etiological
factor.
Soon after the inspection cystcscope was modified so that it
could be utilized for the purpose of catheterizing the ureters the
idea suggested itself to extend its field of usefulness into surgery,
and this led to the construction of the operation cystop, the best
type of which carries the name of one of the leaders in Genito-
urinary work, Bransford Lewis, of your city. While it is very
valuable for such a purpose as the removal of ligature loops, the
cauterization of tumors, and the curetting of ulcers of limited ex-
tent, I consider it not capable of accomplishing more than the
breaking up of very small concretions. But for this purpose I
employ a much milder procedure, the aspiration of stones which
are not too large to pass through the eye of an evacuation
catheter of size thirty-one French scale.
The mortality after litholapaxy in the hands of skillful
surgeons is about one and one-half to three per cent. In the
preantiseptic time, and before the ingenious American surgeon
Bigelow evolved the principle of litholapaxy against lithotripsic
in several sittings, the mortality was as high as thirty per cent.
Lithotomy should be reserved for all those free vesical cal-
culi which are not removable by Litholapaxy. The perineal
178 THE AMERICAN JOURNAL OF UROLOGY
route for this purpose is rarely taken nowadays except in those
cases in which perineal prostatectomy is performed at the same
time.
Suprapubic Lithotomy being anatomically and surgically
correct is generally preferable when a cutting operation is de-
cided upon. The preoperative preparation of the bladder is the
same as for Litholapaxy. I would suggest to distend the bladder
with air instead of water, which insures to a certain degree a
cleaner wound and saves time, which is consumed in drying the
field of operation and the vesical cavity when water be employed.
For large stone, a transverse incision through skin, fatty
tissue and fascia, is preferable to the vertical one. The recti
can be retracted without being cut, and the bladder is also
transversely incised. In this way much space is gained, time
saved, and a hernia prevented.
The stone being extracted, the bladder should be closed by a
double row of catgut sutures wherever possible. This can al-
ways be done unless extensive ulcerations should require special
attention. The old idea that every infected bladder has to re-
main open because the suture line becoming infected would not
hold, has lost its standing, since we have learned to lay the first
row of sutures exclusively into the muscular coat in such a way
as to approximate broad surfaces of the same by retracting the
serosa and preventing the mucosa from being caught between
the muscle fibres. If the sutures are placed in this manner there
is no chance for urine leakage, and no occasion for the employ-
ment of a retention catheter, the detruso being able to func-
tionate normally. Eventually, as in Litholapaxy, catheteriza-
tion and irrigations at suitable intervals might be advisable.
Suprapubic cystotomy can and has also been performed
under spinal anaesthesia when certain conditions did not permit
a general anaesthetic. In women colpocystotomy is usually
practiced not only because the gynaecologist attends the ma-
jority of cases of vesical stone in the female sex, but also for
cosmetic reasons which should be taken into account, particularly
in girls and young women. A decided disproportion between
the stone and the vagina as found in young girls and old women
might compel the suprapubic route.
The mortality after Lithotomy in the preantiseptic time
reached over twenty-four percent, at present the figures given
by different surgeons vary between seven and fifteen percent.
The percentage of recurrence after operation for vesical
CHRONIC GONORRHEAL PROSTATITIS 179
stone does not depend on the method selected. Recurrence will
be observed whenever renal caculi pass down into the bladder,
when the vesical trouble which caused the stone is not properly
attended to or for certain reasons reappears.
Considering that patients after Litholapaxy sometimes
leave the hospital on the day of the operation frequently within
the next twenty-four or forty-eight hours and rarely later, and
then on account of their general debility, furthermore that pa-
tients on whom Lithotomy was performed are confined in the
hospital from ten days to many weeks, and comparing the above
figures of mortality after either operation I do not need to say
more, why Litholapaxy should be the operation of choice for
vesical calculosis.
Xo. 5 North Wabash Ave.
Contributed ! v the Author to The American Journal of Urology.
CHRONIC GONORRHEAL PROSTATITIS
AX ENUMERATION OF A FEW OF ITS UNUSUAL SYMPTOMS TREAT-
MENT AND A REPORT OF 75 CASES TREATED IN DIS-
PENSARY AND PRIVATE PRACTICE.1
By Robert Burks Anderson. M.D.,
Associate Physician to Long Island College Hospital; Surgeon-in-Chief
(Genito-Urinary) to Samaritan Hospital.
WHEN a young man with a gonorrheal past has a his-
tory of marked sexual disturbance, painful urination,
especially at the end of the act, a feeling of heaviness
and fullness in the perineum, a stubborn urethral discharge, or
a recurrent urethritis or epididymitis, it requires no special
knowledge or skill on the part of the medical adviser to see that
trouble exists somewhere in the urogenital tract, and that a
thorough examination of his patient's excretory system is de-
manded whether his patient presents few or many of these symp-
toms. But many cases of chronic gonorrheal prostatitis present
few of the symptoms of gleet. They have in the dim past a
gonorrheal history, but that was long ago. Now they suffer
with pains in the back, loins, thighs, pubic region, testicles : or
they are invalided with persistent frontal headaches, mental de-
pression, irritable temper, marked neurasthenia and hypochon-
l Read before the "Hartford County Medical Society," Hartford, Conn.,
180 THE AMERICAN JOURNAL OF UROLOGY
dria, sexual impotence and mental states bordering on insanity.
The physician with wrinkled brow thinks of lumbago, sciatica,
renal colic, vesical calculi or some grave nervous disease or men-
tal condition, but the cause of at least a few of these people is
a chronic prostatitis the origin of which goes back to the long
forgotten gonorrhea. A thorough examination will often prove
the truth of this statement. To this end if the urine is not clear,
the bladder is filled with sterile water and the patient instructed
to micturate. This process is repeated until the fluid passed is
clear. The prostate is then massaged and the secretion thus
obtained examined for pus cells and gonococci. If on the first
examination only pus cells, a few red blood cells and pus cocci
are found, another examination is made after an irritant has
been applied to the posterior urethra, for where pus cells are
found a pathological process exists, and if a sufficient reaction
is produced in the diseased gland, gonococci will be found in the
exudate. Any prostate thus examined the secretion from which
contains pus cells and gram free, intracellular diplococci, whether
disease of the seminal vesicles can or cannot be determined, is in
the terms of this report a chronic gonorrheal prostatitis.
What do we mean by the term "cured"? As far as this
report is concerned a chronic gonorrheal prostatitis is discharged
cured when the symptoms improve and the amount of pus is seen
to diminish and entirely disappear in the urine; when the referred
pains cease and the processes of micturition and defecation are
normal ; when the urine and the discharge from the prostate ob-
tained by massage contains no pus cells and no gonococci on
successive examinations; the patient is then discharged and in-
structed to return at the end of two months for re-examination.
The absence of gonococci at any particular examination does not
mean that they may not be found at a later examination.
Successive examinations showing no gonococci and very few pus
cells are necessary to assure the patient that he is cured of his
disease.
PRINCIPLES OF TREATMENT.
First: — To remove from the diseased gland the products of
an inflammatory, round-celled infiltration and stimulate the nor-
mal cells of the organ to inhibit the growth of the invading
parasites by the production in the diseased part of a local arti-
ficial congestion.
Second: — To prevent the production of an acute local in-
flammation.
CHRONIC GONORRHEAL PROSTATITIS 181
Third: — To give fixed periods of rest that an organ long
irritated and congested may regain its normal tone.
Gonorrheal inflammations are characterized by round-celled
infiltrations, and when this process becomes chronic the diseased
organ has a diminished blood supply and suffers from partial
lymph stasis. The removal of these inflammatory products from
the diseased organ and the stimulation of the inherent properties
of the cells to inhibit the growth of the invading parasites con-
stitutes the basic principle of treatment. " Hence chronic gon-
orrheal prostatitis is cured by the utilization of the same nat-
ural processes as act in the case of any infection which, because
of anatomic or pathologic conditions, is not accessible to the
direct action of a germicide. These natural properties are the
inherent properties of the living cells." When the natural re-
sistance is strong enough to inhibit the growth of gonococci in
the ducts, acini, glandular or periglandular tissues, a chronic
gonorrheal prostatitis is cured. If this natural resistance were
strong enough to stop the growth of gonococci at the moment of
their entrance into the urethra, an acute or chronic gonorrheal
prostatitis would not develop. In this way can we best explain
the immunity in some and the infection in others when exposed
to the same source of contagion. There are no drugs known at
the present time, tolerant to the urethra, which possess the power
of penetrating the mucous membrane and the glands and ducts
communicating therewith to a sufficient degree to destroy all gono-
cocci in a chronic gonorrheal prostatitis. The great majority
of these cases are cured by the operation of a rational local
therapy all parts of which aim at the production of a local con-
gestion in the diseased parts, thus promoting the absorbent and
bactericidal properties of the blood manifested by an increase in
the amount of blood serum to the part and a migration of leu-
cocytes to the diseased area. Whether the treatment be irriga-
tion, instillation, dilatation, massage, or the topical application
through the posterior endoscope of germicidal irritants to the
verumontanum and prostatic ducts, the aim is the production of
a localized artificial congestion of the diseased part which makes
possible the activity of the natural defenses of the body against
the continued activity of infectious organisms.
True, this production of a localized congestion in the pres-
ence of pus and gonorrheal micro-organisms results at times in
the production of an acute inflammation instead of a local con-
gestion ; and for a while the patient seems worse. But the prin-
ciple of treatment is not at fault. It is the failure of the physi-
182 THE AMERICAN JOURNAL OF UROLOGY
cian to recognize the pathological condition of the diseased gland
and apply the proper amount of stimulation to the chronically
inflamed organ.
REPORT OF 75 CASES TREATMENT AND ANALYSIS OF RESULTS.
The cases have been classified for convenience as follows :
Those cases of chronic gonorrheal prostatitis which on rectal
palpation show (1) no change in the size, contour or consistence
of the prostate; (2) marked changes in size, contour and con-
sistence of the prostate, the gland always larger than normal
either as a whole or in parts; and, (3) marked changes in size,
contour, and consistence, the gland always smaller than normal.
Before considering the first group, certain instructions are
impressed upon all gonorrheal prostatics. He is warned of the
dangers of alcoholism and the performance of the sexual act.
Men suffering from syphilis, rheumatism, gout, amemia and
malnutrition receive appropriate treatment. Local conditions
in the region of the prostate and allied gonorrheal complications
like hemorrhoids, fissure in ano, fistula in ano, anterior gonorrheal
patches, cystitis, periurethral abscess, stricture epididymitis re-
ceive immediate attention, and their treatment and cure well
under way before the prostatic treatment is begun.
CLASS i: NINE CASES.
Cases of chronic gonorrheal prostatitis showing no change
in size, contour, or consistence by rectal palpation and charac-
terized clinically by a slight urethral discharge which clears up
quickly after a few treatments of nitrate of silver irrigations to
reappear again a few days after treatment. A superficial catarrh
of the posterior urethra, prostatic ducts and a few glands about
the verumontanum. The acini filled with desquamated epithe-
lium and leucocytes.
Coin plaint on Presentation for Treatment : — Morning drop,
3; venereal ulcers (three chancroids and one chancre), 4; fre-
quent micturition, 1 ; and one who came in with his friend and
finding shreds in his own urine requested treatment.
Xumber of previous attacks of gonorrhea or acute exacer-
bations of a chronic gonorrhea : — Once, 6; twice, 2; three times, 1.
Time of Treatment : — Less than five weeks, 2; less than eight
weeks, 4 ; less than three months, 3.
Manner of Treatment : — Irrigation of the anterior and
posterior urethra with sterile water, weak solutions of protargol
1/10 to 1/4%, followed by instillation of nitrate of silver to the
CHRONIC GONORRHEAL PROSTATITIS
183
prostatic urethra, varying in strength from 1/4 to V/c . Mass-
age, dilatation and endoscopic application were not used.
Results of Treatment : — All were discharged cured. One
appeared three months after the date of discharge and was found
on examination not cured. This case after six weeks' treatment
was cured as proven by an examination six months later. 1 ive
others of the nine reported later and were found cured.
Complications during treatment, none. Complications on
presentation for treatment : buboes and chancroids, 2 ; chancre,
1 ; anterior gonorrheal patches, 4.
A few axioms in this class of cases :
1. " Make haste slowly." Do not convert a superficial ca-
tarrh into a periglandular infiltrate.
2. Be careful about discharging these patients as cured. A
few deep seated infected glands may light up the whole process
again.
class ii : — 47 CASES.
Cases of chronic gonorrheal prostatitis which show on rectal
palpation marked changes in the gland. The prostate is larger
than normal, either the whole gland or parts of it : surface un-
even, smooth areas alternating with nodular projections and
small depressions ; consistence not uniform, some places hard,
others soft and boggy, and still others give the sensation of a
loss of tissue. Inflammation has extended to and through the
walls of the ducts and acini ; a glandular and a periglandular
infiltrate is poured out ; the prostatic ducts are swollen and dis-
tended and the small cavities filled with a milky, even, purulent
fluid consisting of desquamated squamous epithelium, pus cells,
granular matter, pus and gonorrheal micro-organisms. The
walls of the ducts show cloudy swelling and are permeated by leu-
cocytes and epitheloid cells which invade the periglandular tissue.
In some places complete destruction of glandular tissue has taken
place, in others cyst formation is going on. The connective
tissue bands between the acini are more abundant than normal
and feel like scar tissue. As destruction of the glandular sub-
stance progresses, cavities are formed separated from one another
by scar tissue. Thus in one and the same prostate may be found
in one part a beginning catarrhal inflammation, in another part
cyst formation, and in still another part a round celled serous
infiltration.
Complaint on presentation for treatment : — Persistent ure-
thral discharge, 9; recurrent swollen testicle (epididymitis), 3;
184 THE AMERICAN JOURNAL OF UROLOGY
difficult urination (pain at end of the act), 9: pains in testi-
cles, thighs and back, 2 : buboes and chancroids, 5 : painful and
frequent urination, 4 : hemorrhoids, 1 ; loss of flesh and strength,
and headaches (neurasthenics), 3: painful and stiff joints, 3;
morning drop, 2 ; sexual impotence, 2 : syphilis, 4.
Time that has elapsed since an acute gonorrhea or an acute
exacerbation of an old gonorrhea: —
Months 2 Si 4 5 6 7 8 9 11 6 years, 5 years.
Number 7 12 6 5 3 2 4 1 2 4 years, 1 year.
Time of Treatment: — Including periods of rest.
Months 2 3 4 5 6 7 8 9 11 12 14 18
Number 55836524 3 4 1 1
Manner of Treatment : — All these cases have received irriga-
tions of boric acid, sterile water, oxyevanid of mercury, protar-
gol, nitrate of silver, and zinc sulphate and instillations of nitrate
of silver varying in strength from J to 6%. Eight have received
application of nitrate of silver or tincture of iodin to the veru-
montanum and prostatic ducts through the posterior endoscope.
All have received prostatic massage.
Massage must be purposeful, the strokes made from the base
towards the apex and from the lateral lobes toward the isthmus.
The older the case generally speaking the more pressure can be
used. The reaction following the use of the posterior endoscope
was generally stormy. However, six of these cases would prob-
ably not have been cured had not the instrument been used.
Results of Treatment : — Forty-five of these cases have
been discharged cured. Nineteen since treatment are the fathers
of healthy children. Thirty-seven have returned for examination
from four to eight months since the date of discharge and all were
found were free of the gonococci. Two I have been unable to
cure. One was treated eighteen months with periods of six weeks*
rests. The other after fourteen months treatment disappeared
and was not heard from for six months when he appeared for
examination. He was not cured although his prostate was in
better condition than the date of his last treatment.
The reaction to some treatments was indeed angry. Seven
have developed during treatment acute epididymitis, two acute
retention and eleven urethral fever. But on the other hand,
many of the cases were savage.
Complications found on initial examination : — Stricture, 10;
cystitis, 7; seminal vesiculitis (palpable seminal vesicles), 4;
CHRONIC GONORRHEAL PROSTATITIS
18a
gonorrheal arthritis, 3; epididymitis, 2; hemorrhoids, 1 ; chronic
gonorrheal prostatitis following an acute prostatitis, 5 ; buboes,
single, 5; double, 1; severe constipation, 13; pediculosis, 1.
A few axioms in the treatment of this class of cases :
" Be not weary in well doing, for ye shall reap if ye faint
not."
Clean the prostatic urethra and glandular ducts by massage
and irrigations and use pressure enough during massage and a
strong enough instillation to produce an appreciable reaction and
then let the patient rest.
Periods of rest are as necessary to successful treatment as
periods of irritation.
CLASS III.
Cases of chronic gonorrheal prostatitis which show by rectal
palpation marked change in the size and consistence of the gland.
The pathological process has advanced further in these cases
than in Case II. The prostate is smaller than normal, surface
uneven, and consistence not uniform ; large, hard sclerotic areas
alternating with pit-like depressions. The chronic prostatic
fibrosis; areas of complete glandular destruction followed by scar
formation alternating with areas of glandular and periglandular
infiltration.
Complaints for which patients sought relief: — Indefinite
pains in the back and loins (marked neurasthenia), 3; frequent
and burning micturition on examination found to be due to resi-
dual urine with no apparent cause, 2 ; fistula in ano, 1 ; pains in
back and thighs, 2; cloudy and turbid urine, 12. Note that few
of these complaints refer directly to the uro-genital tract.
Time since last acute gonorrhea or an acute exacerbation of
a chronic:
Time, 4 3 1
No. More than 4 yrs. 5 or 6 yrs. 6 years with external ure-
throtomy for stricture.
And one said he " had always had it."
Time of treatment including periods of rest:
Number 3 2 1 2 1
Months 7 84 to 9 10 12 24
Manner of Treatment : — Five were treated by irrigations,
instillations, massage, and dilatation. Four were treated w ith all
these and application of nitrate of silver and tincture of iodin to
186 THE AMERICAN JOURNAL OF UROLOGY
the prostatic urethra and veruraontanum. Treatment in these
cases is tedious and the patients hard to handle. More intense
irritation is needed to produce a reaction than in all other cases.
Dilatation to be effective is done by the dilator, as the conical
sound is too small to produce results.
Massage in the hard prostate is difficult. In general, find a
soft place and massage. Others will appear as the treatment
proceeds. Firm continued pressure of the gland against the pubic
bone will often convert a hard irregular lobe into cne having soft
fireas throughout it. The direct application of strong solutions
of silver nitrate and tincture of iodin to the posterior urethra is
of decided benefit in these most chronic cases. Small prostatic
cysts are broken up and the germicide acts as a cautery to the
posterior urethra and gland.
RESULTS.
Eight of the nine cases have been discharged cured. Two
are the fathers of healthy children. Three have returned for ex-
amination as instructed and found cured. One is still under
treatment after 2 years. Of the remaining ten cases none were
discharged cured. live left after the first treatment, two after
a diagnosis had been made, two after three weeks and one after
two months. The most of them belong to that band of gonor-
rheal pilgrims wandering from place to place seeking relief.
Such is the result of five years experience with chronic gon-
orrheal prostatitis. Ten or 13.3rr left before treatment was
completed; 3 or Vc are failures; 62 or 8&.7% are cured; 21 or
are the fathers of healthy children. It is no record calling
for self-approbation. But when we consider that chronic gon-
orrheal prostatitis is a condition of serious import to human
economy, that it is the most frequent complication or rather ex-
tension of gonorrheal urethritis, that it has long been recognized
as a frequent cause of stubbornly resisting urethral infections and
inexplicable reinfections ; that it has long been known as the most
common cause of marital infections communicated a considerable
time after the original gonorrhea ; that it is a condition present-
ing no symptoms at all or on the other hand a multitude of
symptoms ; that it is difficult to prevent and hard to cure — when
we consider all this, are not these cases worthy of the physician's
most serious considerations and untiring zeal?
925 Sterling Place. Brooklyn-.
CURRENT UROLOGIC LITERATURE 18T
Review of Current Urologic Literature
ANNALES DES MALADIES VENERIENNES
Vol. VI, No. 2, February, 1911
1. Hectine in the Treatment of Syphilis. By F. P. Guiard.
2. Some Rare Cases of Dental Dystrophies. By Serge Bogrow.
1. Hectixe in the Treatment of Syphilis. — F. P. Guiard
contributes a comprehensive review of the mode of action and
therapeutic value of hectine (sodium benzosulphone-paraamino-
phenylarsinate) in the treatment of syphilis. He devotes special
attention to the local inflammatory or painful reaction which is
produced by this remedy. The article is accompanied by a de-
tailed study of a number of cases, illustrating the action of hec-
tine. As is well known, hectine is an organic arsenic compound,
discovered by Mouneyrat, about two years ago. This product
is claimed to be much less toxic than atoxyl and arsacetine, and
is said to be well borne by the tissues, without any serious dis-
turbances. The author's personal experiences with hectine lead
him to conclude as follows :
(a) The Physiologic and Toxic Effects of the Remedy.
Hypodermic injections of hectine, even in daily doses of 0.2 gram.,
can be repeated as often as 30 times in succession, without pro-
ducing the slightest untoward action upon the general system.
On the contrary in this dosage, 30 injections of hectine seem to
have a favorable influence upon the economy, to produce favorable
nutritive changes and to contribute to the patient's strength. In
3 of the patients, an increase in weight of a noteworthy character
was noted.
(b) Effects Upon Eyesight. — Some of the other organic
arsenic compounds, have, as we know, given rise to some severe
complications, on the part of the eye, including in some instances,
complete blindness. Slight and transient disturbances of vision
have indeed been noticed with hectine, but in the author's ex-
perience, the eyesight was not affected in any way, in any of the
cases treated with this remedy.
(c) Local Reactions. — These varied considerably, according
188 THE AMERICAN JOURNAL OE UROLOGY
to the location of the injection. There was almost no reaction,
or at least a pain which could easily be borne when the remedy
was injected intramuscularly into the buttocks. On the other
hand, the local disturbances were much more severe when the
remedy was injected into the genitals, as in cases of chancre. At
first there is more or less severe burning, followed by an intense
neuralgic pain, which lasts for a number of hours. A local irrita-
tion is also noted in the cellular tissue, which is followed by local-
ized indurations, variable in size. Sometimes the skin over these
indurations turns red, but it rarely ulcerates and usually the hard
nodules are absorbed within a few days.
The local use of hectine, without the use of internal treat-
ment is in itself sufficient to abort syphilis. This has been the
experience of the present author. He considers this property of.
hectine as the most important of all its virtues. The only cri-
terion for a completed cure which he acknowledges, is the total
absence of any visible lesions. He does not regard the presence
or absence of the Wassermann reaction as of any distinct value in
this connection.
ANN ALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Vol. XXVIII, I, No. 3, February 1, 1911
1. The Operative Treatment of Stones in the LTreters. By Dr.
Fabbricante.
2. A L^nique Case of Congenital Malformation in the Urethra
Detected by the Urethroscope. By. J. Chadzynski.
3. Knotted Bougies in the Bladder and the Urethra. By O.
Pasteau.
4. Supernumerary Kidney Diagnosed in Vivo. By A. Isaya.
1. Treatment of Stones in the L'reter. — Fabbricante
says that the surgery of the ureter has developed only within the
past twenty years, although as early as 1856, Gigon advised the
opening of the ureter, the removal of a stone and the establish-
ment of a fistula by sewing the end of the ureter to the skin. This
idea, however, did not meet with favor. The author reports a
case of stone in the ureter in a girl aged 17, upon whom he oper-
ated in October, 1908. An incision was made, beginning about
2 fingers' breadths above the iliac crest, a little behind the axillary
CURRENT UROLOGIC LITERATURE
189
line, and curving towards a point situated a little above the
anterior superior iliac spine, travelling then parallel to the liga-
ment of Poupart. and ending near the rectus muscle. The mus-
cles and fascia were divided down to the peritoneum, and the latter
was detached as far as the median line. The ureter was easily
found and was followed down as far as the bladder. Attempts
were made to milk the stone into the bladder, but this proved im-
possible. It was possible, however, to force the stone upward to
some distance. An incision was made over the ureter at the point
where the stone was situated, and a calculus, of the size of a
plum-pit was easily extracted. The ureter was then explored with
a probe up to the pelvis and down to the bladder, without encoun-
tering any obstacle. The canal was therefore sutured in such a
manner as to transform the longitudinal incision into a trans-
verse. The patient made a good recovery.
Reviewing the literature of the subject, the author finds but
two cases in which calculi have been removed from the ureter only.
There are a great many more cases in which, in addition to
ureteral calculi, stones are present in the renal pelvis. Stones in
the ureter alone, are comparatively rare, and often give rise to
no symptoms of any account. Whenever we encounter a renal
colic it is necessary to examine, not only the kidney, but also the
ureter, throughout its entire extent. The best method of diag-
nosis, in searching for stone in the ureter, is undoubtedly radio-
graph}', but clinical symptoms should not be neglected. A stone
which has passed beyond the pelvis is usually arrested at one of
three points of constriction which are normally present in the
ureter. The first of these is located about one cm. beneath the
pelvis, a.t what is known as the neck of the ureter. The second
point is located at the level of the iliac crest, while the third is
situated at the point where the ureter penetrates into the bladder.
Besides these three points, which are favorite resting places for the
stone, the latter may also be arrested at the point in the ureter
where it originally developed. This applies, of course, to stones
which are primarily ureteral. The most preferable method for the
extraction of ureteral stone is the extra-peritoneal. The best in-
cision is that which gives the greatest facility of access over the
entire course of the ureter, namely, the incision described above.
In specially favorable cases, however, an attempt may be made to
190 THE AMERICAN JOURNAL OF UROLOGY
remove the stone through the vagina. If the stone has been dis-
covered in the ureter, this canal need not be separated from the
peritoneum, but should be opened by a small incision, and the stone
should be extracted without enlarging the incision, if possible.
The ureter should be carefully sutured and then the abdominal
wall closed layer by layer. A small drain should be left in place
at first.
2. Ax Unusual Case of Congenital Malformation of
the Urethra Discovered with the Endoscope. — Chadzyiiski
reports an unusual malformation which he happened to detect
through the endoscope, in a case of chronic urethritis and pros-
tatitis. The malformation was not detected until the third ex-
amination of this patient with the endoscope, when a tube of large
calibre was used. The first impression was that there was a
marked fold of the mucous membrane in the visual field, but when
the tube was moved to one side, a ridge, two or three millimeters
in thickness was discovered, which on further examination, proved
to be a band of tissue inserted above and below, but arching over
a portion of the urethral mucous membrane. The patient did not
feel any inconvenience as a result of the presence of this anomaly,
nor did it interfere with the passage of sounds or dilators. The
recess underneath it was not infected, and there was no inflam-
matory zone around it, nor any secretion in the folds alongside
the band. A platinum wire was passed beneath the band, so as to
make sure that it was free from adhesions, save at its two ex-
tremities. The author consulted a number of his colleagues who
have had much experience with the endoscope, but they all declared
that they had never encountered a similar anomaly in their work.
A search of the literature was also unproductive of any evidence,
that such anomalies have been recorded, save a quotation in a
thesis published in 1905, by Foisy. This author mentions the
fact that, as early as 1856. Jarjavay, described the formation of
bands or folds in the urethra, and mentions the fact that he had
met with a case in which there was a diverticulum situated imme-
diately in front of the prostatic portion and limited below by a
valve, thus presenting a pocket which was open towards the bulb.
The present author has noted three cases in which the valve and
pocket described by Jarjavay, were present in the prostatic por-
tion.
CURRENT UROLOGIC LITERATURE 191
It is possible that some of the cases of persistent chronic
urethritis are due to the presence of such pockets, in which the
gonococcus find a convenient hiding place. In the present in-
stance, as has been said, there was apparently no infection in the
pocket under the cord, but the patient insisted on having the
cord removed, after he had heard that this anomaly was dis-
covered. Accordingly, the upper attachment of the band was
severed by means of a curved galvanocautery tip, which was in-
troduced under the band. The lower attachment, was severed
by means of a snare. The patient was operated on March 12,
and examined again on the 22nd. At the site of the upper attach-
ment, there was a minute white elevation, the lower attachment
being hidden in a fold of the mucous membrane. The cautery tip
could be introduced to a distance of over a centimeter, into the
fold, representing the pocket under the band which had been re-
moved.
3. Knotted Bougies in the Urethra or the Bladder. —
Pasteau speaks of an accident which may occur in connection with
the introduction of filiform bougies. In a case, which he reports,
the bougie became knotted in the urethra. A man of 30 years of
age, with multiple strictures, came to the hospital to have his
urethra dilated. After several attempts, a filiform was intro-
duced into the stricture, but when the time came for removing
the bougie, the latter was found to be held back at the level of
the perineum. The bougie could not be pulled forward nor pushed
backward. By palpating the urethra, a small irregular nodule
was felt along the bougie in the perineum. A more careful pal-
pation disclosed the fact that the bougie had become knotted.
Urination was impossible, and it was evident that the bougie would
have to be removed at once. Two methods suggested themselves.
Internal urethrotomy, which could be performed if it were pos-
sible to introduce a new filiform guide alongside the knotted
bougie. Over this filiform guide, a urethrotome could be intro-
duced and the obstruction severed. . The other method, which was
indicated if the first proved impracticable, was external ureth-
rotomy. After several attempts, a filiform guide was introduced
and internal urethrotomy was performed, allowing the removal
of the knotted bougie. An indwelling catheter was then intro-
duced, and the patient made an uneventful recovery.
192 THE AMERICAN JOURNAL OF UROLOGY
Observations of this kind are rare. The author was able to
find but one similar case reported, in which the bougie was knotted
in the urethra. Several cases, however, had been reported, in
which a filiform was knotted in the bladder, and the present
author gives brief summaries of three such cases.
The manner in which these bougies become knotted has been
a subject of discussion. Some believe, with Poulet, that the knot-
ting occurs as the result of a contraction of the bladder walls.
Others, like Desnos, believe that the knotting is the result of a
too rapid evacuation of the bladder, whereby the flow of urine
plays against the bougie and gives rise to the formation of a more
or less complicated knot. Others, like Lebreton, blame the acci-
dent upon the fact that the bladder is too small or contracted, so
that the bougie is bent upon itself within its cavity, but does not
find sufficient room to bend without knotting. In such cases, the
precaution should be taken to distend the bladder, after the
bougie has entered it. Others still, like Poncet, believe that the
formation of the knot is simply due to a twisting of the bougie
at the moment of its introduction. While this explanation may be
admissible for knots formed within the bladder, it does not seem
to apply to those formed in the urethra, unless there be some
dilatation of this canal, in which the bougie may twist and bend,
and thus form a knot.
The author has tried to find out how such an accident could
happen in the urethra. For this purpose he has examined the
ends of filiform bougies, which had been introduce^ in some diffi-
cult cases of stricture, and in this manner he has been able quite
readily to prove how such knots were formed.
Assuming the presence of a very narrow stricture, the bougie
encounters the narrowing, and if some efforts are made to intro-
duce it, it may bend upon itself. If there is no anterior stricture,
or if the anterior stricture is easily entered, the end of the bougie
will simply come out at the meatus. If on the contrary, there is
a stricture behind the first, the bougie is again arrested and again
bends upon itself, but in the opposite direction. As an example,
the author cites the case of a man, aged 49, and shows the manner
in which the filiform bent in this case in the accompanying dia-
gram. (Figs. 1 and 2.)
It must be remembered that, if in this case, a bougie had been
CURRENT UROLOGIC LITERATURE
193
used, the end of which was twisted in the form of a spiral, one
would have a condition which favors the formation of a knot, as
shown in Fig. 3. The knot would be pulled tight between the
two strictures by any effort to remove the bougie from the urethra.
The conditions which are necessary for the formation of a knot in
a filiform bougie in the urethra are, two strictures, — one in front
of the other, the knot always being formed between the two. If
the first stricture is not very tight, the knot does not interfere
with the removal of the bougie ; if the stricture is tighter the
removal of the knotted bougie becomes impossible. If gentleness
be employed in the exploration of the urethra, this accident will
be exceptionally met with. It is well, however, to remember the
following principle: In cases of stricture, after a filiform bougie
has been felt to impinge against an obstruction, if there is any
reason to suppose that the bougie has become folded upon itself,
it is better to remove it completely before trying to pass the
obstruction, so that the risk of causing the formation of a knot
in a bougie may be avoided. If we have a case before us, in which
194 THE AMERICAN JOURNAL OF UROLOGY
a knot has already formed in a filiform bougie in the urethra, our
conduct should be as follows :
{A.) If urination can take place alongside the bougie, the
latter may be simply allowed to remain in place. Its sojourn
in the canal may soften the obstruction, enlarge the opening, and
enable us to remove the instrument within a day or two.
(B.) If urination is impossible, with the bougie in place, we
must resort to urethrotomy. If we can pass a guide, alongside
the bougie down to the bladder, and over this guide a urethrotome,
internal urethrotomy should be performed. It is well to be sure
after this operation, that the knotted bougie has been extracted
in its entirety, and that no segments of it have remained in the
canal, after having been severed by the blade of the instrument.
If internal urethrotomy cannot be performed, external urethrotomy
is indicated. The knot is then easily detected and cut off.
4. Supernumerary Kidney Discovered During Life. —
Isaya, reports a case in which a third kidney was discovered dur-
ing the patient's life. The presence of a third kidney is the least
frequent of all congenital anomalies of this organ. In most cases
reported, the third kidney was discovered at autopsy, and there
are but few instances on record, five in addition to the present one,
in which the third kidney was discovered during life. In the pres-
ent case, the patient was a woman aged 27, who since the age of
6, had been complaining of pain in the right loin, corresponding
to the region of the kidney and radiating downward towards the
pubis. This pain recurred in attacks at intervals of about two
years, and was accompanied always by bilious vomiting. There
were never any disturbances of urination, nor any jaundice during
the attacks. Seven months before admission, the patient had been
examined by a physician who discovered an abdominal tumor,
situated on the left side in the hypogastric region, and easily
movable without pain. The tumor had not grown larger, but
the patient complained of a sense of weight and of pain in the
abdomen, especially after meals and after exertion. She was also
troubled with constipation.
L'pon examination, a tumor was found about three fingers'
breadths to the right of the navel, of the size of a large egg,
hard, elastic in consistence, irregular in shape and not displaced
by the movements of respiration, but movable in every direction.
CURRENT UROLOGIC LITERATURE 195
The tumor, however, was hut slightly movable upward, and by
energetic maneuvering was displaced towards the right side under
the arch of the ribs. The intestines, when dilated, were found to
lie in front of the tumor. On bimanual palpation on the right
side, it was noted that the kidney on that side was slightly dis-
placed downward, but it was not enlarged, nor painful. The
probable diagnosis of a benign mesenteric tumor was made. A
laparotomy was performed and a third kidney situated on the
right side of the spinal column was found. This organ was of the
size of an egg, shaped like a bean, and had its own vessel and
ureter, which after an independent course of about five centi-
meters ended in the right ureter. The supplementary kidney was
normal in appearance and the patient's pains were probably due
in large part to a prolapse of the transverse colon. Therefore,
the third kidney was left alone, and the colon was replaced in its
normal position. The left kidney did not show anything abnor-
mal. On examining the patient some days later through the
cystoscope, two apparently normal ureteral orifices were found.
ANN ALES DES MALADIES DES ORG AXES
GEXITO-URIXAIRES
Vol. XXVIII, I, Xo. 4, February 2, 1911
1. The Phenolsulphonephthalein Test for Renal Function. By
L. G. Rowntree and J. T. Geraghty (to be continued).
2. Modern Instruments for Suprapubic Cystotomy. By F.
Cathelin.
2. Modern Instruments for Suprapubic Cystotomy. —
Cathelin presents a number of improved instruments for the opera-
tion of suprapubic cystotomy. This procedure is now used less
than formerly, but still it is important to reduce its technique to
the most convenient form. As a matter of fact, the suprapubic
operation of opening the bladder can be performed with almost
no instruments. Yet, it is useful to have special tools for this
purpose, because they enable the surgeon to operate conveniently,
even in cases with very small and very extensively diseased blad-
ders. For this purpose the author has devised six instruments,
which with the six other tools that are necessary for any opera-
196 THE AMERICAN JOURNAL OF UROLOGY
tion, constitute the entire armamentarium necessary for this pro-
cedure.
The six ordinary instruments primarily needed are, a rather
large scalpel, a mouse tooth forceps, a pair of straight scissors
of good size, a bent Reverdin needle, and two rather long
Kocher's forceps.
The special instruments are six in number, but only four of
them are indispensable for suprapubic cystotomy. These are :
(1). A tunnelled hollow metallic catheter with stop-cock.
This instrument has a Benique curve, with a tunnel upon its con-
vexity, and two large eyelets near the beak. The stop-cock is
placed near the proximal end. The advantages of this instru-
ment is that it enables us to wash out the bladder, or to fill it with
water or air without the necessity of having an assistant, holding
an ordinary catheter in the meatus, so as to allow us to inject air,
for example. The curve is purposely made so as to allow easy
entrance in cases of enlarged prostate. This is not a matter of
indifference, because in many cases, the operation is performed in
old men. The beak is useful when a guide is wanted by the sur-
geon before entering a small thickened bladder, which will not
distend and which is difficult to distinguish from the neighboring
tissues. The tunnel has been provided for cases of external
urethrotomy, the groove being intended to receive the point of
the knife as it cuts into the urethra.
f (2). ]A modified self -retaining retractor, with small bent
blades. — -This retractor is only a modification of that commonly
employed. The latter has the disadvantage that on account of
its large blades, it cannot easily penetrate through a small in-
cision. Personally, the author strongly advocates very small
incisions. The blades of the retractor are therefore half the size
of those ordinarily employed. The incision used by the author
extends only three or four centimeters above the symphysis. Fur-
thermore, the author has had small hooks placed upon the spread-
ing arms of the self-retaining retractor, with the aid of which the
sutures which hold the bladder edges open can be fastened.
(3). Bladder Forceps. — Instead of the old suspensory
sutures which are so inconvenient, the author employs a narrow
bladed forceps, 22 centimeters in length, and provided with one
serrated blade and one smooth blade. This forceps has great
CURRENT UROLOGIC LITERATURE
197
advantages, over suspensory sutures, which damage the walls of
the bladder. Thanks to its length, the forceps can be handled the
moment the incision into the bladder has been made, and it does
not interfere with the field of operation. The forceps does not
cause any traumatism, nor does it injure the operator's fingers,
while these are engaged within the bladder. The forceps there-
fore, is superior to those of Pean and of Kocher, which caused
tearing of the walls, and to the mouse-tooth forceps, which may
injure the operator's fingers.
(4) . Retractor, with small straight and long blades. This
retractor is composed of two ordinary spreading arms, working
upon a ratchet, and with finger-grips, but its blades are straight,
narrow, and their ends are bent at right angles, like those of a
Farabeuf retractor. They may be called automatic Farabeuf
retractors, and their advantage is, that they separate not the
walls of the bladder, but the two lips of the opening, which always
tend to adhere to each other.
(5) . Vesical depressor. — This instrument is designed to be
attached by its fixed portion to the retractor with small bent
valves. It consists of two portions, a handle, and a blade which
plays in a hinge wherein its position can be adjusted with the aid
of a ratchet wheel. The advantage of this depressor over the fixed
retractor, is that it can be adjusted in such a manner as to be out
of the way, and to allow the operator to inspect the posterior as-
pect of the bladder.
(6) . Prostatic forceps. — These are designed for the removal
of the prostate after enucleation. The forceps consists of a very
long shank, facilitating their use in very fat patients. The
blades are rectangular fenestra, serrated and with smooth slightly
bent edges at the distal end. These forceps work very satis-
factorily.
The six instruments above described, which have been devised
by the author, have given very good results in his operative
work. He advises surgeons who have to perform suprapubic
cystotomy in many cases to adopt them. Their apparent com-
plexity is compensated by the great security of technique which
they make possible.
198 THE AMERICAN JOURNAL OF UROLOGY
FOLIA UROLOGIC A
Volume V, No. 8, February, 1911
1. Contributions to Freyer's Method of Prostatectomy. By Paul
Steiner.
2. Contributions to the Histology of Hypertrophy of the Pros-
tate. By D. Veszpremi.
3. Instruments for the Treatment of the Posterior Urethra. By
F. Dommer.
1. Contributions to Freyer's Method of Prostatec-
tomy. Steiner contributes a very comprehensive review of his
work with Freyer's method of prostatectomy. He has performed
this operation in 43 cases, the ages of the patients varying from
52 to 78 years. Steiner believes that the operation is not indi-
cated in the first stage of prostatic hypertrophy, save in the
cases showing some evidence of malignancy. When a radical
operation has been decided upon, we must remember that the re-
moval of the prostate must be so managed that the obstruction
will be permanently done away with. Of the two methods, the
suprapubic is to be preferred in suitable cases. In reviewing the
history of the operation, the author credits Fuller (1895) and
Frever (1900) as the first to perform total removal of the pros-
tate by the suprapubic route ; but he properly states that Freyer
has contributed much to the elaboration and popularization of
the operation.
The patients should be carefully prepared. In the first
place, they should be thoroughly examined as to the condition of
their heart, lungs, digestion and kidneys. In patients with ad-
vanced years, one frequently meets disease of the arteries or the
heart muscle. If the condition of the circulation is one that can
be improved, the proper stimulants should be given, such as digi-
talis and camphor. The condition of the kidneys and of bladder
requires special attention and the functional conditon of the kid-
ney should be tested, if possible, although this is not easy, owing
to the difficulty attending the passage of ureteral catheters. It is
best to improve the condition of the bladder, and to reduce the
residual urine as much as possible before operation, by employing
careful irrigations, and systematic catheter life. Often the pa-
tients will improve remarkably under these measures.
In cases in which the patient is evidently septic, and remains
so even after the local measures outlined above, a preliminary
suprapubic incision should be employed. The operation, there-
CURRENT UROLOGIC LITERATURE
199
fore, will be carried out in two stages in such patients. Fre-
quently, after the first incision, careful drainage will remove the
septic condition and will greatly diminish the shock of the second
operation. The latter should be undertaken when the patient's
general condition improves, when his urine grows clearer, and
when the function of the kidneys becomes more normal. Usually
the interval between the first and the second stages will be from
four to eight weeks. Internally, such patients also should be
given urinary antiseptics.
Regarding the technique of the operation, the author favors
lumbar anesthesia with tropococaine. He records no unpleasant
incidents, even in cases of men over 65. Only in two cases did he
have occasion to supplement this method with ether inhalations,
and then merely with a few whiffs of ether. The position of the
patient favored by the author is that of a moderate degree of
Trendelenburg's posture.
The field of operation is surrounded with carefully adjusted
cloths, a screen being drawn in front of the patient's face, and
another cross the body over the symphysis. The latter serves to
isolate the field of operation from the assistant who manipulates
the rectal part of the operation. A solution of mercury oxy-
cyanide 1 :2000 is used to wash out the bladder. Care is taken
that no fluid remains in the bladder. The latter is not filled with
air until after the abdominal muscles have been divided, as this
allows the operator to regulate the degree of distension, under the
guidance of the eye.
The bladder is opened in the usual manner, and the sides of
the opening are fastened with the aid of two silk sutures held by
an assistant with clamps. Much care is taken not to injure the
prevesical peritoneal fold, and the opening in the bladder is sur-
rounded by strips of sterile or iodoform gauze. The bladder is
opened, either by a longitudinal or a transverse incision. The
cut is made rather small and high up towards the apex of the
organ. Any urine that may have accumulated is carefully re-
moved from the cavity by means of sponges. After putting the
retractors in place the prostate is enucleated according to Frey-
er's method. The chief point is the finding of the proper stratum
for this enucleation. If the finger gets into the right layer, there
is no trouble, and we avoid removing the prostate piecemeal. If
possible, the entire gland with the prostatic urethra is removed.
It is advisable not to tear the membranous urethra, but to cut it
off with scissors. After the removal of the gland, the hemor-
200 THE AMERICAN JOURNAL OF UROLOGY
rhage can be arrested by compressing the prostatic lodge. If the
hemorrhage is severe, massage of the cavity of the prostate may
be tried. This is done by making counter-pressure between one
finger in the rectum and a finger in the other hand in the pros-
tatic cavity, massaging the parts between for about five minutes.
Irrigation with very hot boric acid solution is also a good method,
although it may carry infection from the bladder into the tissues
immediately around the prostate. Another way is to pack the
cavity with gauze, saturated in a solution of adrenalin, the end of
the gauze being carried out externally through the wound. Still
another method which is not to be recommended, however, is the
use of an iodoform and antipyrin tampon (according to Miku-
licz) in the bladder. The trouble with this method is that the
drugs mentioned are not well borne by some of the patients whose
kidneys have been impaired. The best method is simply to tam-
pon both prostatic cavity and bladder with sterile gauze strips.
During the packing of the prostatic cavity? an assistant should
make counter-pressure through the rectum, and control the com-
pression. The packing may be removed after three or four days.
As regards drainage, the best method involves the use of
Freyer's tube with two lateral windows, but we should take care
that the tube should not reach down to the prostatic cavity, other-
wise there will be interference with healing and pain. The drain
should not touch the posterior wall of the bladder, otherwise there
will be tenesmus. A properly adjusted drain should reach only two
or three cm. into the bladder. The chief point in the success of the
method is the adjustment of this drainage-tube. The latter should
not be stitched to the muscles or skin, nor to the bladder, but
should be allowed to rest in the wound, which may be reduced in
size to the proper diameter. The author does not use any per-
manent catheters after the operation, because the Freyer tube
gives good drainage, while the permanent catheter often produces
inflammation and suppuration in the prostatic cavity. He never
uses perineal drainage in these operations. As regards the clos-
ure of the wound, Steiner believes that it is best t^ nThm it to heal
without any sutures, and packs iodoform strips so as to drain the
cavity of Retzius. The wound is covered with gauze and cotton
and binders are applied. The saturated gauze is removed daily.
In order to prevent eczema around the wound he is in the habit of
applving an ointment of xeroform. A useful adjunct to the tube
is an outlet made of hard rubber and bent at right angles which
carries the urine into the receptacle placed between the patient's
legs.
CURRENT UROLOGIC LITERATURE 201
The chief elements in the after-treatment which Steiner em-
phasizes are that the patient be allowed to get up as soon as
possible, that the gauze over the wound be changed frequently,
that the wound itself be protected and that external cleanliness is
of extreme importance. Irrigations through the tube are not
necessary? provided the tube be kept free from clots with the aid
of a dressing forceps. The tube is removed on the fifth day,
together with the drainage strips, and a smaller tube is introduced
which is removed after two weeks. Gradually the abdominal
wound closes and usually has healed entirely on the 18th to the
30th day. The healing may be hastened by an indwelling catheter
in the urethra, but the author does not favor this. After the
wound has healed or almost closed the patient gladly takes pro-
longed lukewarm baths. Some patients can sit up, even on the
day after the operation, and as soon as possible they are allowed
to walk.
Incontinence of urine is a rare complication in these cases and
is due to the tearing of the membranous urethra. Incontinence
may be only temporary. Fistulae of the bladder are seen chiefly
in cases in which the wall of the bladder has been sutured to the
abdominal muscles. In none of the author's cases was there a
fistula of this kind, and he attributes this to his practice of avoid-
ing these sutures.
In speaking of the influence of prostatectomy upon the sexual
function, the author emphasizes the fact that in the suprapubic
method the ejaculatory ducts and their surroundings are left in-
tact. The advantage of Young's perineal method is that he saves
these parts, even after removing the prostate through the perin-
eum. It is upon the preservation of the floor of the prostatic
urethra and its anatomical features that the preservation of the
sexual function depends. In a number of cases elderly patients
have been sexually improved by the operation. In summarizing
the results of the cases in which he performed the Freyer opera-
tion, the author gives the following figures : Eleven patients
were operated upon in the stage of complete chronic retention with
aseptic bladder; ten of these recovered. Nine patients were
operated upon in the stage of chronic complete retention with in-
fected bladder, and of these six recovered. Four patients were
operated upon in the stage of chronic incomplete retention, with-
out distension of the bladder and without infection, and all four
recovered. Fifteen patients were operated upon in the stage of
chronic incomplete retention without dilatation of the bladder,
and with infection. Of these ten recovered. Four patients were
202 'THE AMERICAN JOURNAL OF UROLOGY
operated upon in the stage of chronic incomplete retention with a
distended bladder, and three of these were cured. In all the re-
covered cases, the cure was complete and permanent.
2. Contribution to the Histology of Prostatic Hyper-
trophy.— D. Yeszprcmi examined the prostates removed by
Steiner whose report appears in the preceding article. As the
result of the histological study of these prostates, the author con-
cludes that the hypertrophied gland does not assume any charac-
teristics which might be seriously considered as representing a
true tumor such as an adenoma. Nor does the microscopical pic-
ture prove the presence of an inflammatory process. In the few
cases in which the histological examination showed signs of an
advanced chronic inflammation, the prostate showed lesions which
were characteristic of a sclerosis rather than of a true prostatic
hypertrophy.
3. Instruments for the Treatment of the Posterior
Urethra. — Domraer describes a set of instruments which he has
adopted for use with the Wossidlo urethroscope for the posterior
urethra. In describing their instruments both Wossidlo and Gold-
schmidt intended their appliances especially for the examination
of the posterior urethra. Both authors succeeded, each in his
own way, in securing this end. The author familiarized himself
thoroughly with the method of examination and the appearances
of the parts visible with these instruments, and it occurred to him
that it would be desirable to have an electrode which could be em-
ployed for the local treatment of the colliculus. This electrode is
adjustable to the Wossidlo instrument projecting from the win-
dow of the latter in such a position that it impinges upon the
seminal hillock when the latter is in the window. Another appli-
ance devised by Dommer is a small curette which enables one to
treat the same portion of the urethra locally. A small urethro-
tome was also devised by the author for use with the Wossidlo
instrument. The latter is made somewhat larger than the original
instrument, so as to facilitate the manipulations through its tube.
All these local measures can be applied through the Wossidlo in-
strument, directly under the control of the eye, much in the same
manner as the appliances devised years ago by Kollmann.
The author recommends the use of the electrode and the
curette. The knife is not so frequently required in the posterior
urethra, as strictures in this part of the canal are usually suf-
CURRENT UROLOGIC LITERATURE 203
ficiently soft to allow of distension by sounds or dilators. The
curette is useful in the removal of soft infiltrations and ulcerated
processes.
ANN ALES DES MALADIES DES ORG AXES
GEXITO-URIXAIRES
Volume XXIX, Sec. 1, Xo. 5, March 1, 1911
1. Polycystic Kidneys. By Professor Pousson.
2. An Instrument for the Exact Application of the Separator in
Women. By D. Taddei.
S. Experimental and Clinical Study of the Function of the Kid-
neys with Phenolsulphonephthaleine. By L. G. Rown-
tree and John T. Geraghty. (Concluded.)
1. Polycystic Kidneys. — Pousson reports a case of multi-
ple cysts of the kidneys. The patient was a woman aged 34,
who in July, 1909, felt a sudden pain in the region of the left
kidney. At first the pain was violent and later subsided some-
what, but continued for two months, being especially severe when
the patient stood up. She remained in bed most of the time, had
severe gastric disturbances and continued headaches. The
woman herself noticed that there was an increase in the size of
the left kidney and her physician, upon examination made a diag-
nosis of hydronephrosis. There was albumin in the urine. After
two months she gradually began to get up and wore a belt which
helped her a good deal. In April, 1910, without cause she was
suddenly seized with a new painful attack on the left side, accom-
panied by vomiting, headache and sometimes violent cramps in
the ankle. Since then she has had constant but less severe lum-
bar pains, while the headaches and cramps also continued.
On examination, we found her to be a woman with marked
emaciation. On the right side a kidney increased in size was felt
which was smooth, movable, not acutely painful, and could not be
replaced in the lumbar fossa. On the left side, the kidney was
equally well felt, but much larger, filling the entire lumbar fossa
in which it was fixed, and presenting a nodular surface. This
kidney was very painful to the touch.
There was no disturbance of urination, save that it was some-
what more frequent at night. The urine was dark and clear,
with diminished quantity, and contained some albumin. There
was an increase in the size of the kidneys on both sides, espe-
204 THE AMERICAN JOURNAL OF UROLOGY
cially on the left. The diagnosis of multiple cysts of the kidney
was made provisionally.
Some thirty years ago, it was thought quite impossible to
make a diagnosis of this disease, which was usually discovered at
autopsy. To-day, we have some methods at our command which
assist in the diagnosis. For example, the comparative study of
the functional condition of the kidneys, and the radiographic
study of kidney shadows. In the five cases of cystic kidney diag-
nosed during life by various authors up to 1896, the symptoms,
while not perfectly characteristic, were very suggestive. Since
then Ferron, in 1908, has added a number of similar cases to the
collection now existing in literature. The similarity of the symp-
toms of these kidneys with those of chronic nephritis is striking
in many cases. These patients often exhibit marked general
weakness, pallor, dryness of the skin various peculiar skin sensa-
tions, loss of appetite, nausea, vomiting, headache, and disturb-
ances of vision and hearing. There are also attacks of shortness
of breath and oppression, muscular cramps, especially of the
ankle, etc.
The symptoms cited represent a more or less marked uremic
intoxication, but in addition there are symptoms which are refer-
able to mechanical interference with the circulation. These con-
sist of an increase of arterial pressure which results as in Bright's
disease; in a hypertrophy of the left ventricle, and sometimes in
dilation of the right ventricle.
The urinary disturbances which always must be looked for
in these patients, even when they seem to be absent, complete the
clinical picture and make it particularly similar to that of
Bright's disease, especially of interstitial nephritis. We fre-
quently find in these cases increased frequency of urination and
an increased amount of excretion, just as we do in interstitial
nephritis. In fact, it might be said that the cases reported in
literature do not allow any distinction between multiple cysts of
the kidney and chronic nephritis. Were it not for two symptoms,
which are met with in the former affection, namely the pain in
the lumbar region and the increase in the size of the kidney, it
would be difficult to distinguish these two maladies. Cases of
chronic nephritis with local pain arc exceptional. In polycystic
kidney, the tumor is usually bilateral, but more marked on one
side than on the other, and presents an uneven surface. The
nodular character of the tumor may be detected upon palpation or
with the X-rays. The bilateral character of the tumor and the
CURRENT UROLOGIC LITERATURE 205
pain is important in diagnosis, especially in differentiating from
stone.
One feature in polycystic kidney prevents us from detecting
these cases early, namely the very slow and insidious growths of
the cysts. In some cases the condition has been detected after
death from other causes, and no symptoms whatever have been
noticed during life which could be interpreted as belonging to
polycystic kidney.
The question of treatment in these cases is very important.
Medical treatment is usually of no value when there are symp-
toms of uremia, or violent pains, or when death is threatened.
The question of operation will then naturally arise. Until lately,
there has been a general opposition to surgical interference in
cases of polycystic kidney, because of the fact that the condition
almost always affects both organs, and because also of the false
conception of the origin of the cyst-formation. Various theories
have been held regarding this peculiar disease, but according to
the present author's opinion, the cysts are due to an inflammatory
process, although there must be some truth in the theory of a
new growth formation or degeneration. Surgery, therefore, also
seems powerless in checking the disease, yet it might be employed
to relieve complications and to combat symptoms which are suf-
ficiently severe to threaten the existence of the patient. The
indications for operation in such cases are the compression of
neighboring organs by the . tumor, severe pains, hematurias
uremia, and interference with urinary secretions or suppuration
of the cysts.
In the case reported in the present communication, the
operation of nephrotomy was performed chiefly for the relief of
pain, and for the diminution in the urinary secretion. Not only
has this woman borne the operation well, but her pains disap-
peared, the quantity of urine was increased, the headache and the
cramps in the ankle vanished.
2. An Instrument for the Accurate Application of
the Separator in Women. — Taddei describes an attachment to
the separator of Luys which makes it possible to apply that in-
strument with greater accuracy in women. He has used this
appliance for five years, and has had very good success with it.
The apparatus is made by Gentile at Paris.
It is a well-known fact that the apparatus of Luys is the best
separator for the bladder which has hitherto been devised, yet it
has one defect when used in women, namely that it easily slides
206 THE AMERICAN JOURNAL OF UROLOGY
about in the urethra, which is large in diameter. In men, on the
contrary the instrument is much more accurately maintained in
place, thanks to the narrowness and rigidity of the urethra. It
is difficult to apply the apparatus accurately in women, especially
in older women with relaxed pelvic tissues. In such cases, it is
difficult to make the curved part of the instrument hug the wall
of the bladder closely, unless we make counter pressure with a
finger in the vagina.
In consequence, the author conceived the idea of having an
attachment constructed which could be introduced into the vagina,
and would enable one to approximate the wall of the bladder and
the anterior wall of the vagina, thus giving the curved part of
the instrument something to rest upon. The new attachment
consists of a clamp which can be fixed to the outer end of the
separator and of a hinged lever which can be introduced into the
vagina and set at an angle with the separator with the aid of
a thumb screw. The vaginal portion of the apparatus consists
of a stem of solid metal and a curved concave portion which cor-
responds to the curve of the separator. After the separator has
been adjusted, with the clamp of the attachment in place, the
vaginal blade is set, so that the vaginal curve holds the wall of
the bladder in the vagina against the curve of the spectator.
The method of applying the instrument is simple. After the
usual preparations, the entire apparatus is sterilized, and after
the bladder has been washed and found to emit absolutely clear
fluid, the curve of the separator is introduced into the bladder.
After the separator membrane has been raised, the valve in the
vagina is adjusted. It is first passed into the vagina by an
assistant with the curve directed upward, and is then pushed
against the separator as it lies in the bladder. To make sure
that the instrument is in place, a slight pull is made upon the
handle and should show that the tissues are grasped securely so
that the instrument cannot slide.
The modified instrument is particularly applicable to cases
of cystocele, but is also useful in multiparae, in fact in any
woman. The same instrument slightly modified can oe used in
men, with the attachment introduced into the rectum. The in-
strument is simple and not costly. Unless the operation of sepa-
rating the urine be performed under the most rigid rules of tech-
nique the results are always uncertain.
3. The Phthaleine Test in the Functional Diagnosis
or the Kidneys. — Rowntree and Geraghty give the following
CURRENT UROLOGIC LITERATURE 207
technique for the application of the phthaleine test : — Twenty
minutes before the examination, the patient is given from 600 to
800 cc. of water for the purpose of promoting urinary secretion.
The ureters are then catheterized. As it is essential to collect
the entire urine secreted by each kidney during a definite period,
we have adopted in our work a special catheter. This catheter
is preferably a No. 6 or No. 7F Albarran catheter, with an end
shaped like the mouth-piece of a flute. Catheters which have no
beveled end-opening, but merely side openings, do not give abso-
lutely trustworthy results. In women, one may employ Kelly's
method of cystoscopy, and larger catheters which completely ob-
struct the ureter may be used. These catheters, however, cannot
be used in the male.
The catheter should be pushed into the ureter for a distance
of about 10 cm. The cystoscope should then be removed and a
thread should be attached to the catheter in the right ureter, so
that one can always recognize it. Next a small rubber catheter
should be introduced into the bladder, and the latter should be
completely emptied so that one can afterwards detect the slightest
leakage of urine alongside the urethral catheters. A specimen
of urine must then be taken from each side in order to make the
usual urinary examination. In many cases, the authors also took
samples at this point for the purpose of looking for the quantity
of creatinin.
In their earlier cases the authors injected subcutaneously
thirty milligrams of phthaleine, but in the more recent cases they
used only six milligrams. The time of the injection and that of
the first appearance of the drug in the urine are noted. After that
time the urine is allowed to collect for an hour. Its quantity and
its specific gravity are noted. One cc. is taken for the purpose
of determining the urea. Finally the quantity of phthaleine
eliminated is determined.
Upon the basis of their study of 42 cases of renal infection
the authors draw the following conclusions regarding the value
of the phenolsulphonephthaleine test :
1. The functional tests of the kidney, when carried out in
conjunction with a careful clinical study of the case, furnish with-
out any doubt information of great value upon the condition of
the kidney.
2. The phthaleine test, as practiced by the authors, pre-
sents many advantages over the tests which have been proposed by
others until the present date.
3. Phthaleine itself is better adapted for the functional
208 THE AMERICAN JOURNAL OF UROLOGY
diagnosis of the kidneys than any other substance which has hith-
erto been employed for the same purpose. The reason for this
lies in the prompt appearance of the drug in the urine and its
rapid and complete elimination by the kidneys.
■i. The method of estimating the quantity of the test sub-
stance excreted is simple and very accurate.
5. The permeability of the kidney for this substance is di-
minished in chronic nephritis, and the decrease is more marked in
the interstitial variety.
6. The test has proved of great value in showing the true
state of the kidneys of patients presenting urinary obstruction
of prostatic origin. In such cases the test is of greater value
than the study of the quantity of urine excreted, the amount of
total solids, of urea, and of the total nitrogen. The test allows
the surgeon to choose a time for operation when the kidneys are
in a satisfactory functional condition.
7. The improvement noted in the cases of prostatic ob-
struction by the use of preparatory treatment is demonstrated
remarkably by the phthaleine test, which also indicates the most
favorable time for operating.
8. In lesions of the kidney, the absolute quantity of labor
furnished by each kidney, and also the relative proportion and
work done by the two kidneys can be determined when the urines
are examined separately.
SEVENTH INTERNATIONAL CONGRESS OF DERMATOLOGY AND
SYPHILOLOGY, ROME, 18-23 SEPTEMBER, 1911.
In May, the final Program of the Congress will be published, giving all
necessary informations, the order of business, and the scientific articles of
each session.
In order to complete the Program those who contemplate attending the
meeting and read a paper, are requested to send the title of the same to the
Seceretary General, before the last day of April, together with a brief ab-
stract typewritten, to be placed on the program.
In reference to the special reductions of price, on the Italian Railways,
the members of the Congress will find a special ticket for sale in all the
Italian R. R. depots and Agencies at the price of 1. 10.50— $2.10. Together
with this special card a booklet will be sold with eight tickets, each one en-
titling the bearer to a trip at reduced rates from 40 to 60 per cent., according
to the length of the voyage. The booklet will be recognized for 45 days, and
the Coupons will be accepted on all trains.
In reference to Hotel accommodation the Committee of arrangement has
accepted the offers of Cook Agency (Esedra di Termini, Roma) and of
Chiari and Sommariva Piazza Venezia, Rome, who will assign the members
to the different Hotels, and give the addresses of the best Restaurants in
every Italian City.
The members are requested to write to either one of those agents and
state the class of accommodation they desire. A. Ravogli,
Secretary for the U. S. A.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII JUNE, 1911 No. 6
Contributed ly the Author to The American Journal of Urology.
SUMMARY OF RESULTS REPORTED FROM THE USE
OF VACCINES AND THE SERA OF GONOCOCCI
AND OTHER PYOGENIC ORGANISMS IN
UROLOGY.1
By R. F. O'Xeil, M.D., Boston, Mass.
THIS summary of results is based upon the consideration of
ninety-five general and special articles on vaccine therapy
which have appeared in the literature of the last few years,
upon personal communications and personal experience, articles
reviewed varied from careful and exhaustive studies of the subject
to the report of a case, or a series of cases, more or less accurately
followed.
First, as to the question of a stock or an autogenous vac-
cine: In gonorrhoeal infection in general most reports are that
a stock vaccine made from a good strain is as serviceable as an
autogenous one. In joint infections the autogenous is to be
preferred and used if possible. In other infections antogenous
vaccines are to be used.
To have any general application of this treatment in gonor-
rhoea, a stock vaccine would have to be employed, for the double
reason that the preparation of an autogenous vaccine requires
time and skill and in a chronic case it may be very difficult to
procure sufficient material to make a good one.
The limitations of the doses of the ordinary organism have
been pretty well worked out, so that now the regulation of the
amount and frequency of the dosage by the estimation of the
opsonic index seems to be unnecessary, quite as good results
i Read before the American Association of Genito-Urinary Surgeons, at
the Eighth Congress of American Physicians and Surgeons, 1910.
209
210 THE AMERICAN JOURNAL OF UROLOGY
being obtained when these are regulated by the clinical symptoms
and reaction.
Effects of Gonococcus Vaccine in Urethral Gonorrhoea. The
almost universal opinion is that vaccine treatment in acute and
chronic urethral gonorrhoea, whether a stock or autogenous vaccine
has been used, has proved to be of no value. That urethral dis-
charge is uninfluenced by vaccines has been noted by those treat-
ing cases of arthritis. For example, Hartwell says, " No effect
was noticed on urethral discharge, even in cases when local treat-
ment was withheld."
A few men have thought that their cases seemed to do better
when vaccine treatment was used as an adjunct, particularly in
the declining stage. These cases mostly received active local
treatment, and these impressions do not agree with the' larger
series of cases.
Ant i gonococcus Serum in Urethral Gonorrhoea. Precisely
the same statements apply to antigonococcus serum in urethritis.
Gonococcus Vaccine and Antigonococcus Serum in Locak
Gonorrhoea! Complications. Apparently favorable results in
epididymitis are reported by a few observers. They are not
many cases, and in most the ordinary methods of treatment were
employed as well. It is, therefore, difficult to say what role the
vaccines play in a condition which varies clinically to such an
extent as does this. Ke}*es believes that he has succeeded in a
certain number of cases in aborting the disease when he has
been able to minister the vaccine very early in the course.
In gonorrhoeal prostatitis and vesiculitis there is very little
to show that vaccines are of any benefit, except as has been
stated, that some men think their cases of chronic urethritis do
better when the vaccine treatment is added. Garton, in the
U. S. Naval Bulletin, 1908-09, reports a case of prostatitis of two
years' standing in which a cure was obtained in five weeks by the
use of a stock vaccine.
Vaccine therapy is, on the whole, of very doubtful value in
local complications.
Serum. Better results are reported from the use of anti-
gonococcus serum. In epididymitis, in Dr. Swinburne's hands,
the serum has been satisfactory, particularly in relieving pain.
VACCINES AND THE SERA OF GONOCOCCI 211
In twenty-seven cases of epididymitis the majority were relieved
of pain in forty-eight hours and almost all went on to complete
recovery. He also thought improvement was to be seen in one
case of acute prostatitis and a case of vesiculitis.
Rosenthal reports four cases of epididymitis, with one cure
and improvement in two cases; also four cases of prostatitis, with
improvement in two.
Autogenous and Stock Vaccines in Gonorrhoeal Septicemia.
In speaking of vaccine treatment in general, Thomas and others
say : " Never undertake the treatment by immunization in acute
diffused infection associated with septicemia, sapremia or marked
toxemia," for in these conditions the body is developing its own
immunity.
The following cases are of interest in this connection : Eyre
and Stewart report in the Lancet, July, 1909, a case of gonor-
rhoeal septicemia where the gonococci disappeared from the blood
under the use of an autogenous vaccine ; the patient was doing
well when death occurred from an infection with the pneumococ-
cus.
Dieulafoy reports in La Presse Medicate, in May, 1909, two
cases of gonorrhoeal septicemia, where the organisms were cul-
tured from the blood; the first case following a urethral infection,
the second a polyarticular joint infection. These cases were
treated with a stock vaccine with apparently good results, that
is, the temperature and symptoms subsided, although the gono-
cocci were present in the blood for some time. In each of these
cases typhoid fever developed before the patient left the hospital
and ran the regular course, ending in recovery ; the typhoid
appearing after the apparent clinical cure of the gonorrhoeal
sepsis. He believes the vaccines raised the patient's immunity.
These are the only reports I have been able to find and are not
a sufficient number upon which to base any definite conclusions.
I have found no reports of the use of antigonococcus serum in
such conditions.
The Effect of Gonococcus Vaccines and Antigonococcus
Serum on Joints. In a general summary of the results of gono-
coccus vaccine therapy, Ebright makes the following statement:
" The only lesions that respond with sufficient uniformity to put
212 THE AMERICAN JOURNAL OF UROLOGY
the treatment on a secure plane are the joint lesions." It is to
be combined with other forms of treatment and may be regarded
as an advance in therapeutics. The relief of symptoms, par-
ticularly pain, is often prompt.
Hartwell, in a careful studj^ of fifty-one cases, draws the
following conclusions : An autogenous vaccine is to be used, if
obtainable. Gonorrhoeal vaccines are valuable agents in all
stages of arthritis, except when anchylosis or other marked joint
changes have taken place. It is to be remembered that these
lesions show a varying clinical course. In nine acute cases with
.suppuration, six recovered with no other surgical measures but
aspiration. Vaccines do not produce immunity, as shown by
successive polyarticular infections.
There are many cases reported where apparently excellent
results have followed the use of the serum. Herbst considers it
of great value in toxemic joints, with the following restrictions:
The original focus should be cleared up before or at the same time
the serum is used. The serum should be used in sufficient quan-
tity, 24 to 30 c. c. A correct diagnosis must be made, remem-
bering that a non-gonorrhoeal rheumatic articular condition may
exist with a gonorrhoeal process.
In a personal communication, Dr. C. F. Painter of Boston
expressed the following view: He has found the vaccines to be
more efficacious in the early cases, and the serum in the later ones;
but because of the very varying clinical course of gonorrhoeal
arthritis, looked upon both as adjuncts to the treatment ordin-
arily employed.
Clinical Diagnostic Reaction. A point of considerable inter-
est is the value of the clinical gonococcal vaccine reaction in
diagnosis. Irons found that no reaction took place in eight non-
gonorrhoeal patients, even after the administration of large doses
(500,000,000), and that some suspected cases all showed re-
action and a focus of gonorrhoeal infection somewhere.
Others have noted the reaction following the administration of
vaccines not only in joints, but in other lesions, and have re-
garded it as a means of determining cure. If this is at all
constant, it would prove of distinct value, at any rate it should
be further investigated.
VACCINES AND THE SERA OF GONOCOCCI 213
Vaccines in Other Infections of the Urinary Tract. This
brings us to the consideration of the infections of the urinary
tract with other organisms, and the effects of vaccines on bac-
teriuria, and pyuria resulting from pyelo-nephritis, pyelitis and
cystitis.
Infections with the Colon Bacillus. The most important
organism in this connection is the colon bacillus. Before speak-
ing of the employment of vaccines it must be remembered that the
acute urinary infections tend toward recovery under internal
medication. It is a well-recognized fact that in cases which do
not recover there is some obstruction or abnormality in the
urinary tract interfering with complete drainage. Also, that
these chronic cases are very stubborn, run a varied clinical course
and are particularly liable to acute exacerbations. In regard
to the results of vaccine treatment in these conditions it would
seem, at present, as if a large enough number of cases had been
followed for a sufficient length of time to justify the following
conclusions :
In acute and subacute pyelitis good results are reported with
the remission of temperature and relief of symptoms, which is
entirely in accord with the ordinary clinical course of the disease
treated by the usual means.
In chronic pyelitis and pyelo-nephritis they have proved un-
availing. They do not prevent exacerbations, nor do they affect
the amount of pus or of bacteria present in the urine; the sud-
den fall of temperature and improvement in symptoms seen in the
exacerbations being due to the reestablishment of the temporarily
shut off drainage rather than to the action of the vaccines, and
are seen in cases when vaccines are not used.
In bacteriuria, even after long administration, they fail to
clear the urine of bacilli. In some of the milder bladder infec-
tions they have seemed to have given symptomatic relief, lessening
pain and frequency of micturition. In the more severe cases of
cystitis, with changes in the bladder wall, they have had no effect.
The reported results of anticolon serum are as yet too
meager from which to draw any conclusions.
Staphylococcus Infections. Bacteriuria, due to the sta-
214 THE AMERICAN JOURNAL OF UROLOGY
phylococcus, has proved just as rebellious as that due to the
colon bacillus.
There are a few cases reported of post-gonorrhoeal prostatitis
(Rooker and Robinson), in which the continuation of symptoms
has been due to the staphylococcus, where apparently good re-
sults have followed the use of a stock vaccine.
Other Organisms. A case of pneumobacillus pyelitis is re-
ported (Mills) which was treated with an autogenous vaccine
regulated by the opsonic index. This case appeared to be a self-
draining pyelitis which recovered. The urine contained bacteria
for some time, but they eventually disappeared.
A case of interest is one of pneumococcus urinary infection
which occurred at the Massachusetts General Hospital on the
service of Dr. F. C. Shattuck, who kindly gave permission to
quote it. An autogenous vaccine was made but not used, as
prompt recovery took place under the use of urotropin.
One case of ulcerative cystitis is reported (Rosenow), due
to a pseudo-diphtheria bacillus treated with an autogenous vac-
cine with seeming improvement. There was, however, in this
case drainage by a vesico-vaginal fistula.
A case of cystitis (Clarke), due to Gaetner's bacillus, treated
with an autogenous vaccine, recovered in ten days. The short
duration of this case makes it of little value.
A few cases of proteus infection of the bladder were treated
with negative results.
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Allen, R. W. 2d Ed., 1908, London. Vaccine therapy and the
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VACCINES AND THE SERA OF GONOCOCCI 215
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121-125.
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xv, pp. 614-629.
Stephens, E. L. Interned. Journ. Surg., New York, 1909, xxii,
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Vail, R. Illinois Med. Journ., Springfield, 1908, xiii, pp. 25-28.
Whitehouse. The Practitioner, London, April, 1910, p. 485.
216 THE AMERICAN JOURNAL OF UROLOGY
Whitmore, E. R. Philippine Journ. of Sc., Manila, 1908, iii,
pp. 421-430.
Articles on Use of Serum in Gonorrhoea and Complications.
Baumann, F. Chicago Med. Recorder, 1908, xxx, pp. 696-698.
Chassaignac, C. Am. Journ. Urol., New York, 1908, iv, pp.
381-385.
Rogers, J., and J. C. Torrey. Journ. Am. Med. Ass'n., 1907,
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635.
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825-827-
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687-688.
Thomas. B. A. Journ. Am. Med. Ass'n., 1910, liv, pp. 258-260.
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358.
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347-380.
Uhle, A. A., and W. H. McKinney. Journ. Am. Med. Ass'n.,
1908, li, pp. 105-108.
Articles on Use of Vaccines in Gonococcus Septicemia.
Dieulafoy, G. Presse med., Paris, 1909? x<v*ii, pp. 353-360.
Also: Bull., d'Acad. de med., Paris, 1909, 3 s., lxi, pp. 594-620.
Dieulafoy, G. J. de med. de Paris, 1909, 2 s., xxi, p. 383.
Dieulafoy, G. Internat. Clin., Philadelphia, 1909, 19 s., iii, pp.
59-70. This is an abstract from above translated.
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pp. 76-81.
Articles on Use of Uaccine in Gonorrhoea Arthritis.
Cole, R. J., and J. C. Meakins. Johns Hopkins Hosp. Bull.,
1907, xviii, pp. 223-232.
Hartwell, H. F. Annals of Surg., Philadelphia, 1909, 1, pp.
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VACCINES AND THE SERA OF GONOCOCCI 217
Robinson, W. J. Am. Journ. Urol., New York, 1 908-09, v, pp.
110-112.
Ravogli, A. Lancet, Clin, Cincinnati, 1908, xcix, pp. 530-533.
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Gayler, W. C. Journ. Am. Med. Ass'n., 1908, li, p. 674.
Herbst, R. H. Illinois Med. Journ., Springfield, 1909, xv, pp.
643-646.
Herbst, R. H. Journ. Am. Med. Ass'n., 1908, 1, p. 1678.
Myers, S J. Louisville Month. Journ., M. and S., 1 908-09, xv,
p. 376.
Plummer, H. E. Vermont Med. Month., Burlington, 1909, xv,
p. 71.
Perez-Miro, A. Therap. Gaz., Detroit, 1908, 3 s., xxiv, pp.
250-253.
Articles on Gonorrhoea! Vulvo-V aginitis.
Butler, W. J., and J. P. Long. Journ. Am. Med. Ass'n., 1908,
1, pp. 74-4-74-7; 1908, 1, pp. 1301-1304.
Butler, W. J., and J. P. Long. Illinois Med. Journ., Spring-
field, 1908, xiii, pp. 538-543.
Churchill, F. S., and A. C. Soper, Jr. Journ. Am. Med. Ass'n.,
1908, li, pp. 1298-1301.
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pp. 158-172.
Articles on Colon Bacillus Infections.
Butler, H. O. Lancet, London, 1909, i, p. 1681.
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Journ., 1968, clviii, pp. 37-85.
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Journ., 1910, clxxii, p. 409-415.
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Makins, G. H. Tr. Clin. Soc, London, 1907, xl, pp. 146-155.
218 THE AMERICAN JOURNAL OF UROLOGY
Routh, C. F. Brit. Med. Journ., London, 1910, i, p. 191.
Rollestone. The Practitioner, London, April, 1910, p. 439-
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Contributed by the Author to The American Journal of Urology.
YPHILIS has been known over 400 years, and for the same
length of time Mercury lias been used and recognized as
an excellent and efficient remedy against it. But al-
though in hundreds of thousands of cases the Etiology, Symp-
toms. Prognosis, and so on, have been thoroughly studied: until
lately many important questions still remained unsettled, so
that both physician and patient were often left in doubt at crit-
ical moments. How often have we wished to begin Mercurial
treatment at once, but had to wait on account of the dubious
character of the infection ! For it was a ticklish question to
settle whether the patient really had Syphilis or a harmless
lesion, which required no treatment, and one often waited weeks
and months for secondaries and so lost the best time for using
remedies ; for it is self-evident that the sooner treatment is be-
gun, the quicker and more certain will it be effective.
*Read before the " Hartford County Medical Society," Hartford, Conn.,
April 4. 1911.
Articles on Other Infections.
SALVARSAX IX SYPHILIS*
By Chas. S. Sterx, A.B., M.D.
SALVARSAN IN SYPHILIS „ 219
Syphilology has progressed more in the last seven years
than in hundreds of years before. In the first place, 1903,
Metschnikoff and Roux in Paris discovered that Syphilis could
be transmitted to animals, and by this means it became possible
to study exactly and clearly many questions which theretofore
were impossible to follow out. For intsance, what parts of the
body were most prone to be attacked, where the poison concen-
trated itself, if the animal was really cured after a certain rem-
edy was used, and whether, after an apparent cure, a so-called
immunity was established. (On the latter point, as a matter
of fact, it is now settled that if a patient is cured of Syphilis
he is not immune, but can again acquire the disease if exposed.)
Then (1905) came the great discovery by Schaudinn and
Hoffman of the Spirochete Pallida, the microscopic parasite
which he proved to be the cause of Syphilis. This discovery
enables us to make an early positive diagnosis in cases where
it was formerly impossible, and in this way we can start treat-
ment earlier.
Then came the great discovery of Wassermann, 1907, by
which a diagnosis of Syphilis, especially latent forms, can be
ascertained by examination of the blood. This is important in
its bearings on cases which have undergone treatment, and which
otherwise could not positively be declared cured ; important as
well for the purpose of continuing treatment, of knowing the
existence of Syphilis, and so forfending later dangerous lesions,
and yet again in deciding whether a patient is cured and able
to marry.
Lastly, in 1910, came a great step forward, in treatment
— the invention by Prof. Paul Ehrlich, of Salvarsan. The ef-
fectiveness of this new remedy to cure Syphilis has been so firmly
established within a short time, and the consequences thereof are
of such world-wide significance, that this may well be counted
one of the most important events since the turn of the 20th
century.
NH2 || I
OH OH
Dioxydiamidoarsenobenzol ! — by its inventor Ehrlich,
220 . THE AMERICAN JOURNAL OF UROLOGY
named " Salvarsan," has now been used for the treatment of
syphilitic patients about fifteen months, only the last four of
which has it been available by the profession at large. The
importance of my discussion concerning its value, therefore, is
necessarily restricted, because of the short time elapsed during
which all these observations have been made. Undoubted bene-
fit has followed its use in by far the largest number of cases;
but many reports give dubious or uncertain results, some claim
negative effects, while still others attribute actual harm from
giving " Salvarsan." A study of the various writers is unsat-
isfactory, even if we eliminate the numerous superficial reports,
which, crowding the recent plethoric literature on this subject,
are rather haphazard in their statements. For elements of er-
ror, in diagnosis, in application of the 606, and in the personal
equation of observers themselves, leave numerous definite facts,
for which we are seeking and waiting, still unsettled. How-
ever, we do know what Prof. Ehrlich established regarding the
remedy before it came into general use. In his laboratory, at
Frankfort on the Main, where I had the opportunity of spending
a little time, he first conducted a long series of experiments,
till he absolutely proved that the new substance cured animals
of Syphilis. He then, under certain restrictions, distributed
the remedy among some 500 reliable and well-known Professors,
principally in Germany, but also in other countries, and from
their reports he was satisfied that it produced the cure of Syph-
ilis in humans as well. While at the same time was demonstrated
that with proper care it could be used without danger. But
before permitting its general use it was tested out in some
30,000 cases, and he then gave it over to the manufacturers
for distribution to the profession at large, and expressed his
opinion concerning it, somewhat as follows :
" It is established with certainty that the preparation is
the mightiest specific against Syphilis. . . . Especially in
cases where former remedies have been unsatisfactory, or where
such could not be used longer. It is well known how wonder-
ful and magical the cures have been in just those severe syph-
ilitic headaches and throat troubles that have resisted the usual
remedies.
SALVARSAN IX SYPHILIS
Even though there is a question concerning eventual bad
effects of the preparation on the eye and ear, this has not hwn
established. Concerning harm to the optic nerve, it was estab-
lished in September already that not a single case of blindness
occurred in 8,000 cases ; and by December, out of 25,000, only
a single case of atrophy of the optic nerve was reported, and
this one case had been treated previously with other arsenic
preparations. And Ehrlich states that in all previous experi-
ence with arsenic cures, he found the eye especially sensitive
when other arsenic preparations were used later. (On the other
hand, from 250 to 500 cases of blindness occurred after the use
of Atoxyl.)
He speaks of five cases of death following injection of
606, occurring in patients suffering with heart disease, bad
arteries, or severe kidney or brain affections; but he objects
to these cases being counted as deaths due to the preparation,
as he had distinctly stated that it should not be used in patients
having such complications. Nor should cases which showed poor
results where the preparation was badly introduced be counted
against it; for most of these were due to wrong manipulations
in compounding the 606, or too small a dose being administered,
or the manner of injecting it being such that only partial ef-
fects could take place. Most of the recurrences of symptoms
were due to insufficient dose.
The majority of cases can be cured, and the cure estab-
lished by Wassermann's test, and absence of further syphilitic
manifestations. Should these reappear, however, Mercury can
still be used in addition to the Salvarsan, and the latter also
repeated.
As a rule in the primary and early secondary stages (i. e.,
2, 6, 8, months after infection, when symptoms are usually very
difficult to control,) the intra-venous injection should be used
and repeated if necessary. But cases with heart disease, and
tertiary, malignant, and hereditary Syphilis should not have
the intravenous. Ehrlich is certain that Salvarsan if used as
he directs, can effect a complete sterilization — that is CURE."
Prof. Xeisser of Breslau, the discoverer of the Diplococcus
of Gonorrhea, speaks in glowing terms of Ehrlich and his new
222 THE AMERICAN JOURNAL OF UROLOGY
remedy, while sounding a warning note regarding its limita-
tions. He says there is no question of magic or witchcraft
about it. But, on the other hand, this much is certain: That
the new preparation will cure Syphilis more quickly, more
surely, and more comfortably than any other remedy used 'here-
tofore— though at the same time, Mercurial treatment must
still hold a worthy and honorable position in the future, as it
has in the past.
Salvarsan works quicker and destroys the Spirochetes more
effectively than Mercury. One injection of 606 will often do
more than a long Mercurial course, though it should not be
supposed that one injection will complete a cure. Then again,
by the use of this remedy the lesions of the skin, lips, mouth,
etc., are rapidly dispersed, and as just these lesions are the ones
which especially disseminate syphilis by direct contact, a great
source of spreading the infection is thus closed off. This is
very important in respect to lessening the number of cases ac-
quired from such sources.
Neisser further states unequivocally that there is no dan-
ger from the remedy — that up to this time there have been few
remedies so powerful and efficient which were at the same time
as safe to use. And he also says that there have been no cases
of blindness which should be placed at its doors, or for which
it can be held responsible.
It is now six months since its use was begun in this coun-
try, and though we have heard of many cases from various
quarters, there is not as great enthusiasm apparent here as at-
tended its first successes abroad. The general trend of opinion
may be culled from the conclusions arrived at by different ob-
servers, such as the following:
Dr. Corbus of Chicago concludes :
" 1. We have in the Ehrlich remedy, a powerful agent
against Syphilis.
2. A single injection has in favorable cases approximately
the same result as four or five months' treatment with Mercury
and Iodin.
3. It may show a brilliant effect in cases in which Mercury
and Iodin have failed.
SALVARSAN IN SYPHILIS
223
4*. Salvarsan has advanced the treatment of Syphilis in a
decided manner, but on account of its strong arsenic content,
repeated doses may have a disastrous effect on the human or-
ganism.
5. Every physician should master the technic before at-
tempting to use it. Only in this way will the drug be safely
guarded from many pitfalls."
Dr. Engman of St. Louis says: <; To be perfectly fair we
have seen equally as rapid disappearance of skin manifestations
from the use of injections and mercury (as from Salvarsan) ;
Reasoning from analogy and our knowledge of chemical
therapy, a certain per cent, of cases will also, no doubt, prove
rebellious to Ehrlich's remedy ; but no matter how many, may
prove rebellious, it has a remarkable effect on the cutaneous
manifestations of Syphilis."
Dr. McKenna of Chicago concludes :
1. The medical profession should use every effort possible
to eradicate the idea that appears to have become prevalent
in the minds of the laity, and, indeed, of many of the profession,
that a single dose of Salvarsan will permanently cure Syphilis.
2. Salvarsan should be administered under the best sci-
entific conditions possible, which means that no patients should
be treated until they have been in a hospital four days and
careful records made of their physical condition. Only patients
in a healthy condition, aside from the spyhilitic taint, should
receive this form of treatment. Any attempt to treat patients
when these precautions have not been taken, or any unscien-
tific use of the preparation, should be strongly opposed by the
profession, as these attempts are sure to result disastrously
to the patient, and also to detract from the merits of the remedy.
3. Salvarsan is the treatment of election in the condition
of Syphilis enumerated in this paper, but under all circumstances
should be followed by Mercury or the Iodins, or both.
4. Administration by the intramuscular or supraf ascial
route should first be instituted, as it is the safest method, and
in the event of the patient not becoming Wassermann-negative, it
is then time enough to employ the more dangerous intravenous
method."
224 THE AMERICAN JOURNAL OF UROLOGY
Dr. Wolbarst of New York, says : " Brief!}', we may con-
clude that the remedy gives evidence of being able to combat
successfully conditions that remain unaffected by mercury and
iodines for months and years : that while it is wonderfully ef-
fective, it must be used cautiously ; certain persons show a sus-
ceptibility towards the drug, with the result that alarming
symptoms may arise ; these alarming symptoms disappear as
soon as elimination is augmented : at no time do the patients give
evidence of being 6 sick,' even when the temperature runs above
105 F. The high temperature is due to the reaction of meta-
bolism, caused by the absorption of the arsenic. Lastly, we have
added to our therapeutics, through the immortal genius of Ehr-
lich, the most powerful weapon in the fight against Syphilis that
civilization has ever known."
And yet we cannot entirely depend upon these first conclu-
sions, inasmuch as different technics were used. Wasserman's
& Noguchi's control reactions, and tests for spirochetes were fre-
quently omitted, and other treatments were often used synchron-
ously ; and then again we must not close our eyes to a considera-
ble error,* arising through faulty technic, incorrect dosage, and
lack of continued observation of patients over a sufficiently long
period. There seems some discrepancy between the effects of
Salvarsan here and in Europe, which may be accounted for in
part by a difference in severity of the disease per se, and also
the difference in environment. The cases I saw at the hospitals
in Berlin last September were mostly of a severer type than we
are accustomed to meet here, and vet there were very few excep-
tions to the complete cure of syphilitic manifestations within one
to four weeks after the injection of " Salvarsan." The various
methods of injecting " Salvarsan" which I saw, have been fully
described elsewhere. At present the most favored technics are
the intravenous and intramuscular. But this phase of the sub-
ject need not be entered into here.
There can be no doubt of the value of Salvarsan as a cure
for Syphilis in most of its stages, but it must be used with due
care and a thorough knowledge of its methods of introduction,
of its effects on the organism (Herxheimer Effects, etc.), and of
its dangers.
CURRENT UROLOGIC LITERATURE 225
Personally I am enthusiastic as to its value, but submit
that more time is necessary before anyone can absolutely con-
clude as to end results following treatment with Salvarsan.
I would rather wait until a sufficient number of the cases
treated shall have remained cured over a period of at least three-
years. Meanwhile let us use the remedy and be deeply grateful
to its inventor, Professor Paul Ehrlich, for the wonders it is
now accomplishing.
Review of Current Urologic Literature
1
ANN ALES DES MALADIES VENERIENNES
Volume VII., No. 3, March, 1911
Ehrlichs " 606 " in Intramuscular Injections in the Treatment of
Syphilis. By Alfred Levy-Ging and Louis Duroeux.
Intramuscular Injections of " 606." — Levy-Bing and
Duroeux contribute an extended memoir to the literature of
" 606." Their report includes a study of 38 cases, covering a
variety of syphilitic conditions. Their study is one of great de-
tail and contains many valuable suggestions, so that it merits
somewhat extended notice. The paper opens with a few remarks
concerning the tremendous enthusiasm which was manifested by
some physicians in France when the remedy was first introduced.
The present report covers an experience of six months, during
which patients had been followed very carefully. The purpose of
the study was to follow up a small number of cases for a long
time, from day to day, rather than to take a large number of pa-
tients and work less systematically. Every patient was examined
thoroughly and in following up the cases the urines were tested
for arsenic. At first the authors employed intramuscular injec-
tions of watery solutions of salvarsan, according to the methods
of Alt and of Blaschko, but they found that these methods were
unsatisfactory on account of the local complications and the diffi-
cult technique. Oily solutions were then tried, and were used
in the remaining cases. The authors strongly favor this method
of administration. Salvarsan was given by them in a medium
very much like that used for the suspension of mercury known
226 THE AMERICAN JOURNAL OF UROLOGY
as gray oil. One part of sterile anhydrous wool fat and nine
parts of sterile oil constituted this excipient. The method of
procedure consisted of placing the dose of salvarsan in a small
sterile mortar. Over this about two cc. of the oily medium were
poured, and the mixture was effected with the aid of the pestle.
When the emulsion was perfect, it was drawn into a sterile syr-
inge. The pestle and mortar were rinsed twice or thrice with a
very small amount of the medium (about 1 cc), and the result-
ing liquid was each time drawn into the syringe. In the mean-
while, the needle was plunged into the muscle and watched, to
see whether any blood came up. The oily fluid was then injected
in the usual manner. With this method the product was depos-
ited in the tissues without undergoing any chemical changes.
The therapeutic action of these injections was not appreciably
slower than that of the watery solutions.
The only trouble with this technique was that the needle
became quickly obstructed, and the rest of the suspension could
not be injected. To avoid this, the authors had a special syringe
constructed. This was built of metal and glass, holdmg 10 cc,
the piston working through a head-piece wherein it could be ar-
rested with the aid of a screw-thread. The piston itself was
made of rubber. The needle was of considerable diameter, with
a conical head, smoothly finished so that there were no projections
wherein the particles of " 606 " could catch.
Various parts of the body were used for the injection. At
first, the space between the scapula and the spine was chosen.
This is a bad place and should never be used. Next the injec-
tions were given into the buttocks, and finally into the region
which the authors first described, namely, at a point equally dis-
tant from the anterior superior spine and the uppermost end of
the inter-gluteal fold, the needle being directed downward and
inward. For disinfecting the skin, tincture of iodine, or Hoff-
man's solution (Hoffman's Anodyne?) were used. There was
no necessity for the use of collodion or adhesive plaster after the
injection. Slight massage suffices. In general, the doses were
high, at least 0.5 ; more frequently 0.6 or 0.7, in women, and
0.7 or 0.8 in men. The dose of OA is regarded as insufficient by
the author, although in tertiary lesions smaller doses were found
necessary than in primary or secondary cases. A careful study
of the cases^ observed led the authors to the following conclusions:
Salvarsan is a very active remedy and of great value in treat-
CURRENT UROLOGIC LITERATURE 227
ment of some manifestations of syphilis, but cannot be said to
constitute the sole remedy for this disease. It should be used
with the greatest prudence in pregnant women, for its vaso-dila-
tor action is very intense and in almost all their patients the
authors noticed that the menstrual periods occurred prematurely,
were very abundant, and often amounted to real hemorrhages.
" To sum up, we find that intramuscular injections of sal-
varsan have not given us on the whole, much superior results as
compared to those which we are in the habit of seeing after in-
jections of soluble mercury salts, when employed in sufficient
doses. We recognize, however, that salvarsan is an excellent
healing remedy (epidermizing) in the treatment of syphilis, and
that it has the following indications:
1. Primary lesion, either ulcerating or phagedenic, in
which prompt action is necessary in order to secure rapid
healing ;
2. Ulcerating secondary or tertiary lesion of an extensive
character, upon the skin or mucous membranes, in which it is nec-
essary to arrest rapidly the process of necrosis ;
3. Lesions which arrest the action of mercury ;
1. Cases in which for some reason (stomatitis, enteritis,
idiosyncrasy, etc.), the patient does not bear mercury treatment,
or bears it badly.
5. In the interval between two treatments with mercury,
during the obligatory period of rest, salvarsan may be used as
an adjuvant to mercury and as a reconstructive.
Finally, in our opinion, the use of salvarsan should not ex-
clude mercury, but both should be combined in combating as suc-
cessfully as possible the manifestations of syphilis."
RIVISTA UROLOGICA
Volume I:, No. 10, December 15, 1910
1. A Critical Study of the Various Methods of Dealing witli the
Pedicle of the Kidney. By F. Cathelin.
2. On the So-Called Essential Hematurias. By C. Santini. (To
be Continued.)
3. Two Cases of Uncommon Types of Inguinal Hernia with
Prostatic Lesions in the Same Patients. By D.
Giordano.
4. The Surgical Treatment of Nephritis. By B. Cimino.
1. A Critical Study of the Various Methods of Dealing
228 THE AMERICAN JOURNAL OF UROLOGY
with the Pedicle of the Kidney. — F. Cathelin remarks that
the treatment of the pedicle of the kidney is the most important
point in the removal of that organ. Often the success of the
operation depends upon this feature. It is not astonishing,
therefore, that a great deal of study has been devoted to the
methods of dealing with a renal stump. The methods which
may be applied for this purpose are six in number.
1. Ligature in mass. This means the tying of the entire
pedicle, as is customary in dealing with other pedicles in surgery.
The pedicle is first grasped with a curved clamp, which may be
reinforced with one or more additional clamps, the application
of a ligature, and is followed by the excision of the kidney. This
technique is very imperfect, because every element of the stump
is included in a single ligature, not even excluding the ureter.
The latter may be large, thickened, dilated, and its presence may
interfere with the healing. The pedicle thus treated is large
and difficult to handle. No matter how secure the ligature may
seem, it may be displaced by the movements of the stump, and
thus a severe secondary hemorrhage might occur. A very im-
portant objection against this method is also the fact that in the
ligature are inclosed nerve fibres, which afterwards give rise to
severe pain. The method of ligating the mass therefore is a poor
one, and should be abandoned. It is, of course, utterly unsuited
in those cases in which there is an involvment of the upper part
of the ureter in a diseased process, such as tuberculosis, etc.
2. Ligature of the vessels alone in mass (excluding the
ureter). This method differs from the previous one, in that the
ureter is first isolated and the vessels are tied with a ligature. A
clamp is always passed beneath the kidney and is mo^e secure in
this method because it has less tissue to compress. This method
is undoubtedly better than the first, but still imperfect, because
the stump is large and the ligature cannot be absolutely secured.
3. A Mixed Ligature. A distinct advantage in the meth-
ods of dealing with the stump is represented by this procedure
which has been well- studied by Pasteau. It consists in applying
a ligature before the attempt is made to sever the kidney. The
first thing done is the application of a clamp, and then above
and below this clamp, .ligatures are carefully applied and tied.
The incision is then made between the ligatures. The trouble
with this procedure, however, is that the kidney, being in place
during the tying of the ligatures, interferes materially with this
process.
CURRENT UROLOGIC LITERATURE 229
-i. The Separate Ligation of each Structure. This is the
ideal method of dealing with a stump, which the author has pro-
posed some years ago, and is the true anatomical method, resem-
bling as it does, the manner of tying the ovarian stump. It con-
sists in drawing the kidney forward as far as possible, displacing
it from its niche and wrapping it with a gauze compress. Next,
the various elements of the stump are separated with the fingers
and held with the aid of another gauze pad. Each of the vessels
is then taken up with an artery clamp and is tied separately,
often without the patieru losing a single drop of blood. The
best material for the ligature is cat-gut, provided a good quality
of No. 4 gut be used. After the vessels have been tied separately
and the kidney has been removed a general ligature is applied
half a centimeter beneath all the others, and is tied with a double
sailor's knot. Finally, in sp:tc of the great security of this
method, a third general ligature is applied one centimeter beneath
the second, No. 4 catgut being used. In this manner one secures
a very safe ligation of the stump. In over 100 cases thus treated,
no accidents of any kind were noted.
5. Subcapsular Ligature. This method is recommended
especially by Albarran in secondary subcapsular nephrectomies.
It consists in, first enucleating the kidney, then isolating the
pedicle by blunt dissection, and tying the pedicle beneath the
capsule. It is a delicate and difficult method, and is dangerous,
so that it should be rejected in favor of some method involving
the use of a permanent clamp.
6. Forcipressure. This method is very old and has been
used for the renal as well as for other pedicles. The cases which
require the application of a permanent clamp are those in which
the ligature cannot be employed for various reasons. Among
these are the cases with thick infiltrated pedicles surrounded by
adhesions, such as are found in certain infected and tuberculous
kidneys. There are also cases with very short pedicles, in which
the kidney cannot be moved sufficiently to allow of convenient liga-
tion. In cases in which the nephrectomy has been performed by
stripping the capsule, the clamp is also the best method of treat-
ment. Finally, in some cases, in which the twelfth rib is abnor-
mally long and the space under it narrow, and in which the pedi-
cle is situated high up, usually require a clamp. The advantages
of a permanent clamp are evident. Their use shortens the opera-
tion, and makes it less dangerous, and moreover they are very
safe and avoid the danger of secondary hemorrhage.
230 THE AMERICAN JOURNAL OF UROLOGY
Certain precautions should be observed, however, in applying
the forceps, without which it is impossible to be sure that the
stump has been securely clamped. The clamp, whether straight
or curved, should have elastic blades and should be clamped as
tightly as possible. The patient should then remain lying upon
his side with a cushion under his back. The clamp should not be
removed for at least 72 hours, and when they are removed, this
should be done very gradually, disengaging the pedicle piecemeal,
at intervals of five minutes. First the blades should be slightly
opened, then opened a little more, and finally the clamp should
be slowly removed. The results of the use of clamps have been
very good. In nine cases in which this method was used in the
author's hospital, the clamps worked very satisfactorily.
In closing the author remarks that Tansini cannot claim
legitimately to have introduced this method, inasmuch as it has
been known in France for a great many years, having been prac-
tised many times by Pean. Nor does the author agree with
Tansini that the application of the permanent ligature is useful
in practically every case of nephrectomy. In the present author's
opinion the clamp should be used when the ligature cannot be
conveniently and securely applied.
4. The Surgical Treatment of Nephritis. — Cimino, in
a short communication, remarks that at present the surgical
treatment of Bright's disease is employed exceptionally. In fact,
surgery is invoked in Bright's disease only when medical treat-
ment has failed. In some instances the surgical treatment is fol-
lowed by excellent results, and it is well for the physician to know
in what classes of cases some hope may be entertained for effi-
cient results with surgery. Originally the operation was per-
formed accidentally. Later, when it was found that some im-
provement followed after stripping the capsule, the procedure
was employed deliberately. The best results seem to be obtain-
able in cases of chronic nephritis accompanieel by neuralgic pain.
In these cases the compression of the capsule seems to have a
great deal to do with the pain. When the capsule is stripped
off, the pain disappears, and so does the hematuria which may be
present. The operation of stripping the capsule, however, can-
not be expected to cure nephritis, yet some of the consequences
of the disease may be averted. In some cases the disease seems
to be temporarily arrested in its progress and from a sub-acute
type, a very slow form may be evolved. In any case, the opera-
CURRENT UROLOGIC LITERATURE
231
tion is palliative and not radical in its effects. The procedure
may also be applied in cases of heart disease complicated with
renal disease, as Cathelin has shown in a recent lecture in which
he pointed out that the operation improved the condition of the
heart and blood vessels, caused a disappearance of edema and
dyspnea, and increased the secretion of urine.
FOLIA UROLOGICA
Volume V, No. 9, March, 1911
1. Anatomical Investigations Concerning Prostatic Hypertrophy :
The Process of Repair After the Removal of the Pros-
tate. By J. Tandler and O. Zuckerkandl.
2. Urethral Fever. By Joseph Englisch.
1. Prostatic Hypertrophy. Tandler and Zuckerkandl
point out that prostatic hypertrophy is always an enlargement of
the anatomical middle lobe. This lobe is independent anatomically
from the rest of the organ and develops as a separate structure.
By prostatectomy is not meant the total removal of the prostate
but the shelling out of a mass imbedded in the prostate, belong-
ing to the middle lobe, and connected inseparably with the pros-
tatic portion of the urethra. The anatomical capsule is formed
by a compression of the peripheral parts of the prostate. The
removed pieces of prostates are always the same parts of the organ
from an anatomical viewpoint. In no case is the whole prostate
removed. The method of choice for removing an enlarged prostate
is through the bladder.
The above is a summary of this important research, but
some of the salient points thereof deserve special comment. The
object of the investigation was evidently to determine what part
of the prostate was really removed in prostatectomy, and what
was the process of repair after the operation. In spite of the
great quantity of work done at present upon the prostate these
questions are by no means solved. In removing the prostate
through the bladder, the operator, after dividing the mucous
membrane, introduces his finger and seeks a plane which enables
him to enucleate an enlargement or growth from its surroundings.
This tumor is attached at the bottom of the wound to the urethra
and upon severing the latter it becomes possible to remove the
tumor. Immediately afterwards, the remaining parts shrink,
leaving a small gap in the mucous membrane of the bladder close
232 THE AMERICAN JOURNAL OF UROLOGY
to the normal urethral opening. The mass of tissue removed,
which consists of prostatic substance through which a portion of
the urethra runs, is generally designated as a totally extirpated
prostate, the remaining walls are termed the capsule and the en-
tire process is designated as prostatectomy. The point empha-
sized by the author is, that during this operation it is impossible
to follow definite anatomical landmarks, nor to be sure that we
know the exact relation of the removed mass to the anatomical
structures, in the region in question. Freyer's original idea was
to remove the prostate completely ; in other words to shell it out
outside of its anatomical capsule. This was an erroneous con-
ception. Another error which Freyer made in his original work
was that the urethra remained intact in his operation. This lat-
ter notion was declared as untenable by various writers who fol-
lowed Freyer. Thus Freudenberg in 1909 announced that he had
studied the capsule at autopsy after prostatectomy and found it
to consist of compressed prostatic tissue. On this ground Freuden-
berg declared Freyer's operation to represent a subtotal prosta-
tectomy. In spite of this, the statements still made in recent text-
books, as for example, in Albarran's work on operative surgery,
to the effect that the shelling out takes place between the pros-
tatic substance and the prostatic space wh'ch is lined by aponeu-
rotic tissue, provided the enlargement is adenomatous.
The clinical observation of operative results does not show
the character of the healing process after prostatectomy. It is
therefore necessary to study the whole subject anatomically.
Contemplating the normal prostate, the author finds that its
anatomical capsule is merely a condensation of its glandular sub-
stance. The prostate is very closely adherent to the surrounding
tissue, with the exception of a portion in the posterior aspect,
lying close to the rectum. The division of the prostate into three
lobes, two lateral and one middle lobe, is justified not only by an
examination of the structure of the organ but also by the develop-
ment of the prostate. The middle lobe develops in the center by
a projection of grandular tissue originating from the region of
the colliculus. The prostatic capsule, in the anatomical sense, is
composed by the approximation of the various pelvic fascia.
With the exception of the posterior surface, this capsule cannot
be peeled off, save by artificial dissection. In no instance can the
prostate be shelled out of its anatomical capsule in the manner in
which surgeons enucleate the enlarged organ from the surgical
CURRENT UROLOGIC LITERATURE ■ 233
capsule which is nothing but a condensation of the prostatic tissue
at the outer portions of the organ.
The investigation conducted by the authors consisted in an
analysis of 42 cases. An attempt was made to select typical hy-
pertrophied prostates. The first point which struck the investi-
gators was the evident fact that there is no such thing as a total
enlargement of the prostate. In the most marked cases of hyper-
trophy there were portions of the prostate which could be called
atrophic. In none of the cases was the posterior lobe hyper-
trophied, while in no case was the middle lobe free from enlarge-
ment. The material investigated proved the fallacy of the com-
mon notion that the hypertrophy usually involved the posterior
semicircle of the prostate, and that the anatomical middle lobe
was the seat of origin of the enlargement in but a fraction of the
cases. According to the present authors prostatic hypertrophy
involves exclusively that portion of the gland which is limited lon-
gitudinally above by the internal orifice and below by the mouth
of the ejaculatory duct. That portion of the prostate lying be-
hind the duct is never hypertroplred but rather atrophied as a
result of pressure.
Furthermore, the enlargement affects primarily only those
structures which are in contact with the neck of the bladder and
which lie above the colliculus. This includes the median lobe and
the other parts of the prostate wlrch are above the colliculus. It
is impossible to say why the hypertrophy is thus localized. While
this is the general trend of the process, there are a great many
variations.
An examination of the specimens of prostata tissue removed
at prostatectomies shows that only a portion of the prostate is
removed. The enucleation takes place within the prostate itself,
and on examining the remaining structures in both living and dead
subjects it appears that in no case has a pelvic space lined with
fascia been opened by the act of enucleation. The enucleation
therefore is an intraprostatic procedure. The reason why the
vesical operations are better than the perineal is because the hy-
pertrophy takes place almost exclusively in that portion of the
prostate which is next to the bladder. The vesical method, there-
fore, is anatomically the method of choice. On t\\e other hand,
surgically, a method which enables one to work strictly under the
guidance of the eye is to be preferred. The operation in the
dark, therefore, represented by the vesical method is surgically
inferior.
234 THE AMERICAN JOURNAL OF UROLOGY
%. Urethral Fever. Englisch contributes a very complete
study of urethral fever, beginning with the earliest history of our
knowledge of this interesting condition. This communication is
to be concluded in a subsequent number. A critical examination
of the literature, including a study of typical reported histories
leads the author to conclude that the infectious origin of urethral
fever cannot be denied. The injury in these cases may be slight
but is always present. There still remains a good deal of doubt
however, as to the exact relation of infection to urethral fever.
Thus in some cases, there may have been injuries and infections
previously to the development of the fever, in which no bacterio-
logical examinations had been made. There is a possibility,
therefore, that bacteria had already been present in the blood of
the patient and that the subsequent introduction of additional
bacteria, combined with those already present, caused the onset of
the fever. In some cases in which no urethral injury was re-
corded, there had been no examinations for the presence of bac-
teria in the blood. Such examinations should have taken place
before the urethral manipulation. There is still a possibility that
changes may take place in the walls of blood vessels as the result
of abnormal conditions of the nervous system. The blood vessels
thus become favorably disposed to the entrance of bacteria.
The author lays down the conditions which in his opinion are
essential before one can draw conclusions from bacteriological
examinations regarding the origin of urethral fever. Such ex-
aminations should be made, in the first place, in patients who have
never had any instruments passed into the urethra, especially no
forcible dilatation. Examinations should furthermore be made in
persons in whom dilatation of the urethra had been practised and
were followed by urinary retention. In such cases we have the
proper condition for the entrance of bacteria. Thirdly, bacterio-
logical studies should be made in persons who have had no other
infection such as typhoid fever in which the urinary organs may
have been invaded. In order to get proper evidence the urine,
the blood, and other secretions should be examined bacteriologic-
ally before every urethral manipulation. The examination of the
blood should be repeated after the urethral interference, whether
or not a febrile reaction follows.
The blood should also be examined postmortem. All these
conditions are difficult to follow out, but it is only in this way that
we can gain a proper knowledge of the real character of urethral
fever.
CURRENT UROLOGIC LITERATURE 235
ANNALES DES MALADIES DES ORGANES
GENITO-URINAIRES
Volume XXIX, I, No. 7, April, 1911
1. Surgical Methods of Determining the Condition of the Kidneys,
When Urethral Catheterism and Separation Fail. By
Dr. Rochet.
2. Treatment of Gonorrheal Urethritis. By Dr. Motz.
3. Stricture of the Urethra in the Perineal Region. By Henri
Pied.
4. The Internal Secretion of the Prostate. By N. Serrallach and
Martin Pares. (Barcelona.)
1. Surgical Methods of Determining the Condition of
the Kidneys. Rochet points out that in some cases urethral
catheterism and separation both fail. The bladder may bleed so
readily that the ureter cannot be found, or the ureter may be
hidden by pus, stones, etc. The results of separation may be un-
reliable. The question arises, what shall we do in these conditions.
If there is no apparent enlargement of the kidney on one side,
nor any pain felt more acutely on one side, if there is an absence
of any reliable signs which would lead to the localization of the
trouble, the case in such an event becomes very difficult. If, how-
ever, there are some symptoms which localize the trouble on one
side, some surgeons suggest that an exploratory incision be made
upon the opposite side. This will show the presence or absence
of a second kidney, but will not show the functional value of this
kidney. Another method of obtaming information regarding the
condition of the kidneys when ordinary means have failed is the
catheterization of the ureters through the bladder, after opening
the latter suprapubically. This method was recommended by
Albarran some years ago, and since then by others, including the
present author. Rochet has employed this method in a number
of cases, either deliberately or in the course of suprapubic opera-
tions for bladder lesions, in which it was necessary to know the
condition of the kidneys. The results are excellent. The ure-
thral catheters may be left in place for fifteen or thirty minutes,
if the kidneys are secreting properly. In other cases, the cathe-
ters may be left in place for &4 hours. The advantages of the
method are that we are able to obtain very complete information
regarding the secretion of each kidney. Furthermore, when there
is a chronic cystitis the suprapubic incision is a good preliminary
236 THE AMERICAN JOURNAL OF UROLOGY
measure. The catheterization of the ureters through an open
bladder is sometimes quite difficult, even when the incision is of
considerable size. . There is also a disadvantage in this method
because if we decide to operate upon the kidney afterwards, the
patient will have to be subjected to two different operations.
A second method has been suggested by Jaboulay. It con-
sists in ligatng the ureter after having exposed and opened the
kidney. The object of the ligature is to exclude the urine secreted
by this kidney from the rest of the urinary apparatus. The urine
from the kidney in question, therefore, can be collected through the
nephrostomy wound, while the urine from the bladder will come
from the opposite kidney. In this manner we can get an accurate
idea of the functional value of both kidneys. If the opposite
kidney, however, is found to be functionally inferior, we are obliged
to keep a fistula permanently in the incised kidney. This is al-
ways an inconvenient procedure.
In order to avoid all the various inconveniences connected
with the procedures mentioned, the author recommends the fol-
lowing method: The kidney which is believed to be diseased or to
be the more diseased of the two is not opened, but its ureter alone
is opened in order to obtain the desired information. The ureter
is exposed on the side in question and a small opening is m arte in
it at a distance of six or seven centimeters below the kidney. A
small catheter is introduced through this opening, pointing up-
ward into the pelvis in order to collect the urine from the kidney.
Into the lower end of the opening a ureteral catheter of large size
is introduced, in order to occlude the ureter and prevent any
urine from passing below the opening made in that canal. A
period of fifteen or thirty nrnutes is allowed to elapse and the
urine from the incised ureter obtained through the catheter is
examined. The urine from the opposite kidney is obtained from
the bladder. In this manner we can decide whetther a nephrectomy
is necessary. The author has applied this method in two cases.
In the first case, there was renal tuberculosis, with a very
painful and contracted bladder preventing all examination. The
kidney on the other side seemed to be in fair condition. A
nephrotomy was first performed and a fistula was allowed to re-
main. Three months later, the opposite kidney was found to
functionate perfectly and the diseased kidney was removed. The
patient made a good recovery. In the other case there was also
renal tuberculosis with a contracted bladder which could not be
CURRENT UROLOGIC LITERATURE 237
explored. The ureter was opened on one side and the urine from
the opposite kidney was so suspicious that it was not conside red
safe to remove the kidney, the ureter of which had been opened.
The opening in the ureter was sutured, the patient's condition
was not aggravated apparently, but he died four months later
with advanced changes in both kidneys.
The method of opening one ureter for exploratory purposes
therefore seems useful only for cases in which other means of in-
formation fail. A disadvantage of this method, however, is the
necessity of knowng beforehand which of the two kidneys are
more markedly affected.
2. The Treatment of Gonorrheal Urethritis. Motz
contributes a review of this subject based upon lectures delivered
at the International Hospital in Paris. He begins by emphasiz-
ing the necessity of careful treatment in this affection, especially
in view of the serious complications that may follow. Among the
complications, perhaps the most frequent are orchitis and prosta-
titis. With the older methods of treatment there were 15 to 18
percent, of cases complicated with orchitis and from 35 to 60
percent of cases complicated with prostatitis. Moreover from
personal investigation, the author has found 30 percent, with
vesiculitis. The fact that these complications may be the cause
of debility, sterility and impotence is alone sufficient to show the
need of attention to the treatment of the infection with special
reference to the prevention of complications. Neurasthenia is
also one of the consequences of gonorrheal urethritis, while of late,
the disease has been considered as one of the causes of enlarged
prostate. The negligence which has been manifested in the treat-
ment of this infection is indeed unpardonable. It is astonishing
that some of the old superannuated methods are still used in the
treatment of this disease when we have at our command energetic
and trustworthy methods for arresting the infection and prevent-
ing the various complications. The principle which should guide
us in the treatment of gonorrheal infections as in the treatment
of any other infected wound should be disinfection, immediate and
systematic. The disinfection of a urethra invaded with the gono-
cocci will vary according to the duration of the disease and its
complications.
It will be useless to go into all the details of the attempts
which have been made in trying to abort the disease at its early
stage. The fact that abortive treatment may be attempted with
238 THE AMERICAN JOURNAL OF UROLOGY
some hope of success, provided the infection is not too advanced
is no longer to be disputed. The author believes that the disease
in the great majority of cases remains anterior for the first five
or six days, although there are cases in which the infection spreads
posteriorly during the first few days. In order to be suitable for
the abortive method, the following conditions are required. The
duration of the infection should not be longer than six days.
There should be no acute external inflammatory symptoms. The
secretion should net be abundant and the sensitiveness of the canal
should be about normal. The second glass should be perfectly
clear and the patient should not have been exposed to reinfection
since his infection. The patient should be told that he may have
to come twice a day for several days.
On the first day, after the usual preliminary antiseptic cleans-
ing, an injection is given into the anterior urethra of from three
to four c.c. of a two percent, silver nitrate solution, which should
be kept in the canal for two minutes. About twelve hours later,
the anterior urethra should be washed with a solution of one to
one thousand potassium permanganate. On the' second, third
and fourth days, in the morning, the anterior urethra should be
washed with a solution of 1 :1000 permanganate, while in the even-
ing, ten c.c. of a one-half percent, solution of cocaine should be
injected and the anterior as well as the posterior urethra should
be washed with a solution of from 1 :2000 to 1 :3000 potassium
permanganate.
On the fifth day, and the following days, the patient should
receive daily, irrigations of the same strength of potassium per-
manganate. If on the fifth day, gonococci are still present, it is
well to continue for a few days longer with two irrigations daily.
If the canal be somewhat irritated, the strength of the solution
should be diminished.
Daily irrigation should be continued until the complete dis-
appearance of the secretion, and until the first portion of urine
becomes clear.
An interesting point to be noted in the course of this treat-
ment is the occurrence of a false retention of urine. The patient
complains that he cannot void his bladder, but in reality, he is
only afraid to do so, on account of the sensitiveness of the urethra.
In such cases, a few drops of cocaine solution should be injected
into the fossa navicularis.
CURRENT UROLOGIC LITERATURE 239
Slight bleeding of the urethra may be noticed at the end of
the first week, but this disappears in a few days under the con-
tinued treatment. In one case the bleeding was sufficiently severe
to call for the injection of a ten percent, solution of antipyrine.
These hemorrhages are noticed particularly when strong solutions
(1:1000) of potassium permanganate are employed. It is im-
portant to know whether the blood comes from the urethra or the
bladder. When cystitis develops in these cases, the patient suf-
fers some pain at the end of urination and passes cloudy urine, the
last portion of which is somewhat tinged with blood. When these
symptoms are present it is best to give the ordinary irrigation
and to follow it with an instillaton of a few drops of two percent,
silver nitrate into the posterior urethra and the neck of the blad-
der. No other complications are seen with this method of abort-
ive treatment. An average of two or three weeks is necessary for
this treatment, but if the infection is virulent it may require
longer. In 62 percent, of cases, treated by the author, the dura-
tion of the treatment was fifteen days, while in 85 percent, of
cases, 21 days were necessary. Aside from the shortening of the
treatment, the principal advantage of the abortive method is the
avoidance of complications.
In addition to the above outlined treatment, the author has
also used a mixed treatment with irrigations of potassium per-
manganate employed as outlined above, together with injections
of protargol. In two to five percent, solution, which is allowed
to remain in the canal for from two to three minutes. The results
of this mixed treatment are fairly satisfactory.
In the treatment of acute urethritis three methods are used:
The internal treatment, the local disinfection of the anterior ure-
thra, and finally, the disinfection of both urethras. The latter
is the procedure favored by the author at present. This is his
method in these cases : When a patient presents himself in the
acute stage, too late to receive abortive treatment, he is first exam-
ined for the presence of paraurethral ducts and the two-glass test
is applied. A few cubic centimeters of a one-half solution of
cocaine are injected. The anterior urethra is washed at low pres-
sure with a solution of 1 :3000 mercury oxycyanide, and then the
bladder is filled with the same solution. With the bladder thus
filled, the prostate and vesicles are palpated and the contents of
the bladder voided. If the accessory glands are not involved, the
patient is given directions as to hygiene and diet, and irrigations
240 THE AMERICAN JOURNAL OF UROLOGY
are begun involving both anterior and posterior urethra. These
are given once a day. The solutions used are of mercury oxy-
cyanide, one part in two or three thousand. They are continued
until the discharge becomes very slight and are replaced then by
similar irrigations of permanganate, of the same strength. From
time to time, during this treatment the prostate and vesicles are
examined.
If the posterior urethra is infected, the patient is given uro-
tropin internally and the bladder is irrigated twice daily with the
same solution of mercury oxycyanide unt'l the second glass be-
comes clear. Then the irrigations are given once a day. If the
prostate and vesicles are involved, urotropin is given internally
and two irrigations are given daily for four or five days. The
prostate and the vesicles are massaged every other day and the
patient is told to take very hot rectal irrigations. In this type
of cases, the clearing up of the second glass will take more time.
Instead of mercury oxycyanide, solutions of various silver salts
may be employed. If the first glass fails to clear promptly, an
injection of two percent, protargol may be given anteriorly, and
retained for half an hour. The irrigations should be continued
until the urine becomes clear and the morning drop disappears.
If the discharge reappears and gonococci are present after
two long series of irrigations, we may be sure that we have a
rebellious case with glandular involvment. If the patient cannot
come twice a day he may be allowed to use injections of protargol,
two or three percent., retained for fifteen minutes twice daily, while
an irrigation is given once a day. This method exposes the pa-
tient to a greater frequency of complications.
In subacute cases, there are divergent opinions as regards
treatment. The old method is the use of balsamics towards the
end of the third week and with these the use of astringent injec-
tions. A newer method is that of Neisser and his school consist-
ing of injection of organic silver preparations. In this connec-
tion the author strenuously objects to the policy of allowing an
acute infection of the posterior urethra to go without local treat-
ment. To allow such a condition to go on is to expose the patient
to serious complications. The modern method of treatment in
subacute cases has been worked out by Janet. The best results
of Janet's method of irrigation have, in fact, been observed in the
subacute stage of the disease. Janet advises irrigations of the
entire canal with solutions gradually increasing in strength from
CURRENT UROLOGIC LITERATURE 241
1 :4000 upward. This treatment should be continued until the
urine clears up and the discharge becomes very slight. The irri-
gations are then interrupted and if the secretions become more
abundant and shows gonococi the treatment is again begun and
continued in the same manner. If after a series of injections
gonococci are still present the case should be regarded as tending
towards chronicity and should be treated as a chronic case.
The treatment of the chronic cases consists in the first place,
in determining if possible, the cause of the persistence of the in-
fection. The treatment will therefore vary according to the con-
dition found. The first thing to do is disinfect the surface of the
mucosa and to obtain clear urine. This can be done with a few
irrigations after which a quantity of solution is left in the blad-
der. At first the region of the bulb is palpated and the patient
is asked to void some of the solution. Then the seminal ves'cles
and the prostate are palpated and expressed and the patient al-
lowed to void some more solution. The condition of the glands
examined will appear upon microscopical examination.
The patient is asked to return on another day and the an-
terior urethra is examined. It is here that we find in most cases
the cause of the persistent discharges. The entire urethra is
thoroughly washed, the calibre of the canal is determined and the
anterior portion is palpated over a sound. We find often the
presence of infiltrations which should be massaged over the sound.
The patient is then asked to urinate and the presence of expressed
matter from the glands is determined. A few days later the pa-
tient is urethroscoped and the locality of the lesions is accurately
determined.
If one or more paraurethral canals are detected they should
be opened and disinfected if they are not deep ; if however, they
are very deep, it is best to disinfect them by injecting into them
solutions of protargol, permanganate, etc.
Cases in which gonococci have been found in the vesicles, the
prostate or the posterior urethra, must be treated by irrigations
and massage of the entire tract. Cases with lesions in the an-
terior urethra should be treated by irrigations followed by dilata-
tion. Injections of antiseptic solutions, such as two to five per-
cent, protargol, may also be used in the form of prolonged appli-
cations, i. e. after the solution is injected, the meatus is closed with
a layer of cotton which is firmly tied into place.
242 THE AMERICAN JOURNAL OF UROLOGY
ANNALES DES MALADIES VENERIENNES
Vol. VI, No. 4, April, 1911
1. Syphilis and Sporotrichosis. By Drs. Gougerot and Dubosc.
2. Acquired Syphilis in a Subject with Heredo-Syphils. By. Dr.
Goizet.
1. Syphilis and Sporotrichosis. Gougerot and Dubosc
report a case of sporotrichosis in which there were lesions greatly
resembling gummatous syphilis involving the subcutaneous tissue,
the muscles and the bone. There was also a spontaneous fracture
of the radius.
The resemblance between syphilis and sporotrichosis was
recognized early in the history of the latter disease. A number of
cases have been recorded in wlr'ch sporotrichosis so closely resem-
bled syphilis that the lesions in the skin and the bones were prac-
tically identical with well known syphilitic processes. In the
present case, a new example is shown of gummatous deposits in
the skin and beneath it ; in the muscles and bones, and an involv-
ment of the radius which ended in a fracture of that bone. The
diagnosis of syphilis was made at first. The presence of muscular
gummas and of the fracture of the radius were elements in this
diagnosis. Treatment was begun with injections of mercury ben-
zoate and for a few days some improvement seemed to occur.
Later a thorough examination together with cultures upon gelose
— glucose and peptone demonstrated the presence of sporo-
trichosis. It was fortunate that this diagnosis was made, be-
cause the patient rapidly improved under treatment with iodine
and iodides.
The authors emphasize the importance of certain clinical
signs which allow one to make a differential diagnosis at the first
examination, in cases such as this. The number of the lesion- was
considerable there being seven evident foci. Of these six were
deeplv situated. It is quite exceptional to find syphilitic gummas
so numerous. Gummatous syphilis gives rise to multiple lesions
only in cases in which it affects the skin itself, in the shape of
ulcerating foci. The gummas in sporotrichosis are different from
those of syphilis. In the former infection the muscular gumma
of the arm had completely softened without producing any in-
flammatory symptoms wlr'ch are so constantly found in syphilitic
gummas when the}- liquefy. The contents of the softening gumma
was like that of a cold abscess, the shape of the cavity being cup-
CURRENT UROLOGIC LITERATURE
like. Syphilitic gummas contain a soft mass which cannot be re-
moved by puncture and yields but a few drops of serous fluid. In
the case in question, however, puncture elicited several cubic centi-
meters of yellow slightly cloudy fluid and completely emptied the
abscess. The bacteriological diagnosis is simple and graphic.
Cultures are prepared as follows : A quantity of pus from the
gumma is taken with a sterile syringe, and one-half to one c.c. of
pus are planted upon each tube of culture medium (see above).
The tubes are left at ordinary temperature in a warm room for a
day or two, and a glance at the tubes is sufficient, for the appear-
ance of the colonies is characteristic. Another method is the
serum diagnosis of Widal and Adami, the latter method having
the advantage of giving an immediate answer to the question of
diagnosis and the being available when the lesions are not on the
surface or when culture is impossible. \
2. Acquired Syphilis in a Subject with Hereditary
Syphilis, who Presented at Birth the Signs of Secondary
Hereditary Syphilis. Go'zct reports the case of a man thirty-
eight years of age, who at birth had presented the signs of pem-
phigus, according to the records of the author's father. At the
age of 1-1, the patient had a reappearance of syphilitic ulceration
and these lesions disappeared under treatment. At about the same
time, he showed the beginning of a spinal curvature which, how-
ever, did not develop to a marked degree. In 1902, the patient
enlisted in the army, but could not do any active service. For
five months he was at a hospital for nervous disturbances includ-
ing insomnia, headaches and contractures. At the hospital, he
contracted scarlet fever and was finally discharged from service.
In 1905, he suffered considerably from a varicocele and in the
same year, he was attacked by an eczema occupying the entire
upper portion of his chest and arms. A new attack of eczema
occurred in 1906. Until August, 1908, the patient suffered from
neuralgia and from a nervous depression which interfered with his
occupation. In August, 1908, he developed a cervical adenitis
on both sides, which was very persistent and very marked. He
applied for treatment at a hospital where the diagnosis of a pri-
mary lesion of the left tonsil was made. Six weeks later a very
pale and very transient rose rash appeared. Treatment was be-
gun with a course of ten injections of gray oil. During 1909,
treatment by injection was continued, and the symptoms were
comparatively subdued, except that the pain due to the varicocele
244 THE AMERICAN JOURNAL OF UROLOGY
persisted. During the month of December, the patient was sent
to a watering place for neurasthenia and anemia, and was operated
upcn for varicocele. After the operation a double hydrocele ap-
peared, more marked upon the right side. Th's was punctured
four times on the left side*, and operated upon on the right side.
During this period injections and inunctions of mercury were
continued.
In August. 1910, there was an induration of the right testi-
cle. The patient was ordered internal treatment with iodine and
ten injections of enesol. He then was sent to another health re-
sort where he received twenty injections of mercury benzoate.
In November, 1910, he developed a very painful and marked
swelling of the tonsils and was seen by the author for the first'
time. There was a deep ulcer upon the left tons:l and a very
marked condition of neurasthenia. Treatment was then begun
with hectine in daily doses of 0.10, followed by ten days of rest
after each ten injections. The results of the treatment consisted
in a general improvement without any apparent check upon the
process in the tonsils. The ulcer had increased in size and a sec-
ond ulcer had appeared upon the left tonsil and its inferior pillar.
After the first ten injections of hectine the patient developed a
generalized hemorrhagic purpura, accompanied by an abundant
hematuria. After a second series of injections of hectine, local-
ized purpura developed upon the face and arms, accompanied by
nosebleed and spitting of blood. These symptoms lasted only a
short time. Two days after the last injection of hectine, the
ulceration in the throat began to diminish in size. In spite of
this, the patient wanted to try an injection of salvarsan, but upon
consultation with Professor Gaucher, it was deemed best not to
use this drug in view of the untoward symptoms which had oc-
curred with hectine. Twenty injections of mercury benzoate were
given, accompanied by local applications of a solution of iodine.
After ten injections great improvement was noted, and after
twenty injections there remained only a small ulceration upon the
right tonsil, together with some pain radiating into the corre-
sponding ear.
Tonsillitis and Genito-Urinary Disorders. — G. L. Hun-
ter, Baltimore (J. A. M. A. April 1), after referring
to the recent enumeration of ailments ascribed in certain
cases of tonsillar disease by Rosenheim (Bull. Johns Hopkins
CURRENT UROLOGIC LITERATURE
245
Hosp., November, 1908, xix), says that those treating diseases of
the urinary organs in women are familiar with the so-called rheu-
matic urethritis. There are many cases in which gonorrhea can
be ruled out to a practical certainty and some in which we are at
a loss to ascribe the symptoms to anything but a rheumatic cause.
His experience with these patients is that they respond more read-
ily to local treatment than do these with chronic gonorrhea, and
as a rule they relapse within a few years or months. His impres-
sion also is that in these cases we find the inflammation more fre-
quently in the posterior third of the urethra rather than in the
anterior third, where it is more frequent in gonorrhea. Several
illustrative cases are reported and discussed. He finds the evi-
dence of their connection with tonsillar disorders sufficient to war-
rant a more careful study of chronic urethral cases for, if we can
relieve them by tonsillectomy, as he has done in several of his re-
ported cases, we will make an important advance in therapeutics.
The possible connection between tonsillitis and ureteritis has been
brought to his attention only recently, and he reports two cases
of this type, in one of which the tonsils had been removed. A
suggestive feature in one of these is that the patient had a sore
throat and hoarseness following each attempt to catheterize the
ureter. He believes that this new theory of tonsillar infection or
toxins producing ureteral strictures may be found to explain some
otherwise obscure cases. While not himself familiar with male
genito-urinary work, he is informed that many cases of posterior
urethral inflammation cannot be traced to gonorrheal infection.
Dr. Geraghty of Johns Hopkins Hospital tells him that he has
seen cases of acute prostatitis with abscess formation occur dur-
ing or immediately after tonsillitis, and he thinks that it is not
improbable that some cases of chronic urethritis may have a like
origin.
Foreign Body Calculus. — A case of urinary cal-
culus formed on a pin and weighing 5.5 grams, in a
girl 5 years of age, is reported by I. S. Hirsch, New
York {J. A. M. A., October, 22, 1910).' The symptoms, which
had continued for about 7 months, were those of enuresis, for
which the child had been treated, but a rectal examination, which
had not been made before, showed the probable cause, and this
was confirmed by use of . the sound and X-ray. The stone was
removed by suprapubic cystotomy and recovery was uneventful.
216 THE AMERICAN JOURNAL OF UROLOGY
Hirsch discusses the nature of the calculi and the probable method
of the introduction of the foreign body in this case. Considering
all the facts, he thinks, the pin must have been maliciously intro-
duced into the child's bladder, as the possible penetration from
the intestines after swallowing seemed to be excluded by the his-
tory of the case. Chemical analysis showed the calculus to be
formed of calcium and magnesium phosphates and calcium oxy-
late. The cystitis which existed was accompanied by a slightly
acid urine and the encrustation consisted of the substances found
in such urine.
BOOK REVIEWS
Gonorrhea in the Male. A Practical Guide to its Treatment.
By Abr. L. Wolbarst, M.D., Consulting Genito-Urinary
Surgeon, Central Islip State Hospital; Visiting Genito-
Urinary Surgeon, People's Hospital, West Side German Dis-
pensary and Beth Israel Hospital Dispensary ; Professor of
Genito-Urinary Diseases, New York School of Clinical Medi-
cine, etc. 12mo, pp. 175. New York International Journal
of Surgery Company. 1911.
In this convenient little volume Dr. Wolbarst has collected a
series of articles on gonorrhoea in the male which have appeared
some months ago in the International Journal of Surgery.. The
book is intended primarily for general practitioners, as a guide to
diagnosis and treatment, and is based largely upon the author's
personal experience. A special plea is made for accuracy in diag-
nosis and for conservatism in treatment.
Dr. Wolbarst's book is a thoroughly up-to-date summary of
the subject of gonorrhoea, and may be strongly recommended as a
practical, handy guide for practitioners.-
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII JULY, 1911 No. 7
Contributed by the Author to The American Journal of Urology.
A RATIONAL AND EFFICIENT METHOD OF TREAT-
ING ACUTE GONORRHOEAE URETHRITIS
By F. Kreissl, M. D., Chicago.
IN the treatment of acute gonorrhoeal urethritis one should
bear in mind the following points :
1st. That it is necessary to ascertain the condition as
gonorrhoeal urethritis.
2nd. That the gonococcus cannot be killed with an ax nor
burned out by fire, or suffocated by balsams.
3rd. That the gonococcus having once settled below the epi-
thelial strata it cannot be reached by any drug, be it administered
by mouth, urethra or rectum.
4th. That nature will rid the system of pathogenic organisms,
especially if it be assisted in a moderate and sensible manner.
It should be hardly necessary to say that not every urethral
discharge which follows a cohabitation within a few days is neces-
sarily of gonorrheal origin, or if so, that it is not necessarily
due to a recent inoculation. Hence the importance of using the
microscope in every case of urethral discharge, and of employing
all other diagnostic means if the anamnesis should point to a
previous infection.
It may happen then that a discharge noticeable within forty-
eight hours after cohabitation will be found to be due to a chronic
prostatitis, vericulitis, a urethral stricture, or a follicular catarrh,
which condition becoming aggravated under provocation and
stimulation, is manifesting itself by the urethral secretion. This
may or may not be augmented by the presence of the gonococcus.
As soon as the Gonococcus Neisser was recognized as the
cause of gonorrhoeal urethritis, its destruction in the shortest
possible time and by the most vigorous treatment became the
chief object of our therapeutic measures; and when the specific
247
248 THE AMERICAN JOURNAL OF UROLOGY
action of the silver preparations on the gonococcus became ap-
preciated, they were employed in the strongest possible, not to
say impossible, concentrations.
Several years ago I heard a colleague recommend in a meet-
ing the introduction into the urethra of a solid silver nitrate pencil.
I ventured to ask the gentleman if he would like to have the treat-
ment he was prescribing for his patients, but the answer is still
outstanding.
The idea of using strong germicides for this trouble sug-
gested itself from the results of the laboratory experiments, but
we should bear in mind that the living tissue is not a dead culture
medium and that drugs, which are of sufficient strength, to kill all
the cocci at once will certainly destroy all the living tissues harbor-
ing the same and perhaps even more. Such methods are on the
order of the old Chinese cure of corns — by chopping off the toe —
a procedure, which considering the importance of the organ in-
volved in gonorrheal urethritis, — will never become popular.
We have therefore to be satisfied, in being able to reduce the
virulence of the germ, to check as far as possible its multiplication,
to prevent it from invading the posterior urethra and to avoid
complications. And this must be accomplished without undue
traumatism — mechanical or chemical — to the inflamed area.
Therefore, the principal, upon which a rational method of
treating acute gonorrhoeal urethritis will stand, must aim to de-
stroy and eliminate the gonococcus which appears on the surface,
leaving the extinction of the rest to the action of the tissues into
which our germicides in their permissible strength are unable to
penetrate. In the early and very acute stage the gonococci
abound and multiply rapidly. Consequently the efforts to combat
this condition must be made very frequently, but they have to be
made under consideration of the then highly inflamed and vulner-
able tissues. Therefore frequent injections are indicated with a
very mild germicide and without extreme expansion of the ureth-
ral wall. As soon as the inflammation subsides, the character of
the discharge changes, and the virulence of the gonococcus is
lessened, we find the leucocytosis — nature's attempt to carry the
germ to the surface — decreased. Very natural then, the fre-
quency of applications can be reduced — more for the comfort of
the patient than for any other reason — and the solution employed
made somewhat stronger.
Proportionately to the reduction of the number of injections
ACUTE GONORRHOEA!. URETHRITIS
249
the solution should be retained longer. This concession I make
not because I believe that the longer duration of the contact of the
drug with the diseased area has a deeper reaching effect, but I be-
lieve that under the prolonged pressure of the column of fluid the
contents of the infected follicles are forced into the urethra and
the fluid into the follicle. It is the same idea that prompted the
combination of dilating and irrigating the urethra in chronic
urethritis.
The frequent injections in the very acute stage of the dis-
ease do not represent much more than a flushing of the urethra
with the addition of the gernrcide. I am convinced that both the
flushing and the drug are sharing alike in the ultimate result,
which can readily be proven. If a patient in this stage would
use nothing but frequent injections with hot water, the subjective
symptoms improve, the character of the discharge changes from
purulent to almost watery, and the quantity becomes considerably
less. S'milar conditions may be observed under the internal ad-
ministration of diuret cs with or without the addition of balsams.
The latter have no decided specific action on the gonococens but
they increase the diuresis by stimulating the renal activity.
However, it should be admitted that the number of cocci is
considerably reduced by the use of balsams in conjunction with the
administration of water, either through injections or by mouth.
But whether frequent flushing of the urethra by diuretics or
by inject'on of water is employed, the results will be unsatis-
factory. The acute inflammation will subside, but the gono-
coccus, as a rule, remains, constantly menacing the posterior
urethra and threatening complications. A speedy extinction of
the germ can only be expected by the judicious employment of the
silver preparat'ons, foremost among which I place protargol and
nitrate of silver. Several years ago I attempted to test the rela-
tive efficiency of argyrol, protargol and silvernitrate on gonococ-
cus cultures, under consideration of strength of the solutions em-
ployed and length of exposure to the same. The cultures were
made from the secretion of patients then under treatment for
acute gonorrheal urethritis. I selected for the experiment so-
lutions of different strength such as were commonly prescribed
for urethral injections and exposed the cultures to each concen-
tration of the three drugs for from one to thirty minutes. The
experimental study, which was conducted with the kind assistance
of Dr. Ralph Webster, furnished information similar to that ob-
250 THE AMERICAN JOURNAL OF UROLOGY
tained by almost the identical investigation carried on by Schaefer
about fourteen years ago and published in a paper which I pre-
sented before this society. These experiments were made with
drugs which we considered as germicides at that time and em-
ployed in the treatment of gonorrhoeal urethritis.
Experimental study of argyrol and protargol with gono-
cocci cases Xo. 9S79, Xo. 9378, Xo. 9529:
Tests of gonococcicidal strength of argyrol and protargol.
Owing to the susceptibility of the recently isolated gonococcus to
death from ordinary laboratory manipulations, no tests were made
until the organism was accustomed to a saprohytic existence and
would live for days at roon temperature, to reach this condition
necessitated the making of new growths many days in succession.
Tlrs being accomplished the procedure was practically the
same in Nqs. 9378, 9379, 9529.
Only ascitic and blood agar slants were used. A culture
tube containing a vigorous growth of the gonococcus was filled
to above the slants with sterile water, when, with a sterile pipette
the colonies were mixed thoroughly with the sterile water and a
transfer made to blood agar as a viability test. A solution of
the substance being testes was then added to the mixture of go-
nococci and sterile water to the desired strength and transfers
made at stated intervals. After 48 hours incubation at 37 de-
grees C. the transfers showed the following results :
Exposure
1 min.
2 min.
4 min.
10 min.
20 min.
30 min.
Argyrol
m
XXX X
xxxx
XXX
XX
X
X
Argyrol
20%
XX
XX
XX
X
X
X
Protargol
xxxx
XXX
XX
XX
XX
XX
Y4%
XX XX
XXX
XX
XX
XX
XX
m
xxxx
XXX
XX
XX
XX
XX
i%
xxxx
XXX
XX
X
X
X
2%
XXX
XX
XX
X
X
X
4%
XX
XX
X
X
X
X
5%
X
X
X
X
X
X
The xxx marks crudely represent the comparative number of
colonies shown. The result may be stated briefly: partial de-
struction of viability is shown by all solutions, but is complete in
no strength used. The inhibition of growth is in direct pro-
portion with the strength of solution and length of exposure.
While our findings differ from most of the reports published, we
attribute it to the amount of material carried over to the testing
culture, for incubation. In our work from one to five- drops were
ACUTE GONORRHOEA!. URETHRITIS 251
transferred, while the custom is to transfer but a few loppsful.
Had this latter plan been followed we have no doubt, from the
small numbers remaining viable, in many instances, there would
have been apparently complete gonococcicidal effect. The same
procedure was
made with
silver nitrate so]
lution
and the
results
were
1 min.
2 min.
4 min.
10 min.
20 min.
30 min.
1-2000
xxxx
xxxx
xxxx
XXX
XXX
XXX
1-1000
xxxx
xxxx
xxxx
XXX
XXX
XXX
1-750
XXX
XXX
XXX
XXX
XXX
XX
1-600
XXX
XXX
XX
XX
XX
XX
1-200
o
o
o
o
o
o
1-100
o
o
o
o
o
o
1-50
o
o
o
o
o
o
1-20
o
o
o
o
o
o
Look'ng at the cross marks of the copy of this report you
will observe that the ultimate results of strong, medium or weak
concentrations of argyrol and protargol are the same. None of
them destroys the gonococcus completely. You will further ob-
serve that there is no perceptible difference in the effect of any
of the lower concentrations of either drug. A marked difference
appears as we come to higher concentrations. But these differ-
ences are only pronounced in the first nrnute of the contact of the
drug with the culture.
Hardly any effect is observed from the silver nitrate solutions
used in concentrations which are commonly employed for gonor-
rhoeal urethritis. Here also the length of exposure to the drug
does not seem to have any influence whatsoever. Most positive
however, is the effect of very strong concentrations.
These experiments bear out the contentions which I have
made so often, that drugs which seem to possess gonococcicidal
properties exhibit the same in vitro most pronounced only in con-
centrations which are not permissible in practice on account of
being too irritating or even destructive to the tissues they come in
contact with.
This point is particularly emphasized by the immediate ces-
sation of symptoms following one application of a very strong
silver solution in those cases of chronic gonorrhea in which the
germs have retired into a morgagni crypt, a paraurethral duct,
or hiding in a granulating patch. Here no extensive inflam-
mation can be set off by a vigorous cauterization which will de-
stroy all the gonococci, together with a small area of adjoining
tissue.
252 THE AMERICAN JOURNAL OF UROLOGY
But in this experimental study we also find a strange con-
trast between the apparent indifference of the culture gonococcus
to the milder concentrations of the silver preparations, and of the
susceptibility of the gonococcus to the same solution on the living
tissue. I have never been able to offer an explanation for this
discrepancy which would not be open to objection. Perhaps the
cultured gonococcus has more resisting power because of the ab-
sence of antibodies as they are formed in the living tissues. This
theory might then explain why, under the employment of strong
and irritating drugs in the acute stage, the process is getting
worse and prolonged.
Whatever the underlying cause may be, experience teaches
that for the successful management of acute gonorrheal urethritis
the strength of the silver solutions employed must be in an in-
verted ratio to the degree of inflammation. And experience has
shown that protargol serves this purpose best, both in its im-
mediate effect and its ultimate results.
The patient receives a one-eighth of one percent solution of
protargol, equal to about four grains in six ounces of distilled
water. Of this solution he has to inject from two to three drams,
depending on the capacity of the urethra. The solution has to be
retained for one minute, and this injection is repeated every hour
during the day and every three hours during the night. The
latter point, for which I take the priority, is of the utmost im-
portance for a speedy cure, and neglect of this rule is responsible
for complications and undue prolongation of the disease.
The patient should urinate before each injection so as to
mechanically remove the secretion from the urethral wall. Sex-
ual excitement and physical exertion must be avoided. Regard-
ing diet, my instructions to the patient are not as stringent as is-
customary. Of course highly seasoned foods and alcoholic bev-
erages should be prohibited in the very acute stage of the disease.
But a small quantity of claret diluted with water should be per-/
mitted patients who are in the habit of taking stimulants and if
taken in moderate amount it is perfectly harmeless.
The patient is advised to report in the forenoon of the fourth:
day. He should not urinate nor use an injection for at least
four hours preceding his visit to the office. The discharge will
then be found to be very scanty, thin, of grayish color, and mic-
roscopically very few leucocytes and still fewer gonococci will be
seen. The patient receives then a one-fouth of one percent solu-
ACUTE GONORRHOEA!, URETHRITIS
253
tion of protargol to be injected every two hours to be retained for
one minute and to be used only once in the middle of the night.
He is to return on the fouth day, prepared in the same manner
as previously. As a rule we find then very little grayish secretion,
hardly enough to be spread on a slide, and microscopically we see
very few or no pus cells, a good deal of mucous shreds and a num-
ber of epithelial cells. Usually no gonococci are found, or just
a few extracellular. The decrease of the number of leucocytes
and the appearance of epithelial cells indicates than the gonococ-
cus has lost its virulence and that repair of the damaged tissues
has commenced.
In the total absence of pus cells and leucocytes the patient is
instructed to inject once every four hours, which gives him about
five injections a day. The night injection is discontinued.
If leucocytes and a few gonococci be still present in the dis-
charge, the patient should retain the first and last day injection
for three minutes and continue using the one in the middle of the
night. He is to report after four days without having injected
for twelve hours. Usually then the discharge which has to be
forced out of the orifice on account of its scantiness, contains
some epithelium and mucous, the urine voided is perfectly clear
or carries a few floating shreds.
The number of injections is then reduced to four during the
day, these to be retained for three minutes upon arising and re-
tiring, the other two for one minute each. The patient is to re-
turn after four days — the twentieth day of the treatment — with-
out having used an injection during the preceding eighteen hours.
There is usually no discharge found, or if there be a trace of it,
the misroscopical picture is the same as at the previous examin-
ation and this discharge is eventually the result of a prolonged re-
action, as it follows the application of any kind of silver prepar-
ations. Evidence of this I have often received when patients,
for one reason or another, discontinue the injections at this stage
without a subsequent recurrence of the trouble. From these al-
most uniform findings and the identical course the disease runs, I
am lead to believe that the largest proportion of these cases may
be considered cured in twenty days or less, but that the treatment
should be kept up and gradually discontinued in the following ten
days. For this purpose the patient should be instructed to inject
for three days once in eight hours, for the next three days upon
arising and retiring, and for the last four days once in twenty-
254 THE AMERICAN JOURNAL OF UROLOGY
four hours. These injections should be retained for five minutes
each time.
After a further interval of four days during which no in-
jections are used, the patient if so disposed, should drink some
beer or other alcoholic stimulants, which will bring forth consider-
able typical secretion within twelve hours if the gonorrhea should
not be cured.
This test however, may be dispensed with, because even with-
out provocation the discharge in a case of recent gonorrhea in-
variably returns if treatment be discontinued only for forty-
eight hours. A discharge which persists after this time, but is
found to be free from gonococci, might be due to other germs, or
to an ordinary post gonorrheal catarrh, which readily yields to an
astringent like resorcin, sulphate of zinc, acetate of lead or sul-
phate of copper. Sometimes this discharge is associated with
strictures, either traumatic or a remnant of a preceding infection.
Under a suitable treatment of these lesions the discharge soon
ceases.
If the gonococcus, in spite of this methodical treatment, per-
sists for more than s^x weeks, one has to investigate for the cause
and it will not be difficult to find the same. It is either laxity
of the patient in following instructions, carelessness at the pre-
scription counter, or a constitutional disease like anemia, chloro-
sis, tuberculosis, lues, which is likely to prolong the trouble. In
other cases a stricture, an infected paraurethral duct, or Cowper
gland will be found as the cause.
Another source of an unduly prolonged gonorrheal urethritis,
and one generally not thought of is a certain degree of atony of
the cut-off muscle. In these cases the external sphincter yields
to the slightest pressure of the column of fluid injected into the
anterior urethra, permitting part, if not all of it, to run back into
the posterior urethra. Thereby the purpose of the treatment, the
unfolding of the mucosa and exposure of every diseased area to
the germicide, is frustrated. This abnormal condition may be
readily ascertained in the following manner :
The patient is ordered to urinate, but to keep part of his
urine in the bladder. He then injects a sufficient amount of the
medicine to slightly distend the anterior urethra. This amount
usually varies from two to three drachms. The solution, after be-
ing retained for several minutes, is d-'scharged into a graduated
vessel, and measured. If a part of the medicine should have en-
tered the deep urethra it will be missed in the returned fluid.
ACUTE GONORRHOEA!, URETHRITIS
255
If the patient then empties his bladder completely, the urine
which previous to the injection was voided perfectly clear, will he
found more or less turbid on account of being mixed with that
part of the medicine which has entered the deep urethra.
In this condition the atony of the sphincter muscle must be
corrected by pressure exerted on the perineum in some way, either
by the hand of the patient or by the pat'ent sitting down on a
hard object, for instance the arm of a chair, during the injection.
Protargol solutions, like other silver preparations, should be
dispensed in stained glass bottles, and prescribed in small quanti-
ties, not more than would last from twenty-four to forty-eight
hours. If it were not too cumbersome and practically impossible
to be carried out, I should like to have the solution made up three
times a day, as it has been proven that protargol and argyrol
when dissolved in water are losing a good deal of strength within
12 hours. Perhaps results would then be still more striking.
In cases which give a history of a preceding gonorrheal in-
fection, we shall have to look for lesions left over, and usually we
find periglandulitis and granulations. In patients whose general
health is below par, these lesions are likely to appear within a few
weeks after the onset of an acute gonorrhea, and silver nitrate will
have to be employed instead of protargol. A solution of one in
one thousand injected three times daily or an irrigation with six
ounces of the same strength is generally sufficient. Eventually
urethral dilatation will become necessary to crush the granulations
and promote the absorption of the infiltrations. In other very
stubborn cases, applications of twenty percent silvernitrate so-
lutions through the urethroscope will be required.
Under the above method of treatment if commenced in the first
three days of the disease, and properly carried out, I have yet to
see a case in which complications set in or which, like cases treated
by other methods are indefinitely prolonged and terminate with
definite more or less permanent lesions.
No. 5 North Wabash Ave.
256 THE AMERICAN JOURNAL OF UROLOGY
Contributed bv the Author to The American Journal of Urology.
THE CONTROL OF PROSTITUTION AND VENEREAL
DISEASES IN THIS COUNTRY AND ABROAD.*
By Frederic Bierhoff, M. D., New York.
PROSTITL^TION is an institution which has existed since
prehistoric days; for, already in ancient Chaldea, almost
4000 years ago, it was a recognized practice, and we find
evidences that regulation existed there, prescribing the dress of
the prostitutes, and the places where they might follow their
trade. Moses, also, already recognized the transmissibility of
■venereal diseases, and formulated laws to prevent their transmis-
sion, during the exodus from Egypt.
Solon founded brothels in ancient Athens, and formulated
regulations governing them. He was moved to do this by the
desire to protect the virtuous women of Athens from molestation
and insult, and by the wish to protect the health of the nation.
In those ancient days it was already found necessary to limit the
field of activity of the prostitutes, by segregating them in Piraeus,
the port of Athens.
In ancient Rome, stringent laws were adopted dealing most
harshly with prostitutes and their hangers on, and with adulterers,
etc. The laws were all directed towards the purity of the Roman
women, and of the family ; yet prostitution, in its most vile and
corrupt forms, was never more prevalent than during the days of
Rome's greatest glory.
Venereal diseases are said to have raged among the ancient
Greeks and Romans, and it was the fear of these that is said to
have been in great measure responsible for sexual perversions
among these peoples. I find no mention of the sanitary super-
vision of prostitutes, however, in their history.
Although Paul and the apostles, early in the Christian era,
preached continence and the holiness of matrimony, it was not
long before prostitution again gained a foothold among the chris-
tian peoples, greatly aided in its spread by the wandering priests
-and monks. In the Apostolic constitutions, ascribed to Pope
Clement, we find regulations to be observed by Christian maidens,
to differentiate them from the prostitutes: regulations which
might well be applied in the streets of our own city, where it has
Read before The American Society of Medical Sociology, at the Academy
.-of Medicine, May 12, 1911.
PROSTITUTION AND VENEREAL DISEASES 257
become so difficult to distinguish the painted, powdered and
pomaded maiden or matron from the harlot.
Although various Church councils promulgated laws relating
to prostitution, it is in the Proceedings of the Council of Milan
in the 16th century, that we find the first record of any definite
regulations among Christian nations. In these Proceedings we
find the following: "In order that it may be possible to distin-
guish, at a glance, between the prostitutes and the respectable
women, the Bishop shall see to it that the prostitutes shall, when-
ever they appear in public, wear a distinctive costume, which shall
be a mark of their shameful calling. Should they be strangers in
the city, they shall not be permitted to pass the night at inns or
shelters except their journey compels them to, and then only for a
single day. In every city, it shall be the duty of the Bishops to
assign to these individuals a part of the city in which they shall
all live, at a distance from the cathedrals and the populous quar-
ters of the city. Should they leave this quarter, and dwell, under
whatsoever pretext, in another house in the city, then they shall
be severely punished, as shall also the residents in whose houses
they shall be found."
Turn to whatever time, whatever country, whatever people we
will, and read their history, we find that all of the plans which are
now being tried or recommended, to suppress, or restrict, or regu-
late prostitution, have been tried, long before our day, and have
failed utterly. The prostitutes and their customers have been
looked upon as outlaws, and have been maimed, beaten, pilloried,
banished, even killed, but without any lasting effect upon prosti-
tution. Brothels have been tolerated, or licensed, and enslave-
ment and robbery of the women by brothel keepers, or the author-
ities have resulted. Brothels have been suppressed, and the pros-
titutes were robbed by those who harbored them, as well as by dis-
honest officials, who claimed to procure them immunity from pun-
ishment, while the women were driven from the streets, into nooks
and corners, where they continued to ply their trade in secret, with
the addition, however, that public order was, under these con-
ditions, invariably more disturbed, and that venereal diseases be-
came more prevalent.
Morality and sexual abstinence have been preached before
our day, and the result has been practically, the same as that of
the other methods. The preaching has not been heeded, and the
:moral tone has not been raised.
258 THE AMERICAN JOURNAL OF UROLOGY
Methods have been employed to supervise the health of the
prostitute, whether the public, or clandestine, with but little result,
until the last few years, for it has only been during the most re-
cent times that we have had any adequate knowledge of the causes
of the venereal diseases, and thus any way of studying means to
combat them.
Why have the efforts of those who, on the one side, have tried
segregation, casernation, and sanitary supervision, and, on the
other side, abolition of any control whatsoever, with appeals to
the morals and the reason, or the fear of the community, had so
little effect upon prostitution? Simply because the one side has
looked upon the prostitute as a criminal and an outcast, while the
other side has tried to reason away the sexual instinct in men and
women.
In dealing with a problem of such vast importance to the
welfare of the community as its health, we have no right to distort
facts because of sentiment or prudery. Deep down at the root, we
find that prostitution springs from two great causes ; first, the im-
pulse governing the propagation of the species, — called, by us,
the sexual instinct, — and secondly the social and economic con-
ditions under which mankind has existed and still exists.
Nothing which is natural is immodest, wrong or wicked. It
is only the restrictions placed by mankind upon the exercise of
natural functions, which can make that exercise immodest, wrong
or wicked.
The sexual instinct has been planted in the beings of all men
and women. That it varies in its intensity in different individ-
uals, is a fact known to all of us, who come in contact, as physi-
cians, with men and women. In one individual, male or female,
the instinct may be so little developed that it is easily controlled
or even suppressed. In others it may be normally strong, yet be
controlled, within certain bounds, by an effort of the will; yet,
even then, not indefinitely. In still others, the sexual instinct may
be an impulse so strong that it becomes utterly impossible to con-
trol it, far less to suppress it entirely, and, if it be not gratified
normally, it is sure to break out in abnormal or perverted ways.
It is a fact, however, that in man the sexual instinct is as a gen-
eral rule more strongly developed than in the female, and this is
not the result of the indulgence of the male in the sexual act, but
is based upon natural factors. Man is the active factor in pro-
creation, and the greater degree of sexuality in the male is merely
PROSTITUTION AND VENEREAL DISEASES 259
a survival from the time when, in the prehistoric days of the hu-
man race, owing to the greater destruction of life among the males,
one male was the rate of several females. The polygamous nature
of man, for that is his nature, in spite of what the moralists say,
is then merely a survival of prehistoric qualities, which civiliza-
tion has not yet completely changed. The monandrous nature of
woman is, similarly, also a survival of prehistoric qualities.
How unjust it is, therefore, for us to measure all men and
women according to the same sexual standard !
When we consider the social conditions which foster prosti-
tution, we come to a most complex problem.
If we could have all men and women created mentally and
physically equal, and with similar degrees of sexual desire ; if,
when they grew to sexual maturity, we could have them all mate
for reasons of pure affection only; if there were assured to each
couple, and to their children, enough to live on in comfort, and
enough to meet all reasonable needs of the family ; if there were
no such thing as enforced celibacy, or widowhood, then we might
hope for the abolition of prostitution and later, perhaps also
venereal diseases. But, until- such a day arrives — and it never
will — we shall have prostitution and venereal diseases with us.
Although a number of nations which formerly regulated pros-
titution, have given up the compulsory inscription and the seg-
regation, or casernation of the prostitute, there are others in
which these measures are still employed. The opponents of regu-
lation claim better results from the absence of restrictions, while
those who .support regulation claim the contrary.
The wildest claims are made by the opponents of regulation :
yet, since the abolition of control in those countries where the
opponents have been successful, it is an utter impossibility for
them to present incontrovertible proofs of the correctness of their
claims, since all prostitution has become clandestine, and the pros-
titutes cannot be reached. Therefore their claims cannot be
backed up by adequate proofs. They have simply abolished the
brothels, and driven the prostitute out among the respectable
people. This is exactly what happened, also in the city, some
years ago, as the result of the spectacular raids of a certain clergy-
man. Nor can they produce proofs that the abolition of control
has had a beneficial effect upon the spread of venereal diseases.
In Norway Hausteen (Z. B. G. x, No. 4, 1909) tells us broth-
els were tolerated, and under police control until 1884, when, as a
260 THE AMERICAN JOURNAL OF UROLOGY
result of the movement for the enfranchisement of women they
were all suddenly closed. The prophylact:c control of the pros-
titutes was continued until 1887, when control and inscription was
abolished. Since that time all dealings with venereal diseases had
been in the hands of the general health authorities. Although
the notification to the health authorities of all cases of venereal
diseases has been the rule in Christiania, since 1876, there are no
special regulations intended to check the spread of venereal dis-
eases.
Taken from Hausteen's figures which he has complied from
the reports of the Norwegian National Department of Health, we
find that under the old system there was a steady rise in venereal
diseases from 1876 to 1882, and then a steady decline until 1888.
The brothels were closed in 1884, and all control was abol:shed in
1887. From 1888 until 1897, there was again, a steady rise, al-
most to the maximum of 1882. Then followed a steady decline
again, until 1907, when the curve again begins to rise. Hausteen
has found these fluctuations in the number of venereal cases to be
independent of the presence or absence of brothels, or control,
and finds that, with the depression in the economic conditions in
Christiania, during the eighties there went a decrease in venereal
disease, while, during the period 1889-1898, with the rise of
economic cond tions, there was a corresponding rise in the cure
of venereal disease, to be followed by a fall again, corresponding
with the financial crisis during 1898-99. He states, further, that
it is not to be denied that since the abolition of the brothels in
1884), the evidences of public prostitution upon the streets have
become more noticeable than before the change ; also that the
number of public prostitutes seeking treatment of physicians or
hospitals is relatively small, and that the suspicion, that the num-
ber of servants and working women infected with venereal diseases
has relatively increased, seems to have a certain amount of justi-
fication. Surely this can be no glowing victory for the abol-
itionists.
Prof. Welander of Stockholm — than whom there is no one in
Sweden better acquainted with the problem of control of prosti-
tution—states (Z. B. G. 1911. Nos. 11 and 12): Brothels are
prohibited: most of the prostitutes practice their trade in rented
rooms or in small hotels. Inscription of public prostitutes, with
physical examination, is the rule, but the number of the inscribed
has of recent years been decreasing — from 422, April 1 1904, to
PROSTITUTION AND VENEREAL DISEASES 261
267, January 1 1907, while the population has increased. He
states that the number of clandestine prostitutes in Stockholm is
not very large, and that it is hs belief that the fear of inscrip-
tion has deterred many of these women from continuing to prac-
tice prostitution. Furthermore, owing to the warning given by
the police authorities to young women cited to appear before
them, a large number have been returned to their relatives, or ad-
mitted to charitable institutions, and otherwise turned from pros-
titution. He fears th's might change were sanitary supervision
abolished.
In every district in Sweden there must be at least one hospi-
tal, or one hospital division, which receives and treats venereal pa-
t'ents free of any charge. In Stockholm the St. Gorau hospital
has 272 beds for venereal patients, while the old hospital, with 100
beds, has been reserved for diseased prostitutes.
Welander is of the opinion that the best way to combat the
spread of venereal diseases is to isolate the venereally diseased in
hospitals. Not every case can, however, be so isolated, and not
every one requires it. The large mass of them can be treated
outside of hospitals and will subject themselves to the necessary
treatment. But there are others who are by reason of their mode
of life most dangerous to the community ; the worst of these are
those who practice public prostitution, and these, he believes,
should, when they present evidences of a venereal disease of a
transmissible character, be isolated in a hospital. We know, he
says, that these women seldom voluntarily report their diseases,
and that they are seldom reported as diseased by those who have
been infected by them. There remains to us nothing else than to
subject them to preventive examinations, so long as we require
their isolation in hospitals. But these preventive examinations
must be based upon scientific principles, — such as a careful search
for .gonococci, and a careful examination for evidences of syph-
ilis,— and they must be carried out by competent, experienced
persons.
So, you see, in Norway and in Sweden, those who know and
understand the conditions from actual experience, rather than
from the superficial diletantism of the professional agitator, lean
rather to the wish for an increase in the restrictions than for
their entire abolition.
In Denmark control of prostitution was abolished by law on
March 30, 1906.
262 THE AMERICAN JOURNAL OF UROLOGY
England, as you know, is the paradise of the frenzied agi-
tators and the abolitionists, as it is the home of prudery and
"Mrs. Grundy."* It has no control whatsoever or supervision of
prostitutes and prostitution, venereal diseases and sexual perver-
sions flourish now as they have always done. It is impossible to
get any reliable statistics about the prevalence of venereal dis-
eases in England, excepting for the British army and these prove
the fallacy of the complete absence of supervision, for Great
Britain has for her home forces the proud, though somewhat
questionable, distinction of having the highest percentage of dis-
ability due to venereal diseases of the armies of the world, next to
our own. Hammer tells us (Z. B. G. 1907, No. 1) that in 1902-03
the figures for the European armies were per 1000:
Prussian, Saxon and Wurtcmberg troops 19.4
French 29.9
Austrian 57.5
Italian 91.5
In the report of the Surgeon-General of the Lmited States
army for 1910 we find the statement that, according to the latest
available statistics the figures for venereal diseases in various
armies are :
English home forces 122.7
British (at home) 68 A
British forces, home and territorial 75.8
Austro-Hungarian 51.2
French (at home) 27.8
French, home and territorial 34.8
Prussian 18.7
Bavarian 15.2
United States 196.99
Surely this must be a glorious victory for the abolitionists
as against those who favor control, since the United States can
show 196.99 per one thousand men and England 75.8 against
only a poor 18.7 for Germany and 15.2 for Bavaria.
Austro-Hungary still tolerates brothels and follows the old
system of inscription of public prostitutes, with periodical exami-
nations of these women at police headquarters.
In 1909 while on a visit to Vienna, I tried to acquaint myself
with the conditions and the methods of control in that city. Still
smarting, perhaps, under the disclosures of police corruption which
PROSTITUTION AND VENEREAL DISEASES 263
occurred during the trial of the notorious "Modesalon Riehl" case,
a few years previously, the authorities hedged themselves in with
such a wall of diplomatic requirements, that I gave up the attempt.
It was a unique experience for me in my studies, since this was
the first refusal I have ever encountered.
From another source, however, I have learned that in 1907
there were 15 tolerated brothels in Vienna; also 1,400 inscribed
prostitutes and it was estimated, 30,000 uninscribed, of which
latter class almost 50 per cent were minors. During the trial of
the case of the "Modesalon Riehl" (a notorious Viennese brothel)
it was disclosed that these establishments were protected — yes,
even their profits shared in — by the city officials, and as a result,
attempts have been made to abolish tolerated houses.
In November 1906 a meeting of the Commission was held
in Budapest, under the presidency of the Mayor, to consider the
new regulations formulated by Stadthauptmann Dr. Schreiber.
These contained, among others, the following regulations: The
system of tolerated houses was to be retained. Permits are to be
given only to women over 17 years of age. Of women living out-
side of tolerated houses only one may live in any one house.
These women shall be permitted to frequent certain streets and
certain resorts only. The medical examination shall take place
in some central bureau and shall be free of any charge.
In 1909, the examinations of the prescribed prostitutes, wrhich
were made at Police Headquarters, were such as are made, with
but few exceptions, in other European cities, and left much to be
desired from the scientific standpoint. The diseased prostitutes
are confined in an old barracks-like hospital, where they are kept
until pronounced well. Those who are able to be about take
their exercise in a large, open court-yard. I was informed by
the physician in charge, that Lesbian love was a general and
very troublesome manifestation among the incarcerated prosti-
tutes.
Switzerland does not tolerate brothels and has no system of
inscription or control. In the latter part of November 1906 con-
ditions in Zurich were the topic discussed at a meeting of the asso-
ciation of purists. Dr. iCeller-Huguemin who presented the re-
port, stated as his opinion that prostitution is a necessary result
of conditions at present existing, a physiologically necessary fact,
and that all attempts to root it out by legal measures are fruitless.
The law must seek to grapple with the problem in two directions,
26* THE AMERICAN JOURNAL OF UROLOGY
i. e. the protection of public morals and the preservation of the
health of the community.
The results of the attempts to suppress prostitution to
Zurich, have been to drive the prostitutes to do in secret what the
law prohibits : to bring them more often into contact with poor
families, with bad results to the morals of these, and to make im-
possible any attempts at sanitary control.
At the same meeting, the Chief of Police of Zurich, and City
Councilor Welti, stated that prostitution exists now, just as it
formerly did in Zurich, and that it is an impossibility to root it
out. Prostitution has now found numberless nooks in which to
h'de itself, particularly in the so-called cigar stores.
All through the early history of France we find evidences that
prostitution was very prevalent, in spite of the most drastic meas-
ures to suppress it. The measures simply forced the prostitutes
out among the respectable folk, and led to an increase in crime
and disease, and to the annoyance and molestation of respect-
able women. "It was chiefly on this account," says Delamare, in
h's Traite de la Police, "that the attitude of the police toward the
prostitutes was changed.*' In 1256, Louis IX who had, prev-
iously been most drastic in h's dealing with them, caused his chief
of police. Etienne Boileau, to formulate regulations governing
the prostitutes. Prostitution was thereafter tolerated ; but the
prostitutes were restricted to certain quarters and streets of the
city (Paris) ; their mode of dress was prescribed and the hours set
at which they must leave the streets. Louis IX and Etienne
Boileau may then be regarded as the fathers of the modern police
control of prostitution.
Thus the matter went on until 1560 when brothels were
abolished in Paris ; but the evil of prostitution was not lessened in
the enormous dimensions in which it had grown, and instead of
the public brothels, large numbers of low-class, secret places
sprang up, which were the retreats of thieves and cutthroats.
No sanitary supervision was exercised over these dens, and venereal
diseases were general in them. As a result, the authorities were
soon compelled to again tolerate public brothels.
Thus the matter has continued, with fluctuations, up to the
present day. The police tolerate prostitution, and attempt to
exercise a sanitary supervision over the inscribed prostitutes.
Parent-Duchatelet gives the number of inscribed prostitutes as
3853 in 1867, while he estimated the number of clandestine at 100
PROSTITUTION AND VENEREAL DISEASES 265
times this number. In 1910, I was informed by Dr. Verchere, the
chief physic'an of the police des Moeurs, that the number of in-
scribed prostitutes in Paris was about 7000. He could not even
estimate the number of the noninseribed. Up to a short time ago
there were about 200 brothels, or "Maisons de Tolerance." known
to the police. Now there are only about 50. The number of
houses of assignation greatly increased and there are now esti-
mated to be between 800 and 1000. All of the known brothels
must conform to certain regulations laid down to them by the
police authorities.
I shall not take up your time with the details of the method
of inscription, release from inscription, etc., excepting to say that
the names of those only are entered who apply voluntarily for the
inscription, or of those who have been repeatedly arrested for
soliciting. The legal age of inscription has, since 1893 been 18
years.
The inscribed women are divided, for purposes of exami-
nation, into two classes ; those young in the business, and those
old in the business. The former, who are the more likely to acquire
disease, are examined weekly, the latter every second week. The
examinations take place at the Prefecture of Police. Those found
to be diseased, are sent to the prison St. Lazare, where they are
kept under treatment until pronounced cured, whereupon they are
sent back to the Prefecture of Police for re-examination.
Germany is perhaps the country in which the system of con-
trol has been most thoroughly and carefully tried, and its cities
present examples of inscr'ptions with sanitary supervision, seg-
regation and casernation. I have elsewhere (A. Y. Med. Jour.
Aug. IT and Sept. 7, 1907) given the details of the control — meth-
ods followed, and shall therefore not take them up again here
in detail. The control is in the hands of the police, and exami-
nations are made by police physicians. This holds good whether
the prostitutes live in brothels or not.
Bremen permits prostitutes to live in brothels only on certain
prescribed streets. Hamburg follows a somewhat similar policy.
Nuremberg had in 1906 20 to 22 brothels chiefly located near the
old city walls and gates. In other cities, like Cologne, brothels
are also tolerated. On the other hand, Berlin, Leipsig, Dresden,
Munich, Frankfurt, Stuttgart and others do not tolerate brothels.
Yet they have their inscription lists of prostitutes, and sanitary
supervision.
266 THE AMERICAN JOURNAL OF UROLOGY
It has been my experience that in those cities in which
brothels are tolerated, the streets are freer than in those in which
brothels have been abolished. Compare the streets of Berlin with
those of Hamburg, and the difference is greatly in favor of the
latter. While in Hamburg solicitation upon the streets is a rar-
ity, the principal streets in Berlin literally swarm with prosti-
tutes at all hours of the day and night. It is a well-known fact,
also, that there is an alarming growth in Berlin of sexual crimes
and sexual perversion. It would be unjust to ascribe these facts
solely to the suppression of brothels. I believe the chief cause to
lie in the astounding rapid growth of the city, both in size and
wealth, during the past thirty to forty years. It is a fact, how-
ever, that Berlin has grown to-be one of the most vicious cities in
the world.
In Berlin brothels were definitely abolished in 1844 and since
then the greater part of prostitution has been of the clandestine
type. In 1896 the number of inscribed public prostitutes was
5098. In 1900, 4147, in 1905, 3135.
In 1906 I was informed by the official in charge of the di-
vision of Sittenpolizei, the inscribed numbered about 6000, while
more than 60,000 prostitutes were not under control. In Munich,
I was informed by a prominent police official that in 1906 there
were about 250 prostitutes inscribed on the police lists. The
Munich police department reported, in 1909, (Z. B. G. 1910, No.
5) that they had counted 2076 women whom they knew to be
secret professional prostitutes. Other authors estimate the num-
ber of clandestine prostitutes in Munich to be 15,000. Of the
2076 known to the police 1870 were brought for medical exami-
nation during 1909 and of these 592 (that is 31.6%) were found
to be venereally diseased.
Since January 1, 1907 the police of Berlin have tried to in-
crease the efficacy of their sanitary control, by permitting those
prostitutes who are not inscribed, but who arc known to the police
to be clandestine, to substitute for the examination by the police
physicians examination and treatment free of charge by any one
of a number of specialists, who had volunteered to perform this
work for the authorities. A woman who wishes to substitute this
private for the police examination is given a card and a list of
these volunteer exanrners, from whom she may choose any one.
She must present herself for examination and treatment, at inter-
vals specified by the physician who fills out a report noting her
PROSTITUTION AND VENEREAL DISEASES 267
condition and date for the next visit, which report the woman
must take or send to Police Headquarters. So long as the holders
of these cards obey the orders of their physicians, send in their
reports regularly, and do not engage in public prostitution, they
remain free of any police interference. Should they not carry
out these requirements, however, then they may be arrested and
inscribed. What the effect of this innovation may be, remains to
be seen. Dresden has, as I have stated elsewhere, cut down re-
markably the prevalence of venereal diseases among its inscribed
prostitutes since the introduction of scientific methods of exami-
nation and treatment.
Let us now consider our own city ; New York has, perhaps, a
much more difficult problem to face in any attempts to control
prostitution, than have other cities, since its population is made
up to so great an extent of foreigners, who, coming from the most
widely separated parts of the earth, have brought with them the
habits of their home countries — in many of which the moral
standard is very low, and who have been compelled, in many in-
stances, to leave their wives and families abroad, while in other
cases their earnings, for some years after their arrival here, are
not sufficient to permit of their marrying. Then again, the
growth of the population and its wealth has been tremendous and
this growth in wealth has been always, as stated before, been ac-
companied by a growth in prostitution. A further factor is
added by the large numbers of young men and women who flock
to this as to other cities from the country and the smaller towns,
in search of greater opportunities for advancement. And, added
to all the other factors, are the Anglo-Saxon prudery and hypoc-
risy in all matters relating to the sexual sphere.
In our city prostitution is held by law to be a crime and is
forbidden, and the existence of brothels is also prohibited as
criminal. Yet who that knows the true conditions existing in this
city will venture to say that the law has been successful in sup-
pressing either ! Certainly no one that is at all familiar with the
problem. Prostitution is, perhaps, more prevalent now than ever
before; affects all strata of society, from the highest to the lowest;
is found in all parts of the city, from the slums to the most select
neighborhoods ; and the prevalence of venereal diseases is said, by
various competent authorities, to be rapidly increasing.
Have we a control of prostitution? Of course we have.
Brothels are forbidden : yet they exist in various parts of the
268 THE AMERICAN JOURNAL OF UROLOGY
city, and any "rounder," most of the night-hawk cabmen, and a
good many police officers can give you the addresses of numbers of
them. They are all, of course, clandestine, in so far as their ex-
istence is concerned — and so long as they pay their tr'bute regu-
larly to the interested persons among the police officials. There
13 no doubt that a large portion of our police who are honest men
and who look upon the graft extorted from the prostitutes and
their parasites as "dirty money," yet almost every brothel is made
to pay certain fixed sums for the privilege of opening up, and cer-
tain other sums weekly or monthly for the privilege of continuing
business. So long as they pay, they are usually unmolested.
But neglect to "come over with the coin" is usually quickly fol-
lowed by a raid, or by the posting of an officer before the door of
a house, to warn would-be visitors away. I have spoken elsewhere
of the sums pa d and of the character of the places that exist.
Furthermore, we control the prostitutes by driving them from
one precinct into another : by arresting and fining them or im-
prisoning them in the work-house, by making them pay for im-
munity from arrest, or for the sudden forgetfulness of the police
officer when the woman faces the judge; by making them pa}r
bondsmen, lawyers, etc.. and by making them prostitute them-
selves the more frequently in order that they may be able to secure
the money to pay this tribute.
Our control of the street walkers is really farcical, or even
worse. Soliciting is classed as disorderly conduct, is a misde-
meanor, and is punishable by subjection to the jurisdiction of the
parole officer, by fine or imprisonment, release under bond, or dis-
charge.
The arrest is supposed to be made only after the officer has
been solicited by the prostitute, or when he has heard the pros-
titute bargain with a man whom she has accosted. It was our
present mayor who caused the abolition of the special detail of
police officers who formerly obtained the necessary evidence and
made the arrests, and insisted that only officers in uniform be em-
ployed for this purpose. It stands to reason that no prostitute,
however inexperienced in the business, is going to accost an offi-
cer in uniform or let him l'sten to her bargaining with anyone.
It was formerly the custom of some of the police court judges
to discharge, in defiance of the statute, every woman arrested for
prostitution or solicitation, on the ground that her arrest was a
form of persecution. Others regularly fined the women; but, as
PROSTITUTION AND VENEREAL DISEASES 269
a fine simply means that the woman thus punished has to go hack
upon the streets again to earn the money for th's tribute to the
law, I believe the fine to be not only not a deterrent, but a con-
temptible evasion of the issue, and an oppression of the prisoner.
Other judges placed the new offenders under probation, or warned
them ; the previously sentenced were sent to the work-house.
For the act of prostitution itself, I believe such a sentence to
be an injustice and oppress'on, for I do not believe that the pros-
stitute is a criminal, nor the act of intercourse in itself a crime.
The prostitute, however, who. knowing herself to be venereally
diseased continues to engage in prostitution, is a criminal, and
should — since it is the' common knowledge of all experienced in-
vestigators that these women do not voluntarily interrupt their
activities when d seased, and submit themselves to proper treat-
ment be confined to some hospital, (not to a penal institution)
where she can be properly and adequately treated, and where she
can be employed at some form of labor which will reimburse the
community for her care and treatment, and leave her something
when she is discharged.
It has been advanced that such a form of treatment would be
futile, because the prostitute would again become diseased. That
dees not hold good of syphilis, and need not hold good of gonor-
rhea, if the women were given, during the period of their in-
carceration, some wholesome advice, medical as well as moral, to
enable them to avoid future infection.
It will, perhaps, be argued that such prophylactic advice
would be immoral and a pact with vice. I can only ask : Which
is the greater civic crime — to tell men and women how they may
avoid disease and misery or to preach to them empty words of ad-
vice concerning the salvation of their souls, while their bodily
health is allowed to go to destruction? I see my own way clearly,
as a physician, and shall continue to advise the salvation, first of
the body, believing that the healthy mind is more apt to flour sh
in the body which is healthy.
The much-maligned Page law was, I believe, a step in the
right direction, s nee it took the prostitute, after coniiction for a
misdemeanor, and subjected her to physical examination, by a fe-
male physician, an employe of the health department. If the
prostitute was found to be diseased, she was supposed to be com-
mitted to a hospital, and treated there until pronounced well — or,
at least, no longer infect:ous. The maximum incarceration pos-
270 THE AMERICAN JOURNAL OF UROLOGY
sible, under this law, was one year, and commitment was mandatory
upon the court, when the woman was found to be diseased.
At once upon the application of the law, a storm of protest
arose, having its foundation chiefly in the sympathies of a number
of men and women who, while, actuated no doubt by the best of
motives, have little or no actual . knowledge of the problem of
prostitution and its accompanying dangers to the community.
Several organizations took up the fight, using as their weapons
publications which ingeniously distorted the statements of a num-
ber of authorities and near-authorities upon the question of con-
trol of prostitution, and finally test cases were brought by means
of habeas corpus proceedings in the cases of two prostitutes con-
victed under the Page law, and the decision was rendered by one
of the judges of the Supreme Court, that the law was unconsti-
tutional in that the commitment was obtained upon the evidence
of an individual — the health board examiner — not connected with
the court. Thereupon the examinations and commitments under
the law were interrupted.
Some people think that the matter ended there ; but it did not.
The district attorney carried the matter up to the Appellate Di-
vision and there the matter is at present, still under advisement.
If the Apellate Division declares the law constitutional, then the
examinations will have to be begun again, unless the law is re-
pealed by the present or some future legislature.
The law provided that a woman arrested for prostitution or
soliciting be taken after conviction to a room adjacent to the
court room and there be examined for the presence of any disease
which might be contagious, infectious or communicable. The re-
sult of this examination was then to be reported to the presiding
magistrate.
I am afraid that — judging by the description of the method
of examination given me by one of the examining physicians of
the Board of Health — the methods of examination were incomplete
and not up to the scientific standard we have the right to expect.
Thus from September 1, 1910. until the action of the law was sus-
pended, that is, during three months, 279 women in all, were ex-
amined. Under the old regime 50 to 60 women per night, arrested
for prostitut:on or soliciting was a fair average. Of the 279 ex-
amined 81 were found to be diseased with gonorrhea, none with
syphilis, and none with chancroid. Had the examinations been
carefully made, I feel sure that more would have been found to be
diseased.
PROSTITUTION AND VENEREAL DISEASES 271
The medical examinations. I was told by the examining
physician, were objected to by the women in only one or two cases,
and these women, when the nature of the examination was ex-
plained to them, readily submitted. Many, I was told, welcomed
it, for the private physicians who examine and treat these women
are in almost every case absolutely unqualified to properly examine
them. Furthermore, the women themselves and the brothels keep-
ers do not want them to be declared diseased as that would inter-
fere with their business. Therefore the private doctor who ex-
amines the prostitutes carefully and scientifically soon finds that
they go elsewhere.
The Health Department erred gravely in compelling the
women to wait in the prison for the result of the microscopic ex-
aminations. It should have had a qualified microscopist working
in the courthouse who could have at once examined the specimens
and reported upon them to the examining physician.
It has been advanced as an argument against the constitu-
tionality of the law that the physicians making the examinations
had not qualified as experts, and that the defendants were not per-
mitted to submit counter-testimony. That is of course a valid
argument, but one which is easily answerable. Let the Board of
Health appoint for these examinations only properly qualified ex-
aminers and let them qualify as experts at once upon appointment.
If the Board of Health were in earnest in supporting such a
method of sanitary control, it could easily deputize several of its
female physicians to fit themselves by special study of control
methods, to qualify as experts. Then deputize them as court
officials. Should the prostitutes then desire to present counter
testimony, let the law provide for that possibility, specifying
that this testimony shall be given only by a medical examiner who
shall also have qualified as an expert, the counter testimony to be
based upon the findings of an examination made by both the court
examiner and the prisoner's physician, in the presence of each
other. Should there arise any difference of opinion between the
examiners, then the court might appoint a third expert, who
might act as a referee. In that manner justice could be done to
both the community and the prisoner, and I feel confident that the
appeals from the verdict of competent health board examiners
would soon cease.
I do not need to say again to you that prostitution is based,
not upon the depravity of men and women, but upon physiological
272 THE AMERICAN JOURNAL OF UROLOGY
and economic causes ; that the fight to suppress or abolish it has
gone on since time immemorial, and that we are, at the present
day, no nearer its abolition than was Moses or Solon. I feel sure
that whatever fa lures have followed upon attempts to control
prostitution and the spread of venereal diseases have been the re-
sult of our inability to bring about a trial of up-to-date scientific
methods for sanitary control. Political trickery and official d's-
honesty, combined with our national hypocrisy, have prevented a
full and just trial. We have not yet learned that the rights of
the community overbalance the rights of the individual, when the
health of the former is threatened.
Those who have opposed any control of prostitution have
offer ed little else than lectures on morality and sexual abstinence
as a substitute. I sympathize heartily with the efforts of those
men and women who would try to elevate the morals of the com-
munity and to recla'm those who had erred; but I cannot sympa-
thize with that blindness which continues to ignore the dangers
to the common welfare aris ng from the spread of venereal con-
tagion— dangers admitted to exist even by the most ardent
abolitionists — and hugs to its bosom the fond delusion that it can
banish these dangers while entirely ignoring their source.
What do I believe to be the measures necessary to check the
spread of venereal diseases?
First, educational: I believe that when children of both sexes
reach the age of puberty they should be instructed in school con-
cerning the anatomy and physiology of the sexual organs, the plan
of instruction broadening as the age of the pupil advances.
Above all else, when they are sufficiently advanced, they should be
warned against sexual abuses and the dangers of sexual indulgence
should be pointed out to them. Th's instruction should be im-
parted to them not by ill prepared school teachers, but by prop-
erly equipped physicians. If the Board of Education cannot
undertake this function, I am sure that enough specially qualified
physicians can be found to volunteer to do it.
Second, personal prophylaxis : It is not wrong to instruct
adult men and women in the methods of prevention of venereal in-
fection. It may be advanced that the fear of venereal infection
is the greatest preventive of sexual laxity and that to show people
how to avoid infection is to increase immorality. Those who
have had any experience at all with normal adult human beings
know that when the sexual desire becomes at all strong all dangers
PROSTITUTION AND VENEREAL DISEASES 273
are forgotten or are disregarded. Why then leave them to their
fate when instruction can save them — and so many more who may
be innocent — from serious danger? We need only to read of the
results of personal prophylaxis in the army and navy of Germany,
and recently also among our own forces, to realize that there we
have a very powerful weapon to combat these diseases.
Third, notification to the Board of Health of all cases of
venereal disease.
Fourth, facilities for the treatment of venereal patients: I
do not believe in the establishment of special hospitals for venereal
diseases exclusively. There is still a stigma attached to this class
of diseases in the mind of the community, which would work
aga'nt the seeking of relief in such special hospitals by the af-
flicted. Venereal diseases are a misfortune and not a crime and
those afflicted with them should have the right of admission and
treatment in every city hospital, and also in every hospital main-
tailed by private corporations, so long as these institutions re-
ceive any financial aid from the city. The treatment of the
venereal patients in these Institutions should be in the hands only
of physicians properly qualified as specialists in th's particular
class of diseases. Every hospital should, furthermore, maintain a
dispensary in which a department should be equipped with the
means to properly treat such d'seases, which department should
also be in charge of a competent specialist in this branch. In
order to bring these special hospital and dispensary departments
into close touch with the Health Department, the chiefs in charge
thereof might be deputized as sanitary inspectors acting without
salary from the department. All such chiefs should receive pay
from the institutions. [I believe that all medical officials of
hospitals should receive salaries for their services to these institu-
tions.]
The city should be divided into districts as is done with
ambulance work, each hospital and dispensary being required to
treat free charge any venereal case — ambulant or otherwise —
living within that district and referred to that hospital or dis-
pensary by the Board or Department of Health. The Board of
Health should maintain some bureau to which venereal sufferers
might apply for guidance. The city might pay a per diem charge
to each institution for each venereal patient treated free of charge
there, just as it now does in the case of other charity patients.
274 THE AMERICAN JOURNAL OF UROLOGY
And a charge per treatment might be paid to each dispensary for
each patient treated.
Let there be made a list of volunteer specialists whose quali-
fications shall be passed upon by the Department of Health, who
will agree to examine and treat, free of any charge to the woman,
any prostitute who may be referred to them by the Department of
Health. This plan is similar to the one employed in the city of
Berlin since 1907.
Fifth, inscription : Let the Department of Health establish
and maintain a list upon which those women who wish to follow
prostitution may have their names inscribed voluntarily and upon
which the names of those convicted of prostitution by the police
courts shall be entered. Insist that each woman shall be examined
at least twice a week by one of the specialists from the list or by
one of the deputy inspectors in one of the dispensaries and that
a report of the woman's condition be sent to the Department of
Health. So long as she reports regularly and does not solicit
upon the streets, do not molest her. If she does not report for
examination or is guilty of a misdemeanor, arrest her. Should a
woman so inscribed be found to be diseased, send her to that hos-
pital in whose district she lives. Should she be arrested and found
diseased send her not to the workhouse, but to one of the city
hospitals on Blackwell's Island until cured.
It has been claimed that it is often impossible to cure venereal
patients particularly the women. That is not so. Difficult, yes,
very difficult it may be ; but impossible, no !
But all supervision should not be restricted to the female.
As she is, however, the most active spreader of venereal diseases —
a statement which is readily capable of proof — the greater at-
tention should be paid to her. And those females who practice
prostitution and are found to be venereally diseased should, if they
will not voluntarily subject themselves to treatment and abstain
from prostitution till cured, be con-fined until cured. I say this
because I feel confident that only a small part of the public pros-
titutes will abstain from this traffic while diseased. The clan-
destine prostitutes will more generally make use of the facilities of
gratuitous examination and treatment.
I have found that the large majority of venereally infected
men will avail themselves of facilit:es for gratuitous treatment and
will abstain from intercourse while infected, if the dangers of the
disease to them and to others are explained to them.
PROSTITUTION AND VENEREAL DISEASES 275
Every dispensary or hospital treating venereal patients
should distribute leaflets free of charge, setting forth clearly and
in as simple a language as possible the dangers of indiscriminate
intercourse and the dangers of venereal disease.
Some day our legislators may be sufficiently enlightened to
pass laws which will enable us to examine convicted male vagrants
and to subject the venereally diseased among these to treatment
also.
Sixth, segregation : I believe in the segregation of the pros-
titute in so far as may be possible. I believe that the present
method of total absence of control has been largely responsible
for the great increase in recent years of flagrant solicitation, both
by night and by day, upon every prominent street of our city.
The saddest commentary upon the futility of our present methods
is perhaps the increase in the number of young girls, many of
them apparently just entering upon their teens, who may be seen
with painted faces by day or night brazenly soliciting upon our
streets. It is the consensus of opinion among those who have had
any experience with venereal diseases that it is just these younger
of the prostitutes who are responsible for the greater transmission
of venereal d'seases. They are hardest to reach unless arrested
for solicitation or prostitution.
I believe that there should be specified certain limits within
which prostitutes might live, unmolested by the police, so long as
they keep off of the streets, commit no breach of the peace and are
not infected with venereal disease. I am not in favor of caser-
nation or the confinement of prostitutes to certain tolerated
brothels, since such a procedure leads to their more easy and
general exploitation by the keepers of these houses and their
hangers-on, the cadets, pimps, etc. I believe, rather, that no house
or apartment of prostitution should be permitted to permanently
house more than the keeper and one servant; all others making use
of one of these brothels should be compelled to reside outside of
the brothel.
Permit no liquors to be sold or served in any house in which
prostitution is practiced and punish severely infractions of this
regulation.
Let the police keep a register of all such houses or apart-
ments ; put their keepers under bonds to carry out the regulations
of the police and the Health Departments ; but give them the as-
276 THE AMERICAN JOURNAL OF UROLOGY
surance that any complaints which they or the frequenters of these
places may have to make will be given a fair hearing.
Strictly enforce the Tenement House Law, except in those
cases where a landlord or owner of a certain house may agree to
rent apartments in that particular house to prostitutes only and
not to individuals with children.
It has ever been and ever will be an utter impossibility to reach
every prostitute or every source of venereal infection ; but it has
always seemed to me that to ignore the known sources simply be-
cause we cannot reach all is an evidence of short-sightedness. The
Page law was, I honestly believe, a step in the right direction, even
though it was not perfect. That it was not given a fair trial
I also believe. The opponents of this law have, I believe, set back
the possibilities of the sanitary control of prostitution and
venereal diseases by many years. I hope that if the law should
be amended the changes may be such as not absolutely to emascu-
late it.
That we shall be forced to adopt some method of control I
feel sure. I trust they may be adopted before the Great Black
Plague has done irremediable damage.
PATHOLOGY: Leo Buerger, M.D.
Concerning Cystitis Cystica, 0. Stoerk. (Ueber Cystitis,
Pyelitis, L^reteritis und L'rethritis cystica. Beitraege zur pathol.
Anat. u, z. allge. Path. 1911, vol 51, p 361).
In a comprehensive paper based upon anatomical and experi-
mental studies, Stoerk discusses the theories of cyst formation in
the bladder, ureter, and pelvis of the kidney. The so-called Lim-
beck-Brunn's epithelial nests are the seat of the cystic process.
They may be found throughout the urinary tract either in the
form of totally sequestrated inclusions of epithelium or as sprouts
in continuity with the surface epithelium. The author believes
that the genesis of these bodies may be explained in the following
way. In consequence of destructive changes in the mucosa and
submucosa, there occurs a reparatory connective tissue growth,
rich in the formation of new vessels. By virtue of the persistence
of the increased vascularity of the tissue, an over-production of
epithelial elements ensues which manifests itself in the elaboration
CURRENT UROLOGIC LITERATURE 277
of the above mentioned nests and sprouts. The nests that have
lost their connection with the surface epithelium, have been separ-
ated by reason of impoverished nourishment of the binding isthmus,
coupled with the tearing influences of muscle contraction such as
are so likely to occur in the bladder.
The cysts according to Stoerk arise from the solid cell nests
and not from predestined cell-inclusions. As for the manner in
which the lumina of the cysts develop the author's view is at vari-
ance with most of the other writers who speak of degeneration
and fluidiflcation of the central cells. Stoerk holds that the pro-
cess is secretory and not degenerative. Because of the chronic
hyperaemia and excessive nourishment induced by the new formed
capillaries, the epithelial cells takes on a secretory function, a
metamorphosis that is analogous to the appearance of secreting
cylindrical cells in papillary cystitis.
Renal Neoplasms ix Tuberous Sclerosis of the Braix.
W. Fischer: Die Nierentumoren bei der tuberoesen Hirnsklerose
(Beitraege Zur pathol. Anal. u. z. allge. Path. 1911, p. 235).
From a study of the autopsies of six cases of so-called tuber-
ous (hypertrophic) sclerosis of the brain — (a disease in which the
cerebral hemispheres are studded with hard nodules of glia tissue)
and from a review of the literature the author arrives at the follow-
ing conclusions.
1. Lesions of the kidneys, in the form of anomalies or tumors
are practically always present.
2. In most cases there are multiple tumors, usually of the
mixed variety, made up of smooth muscle, adipose tissue, vessels
and sometimes of kidney parenchyma.
3. These neoplasms are benign and usually give no clinical
symptoms.
Review of Current Urologic Literature
Case of Retextiox of Urixe. George W. Bury, {Lancet
Mar. 4, 1911) reports the following case on account of (1) the
extremely large quantity of urine retained in the bladder without
rupture; and (2) the rapid recovery of vesical tonus after such an
enormous distension.
The patient, a married woman, aged 37 was admitted to hos-
pital with the following history. She had apparently been quite
278 THE AMERICAN JOURNAL OF UROLOGY
well until 14 days previous to admission, when she complained of
severe dragging pains in the lower part of the abdomen, accom-
panied by nausea and vomiting. She noticed also that she had
some difficulty of micturition, but passed a normal quantity of
urine. She recovered in 24 hours and was able to do housework.
Eleven days later the pain recurred and was very severe, and she
had great difficulty in passing urine, and then only a very small
quantity. She also noticed that the abdomen was getting larger
and on this account called in a medical man, who ordered her to
hospital.
L'pon admission to hospital the patient was in a comatose con-
dition ; pupils contracted, equal and reacted to light. She moved
slightly on being spoken to loudly, but did not understand, and
was very irritable on being moved. Breath very offensive; skin
cold and clammy ; pulse feeble and thready, rate 138 ; temperature
subnormal; respirations shallow and sighing.'
L'pon inspection of the abdomen a large tumour was seen com-
pletely filling the hypogastric and umbilical areas, being rather
more prominent on the right side. The limits of the tumour were
well defined and it was arising from the pelvis. On palpation the
tumour was quite hard. The upper level lay midway between the
umbilicus and sternum, 1^ inches to the right of the middle line;
the tumour was slightly moveable, but no fluid thrill obtained.
The tumour was dull to percussion : the flanks of the abdomen and
the side of the pelvis were quite resonant. Vag'nal examination
revealed a lax vagina from old ruptured perineum not repaired.
The arch of the pelvis was distinctly felt, no bladder seeming to
intervene. Just within the reach of the finger was a mass pressing
anteriorly which felt like a soft cervix, but difficult to make out
with certainty. The vaginal vault was capacious, and occupying
the pouch of Douglas was a hard mass with definite limits and
probably connected with the uterus. Per rectum, about two inches
from the sphincter, there was a large tumour, palpable, hard but
resilient, slightly moveable, which lay in the hollow of the sacrum..
It was possible to feel the sacral promontory above the tumour,,
and the tumour was completely incarcerated in the pelvis, and was
probably a retroflexed gravid uterus. This tumour was quite
distinct from the abdominal tumour.
A catheter was passed with difficulty, the urethra being
lengthened. A stream of uterine began to flow under very high
pressure. This was quite clear and not offensive; 166 ounces were
CURRENT UROLOGIC LITERATURE
279
withdrawn. Urine was of specific gravity 1030, acid; no albumin,
sugar, or pus. On examining the abdomen the original tumour
had quite disappeared. An attempt was made to reduce the
pelvic tumour, but this was impossible. An anaesthetic was ad-
ministered, and with two fingers in the rectum the uterus was
replaced above the promontory, and now lay at the level of the
umbilicus. A Smith-Hodge pessary was inserted.
The uraemia was now treated by saline infusion, injection of
digitalin, calomel, and warmth applied to the skin. A catheter
was placed four-hourly, and at first passage 56 ounces of urine
were withdrawn. The general condition gradually improved ;
bowels acted, patient perspired freely, and consciousness returned,
though some delirium wTas present. Forty-eight hours after ad-
mission she passed urine normally and became quite conscious.
On examination of the abdomen a pregnant uterus was palpable
at the level of the umbilicus ; nothing else abnormal. Seven days
after admission the patient was out of bed, feeling quite well and
wearing the Hodge pessary, which kept the uretus in normal po-
sition. She had no trouble or difficulty with micturition and the
urine was normal in quantity and in every other way. She was
discharged quite cured 14 days after admission and advised to
wear the pessary for at least two months.
The Prevalent Misuse of the Prostate ix Gonorrhea. —
Hermann G. Klotz (2V. Y. Med. Journal, April 22, 1911) says
that soon after gonorrhea began to receive more careful atten-
tion from the medical profession more or less general experience
has pointed to the fact that in a large proportion of cases of
posterior urethritis the prostate gland shared the infection. Sta-
tistics of the frequency of these conditions from various authors
exhibit considerable differences, but unmistakably show a large
increase over older reports. This increase has received varying
interpretations. Some authors have attributed it entirely to the
better examination and observation of the patients by their physi-
cians, while others insist on the actually increased frequency of
the cases, and have been inclined to hold directly responsible for
the same certain methods of treatment, particularly the direct
irrigation of the urethra and bladder under high pressure.
To normal men the rectal examination of the prostate in itself
is not an agreable procedure, not on account of pain which oc-
casionally is not entirely avoidable. It is not denied that pro-
static massage in certain conditions brings relief of various path-
280 THE AMERICAN JOURNAL OF UROLOGY
ological sensations and incidentally confers a restitution or im-
provement of the general feeling of the patient. Massage, how-
ever, should be carried out always under control of microscopic
examinations and should not be continued too long or repeated
too frequently. In this connection Klotz remarks:
"There is no rule or gauge for measuring the force which may
be safely applied to the massage of the prostate ; so one may use
sufficient pressure to squeeze some fluid out of the driest prostate
and will consider the appearance of any secretion as sufficient evi-
dence of a pathological condition and as a sufficient excuse for an
indefinite course of massage treatment. I cannot convince myself
that it is contributive to the welfare of the prostate to be squeezed
regularly with more or less energy, the more so as it is generally
considered as the seat of various nervous symptoms which con-
stitute or form part of that complex of symptoms usually de-
scribed as sexual neurasthenia. Indeed, I firmly believe from
actual observations of patients that unnecessary massage of the
prostate, even if not too severe, is liable to produce a more or less
intense and lasting irritation of that gland sometimes with con-
siderable pain and followed by those neurasthenic symptoms,
whether the individual has been infected with gonorrhea or not.
In the former instance the patients are exposed to another danger,
namely, that the prostate in consequence of its treatment may
actually be infected with gonococci which might be present in the
posterior urethra without so far having entered the prostatic
ducts themselves. It is obvious that an organ of the structure
of the prostate, surrounded by a rather resistant capsule, when
compressed by some force from the outside, will have the tendency
to assume its former shape and volume as soon as the pressure
ceases to act."
A Recent Series of 200 Cases of Total Enucleation of
the Prostate. P. J. Freyer {Lancet April 8, 1911) says: "In
a lecture delivered by me at the Medical Graduates' College and
Polyclinic on March 17th, 1909, and published in The Lancet
of May 1st of the same year, entitled 'When to Operate for En-
larged Prostate,' I reviewed 600 cases of my operation of total
enucleation of the prostate for radical cure of enlargement of
that organ. I have now completed a further series of 200 cases
of this operation, the results of which I propose placing before
the profession in the present paper, at the same time, by means of
illustrative cases given in detail, directing attention to many in-
CURRENT UROLOGIC LITERATURE 281
teresting important, and, indeed, remarkable, features connected
with the operation.
These 200 patients varied in age from 52 to 87 years, the
average age being 69] years. There were 11 octogenarians
amongst them. The weight of the prostates varied from \ to 16
oz. In the great majority the patients were entirely dependent
on the catheter for periods varying up to 18 years. Most of
them came in broken health, few were free from serious com-
plications, and many were almost moribund at the time of oper-
ation. Indeed, in the majority of cases the patients have come
under my care for operation when their condition under catheter
life had become so wretched as to render life unbearable.
In connection with these 200 operations there were nine
deaths, or 4.5 per cent, the causes of death being as follows : —
1. Five died from urcemia; in two of which, aged 59 and 71
years respectively? necropsy revealed extensive pyelonephritis ; in
two, aged 76 and 83 years, necropsy showed long-standing back-
ward pressure changes (aseptic) leading to almost complete ab-
sence of secreting tissue in the kidneys, only a thin layer of cortex
remaining; and in one, aged 73, the patient was suffering from an
extreme form of paralysis agitans.
2. Two died from exhaustion. In one of these, in which
death occurred 13 days after the operation, there were almost
daily rigors with high temperature, though the bladder was clean ;
no doubt the kidneys were pyelonephritic, though no necropsy was
obtained ; the other, aged 87 years, had been confined to bed for
six weeks from pneumonia immediately previous to operation.
3. One, aged 74 years, a very stout patient who was suffering
from severe cystitis, chronic asthma and bronchial catarrh with
dilated heart, succumbed from bronchitis 22 days after operation.
Spinal anaesthesia was tried in this case but failed, and general
anaesthesia had to be employed, which, no doubt, was responsible
for the fatal bronchitis.
4. In one case, aged 78 years, double vasectomy and sub-
sequently castration had been performed by another surgeon sev-
eral years before, without any benefit to the prostatic symptoms.
For two years before coming under my care he had passed his
urine through a suprapubic fistula established for this purpose.
The apparatus fitted badly, owing to the bladder being filled by
the enormous prostate, causing great pain and frequent haemor-
rhage, and urine constantly leaked beside the tube. Altogether
282 THE AMERICAN JOURNAL OF UROLOGY
the patient was in an extremely wretched condition, and begged
to be relieved of his prostate at any risk. The prostate, which
weighed 11 oz., was easily enucleated, but the patient succumbed
to shock in eight hours.
It will be observed that in one and all of these nine cases in
which death supervened on the operation the patient was afflicted
with one or more grave complications which must have proved
fatal after much suffering. In no case did death ensue where the
vital organs were sound at the time of operation. Had the cases
been selected, therefore, the mortality would have been nil. But,
as will have been gathered from the cases described in this paper
and numerous others of similar gravity could have been given —
selection would have condemned most of them to a painful death
after more or less prolonged suffering, instead of the complete
restoration to health that ensued in each case from operation.
It is, of course, impossible to avoid a certain mortality when such
cases are operated on ; the wonder is that it is so small considering
the magnitude of the operation and the age and condition of the
patients. But to refrain from operating in such cases, when there
is any prospect of success, is, to my mind, utterly unjustifiable."
Report of a Case of Congenital Cystic Degeneration
of the Kidney. H. Brooker Mills (Med. Record, April 15,
1911) reports the following case: J. B., aged 14 months, was
admitted to the wards of the Medico-Chirurgical Hospital on
June 28, 1910, in the service of Professor Hollopeter through the
out-patient department. The family and previous history of the
patient was negative, and apparently the only abnormal condition
present was an enormous growth on the left side of the abdomen,
which the mother stated had commenced seven months before,
when the child was seven months old, and had been steadily pro-
gressing.
Three blood examinations were made, the first on July 7,
showing reds 6,200.000, whites 11,800, and hemoglobin 70 per
cent. Five days later the reds had dropped to 4,220,000, while
the leucocytes had increased to 14,600, and the hemoglobin to
75 per cent. Six days later the reds had increased to 4,600,000
and the leucocytes to 17,600, while the hemoglobin had dropped
to 70 per cent. The analysis of a catheterized specimen of urine
showed a small ring of albumin, no sugar or indican, and micro-
scopically narrow and broad hyaline casts, and a coarse, granular
cast, with a few urates, leucocytes, and epithelial cells. Photo-
CURRENT UROLOGIC LITERATURE 283
graphs were taken by Dr. George E. Pfahler, radiologist to the
Medico-Chirurgical Hospital, but, except for making certain that
the growth was not an enlargement of the spleen, as had been
suspected, the photographs were negative.
After remaining in the hospital three weeks the child was
operated upon by Prof. William L. Rodman, assisted by Drs. J.
Stewart Rodman and Stillwell C. Burns, for removal of the growth.
A section of the specimen removed was examined in the patho-
logical laboratory, and the pathologist's report proved it to be a
case of congenital cystic degeneration of the kidney. Convales-
cence was uneventual, and the child was discharged from the
hospital one month after the operation, at which time it was in
good condition. It is interesting to note the variations in the
blood examinations, the reds almost uniformly diminishing, the
whites rapidly increasing, and the hemoglobin remaining about
stationary.
In addition to the rarity of this disease, two other points are
important to notice : First, the uniformly unfavorable prognosis
of all cases as claimed by most writers on the subject, either with
or without operation, and, second, the difficulty in making a posi-
tive diagnosis before operation. At least a half dozen competent
men examined this case, and we were aided also by the photographs
taken by Pfahler, as well as the blood reports, uranalyses, etc.,
but, in spite of these aids, the real condition remained undiag-
nosed. The three conditions suggested as being the probable
cause of the trouble were enlarged spleen, hypernephroma, and
sarcoma of the kidneys, all of which proved to be incorrect.
Genital Tuberculosis. — J. R. Goffe, New York (J.
A. M. A., October 15), says that genital tuberculosis
may be either primary or secondary, understanding by
primary that the focus in the genital organs may be
the primary seat of invasion. This has been denied by some
authorities, but cases have been brought to light in which the only
lesions found are confined to the cervix, vagina or uterus. He
does not think that infection by coition with tuberculous men is
probable without the ground being prepared by gonorrhea or the
puerperal condition. The possibility of infection by street dust
swept up by the clothing is suggested. Tuberculous invasion of
the tubes and ovaries may precede that of the peritoneum, be
simultaneous with it, or follow it. Direct primary tuberculosis
through infection by the blood is believed to be very rare. It
•284 THE AMERICAN JOURNAL OF UROLOGY
occurs more frequently by contiguity, secondary to tuberculosis
of the lymphatic system, or bowel ulcer, or by continuity from the
Fallopian tubes. It is desirable, to say the least, that the accu-
rate diagnosis of tuberculosis should be made before operation,
but, with all precautions, the surgeons may sometimes be sur-
prised by conditions found in the abdomen. When he recognizes
that he is in the presence of tuberculosis the situation becomes
clear when he recalls the fact that there is but one basic lesion of
which the case in hand is one of the stages. Nature is ever wag-
ing its war of resistance, though her defense may be overwhelmed
at once, as in cases of ulceration, perforation, cheesy degenera-
tion and mixed infection with resulting hectic fever. On the
other hand, we may have disseminated miliary tubercles with
abundant ascites, the exudate indicating a protective process due
to irritation of the unaffected peritoneum. If the patient gets
the advantage we have an obliterative peritonitis resulting in
fibrous or cobweb adhesions. In a case in which the infection is
from contiguous organs, we find an ulcerative or cheesy form of
growth accompanied by fibrous nodules, cicatrizing ulcers or
masses of plastice exudate, here and there forming bands of fibrous
tissue. These adhesions and bands may form sacculated pseu-
docysts, filled with tuberculous debris and possibly pus, indicating
a mixed infection. The omentum may be matted together by an
extension of the process. The surgeon should be prepared to
meet any of these conditions. In the first or ascitic type the
serum should be evacuated and the wound closed without drainage.
These are the cases in which the patients recover so mysteriously
and permanently and are usually cases of general miliary tuber-
culosis. If a definite focus is discovered in the tubes its removal
is desirable, but if long buried in protecting adhesions it should
not be disturbed. In the second or adhesive class, if the exudate
is general and a tendency to organize into adhesive bands is ap-
parent, it should be let alone unless a distinct focus can be easily
reached and removed. This should depend on the general condi-
tion of the patient. The wound should be closed without drain-
age. In the third class of cheesy deposits any very radical sur-
gery is inadvisable. Adhesions that presumably shut in intesti-
nal ulceration should be carefully preserved, but collections of
debris and pus should be carefully cleansed, and the cavity drained
with cigarette drains of guttapercha tissue. Gauze drains should
be proscribed. Goffe concludes his paper with reports of seven
CURRENT UROLOGIC LITERATURE
285
cases occurring in his practice and illustrating the points made in
the article.
Bilateral Nephrolithiasis; Left Nephrolithotomy. Bv
L. Bolton Bangs (Medical Record, March 23, 1911) reports the
following case: The patient is a male 44 years of age, of ex-
emplary habits, never having used tobacco nor alcohol. Since
his seventeenth year he had had attacks of what he called "irri-
tation" of his urinary organs, compelling him to urinate fre-
quently and causing with each act a stinging sensation at the
head of the penis. With the exception of occasional intermissions
of a few months at a time, these attacks have persisted up to the
present. At 29 years of age he had the first real attack of renal
colic. This was on the left side, the duration of the attack being
thirty-six hours, when he voided with the urine a small calculus.
There was no vomiting nor any perceptible blood in the urine at
that time. Four years later he had a similar attack in the left
side and again a stone was found. In December, 1908, he had a
similar attack, but this time it was on the right side. No stone
was found in the urine; he was ill for several days and confined to
his home for three or four weeks with fever, soreness in the right
side of the body, and generally disability. After this attack he
did not fully regain his health for three or four months. For a
period of about ten years he had, at times, found in his urine
white granular material. In the latter part of 1909 he had. at
intervals, a slight, dull pain in the region of the kidneys, more
noticeable on the right side. This was considered to be "neu-
ralgic," and he paid no attention to it. In January, 1910, at
the end of an act of urination, vesical tenesmus took place, which
forced out a small quantity of pus stained with blood. During
the first half of 1910 he had attacks of fever, with a temperature
rising to 100° or 101° F. During the latter part of the year, al-
though there was no rise of temperature, he had a quick pulse and
was not equal to the demands of his business, becoming easily tired
and experiencing pain in the back on being jolted when riding in a
motor boat or in the cars, or even when walking. At no time has
there been any free blood in his urine.
The urine voided at his first visit was loaded with mucopuru-
lent shreds, had a mawkish odor, and its examination showed the
following: Color, amber; sp. gr., 10/20 acid; trace of albumin;
mucus, moderate large amount : red blood cells, small amount ; no
casts ; epithelia, a few pavement and cuboid ; crystals, a few calcium
oxalate. The patient is large and corpulent, weighing 210
286 THE AMERICAN JOURNAL OF UROLOGY
pounds, and it was impossible to palpate his kidneys. The radio-
graphs, which were made by Dr. Cole, show a stone in each kidney.
The left kidney is somewhat enlarged, the stone occupying a large
area in the tissue of the organ. Subsequently the ureters were
catheterized, and the urine was drawn from each kidney with the
following findings : Right Kidney. — Color, red ; odor, not offensive ;
sp. gr., 1019, acid; albumin, present J per mille ; urea, 1.92 per
cent. ; blood, small amount ; pus, large amount ; casts, few hyaline ;
bacteria, slight bacteriuria ; epithelia, numerous, probably from
renal pelvis. Left Kidney. — Color, amber; odor, not offensive;
sp. gr. 1010, acid: albumin, marked trace, 1.11 per cent; blood
numerous cells; pus, moderate amount; casts, very few hyaline;
bacteria, slight: bacteriuria ; epithelia, numerous cells, probably
from renal pelvis.
A nephrolithotomy of the left side was done on December 20.
The kidney was found to be enlarged, its superior pole adherent
to the pillar of the diaphragm, and numerous adhesions held it so
firmly in its bed that it was impossible to dislodge it onto the loin.
Consequently an incision was made in the cortex of the kidney and
the stone separated from its bed with rapid sweeps of the finger.
The kidney was at the bottom of a deep hole, which made the ex-
traction of the stone difficult, and it was broken into three frag-
ments. Before the stone was removed the surfaces of the wound
were protected by layers of sterile gauze, but with the stone there
came a little flow of purulent urine which had a perceptible am-
moniacal odor. This was interesting, in view of the fact that the
urine obtained by the ureter catheters was odorless. On account
of the patient's condition failing, no attempt was made to suture
the kidney, its cut surfaces being approximated and held by tam-
pons. He had a rise of temperature of 101.8" F. on the second
day, which persisted till the sixth day, after which he did well,
but his pulse remained quick, never being less than 98. His
physician had reported that the patient had had a quick pulse for
several years and that it had ranged from 98 to 120. Primary
union of the wound was secured, with the exception of the posterior
end, where slight infection had taken place, and where the tam-
pons had rested.
The stone showed concentric whitish deposits around small
yellow nuclei. These deposits had probably been taking place
for several years, thus preventing the escape through the ureter
of the small primary concretions and coalescing to form the large
and irregularly shaped stone which I now show you.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII AUGUST, 1911 No. 8
Contributed by the Author to The American Journal of Urology.
THE PRIMARY MALIGNANT NEOPLASMS OF THE
SPERMATIC CORD.
DeWitt Stettex, M. D., of New York.
Assistant Visiting Surgeon to the German Hospital; Instructor in Clinical
Surgery in Columbia University.
THE writer feels that the rarity and diagnostic difficulties of
the following case warrant its publication and also a brief
general discussion of the subject of the primary malignant
tumors of the spermatic cord.
Michael H.,* age 77 years, admitted to Dr. Kammerer's
service in the German Hospital, September 20, 1909.
His family history is negative and he denies venereal infec-
tion. For a year he has had occasional pain in the right testis.
For four weeks he has noticed a swelling in this region. There
has been no loss of weight or strength. There are no urinary
symptoms.
Examination shows a fairly well-nourished, elderly man. He
has a moderate emphysema, with an occasional sibilant and so-
norous rale over various parts of his chest. His heart and his
abdomen are negative.
In the right scrotum is a hard, nodular, slightly sensitive
swelling, somewhat elongated, irregularly ovoid in shape and
measuring about 3x3x5 centimeters, the longest diameter running
parallel to the cord. The swelling corresponds apparently to the
upper part of the epididymis and seems to extend somewhat up
the cord. The testis is normal, as is the remainder of the vas
deferens. There is no hydrocele. The skin is free. The pros-
tate and seminal vesicles are normal to the touch. The inguinal
glands are not enlarged. There are 40 cubic centimeters of
residual urine. There is a small nodule the size of a hazel-nut
* Patient presented at the Section on Genito-Urinary Diseases, New
York Academy of Medicine, January 19, 1910.
287
288 THE AMERICAN JOURNAL OF UROLOGY
in the left side of the perineum, of the same consistence as the
scrotal tumor and to which the skin is attached.
Although the globus minor of the epididymis was free, the
Calmette reaction was negative and the age of the patient was
against the diagnosis, the case impressed one as a tuberculous
epididymitis and an exploratory operation was performed by the
author on September 23, 1909.
The mass was exposed and strange to say found to consist
of an isolated tumor of the spermatic cord, just aboye but entirely
outside of the tunica vaginalis. The testis, epididymis and vas
were absolutely free. The tumor was incised, seen macroscopi-
cally to be malignant, and a castra-
tion done in the usual manner.
The nodule in the perineum was also
exc sed.
The tumor apparently devel-
ops from the areolar tissue of the
cord, as can be seen from the pho-
tographic reproduction of the
specimen (Figure 1). Microscop-
ically it is a very cellular, mixed,
small and large spindle-cell sar-
coma, as is also the perineal nodule.
A nodule higher up in the cord also
gives the same histological fmd'ngs.
This latter nodule was apparently
a metastasis in one of the sper-
matic \eins. Many of the cells of
the tumor show active mitosis and
the intercellular connectiye tissue is
rather scant. The tumor is moder-
ately vascular.
On October 4-, 1909, a small no-
dule was noted in the wall of the
right lower abdomen, seemingly a
thrombus in the right superficial epi-
gastric vein. This was excised un-
der local anaesthesia and found to
be a sarcomatous plug in the vein,
of the same nature as the primary
Fig. 1. Primary sarcoma of
the spermatic cord. Testis, epi-
didymis and tunica vaginalis
are incised and uninvolved.
Hydatid of Morgagni is also
free.
PRIMARY NEOPLASMS
289
tumor. The patient was discharged from the hospital on October
8, 1909, the wounds having healed primarily and no evidence of
further recurrence being present.
I again saw the patient in the beguiling of January, 1910.
He claimed that a few weeks after he left the hospital he noticed
a nodule in front of the anus and that other masses rapidly ap-
peared in the pubic and adjacent regions. On examination there
was found a large mass involving the perineum and extending into
the root of the penis, seemingly infiltrating along the vascular
channels of the corpora cavernosa and corpus spongiosum and
producing a pseudo priapism without greatly increasing the di-
ameter of the organ. There was a large mass over the left
saphenous opening, most probably a metastasis via the superficial
external pudic vein. Two smaller nodules were found along the
course of the left superficial epigastric vein and one in the left
superficial circumflex iliac. He had a slight cough but no signs
of fluid or consolidation in the chest. There were occasional moist
rales. Abdominal examination was negative.
I subjected the patient to a course of treatment with Coley's
fluid, which he stood well. I began with J drop and increased the
dose gradually to 5 drops every second day. I injected the fluid
directly into the tumors. There was a moderate general reaction
and the nodules that were injected did really decrease in size,
soon, however, a new nodule appeared on the left chest wall ;
metastases were noted along the vessels of both arms ; flvrd ap-
peared in both chests ; an increasing oedema of the penis, scrotum,
and lower extremities, due to actual compression, developed ; cach-
exia became very pronounced and progressive, and the patient died
March 5, 1910. No autopsy was obtained.
It had originally been the writer's intention to make a careful
research of the literature of this subject and to collect all the
cases of this type that have hitherto been reported. Inasmuch,
however, as this has been very recently done in two excellent
French papers (Tedenat and J. Martin, Tumeurs malignes du
cordon spermatique, Archives generates de chirurgie, 1908, II.
113; M. Patel and A. Chalier, Les tumeurs du cordon spermatique,
Revue de chirurgie, 1909, XXXIX, 119, XL, 167), he has aban-
doned the project as unnecessary, especially as there have been no
contributions on the subject since the paper of Patel and Chalier.
He has found also that most of the reports in the older literature
are so vague clinically and so entirely indefinite pathologically, as
290
THE AMERICAN JOURNAL OF UROLOGY
to render them quite unfit for statistical study. The authors,
referred to above, have made as careful a study of the question as
the material permitted and little could be gained by further in-
vestigation.
Of course, it is well-known that testicular tumors may sec-
ondarily involve the spermatic cord, but the majority of the
surgical and pathological text-books totally ignore or only very
casually mention the possibility that malignant neoplasms, and
very virulent ones at that, may develop primarily in the cord itself.
The importance, so far as diagnosis, treatment and prognosis is
concerned, of appreciating this fact is obvious. Naturally these
tumors are not a very common occurrence. Tedenat and Martin
collected a total of 24 from the literature, including 3 which had
not yet been published. Patel and Chalier who have studied the
subject much more carefully have found something like 34 fairly
authentic cases, although they have rejected a number of the cases
of Tedenat and Martin as questionable.
The most common type of malignant tumor of the cord is the
sarcoma, which is usually spindle-celled, but may be of the giant-
cell variety. Frequently the tumor is of the fibrosarcoma type.
Of the 34 cases of Patel and Chalier, 22 were simple sarcomata or
fibrosarcomata. It is assumed that they develop from the areolar
tissue of the cord. Next in frequency come the so-called mixed
tumors of the malignant type. They are presumably of embryonal
origin, arising from rests of the Wolffian body or the Mueller-
ian duct or from the vas aberrans of Haller, the paradidymis of
Waldeyer or other embryonal organs. Pathologically, the great-
est variety of combinations is possible, though mucous tissue is
always the basis of the tumor. The following types have been
reported : myxosarcoma, myxochondrosarcoma, lipomyxosarcoma,
fibromyxosarcoma, myxolipofibrosarcoma and myxochondrofibro-
sarcoma. In the Patel and Chalier series there were 10 of these
malignant mixed tumors. One case of carcinoma has been re-
ported by Tedenat and Vieu. This tumor presumably developed
from Wolffian rests. The cells of the tumor were of the cubical
or cylindrical type. The case, which stimulated Patel and Cha-
lier to their researches, was a malignant leiomyoma in a boy of
15. It is unique.
Although the malignant tumors of the cord may develop
at any time of life, they are most commonly observed in middle-
aged or elderly individuals. In about 50% of the cases trauma-
PRIMARY NEOPLASMS
291
tism seems to have acted as an etiological stimulant. The tu-
mors seem to be most frequently situated on the left side. They
vary greatly in size, and may, if not interfered with, reach colos-
sal-proportions. They are usually situated in the scrotal part
of the cord, but they have also been found in the inguinal por-
tion.
In shape the tumors are generally pyriform and their long
axis is parallel to the cord. Their surface is often irregularly
nodular and their consistency hard. A complicating hydrocele
is quite common. The inguinal glands do not seem to become
involved. Extension is usually by contiguity into the scrotum
and also along the cord to the iliac fossa. Attention should be
again called to the striking venous type of metastases observed in
the author's case.
The rapidity of growth is very variable. It may be rapid
from the onset or a tumor may be present for years without in-
creasing in size and then suddenly begin to grow with great rapid-
ity. In such a case it must be assumed that a primarily benign
tumor has undergone malignant degeneration. This evolution en
deux temps applies particularly to the mixed tumors.
The malignant tumors of the spermatic cord must be differ-
entiated from the benign variety, of which the lipoma, the fibroma,
the myoma and the benign teratoma are the most common forms.
The consistency of the neoplasm and its rate of growth usually
make this different'al diagnosis easy, although it must never be
forgotten that the benign growth may at any time become malig-
nant. In the diagnosis of the disease under consideration, the
possibility of a secondary involvement of the cord from a primary
testicular tumor or tuberculosis must not be overlooked. If there
is no marked hydrocele this question offers little difficulty. Fin-
ally irreducible cp'ploceles and tense hydroceles of the cord must
be thought of.
The prognosis of these malignant tumors of the cord is very
bad. Recurrences, usually local, occur early even after the most
radical removal and death follows within a short time. The case
of carcinoma was alive 10 years after operation.
Treatment of these cases is necessarily the most radical cas-
tration. The cord should be ligated as high as possible in the in-
guinal canal. As a prophylactic measure all cases of benign
tumor of. the cord should be operated upon. If the tumor can be
enucleated well and good, but if there is any difficulty connected
with this procedure one should not hesitate to remove the testicle.
292 THE AMERICAN JOURNAL OF UROLOGY
Contributed by the Author to The American Journal of Urology.
UROLOGY— PAST, PRESENT, AND FUTURE.*
By Dr. M. Krotoszyer, San Francisco, Cal.
THE first meeting of the recently formed Section on Urology
of the San Francisco County Medical Society marks an
epoch in the history of Urology on the Pacific Coast. This
occasion — all important and welcome to those of us whose interests
and efforts are bent towards this hitherto neglected branch of
scientific medicine should not be permitted to pass without a few
appropriate remarks upon the past, present and future aspects
of Urology.
The history of Urology is best divided into two parts : the
pre-cystoscopic and cystoscopic era. The first era produced two
distinctly different types of workers in the field of pathologic
conditions of the genito-urinary tract. The one group of great
clinical surgeons, who owing to the material at their hands or on
account of an individual inclination devoted their rare gifts of
observational genius and technical skill to the study and treat-
ment of diseases of the urinary tract — men like, Thompson of
London, Dittl of Vienna, Guyon of Paris, and many others ; the
other group comprising the so-called genito-urinary specialists,
who treated venereal and in most instances skin-diseases and per-
formed the minor surgery pertaining to the lower male genito-
urinary tract. While the genito-urinary and skin — or as he was
shorter and less respectfully dubbed — clap-specialist did not rank
highest in the estimation of the profession at large, nevertheless
it must not be forgotten that one of their rank and file, Albert
Neisser, discovered and first described the gonoeoccus. Through
this discovery the impetus was given to the present scientific con-
ception of the pathology and treatment of gonorrhea, its various
complications and sequels and this pathological condition form-
erly considered a negligible quantity was quickly raised to a
respectable position in medical nomenclature.
Many and noteworthy were the advances in urological surg-
ery during the precystoscopic era. Time and space however per-
mit to point to but a few of the most prominent facts. The
Frenchman, Civiale, gave us the Lithotrite and with the discov-
ery of the lithotritic aspirator by the American Bigelow begins
"Chairman's address delivered at the first meeting of the Section on
Urology of the San Francisco County Medical Society.
UROLOGY— PAST, PRESENT AND FUTURE 293
the era of modern Litholopaxy, an operation in which our own
Chismore excelled. Gustav Simon of Heilelberg planned and suc-
cessfully carried out the removal of a kidney, an organ, without
which continuance of life was considered impossible up to that
time. The urine of the left kidney of a middle-aged woman was
secreted through an incurable uretero-uterine and uretero-ab-
dominal fistula, while the bladder-urine, representing the secretion
of the right kidney, was found to be normal. By these means
Simon was enabled to ascertain two facts, which in the present
cystoscopic era are considered indispensable prerequisites to a con-
templated Nephrectomy viz : the presence of two kidneys and the .
integrity of the remaining organ. Simon's first Nephrectomy was
successful, the patient making an uneventful recovery ; the pa-
tient in whom he, two years later, performed his second Neph-
rectomy without the knowledge of the condition of the remaining
kidney died 21 days after the operation from "pyaemia" according
to the official record, but most probably from deficient function
of the remaining kidney.
While in precystoscopic times great clinicians studied and
clearly described urological lesions, while a few great surgeons ex-
erted their rare technical skill towards the treatment of disorders
of the urinary tract, while men like Thompson and Guyon cre-
ated famous urological centers at St. Peter's Hospital in London
and the Hopital Necker in Paris, where an international audience
of physicians sat at their feet listening to their classical lectures
on matters urological, nevertheless, it is true, that Urology as a
science per se exists only since its fundaments of diagnosis and
treatment were created by Cystoscopy. Up to the advent of the
Cystoscope we possessed a number of famous and gifted genito-
urinary surgeons, who by their superior intuition, their enormous
experience and individual skill were able to recognize and success-
fully treat lesions of the urinary tract, that remained a noli me
tangere to the average medical man. What narcosis and asep-
sis have done towards advancing and popularizing general surg-
ery, Cystoscopy has accomplished for Urology. From the hands
of a few gifted observers and born technicians Urology has come
within reach of every honest practitioner who is willing to de-
vote his time and energies to the technique and scientific study of
this special field of medicine.
Great and revolutionizing were the changes in the conception
and treatment of urological lesions since Nitze presented his first
294 THE AMERICAN! JOURNAL OF UROLOGY
Cystoscope. Hypothetical or theoretical views, to which in pre-
cystoscopic times clinicians adhered for want of better or exact
means of interpreting urinary symptoms, were replaced by a real
diagnosis. Our views upon the inflammatory conditions of the
bladder and the upper urinary tract, upon the cause of pains and
the sources or hemorrhage were radically changed. Cystoscopy
and its logical sequel, ureteral catheterization, enabled us to local-
ize the focus of an existing distressing pyuria an to devise its
proper and effective treatment. The speculative and in most in-
stances fallacious teachings upon the topical diagnosis hematuira
were replaced by the exact recognition of the bleeding focus Cas-
per and Richter's work on kidney-function did not only enable us to
diagnose obscure renal lesions in their incipiency, but also proved
most valuable for the diagnosis of abdominal lesions in general.
The differential diagnosis of gall — and kidney-stones and ap-
pendicitis on one side and spleen — and kidney-tumor on the other,
of retroperitoneal, perityphlitic and perinephritic abscesses and
other obscure intra-abdominal lesions is materially aided and in
many instances made feasible only by means of our modern urolog-
ical diagnostic methods. Our views upon the pathology and treat-
ment of tuberculosis of the genito-urinary tract have been revolu-
tionized. Renal surgery has profited immensely through modern
urological diagnostic means and the mortality of Nephrectomy
alone has been reduced from about 4-0 to less than 5rf. Kiimmell
for instance lost in precystoscopic times 3 out of 12 cases against
4 of 106 nephrectomies for tuberculosis at the present time and
his death-rate of the same operation for aseptic stone-kidney has
fallen to less than 3%.
The ranks of those physicians, who still consider cystoscopy
and the newer diagnostic urological methods superfluous, too pain-
ful and often dangerous are gradually thinning out. Neverthe-
less, it is true, that cystoscopy is only slowly gaining ground and
that the opinion is prevailing among the profession, that the
method is unusually difficult of execution and unsafe as regards
practical results. If properly executed, though, Cystoscopy and
ureteral catherization are almost painless procedures and I venture
the contention that every well-trained physician possesses the
moderate dexterity required for the execution of an ordinary
cystoscopic examination. It is, as I know from personal experi-
ence, a method that can easily be learned and no student of medi-
cine should be permitted to enter upon his practical career without
UROLOGY— PAST, PRESENT AND FUTURE 295
at least a superficial knowledge of the modern urologic diagnostic
methods which furnish the key to the correct interpretation of
many gynecologic, neurologic and abdominal lesions. A note of
warning on the other hand, must be sounded against the opinion
prevailing in many minds, that the possession of a cystoscope is
coincident with the correct interpretation of intravesical pictures
or that it entitles its injudicious owner to apply, for instance, to
a contracted tubercular bladder. The cystoscopic tyro is re-
sponsible for the mistrust still extant in a large and justly con-
servative portion of the profession towards a method that, only if
properly used, represents a veritable diagnostic and therapeutic
boon to physician and patient alike.
The remedy for this evil lies in the hands of our medical
under-graduate colleges, who gradually are awakening towards
recognizing the importance of competent instruction in modern
Urology, which must be accomplished in spite of the overcrowded
curriculum of clinical semesters. For the fate and welfare of the
sufferer from urinary disturbances lies as ever in the hands of the
family physician or general practitioner who sees the patient
first-hand. While it would be absurd to expect the average
practitioner to be possessed of special knowledge and skill in the
various branches of the medical art and science, he must, neverthe-
less, be familiar with the important points, the possibilities and
limitations, the indications, and contraindications, in fact, the
actual and practical value of certain special methods which to-day
are required for establishing an exact diagnosis. The specialist
should not rank higher than the general practitioner ; the latter
should possess an equally large fund of knowledge as regards the
fundamentals and principles of special methods of diagnosis and
treatment, and the former on account of his constant occupation
with and large experience in a special field should in the more diffi-
cult cases lend the aid of his better trained aye and hand.
Urology as a specialty is still in statu nascendi and does not
yet occupy the secure position that other well established special-
ties hold. While it must be conceded that many general surgeons
or internists possess the knowledge and skill required for urological
work, nevertheless, modern Urology has grown to be an inde-
pendent field for research and teaching with an immense and stead-
ily growing literature, which can only be absorbed by the one who
devotes his life to the study of this special branch. In accord-
ance with a tendency prevailing in other specialties (Gynecology,
296 THE AMERICAN] JOURNAL OF UROLOGY
Ophthalmology, etc.) that all pathological conditions of certain
organs or regions, internal as well as surgical ones, should fall
into the hands of the various specialties. Urology embraces the
diagnosis and treatment of all lesions of the urinary tract. The
surgery of the urethra and bladder as well as that of the ureters
and kidneys must be mastered by the modern Urologist who at the
same time should have exhausted all means of conservative treat-
ment before resorting to radical measures. The modern Urologist
must be well versed in general pathology, bacteriology, radiology
and other auxiliary sciences in order to be enabled to correctly in-
terpret many of the more intricate lesions of the urinary tract.
He must know the relationship of the urinary tract to the general
system and thus avoid becoming a one-sided specialist. The dig-
nity of the urological specialist and his ultimate and lasting suc-
cess depend therefore mainly upon a liberal training in general
medicine.
With LTrology is intimately connected the study of the path-
ology and treatment of the male genital organs, the prostate,
testicles, urethra, etc. and so-called Andrology is and in all prob-
ability always will remain an essential part of the specialty.
Most of our present-day Urologists entered into the speci-
alty either from general medicine or surgery and on account of
their individual inclinations and preliminary training gravitate
more or less either towards the internal or the surgical side of the
specialty; the future, though, will demand an equally thorough
training in all its diagnostic and therapeutic methods. The
future Urologist will obta'n his special education at urological
clinics or hospitals, which will spring up in all parts of the civilized
world. Especially all teaching Hospitals will soon possess well
equipped urological services, which will furnish the teaching ma-
terial to the chair of clinical Urology.
Urology is a border-line specialty ; it draws from all sides to
accomplish its ends and on the other hand entertains many ties of
mutual interest and information with the other specialties as well
as with general medicine. The deliberations and discussions of
this section should be therefore useful and elevating to every mem-
ber of the Mother-Society. The future of scientific Urology in
the West and the success of this section depend not so much upon
the efforts and enthusiasm of the few who are more or less special-
izing in this field, as upon the cooperation and continued support
of the profession at large.
267-2 Pine street.
SUTURING OF THE BLADDER
297
Contributed by the Author to The American Journal of Urology.
COMPLETE SUTURING OF THE BLADDER AFTER SUP-
RAPUBIC SECTION*
G. Kolischer, M. D., and H. Kraus, Chicago.
THE history of complete suture of the bladder after supra-
pubic incision is rather instructive. In this history we
may distinguish three distinct periods. In the first period
any attempt at completely suturing the bladder was considered
a mistake of art. In the second period the complete clos'ng of
the bladder was admitted to be a desirable goal, but the causes
of the failures were not properly recognized; all the stress was
laid on the choice of the suture material and on the method of
suturing employed, hence all the devices of figure-of-eight sutures,
pursestring sutures, flap suturing and finally Rydygier's propo-
sition of using the conglutinating power of the peritoneum as a
guarantee of success in bladder suture. Then came the third
period of evolution, in which two principles were recognized: first
that the complete closing of the bladder after suprapubic operation
is almost always desirable, and secondly that the success of the
suture in bladder work is dependent on the same conditions that
rule plastic work in surgery of other parts.
The medical historian may again in this field of work ex-
perience a striking observation, namely, how long it always took,
and it seems always will take, before sound general principles are
applied to bladder surgery.
The gynecologists in their work on vesicovaginal fistulas
were a long time aware of the conditions of success in closing
bladder defects and acted accordingly, while the surgeons working
on the male bladder were still groping in the dark and were ex-
perimenting, the latter quite often along wrong lines.
The gynecologists knew for a long time that there are two
fundamental factors governing the success of bladder suture;
first the prevention of all tension, and second the bringing in
apposition of rather broad raw surfaces without any interposi-
tion of vesical mucosa. At the same time their experience proved
that the choice of the suturing material is of no importance: it is
the way the sutures are set, and not the material that counts in
results. It also became evident that the existence of a cystitis
is a negligible quantity. There is hardly a case of vesico-vaginal
* Read before a joint meeting of the Chicago Urological and Chicago
Medical Societies, Jan. 14, 1911. — II. Med. Jour., June.
298 THE AMERICAN; JOURNAL OF UROLOGY
fistula operated on that does not present some inflammation of the
bladder.
In spite of all, the suturing of the bladder after suprapubic
incisions was and still is, in some quarters done by general surg-
eons in a nonsystematic way, and the presence of a cystitis was
also a strict contraindication against total closing of the bladder.
Another error in this direction was that after complete suturing
of the bladder the muscles and the skin were closed up. It was
thought sufficient to insert some drainage in order to prevent all
trouble in case some infection should have occurred. But we must,
allow that our means of drainage may fail to thoroughly drain,
and furthermore that in case of infection the subsequent infiltra-
tion and swelling of the involved tissues prevent the drainage
where it is most needed, and that drainage anyhow, can only re-
move exudations in liquid form, but does not prevent the most dis-
astrous local consequences of a violent infection, that is, great
tension and subsequent necrobiosis of the tissues involved. An-
other point is this : in a case of failure of the bladder suture for
some reason there is no assurance that the inserted drain will be
in communication with the leakage and consequently urinary in-
filtration may occur at a point not reached by our drain.
The demands on a method of complete suturing of the bladder
can be formulated as follows : the suturing of the bladder incision
has to be done in such a way as to give the best possible chances
for a primary union and the best possible guaranty against leak-
age; the structures forming the abdominal wall must be handled
by a method that will prevent all disastrous sequelae of urinary in-
filtration or infection occurring during or after the operation ;
and finally this method must permit a quick reunion of the cleft
in the abdominal wall after the above-mentioned dangers are once
excluded.
In order to bring broad raw surfaces together, and these only
without any interpolation of the vesical mucosa, the mucosa is
detached by means of a poker or a knife handle for a few milli-
meters from the rest of the bladder wall. The sutures are now
inserted in such a way that the raw surfaces of the lips of the
bladder incision are drawn together while the detached edges of
the mucosa protrude like a small ridge into the bladder lumen.
It is preferable to begin with the suturing at the lower end of the
incision and to use interrupted sutures, because in this way it is
easier to get the proper apposition. This suture line is followed
SUTURING OF THE BLADDER
299
by a running suture drawing some more muscularis over the first
closure, so as to prevent any leakage. This second suture line
starts and ends beyond the poles of the first suture line. As
material, catgut should be used so as to prevent any immigration
of sutures into the bladder, which phenomenon is frequently ob-
served, when non-absorbable sutures are used.
After the bladder is closed up, interrupted sutures are in-
serted through the fascia of the recti and through the skin ; these
sutures are not tied, and the wound is loosely packed with some
antiseptic. If one chooses to insert separate sutures for the mus-
cles and for the skin, the muscle sutures of course will be catgut ;
if one chooses to insert only one layer of through-going sutures'
non-absorbable material may be chosen. If after twenty-four or
thirty-six hours the gauze is removed and no leakage and no signs
of infection are discovered the fascia and skin sutures are tied.
Should leakage or signs of infection be noticed, the wound is
treated openly until everything is clean and red and then second-
ary suturing may be resorted to.
As to the question of the permanent catheter, most of the
urologists with operative experience become more and more in-
clined to discard the permanent catheter as a means of draining
a completely sutured bladder. It is in fact better to either let
the patient urinate naturally or in case he or she should be unable
to do so to employ catheterization at regular intervals.
As to the contra-indication against complete suturing of the
bladder, it was mentioned before that experience has proven that
the mere presence of a cystitis is no contra-indication whatever
against completely closing a bladder.
A bladder should not be completely reunited after suprapubic
incision if a hemorrhage occurring during the operation had to be
checked by tamponade, or if the operation revealed the existence
of an infiltrating cystitis, which could only be cured by leaving
open a rather large part of the primary incision for some time.
300 THE AMERICAN JOURNAL OF UROLOGY
Contributed by the Author to The American Journal of Urology.
PRESENT STATUS OF INTRAVESICAL OPERATIONS
FOR TUMORS OF THE BLADDER *
By Hcrace Bixxey, M. D., Boston.
A GLANCE through the medical literature of the last five or
six years, bearing on the treatment of bladder tumors,
points clearly to at least one fact, namely, that in North-
ern Europe 'the intravesical operation has met with increasing
popularity. Whereas, at the beginning of the present decade,
Nitze and one or two of his pupils seem to have been the only
surgeons using this method, the reports in European journals,
during the last year, come from at least a dozen surgeons.
In this country. Myer,'1 of San Francisco, and Kolischer and
Schmidt,2 of Chicago, are practically the only surgeons who pub-
lished evidence of personal experience prior to 1908. Since then a
few others have been employing the method, but no publications
have appeared except the brief reports of Young," of Baltimore,
and Beer,4 of New York. The increased popularity of the method
in Europe, and the fact that in tins community the method is em-
ployed practically never, seem sufficient reasons for our looking
more closely into the question of these intravesical operations.
The development of the intravesical method of operating,
which was largely due to Nitze's genius and industry, and the
form of instrument used by lrm, are matters with which every one*
present is doubtless familiar. I shall, therefore, omit a detailed
description of the Nitze instrument, but describe briefly the in-
struments of a different type which have been recently brought to
cur notice by other workers in this field. I shall also give a short
resume of the results of reported cases of intravesical operations,
as far as known, and shall review the opinions expressed by the
more important urological surgeons in the recent French and Ger-
man urolog:cal congresses.
The majority of European intravesical operators and, as
far as I know, of American, use the Nitze instrument in its typical
form. The chief characteristic of it, namely, the rig'dity of the
beak supporting the galvanocaustic snare, has been thought a
disadvantage by a number of operators, and, therefore, the flex-
ible system, so-called, has arisen. The best known of the flexible
system instruments are those of Blum 5 and Kneise.6 The former
* Read before the New England Branch of the American Urological Asso-
ciation. Nov. 29, 1910.
INTRAVESICAL OPERATIONS
301
has advised a mechairsm with a cold wire snare which can be at-
tached to a Nitze double catheterizing cystoscope. The Kneise
apparatus is designed for use with Wossidlo's catheterizing cysto-
scope, and also provides for cauterizing, or injecting solutions
into, the base of the tumor. The main feature of these instru-
ments is the placing of the wire loop on the end of a hollow car-
rier which is introduced through the catheter channel, and can be
advanced into the bladder as far as needed, and moved through a
cons:derable arc. This greater freedom of motion than is ob-
tained with the comparatively short and rigid beak of the Nitze
allows the cystoscope to be held in one position so that the picture
is not constantly shifting. This would appear a decided ad-
vantage and is claimed by the authors to greatly simplify the
technic.
In contrast with this method, known as the indirect, is the one
advocated chiefly by Luys,7 of Paris, and Keersmaecker,8 of Ant-
werp. Luys has developed an instrument resembling an endo-
scopic tube which is introduced with a beak-shaped obturator.
He claims, for its advantages, first, that it is used with air as a
medium, thereby avoiding the obscuring of the field with blood ;
second, that a better view of the tumor is obtained and the cauter-
ization can be more exactly performed, being always in full view
of the operator. Keersmaecker's instrument is much similar to
Luys', but both of these instruments, having no snare mechanism,
necessitate a comparatively large number of sittings for the treat-
ment of anything but the smallest tumor or one with a very small
pedicle. It can be easily seen that growths situated on the mar-
gin of the internal meatus cannot be reached by the indirect in-
struments, but must be attacked through a straight tube.
Frank 0 reports a number of cases in which he has removed polyps
at the bladder neck with an endoscope of his own design. He evi-
dently does not employ it for papillomata within the bladder cav-
ity, as done by Luys and Keersmaecker. While perhaps applicable
to the female, it is hard to see how, in the comparatively rigid
posterior urethra in the male, these instruments can have a very
wide range of usefulness.
In this country, Myer, of San Francisco, has described a
method of operating on tumors in the female bladder. He de-
vised a slender galvano-cautery shaft which can be introduced
by the side of an ordinary cystoscope and a tumor can be attacked
in full view without the necessity of shifting the cystoscope. He
302 THE AMERICAN JOURNAL OF UROLOGY
claims this to be a simpler and quicker method than with the Nitze
instrument, but limited, of course, to the female bladder.
In 1909, Young demonstrated, at the meeting of the Ameri-
can L'rological Association, his operating cystoscope, which con-
sists of a two-bladed rongeur through the shaft of which a small
straight cystoscope is introduced. A tumor or foreign body, if
within reach of its jaws, can be grasped and wholly or partially
removed. He has used this in removing recurrent papillomata.
Still more recently, a method of attacking tumors was published
by Beer, of New York. His instrument consists of a flexible
electrode which can be introduced through a catheterizing cysto-
scope and a high-frequency or Oudin current applied to the tumor.
Owing to the flexibility of the electrode, the scope of the instru-
ment is large and the technic simple. He has used it in two cases,
succeeding in checking hemorrhage and destroying the growth, but
his operations are too recent to say whether or not a cure was ob-
tained.
In considering the results of reported cases, we find that
Nitze's exceed those of any other operator in number, but in his
personal articles he did not prove convincingly that many cases in
which he had successfully removed the tumor had been followed
long enough to determine a cure. His pupil, Weinrich,'10 in 1905,
reported on 170 cases operated by Nitze and himself. Fifty per
cent of these cases showed, on cystoscopic examination three years
after the removal, no recurrence. Twenty of Nitze's cases had
recurred, or 11% of the whole number. There was one death,
and in one case suprapubic cystotomy was performed for hemor-
rhage: result in the remaining cases not known. Other cases are
reported by Suarez,11 one in which two tumors were removed in
five sittings; Weinrich,02 3 additional cases reported in 1906; Cas-
per,13 65 cases with 16 recurrences, in £ of which he was obliged
to perform a suprapubic cystotomy for hemorrhage (he does not
give the length of time since operation in cases that have been fol-
lowed) ; Asch, 14 9. cases, 1 of which had no recurrence seven years
after operation, second one, operated eight years before by Nitze,
in which recurrences appeared at various times, always benign.
Boehme 14 reported 5 cases, four papillomata and one fibroma. In
these, no recurrence had appeared at the time of publication, ex-
cepting one which, after a year, showed a general papillomatous
degeneration. Kneise has performed twenty-five operations with
his flexible operating attachment, but gives no account of results.
INTRAVESICAL OPERATIONS
303
Blum reports 4 cases of benign papilloma which he removed in
from two to eight sittings. Ringleb 14 has performed twenty-
one intravesical operations, once obliged to perform suprapubic
cystotomy for hemorrhage, but gives no results. Operations
performed by the direct method are few in number, but three re-
ported by Keersmaecker and two by Luys. They claim to have en-
tirely destroyed the tumors, but the period of observation is too
short to be convincing of cure.
With the dearth of complete reports of the results of in-
travesical operations, it is difficult to form any definite opinion of
their value, and the question must be still considered an open one,
but it is of interest, perhaps, to review the opinions of those who
have been most vigorously opposed to it, and to mention some of
the advantages claimed by the advocates of the method.
Among the earliest opponents was Israel,15 who did not be-
lieve the operation justifiable on account of the danger of hemor-
rhage on separation of the scar in the Nitze operations. Rov-
sing,14 at the German Congress, in 1909, stated that, since even
the smallest papilloma may be malignant, he considered it unwise
to use a method which entailed any delay, but advocated the more
radical and rapid method of suprapubic cystotomy for practically
all cases. Von Frisch,14 believing that at least 50'c/c of papillo-
mata are malignant, considers the intravesical operation unsafe
and is therefore, opposed to it. Zuckerkandl 14 and Kapsam-
mer 14 are less conservative and advocate its use in very small
papillomata which can be wholly removed in two or three sittings.
In France, Cathelin,10 Rafin and others have been opposed to it on
the ground of technical difficulties and believe that the operation
is less radical than suprapubic cystotomy. On the other hand,
the following definite advantages are claimed for it by Weinrich,
Casper, Luys, Blum and others: (1) Its mortality is practically
nothing (Weinrich, 1 death in 150 cases as compared with 14%
mortality from the suprapubic operation, which is the figure pub-
lished by Von Frisch in his report on 300 cases). (2) The avoid-
ance of complications such as fistula, sepsis, phlebitis or pneu-
monia, involving long convalescence. (3) The ability of the pa-
tient to continue at his work. (4) The more thorough inspection
permitted, less danger of overlooking small beginning tumors than
in the surprapubic method, in which the bladder is somewhat col-
lapsed and the mucous membrane frequently covered with blood or
other fluid. (5) (Important advantage.) The avoidance of
304 THE AMERICAN JOURNAL OF UROLOGY
danger of implanting tumor cells in other portions of the bladder
or in the suprapubic wound which might lead to recurrence. (6)
Its greater applicability for recurrent tumors after removal of
larger growths by suprapubic cystotomy, it being naturally im-
possible to subject a pat 'en t to repeated operations of such grav-
ity.
In weighing the evidence for and against, one is certainly in-
fluenced in favor of the intravesical method, at least in case of
smaller growths, by the fact that the most careful and thorough
suprapubic excision of small single papillomata is sometimes fol-
lowed by the development of multiple recurrences, more or less
approaching the so-called papillomatous degeneration. A number
of these cases, following suprapubic operation, have been reported
by Casper, Lichtenstern,17 Zuckerkandl and others, whereas this
condition seems to develop less frequently after the intravesical
operation, one case only being reported by Asch. As stated be-
fore, however, details are so scanty, and after-results are lacking
in the reports of so many operators that no definite opinion can be
formed on this point.
The results of these reported intravesical operations, number-
ing something over 200 cases, may be summarized as follows :
Mortality, one half of one per cent, or less, there being but one
fatal case in the whole number; hemorrhage, severe enough to re-
quire control by suprapubic cystotomy in & cases ; cure for at
least three years has been established by cystoscopic examination
in 50% of the cases reported by Weinrich. The exact per cent
of cures cannot be figured at present, owing to the failure of the
operators to confirm as apparent cure by cystoscope. For this
same reason, the frequency of recurrence after the intravesical
operation cannot be estimated from the reports. In the original
statistics of Nitze, the recurrences are given as 18%, which is
better than the figure stated by Rafin in his collected statistics of
suprapubic operations, which was £6%.
Inasmuch as Nitze operated on tumors of all sizes, wThile the
tendency at present seems to attack only the smaller benign
growths, it is profable that there is still greater difference in favor
of the intravesical operation in per cent of recurrences.
In conclusion, we may say that the published results of intra-
vesical operations do not at present warrant the adoption of the
method for the removal of primary growths except in cases of
very small tumors or in patients in whom a suprapubic cystotomy
INTRAVESICAL OPERATIONS
305
under an anesthetic is contra-indicated. In cases of repeated re-
currences after suprapubic operations, the method is to be recom-
mended over the performance of frequent suprapubic operations.
My personal experience with the intravesical operation is
limited to one case which I shall briefly report.
A man (G. R.) aged sixty-one was operated on by Dr. Ca-
bot in 1906 for a large papilloma on the left wall of the bladder.
Recent glycosuria cleared up before operation. Suprapubic cyst-
otomy was done and the tumor cut away from the bladder wall
with the actual cautery. Patient made a good recovery, but in
the winter of 1908 hematuria returned and a recurrence of the
growth was seen with a cystoscopy In March, 1908, second
suprapubic cystotomy revealed several large papillomata growths
in both lateral and posterior walls of bladder. These were re-
moved as before. Patient was well, without further bleeding, un-
til the spring of 1910, when he had one or two brief attacks of
hematuria. On Dr. Cabot's invitation, on June 25, 1910, I cysto-
scoped the patient, finding a rough, pinkish oblong mass at the
top of the bladder, apparently in the suprapubic scar. I intro-
duced Young's cystoscopic rongeur, under cocaine, and with 4 oz.
of boric solution in the bladder was unable to reach the growth,
largely, I thing, on account of the moderate enlargement of the
prostate gland. On my drawing off about half of the solution
and pressing down on the suprapubic scar, the growth was grasped
in the jaws and a p'ece amounting to about one third of the whole
mass was removed. Separation of the portion caught in the jaws
of the instrument was difficult and required a rather vigorous pull
before it came away, which was painful. There was moderate
bleeding, enough to cloud the medium and prevent further attack
on the tumor. There was only slight tingeing of blood in the
urine for the next twenty-four hours and no reaction. About ten
days later, second attempt was made, which succeeded in removing
two small fragments only. On inspecting the bladder wall before
attacking the tumor, a couple of small papillomata were seen on
the left side of the fundus near the left ureter. Following the
operation, the patient went away on a vacation, and was ap-
parently free from bleeding for some time. I had hoped to remove
the remaining growths at further sittings, but the patient, in Sep-
tember, had a slight hemiplegia, and soon after attacks of
hematuria recurred, confining him to bed.
Soon after this the glycosuria returned, and uremic symptoms
306 THE AMERICAN JOURNAL OF UROLOGY
developed. His physician recently informed me that the hemi-
plegia became complete, and death shortly followed. Towards the
end, the hematuria was severe, and injections of resorcin into the
bladder were without effect.
REFERENCES.
1 Myer: Am. Jour. Urol., vol. ii, 1905, p. 460; vol. iv, 1908, p. 432.
2 Kolischer and Schmidt: Jour. Am. Med. Asso., July 27, 190T, p. 303.
3 Young: Trans. Am. Urol. Asso., 1909, p. 227.
4 Beer: Jour. Am. Med. Asso., May 28, 1910, p. 1768.
5 Blum: Zeitschr. fur Urol., vol. iii, 1909, p. 116.
6 Kneise: Ibid., vol. iv, no. 6, 1910.
7 Luys: Supplement to Zeitschr. fur Urol., 1909, p. 435.
s Keersmaecker: Ann. des Mai. des Org. Gen.-Urin., vol. i, 1906, p. 935.
0 Frank: Compt. rend. d. Cong. d'Urol., 1905, p. 247.
io Weinreich: Verhandl. Cong. d. Deutsch. Gesellsch. fiir Chir., 1905,
vol. i, p. 223.
n Suarez: Ann. d. Mai. des Org. Gen.-Urin., 1906, vol. i, p. 57; 1906,
p. 887.
12 Weinreich: Arch, fiir Klin, Chir., vol. lxxx.
is Casper: Supplement to Zeitschr. fiir Urol., 1909, p. 441.
14 Boehme, Ringleb, Rovsing, Zuckerhandl, Kapsammer, Von Frisch:
Papers and discussion at 1909 Congress. Supplement to Zeitschr. fiir Urol.,
1909.
is Israel: Med. Klin., 1908, no. 17, p. 639 (Discussion).
ic Cathelin, Rafin: Paper and discussion at French Congress, 1905. Ann.
d. Mai. d. Org. Gen.-Urin., 1905, vol. ii, p. 1625.
i" Lichtenstern: Verhandl. d. Deutsch. Gesellsch. fiir Urol., 1907, vol.
i, p. 409.
URETHRAL HEMORRHAGES.
A. Ravagoli, Cincinnati, Ohio.
SEVERAL cases of hemorrhages from the urethra, which oc-
curred in my practice, have prompted me in the selection of
this theme. All these cases of hemorrhages from the
urethra have to be referred to the class of traumatisms which in
practice are the most common. They have been produced mostly
by the use of instruments in relieving organic strictures. In none
of these cases has extravasation of blood under the skin of the
penis occurred, which is usually found in cases of traumatic rupture
of the urethra, as in the case reported by Seifert.1 The distress-
ing symptom in our cases was the flowing of blood from the
urethra in an alarming quantity, after the slightest and most
1 Seifert. "Seltene Ursache von Blutungen aus der Urethra." Arch. f.
Derm, und Syph. Bd. 97, 1909, p. 19.
URETHRAL HEMORRHAGES
307
gently directed application. Neither one of our patients be-
longed to hematophilic families as in the case of Wrede,2 where a
hemorrhage followed a slight dilation of the urethra.
It is clear that any injury to the penis causing rupture of the
urethra will cause a hemorrhage. It is my purpose to point out
cases of very severe hemorrhages from the urethra following the
slightest and the most gentle maneuver to treat strictures of the
urethra. Hemorrhages, as Friedlaender3 said, can be avoided by
the careful use of instruments, but in some cases they cannot be
prevented. When the mucosa of the urethra or of the bladder
is thick and inflamed, according to Zuckerkandl,4 it is much more
vulnerable, and any instrumental exploration may cause hemor-
rhage. In case a soft and succulent granulation tissue has been
formed, the introduction of a sound in the gentlest way is liable
to produce hemorrhage. Indeed, the appearance of a few drops
of blood after the introduction of a sound may easily result, but
this is of no significance, as the blood stops by the contraction of
the urethra on itself after withdrawing the instrument. In some
cases, however, the hemorrhage is so severe as to frighten the pa-
tient as well as the physician.
When the hemorrhage comes from the urethra in the pars
pendula, a well-applied compression with a bandage around the
penis will soon stop the bleeding. When the hemorrhage has its
origin from the posterior urethra, usually in the bulbar region,
then it is not easy to master the bleeding except by digital com-
pression.
In our practice we had persistent hemorrhage after the dila-
tation performed with Kollmann's dilator for the posterior
urethra. J. N., a strong young man, was troubled with a strict-
ure in the pars membranosa. A No. 12 American steel sound
could be introduced without dfficulty, yet the stream of the urine
was distorted or divded, and drops of retarded urine caused dis-
comfort and a dribbling sensation. The Kollmann dilator was
applied without cocaine instillation, in order that the sensitiveness
of the patient might serve as a guide. The dilator was opened to
No. 30, when the patient complained of a kind of burning feeling.
The instrument was held for two minutes, then closed and removed,
? Wrede. Berlin Klin. Wochenschr. 49, 1908.
3 Friedlaender, Martin. "Die Krankheiten der mannlichen Harnorgane."
Berlin, 1900, p. 114.
* Zuckerkandl, O. Handbook der Vrologle. Bd. I, p. 750.
308 THE AMERICAN JOURNAL OF UROLOGY
when it showed some blood on the rubber cover. The patient did
not complain of any pain, and the urethra was irrigated with 1
to 5,000 solution of permanganate. After the solution was ex-
pelled some pieces of clotted blood came out, and whenever the
patient urinated he expelled a large quantity of blood, although
suffering no pain. The patient was kept in bed with ice bag on
the perineum, whereupon the hemorrhages stopped and the urine
returned free from blood.
In another case V. A., an Italian, had an organic stricture
affecting the bulbar region. The patient could not pass urine,
which was coming drop by drop. No catheter or bougie could
pass the stricture, and a filiform elastic catheter was tried with-
out success. As the patient was requesting to be relieved, a thin
silver catheter, No. 8 Charriere, was successfully introduced, re-
lieving him from a large quantity of urine. A few days later he
came back much relieved. A No. 8 metallic sound was introduced
through the stricture into the bladder without much difficulty, but
a few drops of blood followed the removal of the sound. The
urethra was then irrigated, and after irrigation the blood began
to come out in a full stream. The application of the finger on
the perineum stopped the hemorrhage, and the compression was
continued until the bleeding stopped. A week later we could in-
troduce steel sounds, increasing the size without causing any more
bleeding. The patient was much better and was discharged.
Mr. J. S. for many years had suffered with a stricture above
the bulb. He had been treated by many local physicians without
any satisfactory result. Every time that a sound or a catheter
was introduced bleeding followed. The patient was badly worn
out, he was passing urine nearly by drops, and urination was very
frequent. His sleep was very much troubled by the necessity- of
getting up every half hour. The prostate was normal, the urine
neutral, showing abundant shreds. In the examination a No. 8
metallic sound was introduced, which went through the stricture.
This unexpected success encouraged me in employing electrolysis,
and during the night after its use the patient found it difficult
to expel the urine. A doctor was called, who catheterized him.
On the following day he was losing blood in an alarming way,
while for several hours he had not passed urine. Another tiny
catheter was inserted, but failed to go into the bladder. Hemor-
rhage followed in a terrific way. The digital compression would
stop the hemorrhage, but as soon as the compression ceased the
URETHRAL HEMORRHAGES
309
blood was streaming. In this case the patient was placed under
general anaesthesia. A staff was inserted as far as it could go,
the perineum was opened longitudinally, and then the urethra was
opened and a groove director inserted through the stricture. A
large incision gave opportunity to push the finger into the blad-
der as in lithotomy. A large short catheter was left in the blad-
der and the wound was tightly packed. No more blood appeared,
the wound healing up in three weeks, and the patient has since
passed his urine in the normal way.
Another case was of a young man with hypospadias of first
degree, who had stricture of the bulbar region. His physician
had passed sounds and since then blood had begun to come from
the urethra by drops. With irrigations and instillations of mild
solutions of nitrate of silver no benefit was obtained. The ureth-
roscope was introduced and it showed that the mucous membrane
of the posterior urethra was covered with red, thick, succulent
granulations from which the blood was oozing. A six per cent
solution of nitrate of silver was used, with a cotton tampon, and
the surface was touched every other day. The blood stopped and
also the discharge.
In all these cases to which we have referred the urethra was
infiltrated and granular, and consequently very vulnerable and
liable to bleed at the slightest contact. In the treatment of
organic strictures, when the mucous membrane is thickened and
a process of cavernitis has taken place, the tissues are so thick-
ened and infiltrated that they easily break. The urethra is an
organ supplied abundantly with blood vessels, which have their
origin in the pudenda communis, the end of the arteria hypo-
gastrics. The arteria bulbo urethralis supplies the corpus cav-
ernosum urethra3 and the arteria profunda penis runs into the
corpus cavernosum penis. Blood is abundantly provided by these
arteries. When the circulation is somewhat impaired by the en-
larged condition of the prostate, then the veins are filled, forming-
a stasis. The plexus pudendalis internus surrounds the prostatic
gland, the seminal vesicles, and the pars membranosa of the
urethra, forming a thick net which is also known as the labyrin-
thus santorini. On account of the venous stasis from compression
of the enlarged prostate, or from the inflammatory process, the
tissues are imbibed with blood and any injury is liable to produce
hemorrhages.
310 THE AMERICAN1 JOURNAL OF UROLOGY
Goldberg 1 has referred to severe hemorrhages, which some-
times occur in patients suffering with prostatic hypertrophy.
He remarked that the hemorrhages are often the result of injuries
caused in attempting catheterism. In some cases of prostatics
who have undergone no treatment the hemorrhage may be the re-
sult of chronic cystitis, or from the presence of lithiasis. When
the hyperemi of the mucous membrane arising from the continued
distended bladder is eased by emptying the urine, the diminishing
pressure may be the cause of hemorrhage.
Local infections are sometimes the cause of hemorrhage from
the urethra. In fact an acute inflammatory process of the mucous
membrane of the urethra often causes formation of blood vessels,
and at the same time the effusion of serum makes the connective
tissues loose, and renders them liable to bleed. When catarrhal
ulcerations are formed, the mucous membrane is so vascular that
any slight contact with a sound or with a catheter is liable to cause
loss of blood, and when the tissues of the urethra under the
urethroscope are touched with a cotton tampon, the bleeding
sometimes causes trouble to the operator.
The chronic inflammatory process, according to Zuckerkandl,
may in some cases produce necrosis of the mucosa and the ex-
posure of the dilated blood-vessels, which at the slightest contact
cause stubborn hemorrhage.
As to other hemorrhages we will only mention those caused
by the presence of tumors in the urethra and at the neck of the
bladder, which are usually soft and of villous nature. The hemor-
rhages from these tumors are exceedingly stubborn : often they
are reproduced without injury of any kind. Seifert reported
two cases of hemorrhages from the urethra, caused from varicos-
ities of the veins, which began at the fossa navicularis and ex-
tended to the middle of the urethra. From tuberculosis of the
neck of the bladder hemorrhages may have their origin, and often
in voung men spontaneous hemorrhage from the urethra make
us suspect the presence of miliary tubercular nodules.
In all our cases under consideration in this paper, we find
that the blood is running from the urethra independently from
the urine. The blood is not clotted in the bladder, but comes
from the urethra as an essential hemorrhage. In some cases the
i Goldberg, B. ''Ursachen unci Behandlungs methoden schwerer Blu-
tugen der Prostatiken." Therapic der Gegenwart, 1906, Xo 5. Bef. Zeitschr.
f. Urol, B. 1, H. 1, p. 12.
URETHRAL HEMORRHAGES
311
blood has followed urination, at first the urine coming free from
blood, at the end of the urine was tinged with blood, and then drops
of blood have followed the last drops of urine.
Intermittent spontaneous hemorrhages of the urethra are
usually the result of tumors, or of tubercular ulcerations at the
neck of the bladder. The smallest papilloma, and in the same
way the smallest' tubercular ulceration, may cause profuse hemor-
rhages, which lead the patient to an anaemic condition.
In the cases which we have made our subject of study, we
have had hemorrhages from the urethra always in consequence
of strictures, which are the natural result of a chronic inflamma-
tory process. Hemorrhages have followed the simple introduction
of a sound, the dilatation with Kollmann's dilator, the irrigation
with Janet method, and electrolysis. The fear of hemorrhage
has not prevented us from performing the necessary examinations,
and from applying the proper treatment. When the urethra is
inflamed and studded with granulations it easily bleeds and it is
necessary to master the hemorrhage.
In a slight hemorrhage the application of cold water may
stop the blood, and if in the pars pendula a compression with a
bandage around the penis often is sufficient to stop the hemor-
rhage. When the hemorrhage is from the bulbar region digital'
compression on the perineum usually stops the hemorrhage. The
idea of retaining a catheter or a sound for some time to stop the
hemorrhage is more hypothetical than real. In my cases, at least,
it could not even have been suggested. In cases of bleeding
from the granulated mucous membrane, the best way to stop the
bleeding is to use the urethroscope, and touch up the granulations
with a solution of nitrate of silver from three to eight per cent.
Nitrate of silver coagulates the albumin and covers the granu-
lations with a solid coat, stops the bleeding, constricts the tissues
and the blood vessels, and heals up the surface evenly and
smoothly.
When the hemorrhage is of great volume, and when it is
often repeated, there is no time to hesitate. External urethro-
tomy then has to be performed. We believe that this is the only
possible way to save the patient in so dangerous a condition.
312 THE AMERICAN JOURNAL OF UROLOGY
AN ATTACHMENT FOR DR. BUERGER'S URETHRO-
SCOPE.
By Victor C. Pedersex, A. M., M. D., New York.
AT the St. Louis meeting of the American Medical Associa-
tion in June, 1910, I described to the YVappler Electric
Controller Company, through their representative, Mr.
Wappler there, the following simple attachment to the Buerger
Urethroscope.
It aims to meet those cases in which treatment requires dryness
and applications, such as would be available through the old
straight tube urethroscopes, as the Chetwood pattern for ex-
ample. Any one having the Chetwood and the Buerger instru-
ments might essay to avoid purchasing this extra attachment.
The difficulty, however, is that of recognizing with the older instru-
ments the exact point discovered with the Buerger instrument.
After about a one-half-year's use of this attachment, however, the
writer is convinced of its serviceability.
With the great aid of the magnification and irrigation of the
Buerger instrument a definite lesion is located. The telescope is
then removed without disturbing the sheath of the instrument and
the urethra mopped dry. The attachment is then inserted and
by means of its eye piece which repeats the degree of enlargement
of the Buerger telescope the lesion is again recognized. The
magnifying eye piece is then removed and the treatment applied.
The parts of the attachment are extremely simple as shown in
the cut. They are only two fold, namely a light-carrier with its
electrical connections, practically in duplicate of the Chetwood
light-carrier, which fits into the opening of the sheath of the
urethroscope in such a way as to give the maximum space possible
for the use of instruments. The second part is a magnifying eye-
piece as aforesaid.
The cut shows these parts with great clearness and requires no
further description.
TUMORS OF THE BLADDER
313
THE TRANSPERITONEAL AND SUPRAPUBIC AP-
PROACH TO TUMORS OF THE BLADDER.*
By Charles L. Scudder, M. D.,
Surgeon to the Massachusetts General Hospital; Lecturer on Surgery, Har-
vard Medical School.
THE most common form of the epithelial tumors of the blad-
der is the papilloma. In a certain series of 56 operated
cases of tumor of the bladder from the Rochester, Minn.,
Clinic, 42 were of the papilloma type. This affords an idea of the
frequency with which papilloma of the bladder is found at the
operating table.
There are certain facts of importance which should be con-
sidered in deciding upon the operative attack on tumors of the
bladder :
1. It is impossible for the pathologist to state with certanty
whether or not any given papilloma is malignant without a care-
ful examination of the whole growth, including a section of the
bladder wall from which the growth arises.
2. It is even under these ideal conditions often-times impos-
sible for the pathologist to determine whether or not a given
papilloma is malignant.
3. Practically speaking, all tumors of the bladder cause the
death of the patient sooner or later. The supposedly benign
papilloma causes death by hemorrhage or pyelonephritis.
4. All so-called benign tumors are potentially malignant. A
papilloma which shows no sign of malignancy may become malig-
nant.
5. If the operative deaths and the rapid recurrences of blad-
der tumors are combined, as Watson has very properly combined
them, under the one head of operative failures, these failures have
occurred in 29% of the so-called benign tumors and in 46% of
the cases of carcinoma.
6. Of the urethral operations for papilloma, only 28% re-
mained cured more than one year.
Of the suprapubic operations, not resections, only 27.5%
remained well more than one year.
Of the partial resections, 37.5% remained well more than one
year.
7. Of 55 cases of papilloma operated upon through the
* Read before the New England Branch of the American Urological
Association, Nov. -29, 1910.
314 THE AMERICAN JOURNAL OF UROLOGY
urethra or suprapubically, or by partial resection, 19 had recurred.
8. The statistics of Xitze in 1901 and 1905 are not corrob-
orated by detailed reports of the cases and consequently should
be looked upon as unusually fortunate results.
In view of the aboye facts pointing to the very great malig-
nancy of papilloma of the bladder, and because of the poor surgi-
cal results that hitherto have been obtained by operative treat-
ment, I believe that we should regard, from an operative stand-
point, all of the papillomata of the bladder as potentially malig-
nant, and that they should be treated as if they were malignant
growths, whether there are evidences of malignancy in any in-
dividual case or not.
The approach to the bladder tumor through the suprapubic
incision affords, in a certain number of the cases, satisfactory ac-
cess to the tumor. In a still smaller number of cases the supra-
pubic approach supplemented by a separation of the bladder from
the peritoneum affords easy access to the tumor.
Most bladder tumors are seated at the base of the bladder and
in the region of the ureteral openings. For such tumors and for
those tumors evidently malignant, I believe that the approach
should be by means of the transperitoneal operation of cystotomy.
There are certain cases, too, occurring laterally and in the median
portion of the bladder that will become more readily accessible
through the transperitoneal approach.
The peritoneum is with greater and greater difficulty
stripped from off the bladder as one approaches the posterior
surface of the bladder low down. Consequently the extraperi-
toneal suprapubic route is impracticable in many cases. I be-
lieve that the transperitoneal approach to the bladder affords the
safest means of removing bladder tumors.
The opening of the abdomen enables one to see and palpate
the liver, to inspect the peritoneum, the mesentery and the re-
troperitoneal glands. It is of very great importance that these
parts should be inspected before any radical operation is under-
taken for the removal of a bladder growth. If mestastases are
discovered, as they have been several times, a radical operation
would be of no use. A sufficient number of cases have not vet
been operated upon by the transperitoneal route to establish the
mortality percentage, or the percentage of cures and recurrencces,
but it will not be long before sufficient evidence has accumulated
to reply to these inquiries.
The transperitoneal operation enables the surgeon to operate
TUMORS OF THE BLADDER
with comparative ease, bloodlessly, aseptically and consequently
safelv.
The investigations of Tufficr, De Quervain, Barney and
others have demonstrated that normal, sterile urine is not a great
irritant to the peritoneum, so that under the very careful pre-
cautions taken at a transperitoneal operat'on there need he no
soiling of the peritoneum and adjacent tissues with urine, and
this, chance of infection may be practically eliminated.
The more I have to do with cancer in any form, whether the
supposedly mild squamous-celled epithelioma of the face, or the
squamous epithelioma involving the jaw, the more I am impressed
by the absolute necessity of a very thorough procedure to eradi-
cate the disease at the outset beyond peradventure of a doubt.
It is, far safer, it is far wiser, it is better surgery, to remove
the contents of the orbit when the squamous-cell cancer involves
the skin near the inner canthus in the immediate neighborhood of
the eyeball, even though the eye be intact functionally, than to
temporize with an exe'sion of the apparent growth and be forced
to a subsequent attack upon the orbital contents when the disease
is too far advanced to accomplish more than a palliative operation.
I believe that the same principle holds true in these cases of
papilloma of the bladder, no matter how benign they may appear.
A primary radical excision with the whole thickness of the bladder
wall is indicated in the most benign-appear'ng cases of bladder
papilloma.
The improvement of the operating cystoscope, together with
the high-frequency current, enables those so inclined to operate
upon these growths, and fortunately, and in a way unfortunately,
to successfully remove a few. The advent of the cystoscope has
made certain the location of the bladder tumors. The employ-
ment of the cystoscope for operating purposes seems to me un-
surgical in cases of bladder tumors.
It is by the peritoneal route that a safe and comparatively
easy access is provided to the bladder.
Regarding the technic of transperitoneal cystotomy:
Rydygier, in 1888, suggested this route to the bladder.
Harrington, in 1893, and Mayo, in 1908, have stated the
salient facts in the technic of this procedure. We are all inter-
ested in little details which may contribute to a perfecting of this
technic. Each operator who undertakes th's major but simple
exposure of the bladder will modify his procedure according to
individual preferences.
316 THE AMERICAN! JOURNAL OF UROLOGY
I believe that the use of urotropin two or three days previous
to a contemplated transperitoneal cystotomy is wise. Preparation
of the region of the operation should be as carefully done as for
any abdominal section.
If it is known that a cystitis is present, the bladder should be
thoroughly irrigated before the operation. Tennant, of Color-
ado, has demonstrated recently that an intraperitoneal cystotomy
can be done with safety even in the presence of a severe cystitis.
He reports two cases.
The high Trendelenburg position facilitates the operation
immensely.
The abdominal incision should be an ample one so that the
intestine can be displaced upward behind the omentum completely
and with ease. The edges of the abdominal wound should be pro-
tected by several layers of sterile gauze. I like, personally, to
use for this packing off of the intestine a long roll of gauze which
is wet and wrung out of hot salt solution.
// the tumor has been located by the cystoscope in the upper
portion of the bladder, the incision for opening the bladder may
be placed so as to approximate to the tumor.
If the tumor is nearer the base of the bladder, then a median
opening of the bladder posteriorly will be wise.
The operation may be begun extraperitoneally, suprapubi-
cally and, if more ready access to the bladder is needed, the trans-
peritoneal method may be used.
The urine is sponged from the bladder as soon as it is opened
and the bladder is kept practically dry by occasional gentle spong-
ing. Great gentleness must be observed in handling the bladder.
Trauma however slight may be a factor in the recurrence of blad-
der tumors. Some one has observed that the Trendelenburg po-
sition diminishes temporarily the flow of urine from the kidneys.
An excision of the tumor should include the bladder wall.
This wound in the bladder wall may be closed by interrupted or
continuous suture, or if the wound is not too extensive, the edges
and base of the wound may be cauterized with the actual cautery.
All hemorrhage should be stopped either through application of
the actual cautery or by placing the proper sutures. The suture
should be of either plain or chromic catgut. %
If the tumor involves the ureteral orifice, this should be ex-
cised and the ureter reinserted into the bladder.
Treatment of the bladder wound. — The bladder wound may be
TUMORS OF THE BLADDER
closed by a continuous Connell stitch of chromic catgut through all
the layers similiar to the suture used in the closure of the stomach
or of the intestine. Or if one chooses, the mucosa and the muscu-
laris may be sutured separately. The peritoneum in either case
is approximated separately over the line of the incision in the blad-
der by a continuous linen suture.
Personally I like to use in wounds of the stomach, intestine or
bladder an occasional interrupted stitch to reinforce a continuous
suture. I do not often care to trust to a continuous suture alone
in suturing any viscus.
If the ureteral orifice is involved and that part of the bladder
is resected, or if there appears to be some little oozing of blood, or
if the prostate has been removed, it may be wise to permanently
drain the bladder either by a suprapubic tube or by a catheter
through the urethra. I have used a catheter with the exception
of one case in which no drainage was used. I should prefer to
avoid the use of any instrument in the bladder unless it were in-
dicated by one of the three conditions mentioned. Mayo and Judd
have only rarely drained the bladder in their transperitoneal
cases.
The abdominal wound is closed by layers. If there is a sus-
picion of any soiling of the wound of the abdominal wall, then a
thin small rubber tissue drain had best be introduced between
stitches down to the peritoneal layer of sutures.
In conclusion, with regard to the surgical treatment of tumors
of the bladder, certain of the small apparently benign papillomata
may be safely removed by the suprapubic method, but should be
removed even with this approach by a good margin of excised,
healthy tissue.
The transperitoneal approach to the bladder will enable the
surgeon to successfully attack cases of malignant tumor of the
bladder which, without this approach, might be forced to a more
dangerous extraperitoneal cystectomy. Watson's proposed cys-
tectomy and double nephrostomy should be employed only when a
partial cystectomy done transperitoneally is inapplicable. The
transperitoneal approach to the bladder will care for many cases
that otherwise would have to be treated by Watson's method of
cystectomy.
Transperitoneal cystotomy is a procedure that has come to
stay. Its employment should lower the percentage of recurren-
ces in tumors of the bladder of all grades of malignancy.
318 THE AMERICAN JOURNAL OF UROLOGY
Review of Current Urologic Literature
Acute Urethritis of Chemical Origin, with Report of
Three Cases. William J. Robinson (Med. Record, April 8,
1911) says that one of the most unfortunate terms in our medical
nomenclature is the word gonorrhea : besides the fact that its
etymologic derivation is absurd, it makes us link, against our will,
every form of urethritis with the gonocoecus, so that the word
urethritis has practically become synonymous with gonorrhea or
gonococcal infection and we therefore often forget that there is
such a thing as urethritis of non-gonococcal and even non-bac-
terial org n.
There is nothing strikingly original in the statement that
urethritis may be of chemical origin. Everybody knows, or is
supposed to know, it. Still this is often forgotten. He reports
three cases of chemical urethritis, each of which teaches a valu-
able lesson.
Mr. X., £8 vears old, was to be married on September 21,
1910. Just a week before, September 14% he considered it neces-
sary to cohabit with a prostitute. Men of a certain class seem to
regard it as a sacred obligation to bid adieu to their bachelorhood
in this distardly manner. The temptation is very great to break
out in a tirade against the brutes, who, a few days, sometimes
even a few hours, before going to the marriage bed, will subject
themselves and their future wives and children to the risk of in-
fection, because, forsooth, after marriage they intend to be faith-
ful to their wives and therefore want to have a "last fling." But
what's the use? The brutes don't read medical journals, and if
they do they are not affected by our tirades. And so Mr. X. had
intercourse on the 14th. On the 16th he noticed, or thought he
noticed, a tickling in the urethra. After a few hours the tickling
disappeared. On the 17th he thought it returned. In view of the
close approach of the important day he became thoroughly fright-
ened— though I believe there was really nothing the matter with
him, the tickling being more in his mind than in his urethra — and
consulted — a reputable specialist? Xo : a druggist. The vast
majority of druggists I am familiar with are men of high stand-
ing, well up in their profession, who would disdain to prescribe or
even to advise in cases of venereal disease. But there are black
sheep everywhere, and there is no question that some druggists are
CURRENT UROLOGIC LITERATURE
319
as ignorant as they are imprudent. This druggist seems to have
been particularly ignorant. His advice to the patient was to dis-
solve one antiseptic tablet (containing 7-7 grains of corrosive sub-
limate!) in about half a glass of water and syringe three times a
day. using several injections for each seance. I have known drug-
gists advising the insertion into the vagina of 7-grain corrosive
sublimate tablets as an anti-conceptional measure (and more than
one woman paid a severe penalty for this stupidly criminal ad-
vice), but I had not heard of anybody displaying such dangerous
ignorance.
In the first case the patient, thinking he had gonorrhea went
to a druggist who gave him tablets of corrosive sublimate, one
tablet to be dissolved in \ glass of water and the solution to be in-
jected.
The patient did as told and syringed out his urethra four or
five times with a half-ounce syringe. This was before going to
bed. He suffered agonies the whole night, and the pain at any
attempt at urination was so severe that he abstained. The follow-
ing morning he applied to me. The penis was four or five times
its normal size. The swelling and edema were enormous. The
glans was so puffed that it was difficult to find the meatus. The
patient was badly frightened, but constitutionally he was not ill;
no fever, no malaise, no stomatitis, no bad odor; in short, no
.symptoms of mercurial poisoning. He showed me the tablets
which the druggist had given him; they were, as stated, 7.7-
gra'n corrosive sublimate tablets, combined with an equal amount
of ammonium chloride. He indicated to me the amount of water
in which he dissolved the tablet and the amount was between four
and six ounces. In other words, the strength of the bichloride
solution which he used as a urethral injection was about 1 in 250
to 1 in 350. And in all he used about 3 grains of corrosive subli-
mate: but, of course, he let the injection run right out.
"He tried to urinate unaided, but failed. I then with great
difficulty anesthetized the urethra, passed a small catheter, and
withdrew twenty-two ounces of urine. The patient at once felt
relieved. For the penis I ordered compresses of l'quor alumini
acetatis (Burrow's solution) ; to do away with the strangury I
ordered rectal suppositories of morphine sulphate (gr. J) and
atropine sulphate (gr. 1-60) ; also, internally a mixture of potas-
sium bromide, potassium acetate arbutin, and fiu'd extract of
triticum ; also to drink frequently of a cold infusion of linseed
320 THE AMERICAN JOURNAL OF UROLOGY
(made as follows: Macerate a teaspoonful of whole linseed in a
glass-full of water for five or ten minutes, stirring occasionally ;
strain, and add a dash of lemon juice to take away the otherwise
"flat" taste of the linseed; the demulcent effect of this rather old-
fashioned infusion is not known as well as it deserves to be).
This treatment improved the patient's condition at once. The
swelling went down considerably ; the pain and burning on urin-
ation disappeared almost entirely. Rut on the next day a profuse
thin discharge made its appearance and the urine contained num-
erous flocculi. The patient was, of course, sure he had gonor-
rhea, but I was convinced of the contrary. Numerous exami-
nations failed to disclose a single gonococcus or a gonococcus-like
diplococcus. It was pure — one might say chemically pure — pus,
caused by an irritating antiseptic. I used no local treatment
whatever — only internal demulcents and mild diuretics, and the
discharge gradually diminished; it is now reduced to the fraction
of a drop in the morning, simulating the morning drop of gonor-
rhea, and the urine contains flocculi ; they are, however, entirely
different from Tripperfaden and they, as well as the minute dis-
charge, are entirely free from cocci. The wedding, which was
necessarily delayed for a month, is to take place in a few days and
I have no hesitancy in giving him my unqualified permission.
During one period in the treatment there seemed to be a tendency
to the formation of stricture, but several dilatations with Koll-
mann's dilator, followed by the instillation of a 1 per cent, solution
of thymol iod:de in oil, restored the urethra to its normal caliber,
and it is now perfectly normal in this respect.".
In the seeond case the urethritis was due to the use of in-
jections of zinc sulphate, potassium permanganate and a silver
preparation in a patient, who never had any gonorrhea, but had
appl'ed to a physician for treatment for night losses. In the
third case the urethritis was due to the use of silver nitrate, as a
test of cure. The author especially warns against the use of this
test. His conclusions are as follows :
1. Urethritis of chemical origin is more common than is
generally supposed.
2. While most cases are caused from self-administered in-
jections prescribed by barbers, friends, and others, some cases owe
their origin to the over-zealousness of physicians.
3. The unscientific and unjustifiable silver nitrate test, which
CURRENT UROLOGIC LITE R ATI' KK
321
should be forever discarded, has been responsible for very many
cases of chemical urethritis.
4. The diagnosis of chemical urethritis is made by the history
of the case, the freedom of discharge from gonococci and, gen-
erally, its improvement on being let alone.
5. One of the most useful agents in the treatment of chemical
urethritis is warm sterilized olive or almond oil, or 4 to 1 per cent,
solution of some organic iodine derivative (iodoform, dithymol-
iodide, europhen) in one of the above oils.
Tendency to stricture should be prevented by dilators or by
sounds dipped in the just referred to solutions.
Percussion of the Kidneys. By Otto Lerch (Medical
Record, Feb. 4, 1911) says: "As pleximeter, I use a thin ivory
plate, and as plexor a hammer with a black rubber or ebony handle
and heavy steel head with black rubber t:p.
The hammer is very lightly grasped at the end of the handle
between the thumb and index finger, the end of the handle resting
on the third finger and the palm of the hand. The pleximeter is
placed upon the portion of the body to be percussed, with a slight
movement of the wrist the hammer is lightly tossed up and the
hammer head is allowed to drop upon the pleximeter with its own
weight. As soon as the border of a solid organ or the boundary
between two hollow organs is reached, the rebound of the hammer
will be more or less, according to the amount of air beneath : prac-
tically no rebound is noticed if a solid organ is next to the surface.
At the same time the slightest change of vibrations is felt in the
finger tips that but lightly hold the hammer, as well as in the hand,
and a decided change in the note is readily perceived. We have,
then, at once three criteria by which to judge whether the border
of an organ is reached.
This method excludes to a very large extent the individual
feature of the usually practised percussion and makes the results
mere uniform.
The results that apply to superficial and deep percussion in
the usual way : Application of pleximeter and strength of stroke,
the placing of the pleximeter without pressure, a delicate stroke
for light percussion, a slight pressure of pleximeter and a stronger
stroke for deep percussion, apply to this method. We simply
replace the stroke by the drop. Of course it must be left to the
examiner how much the drop must be, still it is easier to judge on
account of the three criteria we have the rebound of the hammer
322 THE AMERICAN! JOURNAL OF UROLOGY
seen, the change of vibrations felt, and the changing sound heard.
It happens almost da ly in my clinical lectures that I am told that
I change the strength of the stroke on reaching the border of an
organ, the student observing the rebound of the hammer lessening
on reaching a solid organ.
Pinger-fmger and fmger-pleximeter percussion may be used,
but this requires more skill, as it demands a perfect relaxation of
the wrist. With my method I have obta'ned accurate results,
lines corresponding to the large vessels in the chest above the
heart, the deep dullness of the heart and liver, the dullness of the
spleen, lesions in the lungs, and abdomen. The stomach can be
differentiated in most cases from the colon. Results many times
tested and found correct on the cadaver.
With my method I have percussed the kidneys for years, and
have kept record since 1908, now having several hundred cases
tabulated. I find that these organs can be mapped out with ac-
curacy and ease, showing changes in size of a small fraction of
one centimeter.
The percussion is best performed with the patient lying face
downward with a cushion under his belly, in order to put the
muscles of the back on tension. This muscular stretching is not
necessary if disagreeable to the patient. It is immaterial whether
the colon is filled with fecal matter or d stended with gas, and it
is unnecessary to empty the intestines before proceeding to per-
cuss. This method gives good results with infants and adults,
young or old, fat or emaciated, and it matters not whether the ab-
dominal cavity is filled with serum or pus.
That actually kidney dullness is heard, and that these organs
are projected upon the back, that we are not deceived by muscular
dullness or fecal matter contained in the colon is shown by the
location of the percussion dullness, the left a little higher than the
right, exactly corresponding to the location of the kidneys in the
body. The form of the percussion dullness corresponds to the
form of the kidneys, one checking of the other, the right, the left,
the lower border, the upper, the outer, the inner lateral border ;
even the hilum can be mapped out without any difficulty, and as
the location of the left kidney is a little higher than the right kid-
ney, these checks become of still greater value.
In cases of movable kidney with palpable organ the check is
perfect. We find on percussion the palpated organ displaced.
Occasionally it will float back into proper position when the patient
CURRENT UROLOGIC LITERATURE
323
assumes the posture necessary for percussion. However, if we re-
peat the process we will discover this without trouble. Usually
the kidneys will at least partly return to their natural position —
that is, a kidney that can be palpated full length in the abdomen
will very frequently be found only one-third or one-half of its size
downwardly displaced (percussion dullness). If the kidneys have
turned under an angle it may appear smaller in size, and especially
so when completely turned and held imbedded by the intestines.
Rolling the patient in a horizontal position around, himself dis-
places the kidney; making him jump from a chair replaces it.
This may prove a valuable therapeutic measure in Dietch crises.
Nothing more need be said as to the method, except that caution
has to be used when, percussing downward, striking the dia-
phragm a dull note is heard. The percussion must be continued
downward and will clear up again when the kidney is displaced.
Liver dullness and splenic dullness do not interfere. Very light
kidney percussion gives the projection about half size, a super-
ficial dullness of little value for practical purposes except as con-
trol.
In every case the cl'nical symptoms correspond to the per-
cussion figures. If these indicate a contracted condition of the
organ, more or less advanced, one or both of the kidneys will be
found decreased in size. If a diagnosis of congestion of the organ
or of the large white cirrhotic kidney is made the percussion figure
will bear out the diagnosis. In movable kidney we find the ex-
pected downward displacement of the projected figure.
The method was tested upon cadavers here and abroad, by
the author.
Percussion is one of the cornerstones of diagnosis, and its
application furnishes most valuable diagnostic results. Kidney
percussion, which allows us to study the size of the organ, en-
ables us, in Bright's disease, to determine whether one or both
organs are affected. The determination of the increase or de-
crease in bulk, through tumor or abscess of the kidney, is valuable.
In nephroptosis it becomes especially valuable in obese subjects or
patknts with tense abdominal muscles, conditions which sometimes
make it impossible to palpate the organ. In fact, there is hardly
any disease in which a knowledge of size and location of the kid-
neys would not be of value.
These investigations on the cadaver call attention to the im-
portance of intra-abdominal pressure as a factor to keep the ab-
324 THE AMERICAN JOURNAL OF UROLOGY
dominal organs in place. This must be borne in mind when a
laparotomy on thin patients is to be considered.
To sum up : By replacing the stroke with the drop in per-
cussion, we have a method that enables us to make out with ac-
curacy and ease the organs situated close to the body wall or
deeply situated, the percussion lines corresponding sharply to the
organs. We have a method superior to the usual method of per-
cussion, in that it permits us to judge from the rebound of the
hammer the change of vibrations and the percussion note at one
and the same time, and especially that it eliminates largely the
individual element and makes results uniform.
Further, according to the most prominent clinicians, kidney
percussion has been impossible except in cases of very much en-
larged kidneys, when it is for practical purposes useless. My
methods give good results in kidney percussion under any con-
ditions and with any patient, supplementing the diagnosis of the
d:seases of the kidneys and giving a ready and easy means to
determine the actual size and location of the kidneys, which is of
value in all cases, as stated before/'
Tuberculosis of the Kidneys. — Barth (Deui. Mediz.
Wochen., May 25,) has traced to date thirty-seven patients
whose kidney he had removed on account of tuberculosis :
three others died. During the same period he had about
forty other patients with renal tuberculosis who were not
given operative treatment for various reasons. Twelve of the
thirty-seven patients recovered entirely after the nephrectomy and
twelve were materially improved while thirteen have died. Analy-
sis of the cases shows that as long as the tuberculous process is re-
stricted to one kidney and its ureter, nephrectomy promises a com-
plete cure. But if the bladder is involved, a cure can be antici-
pated in only 25 per cent, of the cases : 25 per cent, of his patients
succumbed during the year to the progress of the tuberculosis.
The others all showed great improvement, but about 25 per cent,
succumbed later to the tuberculosis, after an interval of from two
to over nine years. Even when the tuberculous process in the
bladder heals completely, it leaves permanent disturbances in the
form of unduly frequent desires to urinate, particularly annoying
at night. He admits the possibility of a spontaneous cure of open
or closed tuberculosis of the kdnev, but declares that there is not
the least prospect of such a cure after the tuberculous foci begin
to break down and p\'uria appears. The process then spreads
CURRENT UROLOGIC LITERATURE
325
rapidly along the lymphatics in the kidney itself and down toward
the bladder. It is impossible to determine the actual healing of a
tuberculous process in the kidneys except by repeated catheteriza-
tion of the ureter; all other signs and information are deceptive
and worthless. Nephrectomy with unilateral tuberculosis, normal
functioning of the other kidney understood, is, he affirms, almost
entirely free from danger. It should be advocated in every case
of open tuberculosis of the kidney and if possible before the blad-
der is invaded. The open tuberculous process in the kidney can
be detected in the incipient and early stages only with the aid of
the ureter catheter ; chromocystoscopy does not locate the seat of
the process unless there is advanced destruction of kidney tissue.
It is important, therefore, to insist on catheterization of the ureters
and bacteriologic examination of the urine in every obscure case of
pyuria ("catarrh of the bladder").
Huge Hydronephrosis (Two Gallons Capacity). — Dr. H.
J. Whitacre, (J. A. M. A., June 2-1, 1911), reports the following
case :
Mrs. W., aged 68, has been in very good health previous to her
present trouble, which began about twenty years ago. Her first
symptom was a very peculiar sensation in the right leg, while
walking, which extended from the thigh downward, and within
half an hour she could not raise the foot from the floor. There
was no pain elsewhere. One month later she had a second attack
of sharp pain which commenced in the back on the right side and
extended downward into the lower abdomen and into the thigh and
leg in precisely the same manner as the first attack. There was
very great nausea at this time, but no urinary symptoms. Similar
attacks recurred until sixteen years ago, when she suffered from a
severe attack of "gastric disturbance," which was characterized
by very intense pain in the lumbar and right iliac region. Her
physician diagnosticated her condition at the time as one of gas
accumulation and obstruction. The severe symptoms promptly
subsided, but the swelling remained as a soft tumor mass in the
right side of the abdomen. During the next several years the
patient suffered frequently from stomach and liver attacks, as she
designated them. The tumor remained about stationary in size
during this period and could always be felt. Four years ago she
had a very severe attack of abdominal trouble associated with gas-
tric irritability and severe pain in the right side, particularly in
326 THE AMERICAN JOURNAL OF UROLOGY
the region of the liver. During the past four years the tumor has
increased greatly in size and she had many attacks of pain. She
has never suffered from bladder irritability, passes a normal
amount of urine, and has never noticed anything abnormal in the
appearance of the urine. Her main symptoms seems to be refer-
able to the stomach. There have been no symptoms referable to
the genitalia.
The patient appeared to be very well nourished and in fairly
good health. The examination was negative, except for the ab-
domen, which showed a symmetrical enlargement equal to that of
a seven or eight months' pregnancy. On palpation a distinct
cyst c tumor occupying the greater part of the abdominal cavity
could be easily made out, but the right half of the abdomen and
the right flank was distinctly more tensely filled out than the left.
A fluid wave was easily determined.
A midline incision below the umbilicus demonstrated at once
that the cyst was not attached to either ovary and that it was
retroperitoneal. The peritoneum was then divided over the cyst,
and a large ovarian cyst trocar inserted to draw off the fluid.
Two gallons of fluid were withdrawn and perhaps one pint remained
in the cyst, which was not measured. The cyst was then delivered
by a blunt dissection, which extended as far upward as the liver,
without much hemorrhage. A large artery and a large vein were
cut between clamps and later found to be the renal artery and
vein. An examination now revealed no kidney on this side and a
hurried examination demonstrated no special lesion in this ureter.
The incision in the peritoneum was closed by continuous suture
and abdomen closed without drainage. When the cyst was filled
out with cotton the kidney could be easily demonstrated flattened
cut to a brown-paper thi nness on one side of the cyst and the
ureter, renal artery and vein could be seen.
This patient made a perfect recovery and is now entirely well.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII SEPTEMBER, 1911 No. 9
Contributed by the Author to The American Journal of Urology.
CONC ERNING THE ARMAMENTARIUM OF THE CYSTO-
SCOPIST, WITH SPECIAL REFERENCE TO THE
USE AND CONSTRUCTION OF CERTAIN
TYPES OF CYSTOSCOPES
Leo Buerger, M.D.,
Adjunct Surgeon and Associate in Surgical Pathology, Mount Sinai Hospital;
Associate Surgeon, Har Moriah Hospital, New York.
I. CYSTOSCOPES
FOR the past four years I have been employing a cystoscope*
(Fig. 1) which possesses certain advantages over others of
the indirect type. These advantages already discussed at
length in a previous publication, may be brief!}' summarized here.
1. The employment of a catheter for washing out the blad-
der is not necessary, the sheath serving this purpose.
2. The small caliber (24f French), the round shape and the
smoothness in the region of the beak and window make the intro-
duction of the instrument easy, and injury to the deep urethra
is avoided.
3. Two number 6 Fr., or two number 7 Fr., catheters pass
with ease.
4. The telescope and sheath may be removed leaving the.
catheters in the ureters.
5. Irrigation of the bladder may be very rapidly effected by
removing the whole catheter-bearing telescope or by washing
through the faucets in the sheath. This may be continued while
the process of catheterization is going on.
6. By means of grooved beds, the catheters are separated in
such a manner that friction between them is impossible ; a new
catheter can be inserted at any time without removing the tele-
scope.
* Buerger: Annals of Surgery, February, 1909.
327
328 THE AMERICAN JOURNAL OF UROLOGY
7. The proximity of the lamp and objective lens gives the
best illumination for catheterizing purposes.
8. The small size of the lamp and beak make the chances of
contact with the bladder wall very small.
9. Inasmuch as the catheter-bearing mechanism is separable
from the sheath and is not introduced until the bladder is clean,
the likelihood of carrying infection into the ureters is reduced to a
minimum.
10. A large telescope for indirect or retrogade vision may
be used in the same sheath.
11. A small telescope leaves ample room for the introduc-
tion of operating instruments of various kinds.
The result of my own experience in a large number of exam-
inations has been such as to bear out all of these statements. Nor
has it been found advantageous to change any of the salient fea-
tures of the instrument. Experiment and clinical application,
however, have led to the development of improvements in mechan-
ical devices, have suggested to me what variations in style and
size would be most useful for the exigencies of clinical investiga-
tion, and have also brought about the adoption of the most recent
improvements in optical construction.
It is my purpose therefore to report briefly what mechanical
devices have been adopted, to discuss the various types of in-
struments employed in routine and special work, and to describe
what progress has been made in optical construction, insofar as
the latter has any bearing upon the development of a most satis-
factory telescopic system.
Let me first call attention to Type I, which has been found
most generally useful as a routine instrument.* Its sheatli is
round, of a calibre of 24 Fr., and it carries two No. 6 Fr. or two
No. 7 Fr. catheters. Figs. 1, 2 and 3. show the sheath and
obturator, catheterizing and observation telescope of this instru-
ment. Those who are acquainted with the original model, will
note the reinforcement of the ocular end of the telescope by means
of a strong bar, which serves both to make the exposed end of the
telescope more rigid and to give support to the deflecting mechan-
ism. In order to obtain the maximum amount of room between
telescope and the sheath for the passage of catheters of large
calibre, the smallest sized tube must be selected for the inclosure
of the optical system. Such a fine telescope is necessarily supple
* A cross section of this instrument is diagrammatically shown in Fig. 6.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 329
and prone to bend. In those cases where an enlarged prostate,
a rigid neck of the bladder or an anomalous anatomical condition
makes it necessary to depress the ocular of the instrument consid-
erably, a certain amount of bending of the sheath is inevitable.
If the ocular of the telescope be grasped in such cases, the tele-
scope, too, will bend and a portion of the field may be cut off. By
increasing the strength of the telescope in the manner indicated,
the tendency to bend will be avoided. It will be seen in the
chapter on the improvement in the optical system, how even this
interference with the integrity of the field may be counteracted.
Fig. 3.
In the original model the catheters were secured in their beds
by means of a closed ring at the objective end of the telescope.
It was found that the removal of the telescope (for the purpose
of leaving the catheters in the ureters) could be carried out with
greater facility if a temporary clip is employed. The clip pre-
vents the tips of the catheters from slipping from the grooves
and is to be removed as soon as the catheters enter the sheath.
In order to effect the locking and unlocking of telescope and
obturator with ease and with a minimum amount of jar, an im-
proved locking device was adopted. By rotation of a special
screw the telescope can either be tightly drawn into the sheath
or released.
Although the Type I cystoscope answers for routine work,
the surgeon or cystoscopist who has occasion to employ a single
330 THE AMERICAN JOURNAL OF UROLOGY
very large catheter, either oval or round (8 Fr.), may provide him-
self with an additional telescope that has no catheter-groove, and
but a single large outlet. I have been using a similar type of
telescope with a single catheter bed in the newer type of oval
sheath seen in Fig. 7.* Such a telescope (Figs. 7-8) allows of
the introduction of flexible forceps for the removal of specimens
of new growths and permits the passage of other instruments for
operative work.
The smaller round or oval sheathed instrument whose size is
22 Fr., type II, resembles the style just described in every way,
except that it permits of the introduction of but two No. 5 cathe-
ters. In my own experience the advantages of a smaller sized in-
strument have been found to be rather meager. Both of these
instruments (Types I and II) carry observation telescopes that
are large enough to give a brilliant picture, a large field, with
sufficient room left in the sheath for irrigation purposes.
*1 The experimental construction of an instrument of smaller
size than the last has proved to us that the oval sheath must be
adopted for sizes under 22 (French). Thus the author's cathe-
terizing cystoscope for children (Type III) has an oval sheath
(17 Fr.), and a telescope devoid of a special catheter bed. Be-
cause of the proximity of the ureters to the vesical sphincter, the
fenestra was made accordingly small and the canonical distance
was also much reduced. The instrument whose cross section is
shown in figure 4f has been found satisfactory, and takes a No.
5 Fr. catheter with ease.
Where a large catheter (No. 11 or less) is to be used, I have
been employing an oval sheathed instrument, Type IV. The
sheath is made from a tube (25 Fr.), whose sides are flattened.
The telescope ** is similar to that used in the regular instrument,
and a single catheter groove suffices for this particular form.
There is ample room for two No. 6 Fr. catheters, or for one No.
11 (Figs. 7-8). A single outlet answers the requirements even
when two catheters are employed; for the outlet may be capped
with a double perforated tip.
A rational combination of the indirect and direct type of
cystoscope was designed by F. Tilden Brown. In this instrument,
the author's type of fenestra and catheterizing telescope were
* The cross section is shown in figure 5.
f Cross section of the infant catheterizing- cystoscope.
** If a very large field be desired a larger telescope for catheterization
may be inserted.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 331
adopted for use in the Brown sheath. The combination of fenestra
at the convex and at the concave aspect of the sheath permits of
catheterization both by the direct and indirect methods. Al-
though the so-called " universal " or " composite " instruments,
combining the indirect and direct types of catheterizing telescope,
are believed by some to possess certain advantages, it seems to me
that many of the excellent features of the indirect instrument bc-
Fig. 4. Fig. 5. Fig. 6.
come lost when provisions for the direct method are made. Thus
the beak is both too long and too sharply angulated for indirect
catheterization. This as well as many other details have made me
abandon the use of composite instruments.
From the standpoint of mechanics a cystoscope should possess
the following features:- — a sheath with provision for adequate ir-
rigation, a large fenestra situated on the concave side, and a short
beak set at the proper angle, permitting the close approximation
of the mucosa and the telescope. There should be a fixed relation-
Fic.s. 7-8.
ship between the lid, the point of emergence of the catheter, the
center of the lens system, the strength of the objective and the
canonical distance. Such a cystoscope should pass two large
catheters, permit of an interchange of telescopes, and make it pos-
sible to leave the catheters in situ whenever this is desirable.
These requirements have been met in the round Type No. I, in the
smaller Type No. II and in the oval Type No. IV. In all these
instruments of the usual variety, the canonical distance has been
taken at somewhat over an inch, between 25 and 30 millimeters,
332 THE AMERICAN JOURNAL OF UROLOGY
and, in consequence, the magnif ying properties of the lens system
becomes very apparent when close objects are viewed.*
Inasmuch as the conservation of light is a desideratum it is
much better to train the eve to become accustomed to a moderate
sized inner field or, in other words, to become used to but moderate
magnification by the ocular. The larger the inner field with a
given objective, the darker is the picture. In the recognition of
lesions and in the finding of ureters, the clarity of the picture must
not be sacrificed to any apparent enlargement of the inner visual
field. We have therefore cut down the size of the virtual image
considerably in the older models, giving us brighter pictures, the
actual field remaining the same.
Although it was thus found advisable to diminish the size of
the picture in the catheterizing telescopes furnished with the optical
system constructed along the lines laid down by Nitze, Otis and R.
Wappler, recent experiments by R. Wappler and the author,
stimulated by the work of Ringleb, have led to the development of
an optical system which makes possible a more brilliant picture
and larger field in slender tubes, than was formerly obtained in the
tubes of larger calibre. The general principles of this system have
already been published elsewhere, and the physical basis therefor
shall be referred to in our section on the Optical Considerations.
With a knowledge of the intrinsic features, of the optical
properties, and of the mechanical construction of the type instru-
ment, comes the recognition of the work that it will do, but also an
appreciation of its shortcomings for certain atypical cases. Let
us consider for example, the difficulties that may be encountered
when, because of our inability to dilate the bladder, the distance
between the cystoscope and the trigone becomes considerably di-
minished. Such a condition is graphically illustrated in Fig. 9 in
which the process of catheterization at the canonical distance, is
shown. The approach of the ureter to the objective, in cases of
contracted bladder is indicated by the dotted line (B. U.). As
the proximity of the mucosa and the objective becomes progres-
sively greater, magnification becomes marked and the deflector ap-
proaches the floor of the bladder. In such a case we must not
push out too much of the catheter, the experienced eve being
guided by the size of the ureter and the enlargement of the de-
* In the new upright system, we have reduced the strength of the ocular
and also shortened the focal distance slightly. The magnification at close
range is also considerably less than in the older systems.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 333
tails of the mucous membrane. Thus in figure 9, the proper
catheter length KU (in the dotted lines), for such circumstances
is shown. For catheterization at close range all indirect types of
instruments with a canonical distance of 25 mm. or more, leave
something to be desired. A consideration of the same illustration
makes it evident too that in calculating the fenestra, lid and work"
ing distance of the objective in a "baby" catheterizing telescope,
we must be guided by a consideration of the mean distance between
ureteral orifice and the sphincter (U to S), and must reduce the
working length of the fenestra LK.
Fig. 9.
Difficulties increase in those cases where through anomaly, the
ureter is situated very close to the sphincteric margin as shown in
Fig. 10, for here the fenestra itself may partly lie in contact or
even within the sphincteric margin, and the lid may act very close
to, or almost in contact with, the mucous membrane.
The catheter then has a tendency to slide over the ureteral
ostium (Fig. 10, D), it being difficult to utilize the requisite
amount of deflection. In such cases we must not attempt to cathe-
Fig. 10.
terize with the ureter in the center of the field, but it is better to
push the cystoscope inward, which means that with inverted image
the ureter occupies a high position in the field. Additional dis-
334 THE AMERICAN JOURNAL OF UROLOGY
tension is another maneuver that is of value in such cases. Al-
though failure is rare, we always have recourse to either the cvsto-
urethroscope, or to the author's so-called "close vision cystoscope,"
(Eig. 11), which shall now be described.
The essentials of this instrument are a working fenestra at the
convex side of the sheath, and a telescopic system which is of the
indirect type and adapted for work at very short distances. The
sheath is slightly oval and carries a beak with the lamp exposed
on the convex side. The window is spacious, being cut out at the
inferior * surface for a sufficient distance in order to give room
for the indirect method of catheterization. The telescope is pro-
vided with an optical system which resembles that which has been
used in the cysto-urethroscope. The field, however, is somewhat
larger and the deflection of the picture is somewhat less than
90, so that we are looking down but also very slightly forward.
Fig. 11.
With this instrument we are able to cathetcrize at very short dis-
tances, a desirable feature, not only for cases of irritable and
contracted bladder, but also in those anomalous cases where the
ureter and the sphincteric margin are unusually close to each
other. Furthermore it is possible to do operative work in the
neighborhood of the sphincter, where the parts come into view
with the same distinctness as in the cysto-urethroscope but more
highly magnified. Whenever we suspect that an obstruction en-
countered by the ureteral catheter, is neither a stone nor of path-
ological nature, and where with the Type I cystoscope, the cath-
eter will not pass into the pelvis of the kidney, a circumstance pre-
sumably due to the method employed, or possibly to a fold in the
* When in position for catheterization.
** A forward deflection of 5 degrees is sufficient if the instrument is to
be used for near work only. In fact a right-angled prism could be employed
if the working distance remain sufficiently short. More recently the sheath de-
scribed by me in the Amer. Jour, of Dermat., May, 1911, has also been em-
ployed for near work.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 335
ureter, we have been in the habit of using this new type of instru-
ment. For, it permits of indirect catheterization, allows of a
close approximation of the fenestra and the ureteric orifice, and
produces less marked artificial curves or bends in the catheter
before the ureteric meatus is reached. By deflection of the ocular,
this instrument has been developed into an operating instrument
which has been described in a recent publication.1
As to the question of the advisability of adopting the (con-
vex) Brenner type of sheath in routine cystoscopy it may not be
inadvisable to discuss in brief the relative value of the convex 2
and concave 3 types of instrument. The concave type of sheath
was adopted by me because it permits of the employment of tele-
scopes whose optical systems deflect the rays of light 90° just as
in the Nitze cystoscope. When we consider the utilization of
the convex variety (with the lamp placed at the convexity of the
beak), we must be willing to sacrifice right angled vision (deflec-
tion of 90°) for a telescope that looks somewhat forward. For
only in this way will the illumination become adequate. Were
we to use the right angled telescopes the far portion of the field
only would be well lighted, the near parts remaining relatively
dark.
When I recommended the adoption of the lens system with
an optical system the prism of which causes a deflection of less
than 90° for purposes of close vision in the bladder and the ure-
thra, I did not wish to imply thereby that such an optical system
is best for routine work in observation and catheterizing tele-
scopes.
The right angle is undoubtedly the best angle of deflection,
and when used in the sheath of the concave 4 variety makes the
most serviceable type of instrument. In the close vision 5 type
of cystoscope, where we wish to work at close range, in the cysto-
urethroscope,6 and in the operating cystoscope 7 only, is a slight
forward view permissible.
Although it appeared to me when devising the operating
1 Amer, Jour. Dermat., May, 1911.
2 Brenner type,
s Xitze type.
4 Xitze type with lamp on the concave side of the beak.
5 Amer. Jour, of Dermatology and Genito-Urinary Dis., Jan., 1911.
« Amer. Jour, of Surgery, May, 1910.
"Amer. Jour, of Dermatology and Genito-Urinary Dis., May, 1911.
336 THE AMERICAN JOURNAL OF UROLOGY
cystoscope IF that a slight obliquity of vision or forward view
would be attended by but little disadvantage, a more thorough
investigation has shown me that such an optical system should
only be employed for special work such as the rare cases where a
close range is desirable, and for special operative procedures.
The distortion that is an unavoidable characteristic of the for-
ward looking telescopes, makes their use inadvisable for routine
cystoscopy and ureteral catheterization,
Let us explain what is the nature of this distortion and
what anatomical and physical factors are responsible for it.
Every cystoscopist acquires sooner or later a conception of the
appearance of the normal trigone, and he owes his notion of what
is normal partly to his memory pictures of that which his cysto-
scope has unfolded to him and partly to his ability to interpret
what is real and what is the product of optical illusion. If we
do not take time to consider the relation of the cystoscope to
the trigone in ordinary routine examinations we shall fail to no-
tice that even at best the field suffers some distortion when viewed
through a right angled telescope. The diagram (Fig. 28) gives
Fig. 28.
Trigone*
V—
/
E-Ureteral
Bar
Fig. 29.
the position of the cystoscope and the plane of the trigone in an
average case.* It becomes at once apparent that the near parts
will be enlarged, the far part of the field will look small, thus giv-
ing a picture such as is represented in Figure 29, were we looking
H Amer. Jour, of Dermatology, May, 1911.
* In fact the declivity here taken as an illustrative example (3T° ) is less
£han is often encountered and results in less distortion than if the angle were
45°, which is often the case.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 337
upon a ruled surface. By virtue of the obliquity of the trigone,
foreshortening occurs so that the most important area of the
bladder becomes smaller than it really is (in the antero-posterior
diameter) .
Does this picture change with the oblique vision telescope that
must be employed in the " convex " sheaths ? Obliquity of vision
in the forward sense will exaggerate the distortion greatly result-
ing in a marked diminution of the sagittal diameter of the trigone
as is illustrated by Figures 30-31, where the view of the trigone
is evidently much reduced.
Fig. 30.
Fig. 31.
Trigone
c
Bar
A still further disadvantage of the forward view is the cir-
cumstance that the objective lens must always occupy a point
distal * to center of the field of vision. Therefore whenever the
cystoscope is drawn back to view parts in the juxta-sphincteric
region or distal part of the trigone the objective and deflecting
mechanism will engage in the sphincter, sooner in this type of in-
strument, than in those employing the right-angled view. In
truth, a true picture of the trigone could only be had if a right-
angled telescope were placed with the long axis parallel to the
plane of the trigone. This is impossible in practice. It can only
be approximated by elevating the ocular, which limits the field to
such an extent that we can judge only of detail and the topo-
graphic view is lost. The shortness of the trigone, therefore,
and the foreshortening of all obliquely placed fields (except when
* In relation to the patient.
338 THE AMERICAN JOURNAL OF UROLOGY
there is very close approximation of instrument and mucous mem-
brane) are the great drawbacks of the oblique vision system.
It may be urged that; the removal of the cystoscope to leave
the catheters in the ureters, is easier of execution in the convex
type, and that the likelihood of dislodging the catheters in this
procedure is less. This contention does not hold in the case of
the type proposed by me since the separability of the telescope
and sheath, and the long fenestra furnish conditions that are
ideal for the purpose in question. After the telescope has been
removed the sheath may be withdrawn easily without fear of dis-
placing the catheters.
In my own work I find it of value occasionally to employ a
close vision instrument. For this end the convex type * or close
vision type, furnished with a telescope of the variety used in the
cysto-urethroscope, gives me good service. Being adopted for
near work only, the forward obliquity of the line of vision need
only be slight, or may be dispensed with altogether, whereas in a
catheterizing cystoscope for routine work a greater degree of for-
ward displacement is required to insure good light at greater
distances.
The convex type carrying either the old or the new lens sys-
tem,f is therefore not to be recommended for routine cystoscopy
and ureteral catheterization, for :
1. It distorts and foreshortens the trigone, increasing the
normal illusion due to the declivity of the trigone.
%: It necessitates the engagement of the fenestra and de-
flecting mechanism in the urethra when the distal portion of the
trigone and when parts near the sphincter are viewed, making
for traumatism and interfering with the action of the catheter
deflector.
3. It diminishes the diameter of the trigone in an antero-
posterior sense, abbreviating the working distance, making the
approximation of the instrument and the mucous membrane a
prerequisite of good vision.
4. It offers no advantage over the author's concave type
other than that of facilitating the approximation of the objec-
tive lens and mucous membrane in those cases where the capacity
of the bladder has suffered great reduction. In these instances
a specially short lamp used on the concave type will even nullify
this advantage.
* Buerger: Amer. Jour. Dermatology and Genito-Urinary Dis., Jan., 1911.
f Buerger: New York Medical Jour., April, 1911.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 339
The field of usefulness of the convex type should therefore
be restricted to close vision when it is furnished with a special *
optical system and for operative work when provided with an an-
gulatcd ** telescope.
Let us now take a brief survey of those optical principles that
explain the development of the most recent improvements in the
lens system of the cystoscope, and then give the details of a sys-
tem that embodies in a satisfactory way the results of experimen-
tation along these lines.
II. OPTICAL CONSIDERATIONS
For a thorough comprehension of the improvements that have
been made in the lens systems of cystoscopes during the last few
years, it may be well to review briefly some of the underlying ele-
mentary physical facts. It will be remembered that the single
telescope system exclusive of the prism, consists of an objective
lens or lenses, a middle lens or inverting lens, and an ocular or eye
piece. The function of the objective is to gather the rays of an
object or field, into the narrow confines of the telescope, (Fig. 12)
and thus to form a real inverted picture at a point not very far
removed from the image side of the objective or field lens. This
reduced picture is transplanted by the middle or inverting lens to
the eye or ocular extremity of the telescope, where it is taken up by
the ocular, and enlarged so as to become visible. The eye sees a
virtual, enlarged image, whose apparent size depends in a general
way upon the diameter of the telescope and the magnifying power
of the ocular. The illuminated disc that is seen when the objec-
tive of the telescope is held towards the sky, may be called the
" inner field " or apparent or virtual image, the true " outer field "
varying with the relative position of the objective lens and field
upon which the telescope looks. Thus as the objective approaches
the object to be seen, the extent of the actual or outer field dimin-
ishes, whilst it becomes enlarged. The reason for this must be ap-
parent when we consider that the angular field of view, (namely
that cone which represents the visual potential of the objective),
is approximately*!* constant. At infinity, a cystoscope telescope
will have an infinitely great field of view ; and as the field ap-
proaches the telescope, its area will become progressively less. A
simple explanation for this has been given by the author in a pre-
vious communication! and will not be repeated here.
* Optical system of the author's cysto-urethroscope.
** Buerger: Amer. Jour. Dermatology, May, 1911.
f See detailed discussion given in footnote on following page.
% Amer. Jour. Surgery, May, 1910.
340 THE AMERICAN JOURNAL OF UROLOGY
In the paper referred to, a mathematical discussion was
omitted for the sake of simplicity, and an explanation was given,
which although not exact from a mathematical standpoint, was suf-
ficiently reliable for those not interested in the more intricate
phases of the optical problem. f
A good cystoscope telescope must not only bring clearly into
B
Fig. 12.
view a fairly good sized area of the bladder but must also give a
well illuminated, bright picture. For our perception of the details
of a picture depends greatly upon the amount of light that enters
the pupil of the eye. Thus we may enlarge the inner or virtual
field by the use of a strong ocular, just as we may magnify the pic-
ture in the microscope. But the clarity of the picture will suffer
greatly thereby. The experienced microscopist as well as the
cystoscopist will soon learn the great value of concentration of
light in the telescope and will prefer a " light-strong " telescope
to one giving a large but dark view.
Without taking the illuminating sources into consideration,
confining ourselves to the working of the telescope alone, the
amount of light entering the optical system, can be measured by
what is termed the " entrance pupil." The limits of the entering
beam of light are confined by an imaginary diaphragm which we
f For those who may wish to study the prohlem of magnification, as well
as of the variations in the position of the telescopic image, the following dis-
cussion may be of service. It would be best to defer a perusal of it until
the general considerations of geometrical optics to be given later on, have
been mastered.
Given an objective lens of a focus (F) of say 3.5 mm. a canonical dis-
tance of the field from the telescope, of 30 mm. (e) ; a maximum lumen of
Y __ F
5.0 mm. = 2Y. Let x = e-F. Then according to formula (1) — = j3,
y x
(/3 being the relationship between size of image and object.)
When e = 30 mm. j8 == — — — = 0,13
e-3.5 30-3.5
Say Y = 2.5 (one half of the tube lumen)
then y = 19.
When e = 10 mm. |3 - 0.54 for the same angle,
then y = 6 and Y = 3.24.
Therefore the image would vary from .2.5 to 3.24 mm. The angular field
of view would therefore not be constant when it is limited by the diameter of
the telescope.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 341
can place in front of the objective or field lens. This pupil is the
image of that stop, or diaphragm which will to the greatest extent
limit the divergence of the entering beam into the object lens. To
illustrate: — Let L S R T (Fig. 13) be the ocular half of a cysto-
T7\
T ----- 7>s-
\ ^^Rl
A
\
r
Fig. 13.
scope system, L S the objective and R T the middle or inverting
lens. It is evident that only that entering beam will be effective
which can pass an imaginary stop or diaphragm, (P') erected at a
point where image of the middle lens T R would fall if projected
through the lens into the object space. Let us construct the image
of T R at P. A wider beam would come to a focus in the tele-
scope before reaching the middle lens, and thus become lost to the
eye. Only that beam will be wholly preserved which is limited by
the image of the stop T R in the object space.
Given an inverting lens nearer to the objective. How will
this affect the size of the pupil? R2 T2 will have an image at P2
and will consequently allow a larger beam to enter. The entrance
pupil becomes larger as the distance between the objective and
middle lens diminishes. We shall see from the equations that are
to follow how the pupil can be measured.
Let us explain the workings of the pupil by Figure 14 in
c
Fig. 14.
342 THE AMERICAN JOURNAL OF UROLOGY
which A B is the middle or inverting lens, L is the objective lens,
the aperture between A' and B' being the entrance pupil, and C P
the object plane. The beam of light (A' P B') limited by the
pupil and emanating from P, will be focused at Pr where its rays
diverge and fall upon A B. A ray P R falling outside of the
pupil, will naturally strike the wall of the telescope in its passage
towards the imaginary point R'. Hence only those beams that
are limited by the entrance pupil and that fall on the objective
lens will come into play.
ELEMENTARY FORJIUL.E
The mathematical solution of the size of the entrance pupil
is easy if we understand certain fundamental facts and equations.
We may graphically show the method of finding the image of an
object through a simple lens, as given by Gauss, in the following
diagram. (Fig. 15.) The object of O B has for its image I M;
L S, and LI Ss representing the principal planes of a simple lens.
Construct B S through the principal focus f ; it will emerge par-
allel to the axial ray. Similarly B L, parallel to O C will pass
through the focal point f , and meet S-Ss at M. I M will be the
image. In the same way Ii-Mm is the image of Bb-Oo.
From this diagram we obtain the following:
OB: C S = f O : f C
Let O B = y : I M = Y ;
O f = x: f I = X
f C = F
y : Y = x ; F
Y F Formula (1)
y x
B Bb L u
1 r
C
Cc V I 1
Imaqe Space
<
s
5s \m
frMm
Object- Space
5' " ~Ss'
Fig. 15.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST
343
The size of the image is to the size of the object as the principal
focal length is to the distance of the object from the principal
focus.
A simpler diagram is given in (Fig. 16) where 0 B is the image,
L C S the objective lens and I M the image in the telescope. For
the sake of clearness, only one half of the linear object and image
are shown. Let x be the distance from object to the principal
focus; X, from image to the principal focus.* Let e be the dis-
tance between object and objective; E between image and objec-
tive. The canonical distance for air is 25 to 30 mm. and shall be
taken as 30 mm. in our calculations. Furthermore to avoid addi-
tional calculation, the difference of refractive index of the boric
acid solution, on the side of the object space, and the air, on the
side of the image space, will be neglected.
Let us calculate for air where the relations are simpler than
in the immersion system ** actually employed. The changed re-
lations due to the immersion of the objective in boric acid solution,
B
~aJ~ Invoke Space
rI
O |
r- —
x — — -l \v
V 1 — N
Y
o
bjech
Space ^
M
1 E >
Fig. 16.
shall be considered later. Let angle w be one-half the angular
field of view, taken for a given lens as 35° ; Y the image, F the
principal focal length (Fig. 17). Y occupies one half of the di-
ameter of a given telescope tube which we shall take as 5,0 mm.
Then tan w — —
F
Y Formula 2.
F = —
tan w.
The focal length is equal to the ratio of the linear magnitude of
the image formed in the focal plane, to the apparent angular
* Plus and minus signs have also been omitted.
** The objective is immersed in the filling fluid, usually either boric acid
or oxycyanate of mercury solution.
344 THE AMERICAN JOURNAL OF UROLOGY
magnitude of the infinitely distant object: Y being the image of
objects at infinity.
w = 35 c tan w = .70
Y = one half of the tube diameter,* = 2.5
v 2.5
F — = 3.o < mm.
.TO
The focal distance of the lens is then 3.5T if the instrument were
used as a telescope, giving for an infinitely distant object with
an angular field of view of T0°, an image filling the whole tube.
(Fig. 17.)
V
^^^^
F
Fig.
IT.
Referring to figure 16 we
have
y
e
Y
E
Given Y
F
y
X
Y
F
y
^F
X
= e-F
F. y
Y
F + F.
Y
F —
i + y
Y
e
1+7
F
Ee
Formula 3.
x = e-F
Formula 4".
since y e
Y E
E + e
* Allowing for lens mounting, if the total tube diameter be over 5 mm.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 345
1 E + e ; 1 1 1 Formula 5.
F Ee F e E
From Formula 4
e
F ==
tan w =
30
l + y
Y
y (Fig. 16.)
y = tan w (35°) X 30
== .70 X 30 = 21.
Y = 2.5
30 = 3.19 mm.
1 +_21
2J5
Translated into words this means that when the tube diameter
is 5 mm. and there is an angular field of 70 3 , the focal length of
the objective for objects at the canonical distance of 30 mm. is ap-
proximately 3.19 mm.
The Size of the Entrance Pupil : To find equations for de-
termining the size of the entrance pupil.*
Let 3.19 be the principal focal length of the lens and the mid-
dle lens 5.0 mm. in diameter, situated at 100 mm. (1/2 tube
length) from the lens, to find the image of this stop or diaphragm.
In figure 16, let
y = the object ; Y = the image.
x = distance from the object to the principal focus
of the lens.
Then Y F (see formula 1)
y x
y = 2.5
F = 3.19
x = 100 mm. -3.19 mm.
2.50 X 3-19
Y==lo57il9=-082
or the entrance pupil is twice Y = .161
* For a system used in air.
346 THE AMERICAN JOURNAL OF UROLOGY
From this it becomes apparent that the size of the entrance
pupil depends upon the distance of the middle lens from the ob-
jective, as already seen in our diagram, figure 13. Since
v F.
Y =- the greater the distance between the middle lens and
x
objective lens, the smaller the pupil, and conversely.
Formula for Pupil: Another way of arriving at a formula
for the pupil is as follows: —
n = the number of focal lengths contained in the dis-
tance between middle lens and principal focus of
the objective lens; i.e.
x
n — : —
F
Y F F
y x e-F
1 1
e— 1 n
F
F F
x e-F
x e-F
F F F
e
n + l=~
F(n+ 1) = e Formula 6.
e-1
(or more simply, it is evident that = n .". F(n -f" 1) = e.)
F
Y F 1
y x n
Y = 1/2 pupil
2 v Formula 7.
2Y = -
n
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 347
From formula 6
e 100.
100 100
,1 + 1=^^=31-35
2 Y
30.35
2 X 2.5
30.35
0.164
(compare with figure previ-
ously found in the paragraph
on the " Entrance Pupil.")
CALCULATIONS FOR A THEORETICAL SIMPLE SYSTEM.
Let us put the formulas thus far obtained into actual use in
calculating the strength of the lenses and the size of the pupils
and the field of view in the case of a simple cystoscope provided
with but one middle or inverting lens. (Fig. 18.)
W — — zoo — — — — 4 I
r ~
5 i /
— - ~ - . /
1 o \/
- 1 * > ' 1
9 \ \
r >^ i
t_ X >ss.
< — JO — — -i>
\
Object
Entrance
F--5
■I20 >J<- — 120
Er-cfinq Lens F= 60
Fig. 18.
So. 2—
Gut pUt
Assume the principal focal length of the objective to be 3
mm., and that the distance of the object from the field or objec-
tive lens to be 30 mm. (canonical distance).
According to Formula 1
Y F; X
— so also —~
y x F
then xX == F2 9
x = Tl (30-3), hence X = .33 mm.
Hence distance of the first image from objective is 3.33 mm.
Assuming a tube diameter of 4 mm., and a maximum field of
view stop of 3 mm., the following figures may be obtained. Let
it be remembered that this 3 mm. is purely theoretical, and that a
348 THE AMERICAN JOURNAL OF UROLOGY
larger figure, that is a larger first image may be obtained in a
tube of 4 mm.
Then, since Y F X
y x ~F
X
or 1.50 X 27
= 13.50
o
or Diameter of field view = twice this or 27 mm.*
Assume the distance from the first image to the middle lens
is 120 mm.f To get the size of the entrance pupil.
x = 0.33 + 120 = 120.33 ; Tube diameter 4 mm. ;**
4
J==Y=*
Y =— Y =-Ag0 = .05 (approximate)
P or pupil = 2 Y = .10 mm. in diameter.
To get the distance of the entrance pupil from the objective,
we have from the formula cited above,
F2 9
X = — - = .075 (approximate)
x 120.33 V ^ }
Since distance = F + X, = 3 + .075 = 3.075 mm.
The angular field of view (w).
13 50
tan w = — - — = .50 (approximate).
26.925
(for tan w = y divided by the canonical distance (30) minus the
pupil distance, 3.075.)
Hence, tan w = .50 = 26° 34r total angle = 53° 8'.
This is small, as is to be expected from such a small first image,
and, in view of the size of the tube and the relatively large dis-
* For a field of view stop of 4 mm., in which case the first image would
2 v 27
necessarily fill the whole tube, a larger field would result: Thus Cl. =18;
2y = 36 mm. In actual practice such a large field, is difficult to obtain,
t Total tube length about 250 mm.
** It will be appreciatel that we are assuming a very thin tube.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 349
tance of the inverting lens, 120 mm., the total tube length being
about 25 cm.
Let us assume an inverting middle lens with a principal length
of 60 mm. This is the approximate focal length of this system.
For we wish to displace the first image to a point equally removed
from the other side of the lens. To do so X = F.
Y
formula — :
y
F
X
X
~ F
F
then —
X
F
F
= 1.
Hence x
= F
or x + F
= x
+ F
2 F
= 2
F.
That is, an image at a point twice the focal distance is brought
to a focus at a point twice the principal focal distance. ' Hence
we select a focal length equal to one half the desired displacement.
This is 120 mm., in this case, and hence we take it as 60 mm.
According to such an arrangement the inverted second image
near the ocular will be 120 mm. from the middle lens, and of 3 mm.
diameter.
Assume an ocular with principal focal length of 25 mm. Ac-
cording to the usual custom, let the final image appear to be of
the same size as the object, say 27 mm. in this system.
then Y
13.5
y =
1.5
F =
25.
Y
F
Since — ■
y
X
F.y
x =
Y
= -25 X 1.5
13~5
= —2.8 (approximate)
This gives us 25 - 2.8 = 22.2 as the situation of the second image
near the ocular.
350 THE AMERICAN JOURNAL OF UROLOGY
The distance of the virtual image produced by the ocular may
be calculated thus : —
Y X
Since == —
y F
X = F. -I=F.(^)=F.(_9).
y 1.5 v '
Hence X = 25. (-9) = -225 mm.
Hence distance of this image = -225 + 25 = -200 mm., or about
8 inches from the ocular lens.
To find the exit pupil,
y = 2
x = (120-2.8) = 117.2
F = 25
2. (2.5)
Y — — — — .127 (Diameter of pupil = .851.)
11 < .2
Location of exit pupil.
F2 625
X =— — = 5.2
x 117.2
Then the total distance of the final image from the eye = 230.2
mm. = about 9 1/4 inches, which is good enough for clear vision
and easy accommodation. (Fig. 18.)
These calculations have not been given in order to afford an
example for the construction of a simple cystoscope, but to point
out a simple way of arriving at certain data in any cystoscope :
these are the various focal distances of the lenses, the size of the
field and size of the pupils. It must not be forgotten that the
immersion of the objective end of the telescope has not been taken
into consideration. The formulae employed, too, have been sim-
plified and of course apply only to theoretical lenses, where thick-
ness of the lens and other more complicated optical features have
been ignored. In general, however, if we follow the line of rea-
soning and the calculations given, these data can be taken as illus-
trating the general method that is applicable to the construction
of an optical system for a cystoscope.
CONCERNING THE ATTAINMENT OF INCREASED LIGHT
In a previous discussion it has already been shown how the
size of the entering beam determines the amount of entering light
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 351
and how this depends on the situation of the stops, the size of the
tube and the strength of the objective lens. We may now am-
plify this introduction into the subject of available light, by con-
sidering first the approximate theoretical formulae and then tak-
ing a concrete example as is afforded by the new optical system
adopted by the author.*
Y F
Referring to our old formula — = — we have for the estima-
y x
y F;
ticn of the pupil, Y = — ' Pupil = 2 Y. For a practical dis-
x
cussicn, x may be taken as the distance of the inverting lens from
the objective, when discussing the entrance pupil, and from the
ocular, in the case of the exit pupil.
y = 1/2 tube diameter, hence is constant.
F — either objective or ocular focal lengths; in considering
telescopes these are constant.
Hence, Y or En (entrance) = a constant, say C ; or 2 Y, 2
x
En, is inversely proportionate to the distance of the middle lens.
Now for a simple system with one middle lens, and one inversion,
this distance is say 120 mm.
C
Thus, En = —
Let us suppose that the distance x, is reduced by virtue of the em-
ployment of two inverting equidistant lenses, to 80 mm.
80
En: En' = 80: 120
120 3
or this system gives = —
80 2
That is the diameter of the entrance pupil of system En' is 3/2
as large as of system En. Since the total increase of light is pro-
portionate to the area of the entrance pupil,
32 9
— = — = 2/4 times as much light.
2* %■ S
In the new system adopted by the author where there are six
* New York Med. Journal, April, 1.911.
35£ THE AMERICAN JOURNAL OF UROLOGY
middle lenses, with an approximate interval (x) of say 40 mm.,
we gain as follows :
En" 120
(new system)
En v 40
The diameter of the pupil En" is three times as large as of En, or
the area is about 9 times * that of the first system considered.
We may also put the subject in the following way, develop-
ing a general formula expressing the relationship between en-
trance pupil, exit pupil, and principal focal distances of the ob-
jective and ocular. En = entrance pupil; Ex = exit: D = di-
ameter of stops; A = distance between objective and middle lens;
B = distance between ocular and middle lens ; and L = tube
length; F = principal focal length of objective: F of ocular.
Then En approximate (see above) Y — ^ ^
A x
t? DF' • *
jkx = . approximate
B
L
A = B
2
D.F
En=-j-
2
D.F'
Ex
L
if"
Ex F'
En F
THE REDUCTION OF THE ANGULAR FIELD IN ACTUAL PRACTICE
When a cvstoscope is used in boric acid solution, the refrac-
tive index of this solution must be taken into consideration. We
are dealing with an immersion system in which a reduction of the
size of the angular field occurs. In a general way we may say that
an object must be considered as lying further removed in the so-
lution than in the air, or we may say that an object must be far-
* This is only approximate since the first middle lens may not absolutely
determine the position of the stop that gives the entrance pupil. For a gen-
eral discussion, however, these figures will do.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 353
thcr removed in the fluid in order to be brought to the same foeal
point. Tims the objective lens system is practically weakened,
if we may use this term.
In judging of the size of the field of a cystoscope we must
therefore not be guided altogether by what we see in air, since a
considerable reduction occurs in actual practice.
For those who are interested in the mathematical solution of
the influence of different refractive indices, the following discus-
sion may be useful.
Y FX.
Reverting to our formula — = — - = — in which we have
y x F
made no distinction in the focal distances, since in air
F = -¥'
xX = F2
-F/2 -FF'
then x = ==
X X
Now let x — the changed distance of the object in boric acid
solution.
F = the changed focal distance in boric acid solution,
n = refractive index of boric acid solution = 1.335.
Then the new focus
F = -nF'
-FF'
since xX = FF'.
If we multiply F' by n, we must also multiply X.
YF F.nF' F'2
Hence x == = =
x x x
n
x
X
n
Hence x = nX
Hence the distance of the objective is to be multiplied by n( 1.335).
This means that by immersion in boric acid, the field will have to
be situated at a point further removed from the objective
[n( 1.335) times x] to give the same focal distances in the tele-
scope.
354 THE AMERICAN JOURNAL OF UROLOGY
To find the effect on the angular field.
y x
Y ~F
Yx Yx
v = ===
F F
Since F = nF and
YnX Yx
x — nX y - =■
nF F
y remains unchanged.
Hence y (one half diameter of new field) at n.x = y at x.
y
tan w (of new field) —
n.x
tan w = —
x
Since y = y
then tan w' : tan w = x : x.
But x :x = 1 : 1.335.
Therefore at canonical distance, say 25 mm., x being constant,
y or J— the angular field can be obtained by dividing by 1.335.
/it
These formulae expressing on the one hand the effect of an
immersion system cn the focal distance and on the size of the field,
must not be taken as accurate. For, as has been pointed out be-
fore, in this discussion, we are dealing with a hypothetical system
in which the lenses have practically no thickness. No allowance
has been made for this, in order to avoid complicated formulae.
For our purpose it is sufficient to be able to draw the conclusion,
that in watery solutions there is considerable variation in the size
of the field, depending largely on the refractive index of the fluid
employed.
CONCERNING THE USE OF DIFFERENT TYPES OF PRISMS
A comprehensive disquisition on this most interesting part of
the optical system of the telescopes, would carry me too far and I
shall therefore confine myself to a brief mention of those varieties
of prisms and lenses, that have geen found most useful. The
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 355
right angled prism (Fig. 19) employed by Xitze together with
-< — it
Fig. 19.
one or two convex lenses, composes the objective of the simple
Nitze telescopes. Such a prism causes one reversal of the picture
in the sense of North and South, and no change in the East and
West points.
In this country, through the efforts of Otis and Wappler, a
distinct improvement in the Nitze prism was achieved, by the con-
struction of the hemispherical lens (Fig. 20). If the plane sur-
face of such a lens make an angle of 45° with the axis of the tele-
scope, a portion of its spherical surface serves for the entrance of
the field rays and the rest of this surface turned towards the tele-
scope tube, becomes a convex lens for the exit of rays in their path
into the tube. Such a prism or lens-prism combines then the vir-
tues of a simple prism with the properties of a convergent lens.
For the construction of simple telescopes, at moderate cost, such a
combination of prism and lens must appeal to the cystoscope
maker.
Fig. 20. Fig. 21. Fig. 22.
In actual practice, besides giving an increased angular field
of view, this lens has the additional advantageous property of
bringing into better view parts of the field that are practically in
contact with it. Thus in viewing the internal sphincter, the ad-
vantage of the Otis-Wappler system becomes at once apparent.
This feature was formerly of more importance than to-day, inas-
much as we are now able to see the sphincter and posterior urethra
with great distinctness by means of the cysto-urethroscope.*
* Amer. Journ. of Surgery, May, 1910.
356 THE AMERICAN JOURNAL OF UROLOGY
By a backward tilt of the hemispherical lens it is quite easy to
obtain a retrograde view as shown in (Fig. 21). So also by a
forward tilt, and an additional convex surface, a useful prism for
forward vision is secured.** (Fig. 22.)
A recent advance in the construction of cystoscope objectives
is found in the prism lens used in the author's cysto-urethroscope.
I will not dwell at length upon the properties of this prism here,
since the latter has already been presented elsewhere. f Suffice
it to say that the prism in figure 23 causes a double reflection of
the entering rays, in the sense of North and South, thereby pro-
ducing a first image in the prism, whose North, South, East and
West points have not suffered interchange of position, as in the
case of the Nitze and Otis-Wappler prisms. Combined with a
convex lens or made out of a cylinder with a convex surface
ground at one end, this prism lens has been found indispensable
where the requirements of 44 close vision " have to be met. Thus
it makes the ideal objective for the cysto-urethroscope, as well as
for any other instrument whose function it is to bring objects at
very close range into view. It may even be ground out of an Otis-
Wappler prism as shown in (Fig. 25).
Fig. -23.
By the addition of a strong convergent lens, in the form of a
bar carrying a convex surface at one end, we are able to increase
the angular field of the prism lens just described, and can employ
it for the construction of observation telescopes where an upright
and side-correct picture is desired (Fig. 24). The conservation
of the relation of the North and South points in this variety of
prism as compared with the right angled prism, is illustrated by
Figs. 19 and 23.
Finally, for the new, 44 light strong " system * described later
on, we have again come back to the use of the hemispherical lens,
the field aspect of which is ground flat. The correction of in-
verted points of the picture is brought about by an additional
** Suggested by F. Tilden Brown.
f Jour. Amer. Med. Ass., Mar.; 26, 1910; Amer. Jour, of Surg., May, 1910.
* New York Med. Journal, April, 1911.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 357
prism placed in the ocular, just as it had been accomplished in the
Frank modification of the Nitze cystoscopes.
Ill IMPROVED OPTICAL, CONSTRUCTION OF CYSTOSCOPES
In the discussion on Optics, I have attempted to give in as
simple a manner as possible, the working formulae by means of
which it is easy to determine the following : — the requisite focal
length of the various lenses, the size of the tube images, the angu-
lar field of view, and the size of the entrance and exit pupils.
Further, the calculations for a hypothetical simple cystoscope
were given, and the importance of the pupil in determining the
amount of light delivered through the telescope was briefly con-
sidered. For those who are not interested in the mathematical
aspect of this subject, the matter may be put in somewhat different
form. Since it is particularly the question of increase of light
and of field of view that appeals to the cystoscopist, I will review,
here, the essential facts that are important in an understanding
of the new optical systems now being adopted for the author's
instruments ; for these systems give more light and a larger field
than the older types.
In the development of recent improvements in the design of
the catheterizing cystoscope, it was necessary to sacrifice certain
optical features that are of advantage in the ordinary observation
instrument. In order to gain room for two large catheters, the
size of the telescope had to be correspondingly diminished. This
was necessarily attended with a loss of light and a certain con-
striction of the field of view. Although I believe that the angu-
lar field of view of the cystoscope designed by me some three years
ago is quite as large as that of any other cystoscope employing a
telescopic tube of similar diameter, it was deemed desirable to di-
rect our efforts towards improving both the field of view and the
358 THE AMERICAN JOURNAL OF UROLOGY
amount of light. From the optical standpoint, it is of greater
importance to obtain a brilliantly illuminated picture than one of
large surface capacity. It was particularly in quest of an optical
system giving ample light that the efforts of Ringleb in Germany,
and of other workers in this field, have been directed.
R. Wappler, in his construction of the Otis-Wappler-Nitze
telescopes, had already approached the solution of part of the
important problem of illumination, when he increased the number
of lenses between the objective and ocular. Since then Ringleb
had achieved even better results by a still greater multiplication
of lenses. In his system an Amici prism and several middle lenses
were employed. The reason for the utility of increasing the num-
ber of middle lenses in the telescope is very easily comprehended
if Ave remember that the amount of light is, to a great extent, de-
termined by the size of the beam of light that can enter the objec-
tive. The entrance beam is theoretically limited by the so-called
" entrance pupil."
For the sake of clearness let us recall to mind the arrange-
ment of lenses in a simple cystoscope telescope in which for sim-
plicity, the prism has been omitted, and which consists of an ob-
jective, a middle lens, and an ocular.
Referring to figure 12 we see that the actual field is concen-
trated as it were by the objective, which forms a minute image of
a relatively large area, at a point close to the lens and indicated
in the diagram by the small arrow. This small image is trans-
planted by the middle lens to a point close to the ocular, where it
is enlarged by the latter. It is then evident that only the rays of
light that strike the middle or inverting (for it inverts the first
image) lens reach the eye. The question then arises as to what
rays really do strike the inverting middle lens. Fundamental op-
tical principles teach us that the size of the entering beam is de-
termined by the so-called " entrance pupil " of the lens system
under consideration. To ascertain the site and size of the en-
trance pupil of a simple cystoscope, the system must be regarded
as composed of a " stop " at the situation of the middle lens, and
of an objective (one or more lenses) placed just behind the prism.
The size of the pupil is measured by an imaginary diaphragm such
as can be constructed in the object space in front of the objective,
and which shall represent the image of whatever interferes with
the rays at the site of the middle lens. Theoretically the limita-
tion of light at the site of the middle lens is dependent on the tube
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 359
wall or the lens margin. Practically this " stop " is somewhat less
than the tube diameter, since all the peripheral rays falling on
the lens are not available. If we construct an image of the mid-
dle lens, as if it were thrown backward through the objective into
the object space, we will have the so-called " entrance pupil."
Figure 14? will explain how the rays are limited by the entrance
pupil. Let L be the objective, A B the middle lens of the cyto-
scope, C. P. the plane of the field, and P' C the image thrown in
the tube by the objective lens. Let us construct IV A' as the
image of the stop A B. Then only such rays from the object C P
will strike the middle lens, as are limited by the imaginary dia-
phragm B' A'. The beam of light B' P A' enters the lens S, is
focused at P' and meets the middle lens A B ; in other words, it
can reach the eye. Let us follow the ray P R S that falls outside
of the pupil B' A'. Such a ray intersects the others at P' but
strikes the tube in its further course to R' and is almost lost. It
is evident then that the amount of entering light is determined by
the size of the entrance pupil.
If we diminish the distance between the inverting lens and the
objective, the conjugate image of this lens or stop will be situated
farther from the other side of the objective and the pupil will be
correspondingly larger. Let L S (figure 13) be the objective,
R T, the middle lens and T R be the image of R T on the side of
the object space.* T R is the entrance pupil (Pj). Given a
system in which the inverting lens is placed at R2 T2. The en-
trance pupil will be situated farther from the objective, at T2 R2
and will be larger.** With a larger pupil, we attain the desidera-
tum of a larger entering beam of light and consequently better
illumination. In order to conserve this light and to keep the exit
pupil (or that which is determined by the ocular side of the lens
system) relatively large, we must again multiply our lenses, on the
ocular side of the system for the same reason already given for the
objective side of the telescope.
After considerable experimentation a combination of lenses
and prism was adopted for the catheterizing cystoscope, which,
thanks to the skill of Mr. Reinhold Wappler, seems to give a
* By "object" space we mean the space in which the objects lie, in con-
tradistinction to " image space " which is situated inside of the telescope.
** For the sake of clearness the size of the pupils Px and P2 has been
greatly enlarged. In the cystoscope system these pupils are usualy very small
in relation to the tube lumen.
360 THE AMERICAN JOURNAL OF UROLOGY
larger field and more light than any other cystoscope of the same
or even larger diameter constructed heretofore. For the objec-
tive, we have employed the most recent improvement of the Otis-
Wappler prism, namely the hemispherical lens with one plane side.
To increase the angular field, one, and in thin tubes, two plano-
Fig. 26.
convex lenses, were added. Six middle achromatic lenses and an
ocular lens make up the rest of the system.
Let us follow the course of rays in this combination of lenses.
The objective lenses bring about one reversal of the picture, and
the middle lenses are so selected and placed as to cause two addi-
tional reversals. In the sense of North and South, the prism
causes another reversal, so that we have a total of 4 reversals for
North and South points, and 3 reversals for East and West points.
This naturally results in the production of an image whose North
and South poles are upright and correct, and whose East and
West points are reversed. The interchange of these points is then
brought about by a simple reversing prism of 90° that is placed in
front of the ocular. The course of the rays as regards North and
South is illustrated in figure 26 and as regards East and West in
figure 27.
In short, by means of the Wappler lens prism and a combi-
nation of middle lenses giving two inversions * of the tube image,
it has been found possible to conserve as much, and even more light
in a small catheterizing telescope, than we have been able to re-
* By the employment of 9 middle lenses giving 3 reversals, or a total of
5 reversals for North and South, 4 for East and West, together with a cor-
recting prism, the small catheterizing telescope conserves the light quite as
well as the 6 lenses do in the system described. Such a complex system is,
however, hardly necessary in practice.
THE ARMAMENTARIUM OF THE CYSTOSCOPIST 361
tain heretofore in the large simple observation telescopes. The
% field of view has been also increased resulting in an angular field
of view showing a gain of 30' or about half again as large as in
the older instruments.
Conclusions : — In the course of practical work with the cvsto-
scope and as the result of experimentation, certain types of
observation and catheterizing cystoscopes have been devel-
oped. The general form and the mechanical features of the
instrument described by the author, have been found ade-
quate for routine work. For special purposes, an " oval "
type and a " close vision " instrument are considered advan-
tageous. Where the region of the neck of the bladder, the
details of the trigone and the posterior urethra are to be
studied, the cysto-urethroscope must be relied upon.
More striking than the improvements in the general
mechanism and assemblage of parts, has been the develop-
ment of an optical system by means of which the brilliancy
of the pictures has been enhanced and the size of the field
greatly increased.
LEGENDS.
Figs. 1, 2, and 3. Author's cystoscope; from above downward
the following parts are represented: (fig. 1) the sheath with obturator;
(fig. 2) the catheterizing telescope; and (fig. 3) the large observation
telescope. (Type I.)
Fig. 4. Diagrammatic cross section of the "baby catheterizing
cystoscope."
Fig. 5. Diagrammatic cross section of the "oval type" cystoscope.
Fig. 6. Diagrammatic cross section of the "type I" cystoscope.
Figs. 7-8.* Beak end of the author's "oval" type cystoscope,
showing sheath and general construct;on of telescope.
Fig. 9- "Normal" ureteral catheterization: S the sphincter; U
the ureter; L objective lens prism; A bladder mucosa at the canonical
distance; B the same at close range; K ocular end of fenestra.
Fig. 10. Catheterization in the case of an anomalous situation of
the ureter. When the mucous membrane is at the level C. the tendency
of the catheter to ride over the ureter U is shown by the dotted line D.
Fig. 11. Author's "close vision" catheterizing and operating cys-
toscope; a portion of the wall of the sheath is cut out in the drawing to
showT the position of the catheterizing telescope. Only the beak end
of the instrument is shown.**
* Fig. 7 refers to the sheath, figure 8 to the telescope.
** For the newer models of the sheath of the close vision and operating
cystoscope, see Amer. Jour, of Dermtit., May, 1911.
362 THE AMERICAN JOURNAL OF UROLOGY
Fig. 12. Diagram showing the course of the rays in a simple eys-
toscope in which the prism is omitted for the sake of clearness: ab is
the object, aft the first tube image, and AB the virtual as it appears to
the eye.
Fig. 13. Diagram illustrating the effect of the position of the
middle lens on the size of the entrance pupil.
Fig. 11. Diagram showing the exclusion of rays falling outside
of the entrance pupil.
Fig. 15. Geometrical graphic method of determining the image
through the lens whose principle planes are at LS and LI Ss.
Fig. 16. Simpler diagram in which the principle planes of the
lens are omitted.
Fig. 17. Figure showing the relation between tube image and
principal focal length in terms of the angle w. This holds good only
when the objects viewed be at infinity.
Fig. 18. Diagram illustrating a simple telescope of very small
calibre in which calculations have been made.
Fig. 19- Right angled prism employed by Xitze. and its effect
on the relation of the North and South points of the field.
Fig. 20. The hemispherical lens and collective lens forming the
objective of the Otis-Wappler lens system.
Fig. 21. Effect of tilting the hemispherical lens on the location
of the field; the production of a retrograde view.
Fig. 22. Lens prism giving a forward view.
• Fig. 23. Double reflecting prism showing effect on the relation
of the North and South points of the field.
Fig. 21. Same prism (as an 23) with the addition of a conver-
gent lens. In front of it is placed the extra lens-cylinder.
Fig. 25. Same prism ground out of an Otis-Wappler lens.
Fig. 26. The new light-strong system showing the relation of
rays in the sense of North and South.
Fig. 27- The course of the rays as regards the East and West
points illustrating also the correcting prism at the ocular end.
Fig. 28.* The concave (author's type I) cystoscope in position
for ureteral catheterization. Sp, sphincter. Nn O Ss is the angular
field, n S the actual field, Sp U N the plane of the trigone. RF=
fenestra. O the lens, U the ureter.
Fig. 29. View obtained with the above position.
Fig. 30. The convex type illustrating the effects of forward
vision.
Fig. 31. View with the oblique vision type (Fig. 30) showing
the short trigone, and distortion.
* Figs. ^8-31 inclusive were added after the proof reading. They follow
Fig. 11.
CURRENT UROLOGIC LITERATURE
363
ABSTRACTS
Latent Pyelonephritis. — F. Kermauner calls attention
(Wienerklin Wochen, May 18) to Goppert's important research
on pyelocystitis in children, especially in infants ; 89 per cent,
of the children thus affected were girls. Interesting further is
Heubner's assertion that pyelitis is especially frequent in chil-
dren who have had some mild infectious disease, measles or vari-
cella. In infants the pyelocystitis is most frequent in the second
half of the first year and it seems to heal, but it recurs before
puberty in about 20 per cent., and Kermauner thinks that it
probably persists in a latent form for years when the colon
bacillus is involved. This bacillus seems to thrive in the urine,
while the urine is bactericidal for other bacteria. This demon-
strates, he thinks, that colipyelitis may be traced into early child-
hood and that it may flare up after prolonged latency in con-
sequence of some intercurrent injury. The menstrual periods
may influence it to some extent, but the greatest influence is
exerted by a pregnancy. This is liable to act as an intercur-
rent injurious influence bringing on an acute attack in some
cases or merely aggravating the latent pyelitis. He reports a
case in a woman of 30 who had had measles three times during
childhood, r.rd during menstruation had always experienced in-
tense tenesmus and smarting in the vagina. At the fifth month
of the pregnancy there was severe pain in the right kidney re-
gion for a few days, with turbid urine, but no fever and there is
still a sense of oppression in the kidney region. He explains the
case as a latent pyelonephritis, and recommends in such cases in-
ternal treatment with hexamethylenamin, although he does not
think that an acute cure can thus be realized. If this medication
clears up the urine, the diagnosis of latent pyelonephritis is
rendered more probable. He does not advocate catheterization
of the ureter and lavage of the pelvis unless the attack lasts for
more than a week or is unusually severe. With latent pyelitis,
local measures are best deferred until after the childbirth.
Removing Renal Calculi — H. A. Kelly, Baltimore (Jour-
nal A. M. A., July 1), says that a variety of methods should be
at command in removing renal calculi. We have to vary our
procedure according as the kidney is fixed or movable, the shape
364 THE AMERICAN JOURNAL OF UROLOGY
or size of the stone, the length of the lower rib and the stout-
ness of the patient, etc. A nephrolithotomy if well done is a
comparatively safe procedure ; otherwise it may be fatal. Kelly
gives a method devised by himself, which, he says, except in the
simplest cases with an easy exposure, is, as he believes, quicker
and safer and better than pyelotomy or any other transrenal
operation.
The technic is described as follows: "A renal catheter 1.75
mm. in diameter, large enough to obturate the ureteral orifice
and prevent a reflux of fluid into the bladder, is inserted through
an open-air cystoscope and introduced well up to the kidney
just before giving the anesthesia. The patient is then put to sleep,
preferably with gas, semiprone, on an Edebohls cushion. An
incision is made in the loin and the superior lumbar triangle is
pulled open and the kidney exposed and freed on all sides from
its fatty capsule. The stone is then felt and the kidney gently
loosened as far as possible on all sides and brought toward the
wound. Then an assistant forces fluid (1/1,200 silver nitrate)
into the renal pelvis, until it puffs out tense. As a rule, with a
careful preliminary study, the exact capacity of the renal pelvis
is already known. When the pelvis and kidney are swollen up
tense the surgeon first incises the capsule and then plunges a
blunt-pointed, blunt-edged knife through the cortex in the middle
of a pyramid somewhat on the posterior surface, easily entering
the renal at once and enlarging the incision, in a transverse di-
rection if the stones are small. There is a gush of fluid which
stops as he introduces his finger and feels for and finds the
stones, which he at once grasps with a smalll stone forceps and
removes. The calices and the mouth of the ureter are now ex-
amined for more stones and the kidney is palpated on all sides
with both hands, one finger being inside the renal pelvis. After
all stones are removed the wound is plugged or held closed, while
the pelvis and the calices are again distended with the silver
solution, when the finger is suddenly withdrawn, letting the fluid
escape with a rush, bringing any small calculus debris with it.
This may be repeated several times."
He emphasizes the following advantages which he thinks this
method possesses: "1. It involves a minimal amount of damage
to the kidney. 2. It is done through the part of the organ
most easily accessible. 3. The distention is invaluable in offer-
ing a bag of fluid, overlaid with a zone of soft tissue, which is
CURRENT I ROLOGIC LITERATURE
365
easily punctured. 4. An exploration is easily conducted through
the opening, revealing the presence of other caculi. 5. If it is
desirable to keep it open awhile for drainage the transverse in-
cision is a good one for this purpose, as it can be left open
and will close rapidly when the irrigations are omitted. 6. In
the last case in which operation was done no sutures were put
into the kidney, and yet there was no escape of urine after
twenty-four hours and practically no bleeding through the in-
cision."
Renal Infections — Dr. G. E. Brewer, New York, (J. A.
M. A., July 15), discusses the infections of the kidney and says
there are five routes of infection generaly conceded as possible :
1. By direct penetrating wounds. 2. By direct extension from
a neighboring focus. 3. By catheterization of the ureter.
4*. By an ascending process from the lower urinary passages,
and 5. By the blood-current. The first and third of these are
unquestioned. The second is so rare as to be a surgical curi-
osity. He, therefore, takes up the fourth and fifth and gives a
history of the investigations and their results in regard to the
possibility of ascending infection and reports his own experiT
mental studies. From a review of the known pathologic evi-
dence, the experimental investigations of others, his own re-
searches and clinical experience, he thinks we are justified in
saying that: "1. An ascending infection is responsible for a
certain proportion of the acute surgical infections of the kidney.
2. In the great majority of such instances, the infectious ma-
terial is carried upward to the kidney by a reflux of contami-
nated urine into the ureter and renal pelvis through the ureteral
orifice, as the result of some interference with its protective
mechanism. The factors which favor this process are, in the
order of their importance: (a) A chronic obstruction to the
normal bladder outflow, a urethral stricture, obstructive pros-
tatic hypertrophy, prostatic or vesical new growth: (b) acute
cystitis with severe tenesmus and violent expulsive efforts ;
(cc) severe inflammation, ulceration, calculus or new growth
involving the ureteric orifices, interfering with the normal sphinc-
teric action; (d) urethral and detrusor paralysis from spinal
injury or disease; and (e) the possible temporary paresis of the
ureteric sphincter by the passage of a large ureteral calculus.
3. In certain rare instances the process may occur by a direct
extension of the inflammation along the mucous membrane of
336 THE AMERICAN JOURNAL OF UROLOGY
the ureter by continuity of tissue, as proved by numerous clini-
cal observations, although I have been unable to reproduce it in
animal experiments. L In other rare instances the infection
may ascend by the ureteral or peri-ureteral lymphatics, and this
is more likely to occur if there exists an infection in the deep
structures of the bladder-wall involving the vesical lymphatics.
5. As stated by Legueu, these methods in certain cases may be
combined and concomitant."
Next, taking up the subpect of hematogenous infection, he
reviews the investigations of others and gives details of his own
experiments on rabbits and dogs by injecting cultures of various
pathogenic bacteria into the veins. He concludes from all the
evidence obtained by himself and others and the accumulated
clinical experience, that, during the progress of any acute infec-
tious disease, a certain number of microorganisms find their way
into the blood-current and that many of these are excreted
through the kidneys. If the number of these organisms is com-
paratively small there may be no demonstrable injury, but if
the number is large and they are highly virulent or if one or
both kidneys are diseased, overwhelming or fatal toxemia may
follow or any of the pascal types of renal infection suppuration.
While the trouble may be bilateral it is often unilateral on ac-
count of a diminished resistance of the infected kidney from dis-
ease or trauma. While he has been able to produce these lesions
in animals by the B. coli, the Streptococcus pyogenes, the
Staphylococcus aureus, the B. typhosus, as well as the pneu-
moccccus and B. pyocyaneus, in clinical cases he has been able to
isolate only the first four of these. In some of his clinical cases
however, notably one of scarlet fever, search for bacteria proved
negative. He has also been struck in his study of the subject
by the great difficulty in producing ascending nephritis in animals
as compared with the ease with which the hematogenous infection
is produced. This would seem to corroborate the impression
produced by clinical experience that hematogenous infection is
responsible for most cases of renal sepsis, even when septic con-
dition of the lower urinary passages also exists.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
Vol. VII OCTOBER, 1911 No. 10
Contributed by the Author to The American Journal of Urology.
A CLINICAL STUDY OF RENAL FUNCTION BY MEANS
OF PHENOLSULPHONEPHTHALEIN*
By E. L. Keyes, Jr., M.D., and A. R. Stevens, M.D.
IN May, 1910, Rowntree and Geraghty offered before the Am-
erican Association of Genito-Urinary Surgeons an exposi-
tion of the advantages of phenolsulphonephthalein as a test
for the functional activity of the kidneys, and published this two
months later.1 In this communication they tabulated the re-
sults obtained, with these tests upon 130 patients, upon many of
whom other functional tests were employed by way of comparison.
As a result of this comparison they maintained that the phenol-
sulphonephthalein test has many advantages over the tests pre-
viously employed.
A few weeks after this report was made, Dr. Stevens began
a series of observations upon the efficiency of phenolsulphoneph-
thalein as a renal function test, and in October Dr. Keyes joined
him. We have applied the test 154 times (coupled with ureteral
catheterization in 40 instances) to 100 cases.
We propose to record our experiences with the technical dif-
ficulties, with a few variations in methods, and our observations
on patients with supposed normal kidneys and on several groups
of pathological conditions.
TECHNIQUE
As shown by Abel and Rowntree, this drug is excreted almost
exclusively by the kidneys. It is readily identified in urine, even
in bloody urine, by its brilliant scarlet color in alkaline solution —
* Read in part before the N. Y. Academy of Medicine, May 4th, 1911.
1 Journal of Pharmacology and Exp. Therap. July 1910, Vol. 1, No. 6.
367
368 THE AMERIC AN JOURNAL OF UROLOGY
the alkalinity being obtained by the addition of a few drops of
a 25% sodium hydroxide solution.
In all our observations, 6 mg. of phenolsulphonephthalein
(1 c.c. of solution) has been used uniformly. It is injected sub-
cut aneously, or better intramuscularly (exceptions in our work
are referred to later), the time noted, and the first appearance of
a pink tint attentively watched for as urine drips from a cathe-
ter previously inserted in the bladder into a vessel containing a
little alkali. The catheter is withdrawn and the collection of
specimens begins with this first appearance of color. We have
as far as possible collected urines for two full hours at intervals
varying from 1-4 hour to one hour. At the end of each in-
terval of time, catheterization may be resorted to, or the patient
may be allowed to void, provided there be no residual urine.
It is better, though not necessary, to give 200 to 400 c.c. water be-
fore the test, to ensure the secretion of larger quantities of urine,
merely to minimize the error duo to the loss of small amounts
during catheterization and manipulation. Especially is this ad-
visable before ureteral catheterization (or during the first half
hour, in order to combine the experimental polyuria test), as this
procedu/e tends to overcome the functional anuria so often induced
by cystoscopy. We have obtained large percentages of phenol-
sulphonephthalein from small amounts of urine and confirm the
belief of Rowntree and Geraghty that additional water does not
increase the output of phenolsulphonephthalein.
The percentage of phenolsulphonephthalein injected hypoder-
mically which is contained in the several urine specimens is deter-
mined colorimetrically by means of the Duboscq Colorimeter. A
trial by one of us of another and less expensive instrument (Schrei-
ner's) convinced him of the unreliability of the latter for this use.
A standard for comparison is obtained by adding 3 mg. of phe-
nolsulphonephthalein to a liter of distilled water, made thoroughly
alkaline with caustic soda. We agree with Rowntree and Ger-
aghty that this strength of solution affords the most convenient
one, and that in general the most satisfactory results are obtained
when the indicator corresponding to the plunger lowered into the
" standard " reads 10. However, often, especially in dealing with
relatively small amounts of phenolsulphonephthalein or relatively
large proportions of other coloring matter, we have changed the
standard to 5 and feel confident after many comparative tests
that not seldom this is the better procedure. A solution of 1}
A CLINIC AL STUDY OF RENAL FUNCTION 369
mg. to the litre has been tried, but this adds an unnecessary com-
plication and reducing the standard from 10 to 5 gives practi-
cally the same results.
The urines to be tested are each diluted with water to vary-
ing amounts up to 1000 e.c, depending on the depth of color,
NaOH is added till there is no further deepening of color, and
lastly the mixture is filtered. The degree of dilution best suited
to an individual specimen is a matter of experience ; the effort
should be made to compare columns of fluids of approximately the
same height. The color of the urine containing phenolsulpho-
nephthalein is rarely of just the same hue as the standard (with
water as the diluent). The pigments of the urine impart a red-
dish tinge, more marked of course with deep amber urine and with
small percentages of phenolsulphonephthalein. Blood gives a
brownish red tint. A test solution made of urine intsead of water
could be used to obtain a better color for comparison but would
have to be renewed daily (whereas the water-standards remain
constant a long time), and in practice this procedure is unneces-
sary. Chart I indicates the degree of accuracy of the routine
method. Phenolsulphonephthalein was added to eight flasks
each containing 25 c.c of clear deep amber urine, in proper
amounts to make 50% (of 6 nig.), 25r/<-, etc., to \°/c. These
various mixtures were then diluted and treated precisely as in
the usual estimations. The readings made immediately and
two days later are indicated on the Chart (I), also the faded con-
dition of each mixture after standing four weeks by a window
in the sunlight a few hours each day. In 25 c.c. of highly col-
ored urine, two to three per cent, is not easy to read correctly, and
smaller percentages appear as " traces." A small drop of blood
added to 15 c.c. of the 50/V and 25'v mixtures on the second day
altered the readings but little practically — 50 instead of 53.2
and 18% instead of 21. 4'/ . That the percentages of phenolsul-
phonephthalein in urine do sometimes change on standing is in-
dicated on Chart I and needs emphasis. Urines (infected) from
case 86 showed &6.3fc and 17.9% of phthalein the first day after
collection, 22.7% and 10.0% the fourth day, and 16.7$ and
8.9% the seventh day. Hence readings should be made within
24 hours after collection of specimens, if possible, surely within
48 hours.
Rowntree and Geraghty recommend the 2 c.c. Ricord syringe.
It is the most satisfactory in every way except for the great care
370 THE AMERICAN JOURNAL OF UROLOGY
necessary to avoid breakage during sterilization. We compared
seven syringes representing five makes with a standard 1 c.c. glass
pipette such as is used in chemical laboratories. The " Ricord "
cubic centimeter was .96 of that measured by the pipette, and
the other syringes recorded .70, .80, .80, .88, .90, .90 of a cubic
centimeter. These absolute variations are of no consequence if
one will adopt these suggestions. Use only a tight syringe with
a smoothly gliding plunger. Use the same syringe for all cases.
Use this syringe to measure the phenolsulphonephthalein in mak-
ing up the standard solution. Any error in absolute measurement
of the syringe is carried along in the preparation of the standard,
and the final percentage readings will be correct.
To avoid inaccuarcy due to evaporation during sterilization
of the phenolsulphonephthalein solution, it has been our practice
to sterilize a convenient portion and make a standard from this.
A new standard was thus made after each such sterilization. As
a matter of fact, these different solutions were frequently com-
pared and always but once read within one to two per cent, of one
another. In one instance, however, the standard seemed to have
faded 5 to 10c/c in two months.
As to the site of injection, we have used many regions of the
body, but avoided any oedematous spot. Whether the results de-
pend on the site of injection our data will hardly answer. In
eight cases giving a practically normal output, in whom the del-
toid muscle was used, the color appeared on the average in 7 min-
utes. In seven similar instances, in whom injections were in the
thigh, the color appeared in 8 J minutes. The outputs for the
first and second hours in the two groups were practically the
same.
NORMAL. CASES
Rowntree and Gcraghty found as a result of 27 tests upon
21 patients with apparently normal kidneys that the drug ap-
peared in from 5 to 12 minutes, that, as measured by the Duboscq
Colorimeter, from 41.6% to 66.6% was excreted within the first
hour thereafter, from 11.9%' to 26.5% in the second hour; a total
for the two hours of from 6.1% to 85.8%.
Our eleven observations (with intramuscular administration)
upon eight cases with probably normal kidneys, gave similar but
lower figures. The onset of excretion varied from 5^ to 12 min-
utes; excretion in the first hour, 35.7% to 57.9% ; during the sec-
ond hour, 5% to 16,7% ; total for the two hours, 49.4% to
A CLINIC AL STUDY OF RENAL FUNCTION 371
71.2%. (See Chart II). After the second hour the percent-
ages are always very small, often only traces, at mqst (in six
observations) only 4%> during the third hour. Thereafter one
finds traces for variable periods (from 5 to 8 hours) in norma]
cases, though when renal disease restricts the earlier output, the
later amounts are relatively higher.
Thus one needs measure only the output during the first two
hours after the appearance of color in the urine (made alkaline).
Whether the average normal excretion for the first hour, second
hour and total two hours, shall be set as high as 52.3%, 19.0%
and 71.3%, as given in the original series, or 47.0%, 10.2%, and
57.2%, as in ours, the future must decide. We can say that our
observations upon abnormal kidneys, and kidneys suspected of
disease confirms our opinion that 40% for the first hour and
50% for the first two hours, is in practical work a sufficient out-
put for two normal kidneys. It should be noted, however, (Chart
II) that our group of normal kidney cases had some minor ail-
ment or had recently recovered from such. These pathological
conditions may have diminished the excretory functional capabil-
ity of the kidney tissue, which would account for our lower
figures.
It seems that probably this test is of great delicacy ami
surely does show variations in the same individual which cannot
be accounted for clinically. These variations in figures wrhcn
these figures are relatively high, we believe are of no practical im-
portance, bearing in mind the wonderful reserve power of the kid-
neys. The functional capacity of normal kidneys is probably
varying from time to time, with physiological processes, and the
limits within normal, of these variations, we do not know.
For the purpose of estimating the time of maximum output
of Phenolsulphonephthalein after intramuscular injection, there
are arranged in table III four cases with practically normal kid-
neys (output in each over 60% in two hours), in whom the collec-
tions were made at half hour intervals. The kidneys excreted
on an average in the first half hour after the appearance of color
in the urine, 32.3% ; in second half hour, 18.2% ; in third half
hour, 9.8^ ; in fourth half hour, 4.8' < . That is, over 50%; of all
the drug excreted in two hours was recovered in the first half
hour.
Phenolsulphonephthalein wras administered intravenously to
four patients (cases 8, 10, 21, 104) in all of whom the intramus-
372 THE AMERICAN JOURNAL OF UROLOGY
cular method was also employed. In every instance the drug
appeared in the urine at least two minutes earlier when given by
the intravenous route; and a larger percentage of the total
amount recovered, appeared in the first hour. The shortest time
of appearance was 3 minutes (case 104 — 9 days after nephrec-
tomy for tuberculosis). In this instance, the specimens obtained
at quarter-hour intervals showed in the first hour, 18.6c/c , 31. 1< < .
8.0%, 3.8r/r : specimens at half hour intervals during the second
hour, gave 3rr and " trace." 77' < of all the drug recovered
in two hours appeared in the first half hour. Obviously, if one
employed intravenous injections, briefer intervals than one hour
would be necessary.
We have found a very grave source of error in studying the
total kidney function from specimens obtained by ureteral cath-
eterization— and one seemiriffly overlooked by Rowntree and Ger-
aghtv. This is retention of the drug as a result of the functional
disturbance incident to ureteral catheterization, which however
does not seem to vitiate the accuracy of the ureter catheter read-
ings as compared with each other. That this functional disturb-
ance may upset all percentage calculations, whether of nitrogen,
urea, freezing point, or phlcridzin, has long ago been noted by
Kapsammer and others. The error is readily disclosed by a con-
trol observation taken the day before or the day after cystoscopy.
Singularly enough, in the employment of various tests of
renal function, with none of them have we found pre- or post-
eystoscopic control more necessary than with phenolsulphonephth-
alein. We would emphasize that the retention of the drug under
these circumstances apparently does not alter the value of the
test in a differential comparison of the two kidneys, but that the
repetition without cystoscopy is often found necessary to obtain
correct notions of the absolute renal function.
For example, a case of polycystic kidneys (No. 62) showed
on February 2nd, 1911, 1% from the right kidney and 3% from
the left one in one hour, and only a trace from the bladder at the
end of that hour, and again a trace at the end of the second hour.
On the following day the test was repeated without cystoscopy.
It then showed 38. in the first hour, 17.9' < in the second.
56.4 rr in all. Two days thereafter ether was administered and
the right kidney removed. The patient's convalescence was en-
tirely uneventful.
Another case suspected of renal tuberculosis, when cysto-
A CLINICAL STUDY OF RENAL FUNCTION 373
scoped under spinal anesthesia showed only traces of phenolsul-
phonephthalein in the various specimens examined. Indeed so
faint was the color in the first half hour that it was difficult to
determine the precise time of onset of the drug. Yet the next day
the cclor appeared brilliantly in 8 minutes, and 44.6% was ex-
creted in the first half hour, 6.6* '/< in the second, 51rr in all.
Another case, this time a man with very mild bilateral bacil-
lus coli pyelitis, gave by ureter catheter in one hour 4*.3% from
the right kidney, 6.25 % from the left, and a trace from the
bladder; total 11% in one hour. Four days later, without cyst-
oscopy, he excreted 40. 4% in the first hour, 8.6 % in the second,
49.0% in all.
In one instance, however, one of us, not suspecting the possi-
bility of this error, catheterized the ureters of a patient with poly-
cystic kidneys, obtained but traces of color in two hours, and
prophesied that the patient would soon be dead. She thereupon
engaged as a scrubwoman in Bellevue Hospital, worked there for
two months, and then left in a huff, exhibiting every sign of men-
tal and physical vigor.
Since such a marked inhibition of phenolsulphonephthalein
excretion may result from ureteral catheterization cue naturally
infers that the same phenomenon may occur without cystoscopy,
and may render the ordinary, non-cystoscopic readings inaccu-
rate. That such a disturbance does not often occur is obvious,
but that it may occur seems to us probable. But a non-cysto-
sccpic reading requires but little manipulation to terrify, or phys-
ically to disturb the patient. The hypodermic injection is as
painless as may be, and as a rule (if there is no residual urine in
the bladder) the only other instrumentation required is the pas-
sage of a catheter to determine the moment when the color appears
in the urine. Yet we have reason to believe that even this
(whether by urethro-renal reflex, or by psychic inhibition, we do
not know, and for our present purpose it does not matter) may ex-
cepticnally cause sufficient inhibition to vitiate the test. Such
inhibition must be rare, yet the possibility should always be borne
in mind, if the phenolsulphonephthalein test gives results contra-
dictory to those derived from other tests, or from clinical observ-
ations. Under such circumstances it should be repeated.
The possibility of this inhibition is moreover only one of
many reasons why it might be practicable to omit all notice of the
delay in appearance of the drug in estimating percentages, and
374 THE AMERICAN JOURNAL OF UROLOGY
to count the hours from the time of injection instead of from the
time when the drug appears in the urine.
It is true that marked inhibition of phenolsulphonephthalein
excretion by renal disease is often associated with marked delay
in its excretion, yet this delay is totally unreliable, and has been
a negligible factor in most of our cases. Rowntree and Geraghty
themselves concur in this.
MEDICAL. CASES
We have classed 19 of our patients as medical cases (See
Chart IV). The first of this group (case 29) was a man 75 years
old, who at the time of the test presented a typical picture of
broken cardiac compensation in extremis — large heart, very
marked oedema of lower extremities, Cheyne-Stokes respirations,
small, weak pulse, and practically unconsciousness. The output,
35.2 % in the first hour, seemed amazingly large. This experi-
ence stimulated work on medical patients of the cardio-vasculo-
renal group, and gave rise to the hope that the use of phenol-
sulphonephthalein might prove a valuable factor in differentiat-
ing the primary cardiac from primary renal cases. Such a study
to be of value should be substantiated by careful necropsy exam-
inations. We were able to secure but one such (Case 85). The
phenolsulphonephthalein test was done the day before death.
Color appeared in the urine in 11 minutes; 14.5rr of the 6 mg.
injected was recovered in the first hour and 8.0^ in the second
hour. Clinically, the case seemed primarily cardiac, with dysp-
noea and marked oedema of lower extremities and Cheyne-Stokes
respirations. The urine showed a trace of albumin, and a few
granular casts. Blood pressure was 155 mm. Hg three days be-
fore death. Post-mortem there was double hydrothorax ; the left
ventricle was markedly hypertrophied and somewhat dilated ; the
right ventricle much dilated ; the mitral valves thickened ; the
aortic cusps fused for 4 mm. on each side and thickened. Both
kidneys were small, cortex of moderate thickness, markings indis-
tinct, capsule stripped, leaving slightly granular surface. Micro-
scopically there was general chronic passive congestion, and in
different parts of each kidney were to be found sometimes a nor-
mal appearance, sometimes acute inflammation, again chronic in-
flammation, the fibrous tissue crowding the tubules. Some glom-
eruli were normal, others had undergone complete hyaline degen-
eration. On the whole, there seemed a fair amount of functioning
A CLINICAL STUDY OF REXAL FUNCTION 375
kidney parenchyma. The ease is not a very striking one, but
the findings seem to us to tally with the prediction of the test.
The amount of the drug recovered in two hours (20.5%) was
rather low, but not indicating an immediate fatal issue from renal
deficiency.
In the absence of pathological proof, we shall not discuss
the Nephritis cases, clinically so diagnosed. Diagnosis of this
group of diseases and the findings after death are too often at
variance. The data are recorded in table IV. Two patients,
pregnant -4 and 5 months, respectively, both having albumen and
casts in the urine, are of interest because of the relatively high
excretion, in each case over 50% of the drug in two hours. Three
cases of polycystic kidneys (Nos. 56 and 62 of table IV and 61
of table IX) were tested with phenolsulphonephthalein during
ureteral catheterization and all gave exceedingly small amounts :
in but one of these was a second test made, without cystoscopy,
and the output in two hours was 56.4% (contrasted with 10+%
the day before during ureteral catheterization). Our inability
to repeat the test on the other cases leaves us in the dark con-
cerning the absolute functional renal capacity of these patients.
The most striking fact in this group of medical cases is the
uniformly large amount of phenolsulphonephthalein recovered
from cardiac patients with broken compensation, and critically
ill. All had albumin in the urine and usually casts were also re-
corded.
MISCELLANEOUS CASES
Table V gives, in tabulated form, data on a miscellaneous
group of cases, most of them with lesions of the lower urinary or
the genital system. This work is confirmatory of our general
conclusions. The principal facts are stated in the table. No
further elucidation seems necessary in this place.
RESULTS IX PROSTATIC HYPERTROPHY AND CARCINOMA
Let us now consider the results obtained by the phenolsul-
phonephthalein test in cases of prostatic hypertrophy and car-
cinoma.
Drs. Rowntree and Geraghty studied 53 such cases, about half
of them operated upon after the test. We have made 33 tests
upon 17 patients, 9 or them operative.
Rowntree and Geraghty observe that " taken in conjunction
with the clinical conditions, it (this test) is of more value than the
376 THE AMERICAN JOURNAL OF UROLOGY
study of urine output, total solids, total nitrogen, and urea esti-
mations " (p. 627). — "A marked decrease in the amount elim-
inated almost invariably means severe derangement of renal func-
tion " (p. 627).
" When the time of appearance is delayed beyond twenty-
five minutes and the output of the drug is below 20 per cent, for
the first hour, operation is postponed regardless of the patient's
clinical condition. If, under routine treatment, the output re-
mains low but constant, the renal function is probably in a stable
condition, and the operation may be undertaken, care being taken
to select an anesthetic which will not further depress the renal
function. In one instance a successful operation was performed
with an output of 8 per cent, for the first hour, but this output
had remained constant for a period of five weeks. The low out-
put here was ascribed to chronic interstitial changes in the kidney,
and nitrous oxide was accordingly employed."
" When the residual urine is large and the patient has been
leading a catheter life, even if the output at a single determina-
tion is large, operation is deferred in order to determine whether
the functional activity is stable, for it has long been recognized
that following the relief of retention the function of the kidney
is extremely variable. Repeated determinations should be made,
and, except when unavoidable, operations should not be performed
when the tests indicate a decreasing function. There have been
two such cases in our series in both of which operation was fol-
lowed by death from acute suppression."
" Again, when only a trace of dye is excreted, operation
should not be attempted, as grave renal changes exist. Two
cases excreting only a trace died of uraemia within a short period.
In neither case was any operation performed, though clinically
at the time of the first test no evidence of uraemia was detected."
(pp. 667-8).
In our work (see Table VI) the time of appearance of color
has not been a factor of much assistance. In general, the pa-
tients who give a lower output of phenolsulphonephthalein have a
longer lapse of time between the injection and the appearance of
the drug in the urine. The times of delay in three striking in-
stances of low output (Nos. 22, 24, 94) varied between 18 and 50
minutes. W7e ventured the opinion above, that it migth be a satis-
factory working scheme to begin the time of collection of urines
from the time of hypodermic injection, neglecting this interval of
A CLINICAL STUDY OF RENAL FUNCTION 377
" delay," inasmuch as this figure alone is not to be depended
upon as a guide. In such an event, obviously a new series of nor-
mal cases would have to be studied. However this interval is usu-
ally easily ascertained, affords one more (though minor) point of
interest, and includes the time of absorption (from injection to
the presentation of the drug to the kidney cells), which is proba-
bly a very variable factor in ill patients, and one we should like
to differentiate from renal excretory capability. The very long
periods of delay (1 to hours) in five tests on case 95, with rela-
tively good percentages of the drug recovered in each of the two
following hours is suggestive of an occasional possible source of
error if the simpler precedure were adopted.
Concerning operation in the face of low excretion of phenol-
sulphonephthalein, cases 24 and 94 with but traces (2-39c ?) and
less than 5r/ in two hours, respectively, died of typical uraemia
on the 7th and 5th days after prostatectomies, the exit of case
94 being hastened by a terminal pneumonia. No. 24 was a feeble
old man of about 65 years with benign prostatic hypertrophy, a
poor operative risk clinically but with no uraemic signs prior to
operation. He stood preliminary suprapubic drainage but suc-
cumbed to subsequent perineal prostatectomy under spinal anaes-
thesia. No. 94 was an older patient (said to be 80 years) with
a benign hypertrophy but in better clinical condition. We ad-
vised against immediate prostatectomy, basing advice on this test,
but the operator felt justified in going ahead, and removed a cal-
culus and the prostate suprapubically. The patient died on the
5th day, uraemic.
In contrast to these two cases, No. 22 is most instructive.
This man of 55 years, with pasty pale color, had had much vomit-
ing- and chills during the winter of 1910, and had lost considera-
ble weight. His urine contained nearly 5c/c of albumin (by vol-
ume). On October 29 and November 6, phenolsulphonephthalein
was injected, and color did not appear under 45 minutes. In the
subsequent two hours on the latter date, but 5.5 r/c of drug was
recovered. Suprapubic drainage under cocaine was performed
November 8th, and the drug output had risen to 8.-j-rv on No-
vember 11th. Under spinal anaesthesia, perineal prostatectomy
was performed on November 15th. Convalesence was quite satis-
factory and the excretion of phenolsulphonephthalein for two
hours rose to 17.0 /y on December 9th. The preliminary bladder
drainage and use of spinal anaesthesia are regarded as extremely
378 THE AMERICAN JOURNAL OE UROLOGY
helpful features in the conduct of this case, who we believe would
probably have died had immediate prostatectomy under general
anaesthesia been done.
The other operative cases gave good outputs and did well
subsequently. In case 91, this function test was a distinct guide.
The operator had declined to interfere, basing his judgment on
clinical appearance and examination, but did perform perineal
prostatectomy under general anaesthesia on the strength of our
report. The outcome thoroughly justified the advice.
A substantial increase in excretion of phenolsulphoncphtha-
lein after prostatectomy is noted in cases 22, 25 and 26, and
after suprapubic drainage in No. 17, showing improvement in
renal excretion for this drug at least. Case 8 (benign hypertro-
phy) showed no such improvement in renal function after pros-
tatectomy. This man however had been dependent upon, and had
used a catheter regularly for 20 years. Moreover, as proved by
ureteral catheterization 8 weeks after operation, both kidneys
were free from infection. In such an instance, one would hardly
expect removal of the obstruction in the lower tract to materially
benefit the renal excretory function, at least after so short a time.
L'rea percentage and total urea of a specimen of urine col-
lected during a brief interval of time afford no estimate of the
combined function of a patient's kidneys. If it were worth while,
abundant proof of this could be extracted from these records.
But more dependence is usually placed upon the urea percentage
and total urea of a 21 hour collection. We have arranged nine
cases with these data in table VII, and make the reference here in-
asmuch as two prostatic patients afford our most conclusive basis
for comparison of this method of estimating renal function with
the phenolsulphonephthalein test, which compavison is in favor
of the latter. One case (clinically in very poor condition) gave
13.1 grams of urea one day and 38.5 grams a few days later,
while our color test gave uniformly low figures on corresponding
days, therein* agreeing with the clinical facts. The other patient,
who died after operation of definite uraemia, gave before operation
only traces of phenolsulphonephthalein but 16.6 grams of urea
in 24 hours (within normal limits!).
Our experience with hypertrophy and carcinoma of the pros-
tate leads us to subscribe most heartily to the following princi-
ples. We find that —
(1) The phenolsulphonephthalein test does indeed indicate
A CLINICAL STUDY OF RENAL FUNCTION 379
renal deficiency more accurately than any other urinary test ; and
that—
(2) Operation is contraindicated when only traces of the
drug appear in two hours after injection.
But we disagree with Rowntree and Geraghty upon the fol-
lowing points :
(a) We do not recognize a diminishing phenolsulphoneph-
thalein output as an absolute contraindication to operation (note
case 8, table VI).
(b) We do not pretend to know how low the phenolsulpho-
nephthalein output may be, and yet the patient survive prostatec-
tomy. In one case we operated successfully upon a patient under
spinal anaesthesia who excreted only %.5c/c in the first hour (after
50 minutes delay) and 5.5% in the second hour. Moreover —
(c) We feel that apart from hexamethylenamin and water
before operation (both of which may be overdone), the patient's
gratest safeguard, in desperate cases, lies in preliminary drain-
age by suprapubic or perineal section, followed, after an appro-
priate interval, by prostatectomy under spinal anesthesia.
THE TEST IX SURGICAL RENAL DISEASE
The conclusions reached by Rowntree and Geraghty from a
study of 17 cases of renal infection, (of which 6 came to opera-
tion) by ureter catheterization, phenolsulphonephthalein injec-
tion and other tests are as follows (p. 659) :
" It has been demonstrated that the time of appearance and
the percentage output is practically the same for the two healthy
kidneys. When only one kidney is diseased, the time of the ap-
pearance of the drug is delayed en the diseased side and the
amount excreted is not only relatively but absolutely decreased.
The amount of delay in the time of appearance is comparatively
of little value. Reliance is only to be placed upon the quantity
excreted during a period of at least one hour. It is possible by
using large doses and extending the observations for a period of
two hours, each side being collected separately, to demonstrate in
some degree the reserve functional ability of each kidney.
" Although in the majority of these cases of unilateral dis-
ease the combined output is equal to that of two normal kidneys,
the greater part of the excretion is shown to be performed by the
healthy kidney. In proportion to the decrease in function on the
diseased side-, approximately there is a proportionate increase in
the function on the healthy side. In such cases following ne-
380 THE AMERICAN JOURNAL OF UROLOGY
phrectomy the remaining kidney eliminates an amount of drug
which is normally excreted by two healthy kidneys. In all cases
studied, the output from the remaining kidney has been greater
than the combined output from the two kidneys prior to operation.
" In one case of pyelitis no disturbance of function was indi-
cated/5
We have studied S3 such cases, five of whom had previously
been nephrectomized, and five others upon whom, for various rea-
sons, the phenolsulphonephthalein test was not employed in con-
junction with the ureter catheter, leaving 23 upon whom the com-
bined test was applied. Ten patients with renal infection (ta-
bles YIII and IX), and one with cystic kidneys not infected (case
table IV) submitted to nephrectomy after the test. We have
based our deductions chiefly upon these cases.
The technic of the test with ureteral catheterization is not
complicated but the interpretation of results requires close atten-
tion. One should use as large ureteral catheters as convenient;
in our experience the flute-tipped ones drain well and allow the
least extra-catheter flow. With the best of catheters, this leak-
age may occur at any time. Accordingly, the results are of
greater value if the bladder contents (if any) be obtained at the
end of each period of collection. If but one ureter be eathcter-
ized. the bladder will contain the secretion from the other side
plus extra-catheter flow. A dilated renal pelvis (with residual
urine) may greatly vitiate one's interpretation of the test. We
do not for one moment neglect the usual chemical and microscopic
examinations and urea estimations. The latter figures compared
with the output of phenolsulphonephthalein in individual speci-
mens help mightily to clear the skies in some instances.
We shall consider some of the more instructive operative
cases briefly. No. 61 (table IX) with cystic kidneys, one infected,
presented but traces of color in two hours after an injection of
the usual 6 mg. of phenolsulphonephthalein, yet survived ne-
phrectomy admirably.. This case does not discredit the test, how-
ever, for the following reason: The patient was a nervous, ap-
prehensive, mistrusting individual and unfortunately the only test
made was applied in conjunction with ureteral catheterization,
the marked inhibitory effect of which procedure has been already
discussed. .Cases 42* (table VIII) and 67 (table IX) interested
us particularly because of the falling output of phenolsulphoneph-
thalein before operation — from 45.52 ( /< for two hours in Decem-
ber, 1910, to 15+$ in April, 1911, in the former (R. renal tu-
A CLINICAL STUDY OF RENAL FUNCTION 381
berculosis); from »I.8$ to 17.4rr in the latter (L. renal cal-
cuius). The amount of phthalein excreted just before operation
in each case was rather small, yet not small enough for this factor
alone to be regarded a contraindication to operation. Both stood
nephrectomy well and subsequent tests showed gains, a very strik-
ing increase in No. 4°.. The renal calculus patient had pulmon-
ary tuberculosis, which unhappily became acute after a few days,
and was regarded as the chief cause of death on the sixteenth
day following operation.
The increase of phenolsulphonephthalein output after ne-
phrectomy is a striking confirmation of the clinical observation
that one good kidney alone (after operation) does better work
than a normal kidney and a diseased one combined. Case 42, just
cited, is illustrative of this fact, and from No. 75 (table VIII)
we recovered 29 A' < of the drug in two hours before operation,
and 38.1 f/c in two hours just three weeks after.
Two other deaths remain to be recorded. Case 27 was one
cf severe infection of a horseshoe kidney of seven weeks' duration
who died about eight days after operation, which could be little
but an exploratory one. The output of phenolsulphonephthalein
was 25.3r/r in two hours, four days before operation. That
the individual could survive the immediate effects of operation
was about all one could expect any function test to indicate in
such an unfortunate condition. Case 45 tells another story.
The man, aged about 50 years, had had clinically R. pyonephro-
sis for 4 years. Before operation his condition seemed perfectly
good. On January 3rd the phenolsulphonephthalein excretion
was delayed 13 minutes, was 38.4' r for the first hour and 16.6%
for the second; on January 13th he voided 1600 cc of urine with
l(/c urea in 24 hours. Cystoscopy had shown the R. kidney to
be the source of the pus, and R. nephrectomy M as accordingly done
on January 7th. In 50 hours after operation, the patient voided
but 20 ounces of urine : the bowels moved freely : there was re-
peated vomiting. The pulse became irregular and rapid at times.
He had " air hunger," and without showing any nervous symp-
toms or delirium died 53 hours after operation. The tongue was
moist an hour before death. The remaining kidney was removed
post-mortem and examined by Dr. Symmers, who reported as fol-
lows :
" Specimen consists of a kidney 10 cm. in length. Capsule
is thin and surface is smooth, except for a few retained fetal
lobulations. The organ is diffusely bluish-red in color, and on
382 THE AMERICAN JOURNAL OF UROLOGY
section cuts readily. Cut surface is smooth, deep bluish-red in
color and drips blood on pressure. The consistence is that of a
normal kidney. The cortex and medulla are well proportioned
and well differentiated. The cortex does not bulge markedly be-
yond the cut edge of the capsule. The cortical markings are
distinct, especially the vascular apparatus, in which the Mal-
pighian bodies are unusually prominent, standing out as minute
bright red points. Microscopically, the vascular apparatus
throughout is deeply engorged. The inter-tubular capillaries
are widened and tortuous, and the red cells in them are closely
packed and show marked effect of reciprocal pressure, or are even
fused. The epithelium in the convoluted tubules is in a state of
advanced granular degeneration.
" Note — The histological changes in this kidney correspond
entirely with those occasionally encountered in athletes who,
after severe exertion, have suddenly subjected the overheated
body to the effects of cold, in which event contraction of the
peripheral vessels is followed apparently by loss of vasomoter
control in the kidneys. The vessels dilate and become tortuous
and the red cells in them fuse. At the same time, stagnation of
blood results in nutritional changes in the lining epithelium of
the tubules and granular degeneration occurs. Very similar
changes are met with in the kidney in subjects dead of tetanus,
of hydrophobia, or of certain irritant poisons. The condition is
relatively rare, but by no means unknown, as a sequence of simple
ether anaesthesia and sometimes fellows nephrectomy of the op-
posite kidney. In the latter circumstance, the combination of
anaesthesia and suddenly increased functional demands upon the
remaining kidney consequent upen the removal of its fellow, is
possibly the best available explanation. Death usually succeeds
upen complete anuria and may occur within a few hours or be
delayed for days ; thus in one patient death occurred on the
twenty-first day after an operation for epithelioma of the penis."
This wouM seem to be an instance most damaging to the
reputation of the test. Had the pathologist discovered chronic
lesions of the " good " kidney, we should have interpreted it so.
But the congestion was surely of recent origin and doubtless did
not exist before operation. A test of prophetic value is beyond
our fondest hope.
A mild kidney infection (shall we call it pyelitis) may in-
terfere little or not at all with renal function as far as we can
determine it. Rowntree and Geraghty cite such an example,
and from No. 31 of our series, with pus and staphylococci from
both ureters, we recovered 63. + '' in two hours.
A CLINIC AL STUDY OF RENAL FUNCTION 383
Instances illustrating the effect of general anaesthesia are
too few in our series to warrant definite statements yet it would
seem that general anaesthesia does not interfere with subsequent
excretion of phenolsulphonephthalein.
Our conclusions agree quite closely with those of Rowntree
and Geraghty, but we venture the following criticisms :
I. The intake of phenolsulphonephthalein may indeed be
measured more accurately than that of the constituents of urea,
and its output is more prompt and more readily measurable than
that of phloridzin or indigo carmin. Yet, while we have found it
far superior to the other artificial color tests, it shows marked su-
periority to the estimation of urea percentage, and urea in cgm.,
and especially the experimental polyuria test, only as an index
of the total kidney function, not of the relative function of the
two kidneys as compared with each other.
In 12 out of 15 ureter catheter examinations in which the
data justified a comparison of the phenolsulphonephthalein out-
put with the urea in cgm., these two indicators told the same
tale and gave the same ratio of functional ability for the two kid-
neys, while the three cases in which they differed were better diag-
nosed by comparison of successive specimens obtained by ureter
catheter than by any evidence derived from single specimens.
Moreover, the study of successive specimens prevents errors from
eccentricities of urinary excretion during the first half hour of
ureter catheterization.
II. We have found that in 5 out of 11 cases, ureter cathe-
terism so diminished the output of phenolsulphonephthalein
(proved by subsequent tests) as to render it most misleading in
determining total kidney capacity ; although, as we have already
observed, the relative inefficiency of the diseased kidney, as com-
pared with its mate, was correctly indicated by the test.
Hence we deem it advisable usually to make two phenolsulpho-
nephthalein tests, one with ureter catheterism, one without, just
as one would make two urea tests, one with ureter catheterism,
and one on a twenty-four hour specimen of urine. If the output
of the drug is high during ureteral catheterization, clearly the
second test is superfluous for estimating functional ability at
this time.
When the phenolsulphonephthalein test is employed with the
ureter catheter only for the purpose of comparing the relative
efficiency of the two kidneys, the patient's discomfort may be less-
ened, the possibility of error by extra-catheter flow diminished,
384
THE AMERICAN JOURNAL OF UROLOGY
and much time saved by collecting urines for successive brief
periods, and comparing these with each other. As a general rule,
for phenolsulphonephthalein, as for urea readings, 20 to SO minute
periods are preferable to shorter ones.
The microscopic findings remain, as ever, the most important
elements in ureter catheter diagnosis. Urea and phenolsulpho-
nephthalein estimations should confirm these, and successive speci-
mens, for comparative readings, are unnecessary in the majority
of cases, hut are most helpful in the precise interpretation of am-
biguous ones.
That phenolsulphonephthalein is not to be depended upon as
an absolute or infallible guide of the actual renal function, or of
the reserve force of the kidneys to withstand the shock of nephrec-
tomy, any more than any other test, is suggested by the three
casualties cited, in one of which nephrectomy resulted in death
by kidney insufficiency despite a good showing before operation,
and in two of which such death did not result in spite of a falling
output.
Finally, we must once again insist that we agree entirely
with the essential parts of the report of Drs. Rowntree and Ger-
aghty. We have felt obliged to in>i^t upon the points of differ-
ence rather than upon those of agreement between our findings
and those recorded in their publication. In our hands, to be sure,
the test has not been found mathematically accurate, but that is
only because of the unf at homed human element, both in our pa-
tients and in ourselves. We regard it the equal of any test yet
devised for comparing the functional value of the two kidneys,
and superior to any for determining the total renal capacity.
This latter phase of its use is the important one, affording a tan-
gible basis for estimating renal function. Obviously the power
of the kidneys to rid the blood of one drug should not be assumed
to be an indicator of their ability to eliminate all other substances.
Yet in practice, the excretion of the drug under consideration lias
been an amazingly accurate index of renal efficiency. Just how
low the output may fall before the danger point is reached in a
given situation should not be fixed dogmatically. No two cases
are alike in all particulars.
We shall continue to use the phenolsulphonephthalein test,
not only as a help in pre-operative diagnosis, but also in many
other connections.
A CLINICAL STUDY OF RENAL FUNCTION
TABLE I
Test Readings on Duboscq Colorimeter
Each specimen contains 25 cc of deep amber urine plus the amount of a solution
of 0.6 gram of phenolsulphonephthalein to 1000 cc distilled water, required to make
the percentages given. This same aequeous solution was used as a standard for
comparison.
Actum,
percentage
Immediate
READING.
Reading 48
hrs. later
Reading same date
as last column,
after adding i
fiwjr d 1 j \J \ 1 1 1 1 yj
15 CC OF MIXTURE
Reading of orig-
inal MIXTURES,
50
53-7
53.2
50.0
trace
25
25..S
21.4
iS.O
no color
10
10.2
3.0 (?)
no color
5
5-T7
ft. trace
no color
3
3-35
no color
no color
2
2-5
no color
no color
I
trace
no color
no color
V2
ft. trace
no color
no color
( Table II, See Next Page)
TABLE III
Showing Time of Maximum Excretion
(Intramuscular Method of Injection)
Patients with normal kidneys- each giving over 60', in 2 hours.
Case No.
Percentage
1ST V2 HR.
Percentage
2ND Vo HR.
Percentage
3rd y2 HR.
Percentagk
41 H % HR.
38
35-2
20.7
8.0
4.0
39
32.9
18.7
7-4
4.0
40
31.6
19.2
9-9
5.3
3i
29.4
I4.0
13.9
5.7
Average
32.3
18.2
9-8
4.S
386
THE
AMERICAN JOURNAL OF UROLOGY
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A CLINICAL STUDY OF RENAL FUNCTION
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388 THE AMERICAN JOURNAL OF UROLOGY
> I
Remarks •
Mitral Insufficiency. Very large heart.
Marked oedema of lower extremities.
Urine contained Considerable albumin,
hyaline and granular casts. Blood
pressure varied from 70 to [00 mm.
Hg. At time of test, almost in ex-
tremis, unconscious, Cheyne-Stokes res-
piration. Died in a few days. No
autopsy.
Mitral Insulf. Large heart. Moderate
oedema of legs. Orthopnoea. Blood
pressure 170. Urine — trace albumin,
no casts, Sp. Gv. 1025; 36;= in 24
hours, urea 2.6',. Died April 6. No
autopsy.
Very large heart; mitral insulf.; slight
Oedema of legs; moderate dyspnoea.
Temp, not over [00°. Urine — much
alb., no casts, I02S. Bid. press. 125.
Fairly large heart; marked oedema.
Urine — 1020, much alb., hyaline and
granular casts, urea r.6#. Blood pres-
sure, 145.
Fairly large heart; marked oedema; or-
thopnoea. Urine — 1020, trace alb.,
few gran, casts; § 35 in 24 hrs., urea
i.S,. Blood pressure 155. See text
for necropsy findings.
No symptoms. Urine — considerable alb. 1
hyal. granular and epithel. casts. This
urinary condition known to have ex-
isted six years.
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Parenchym.
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CLINICAL STUDY OF RENAL FUNCTION 389
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[Parenchym.
Nephritis
Bilateral
haematuria
Par. Nephr. (?)
Parench.
Nephr. (?)
Pregnant 4 m.
Pathological
urine
Pregnant 5^ m.
Pathological
urine
Interstitial
Nephritis
Ulcer of
bladder
Interstitial
Nephritis ?
Interstitial
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390 THE AMERICAN JOURNAL OF UROLOGY
a
u
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Remarks
Typical picture of cirrhosis. Thin man
with large belly. Been repeatedly
tapped. Urine — 25-40 ^ in 24 hrs.;
10 15, much alb., few casts, urea 1.2$.
Blood pressure no to 135.
Was in good general health when last
seen, 2 months later.
No symptoms.
R. kidney later removed. Normal con-
valescence.
Blood seen coming from L. ureteral ori-
fice. L. nephrectomy stopped liaema-
turia— kidney seemed normal. Urine —
no pus, no casts.
Was having temperature 102° to 1030
daily. Irrational at times. Symptoms
of " wet brain. " No oedema. Heart
not enlarged. Urine — 35 5 in 24 hrs.;
trace albumin, urea 0.9$, granular
casts. Blood pressure 125. Died April
6. No autopsy.
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Hepatic
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L. liaematuria
Alcoholism
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1 )i VGNOSIS,
Organs
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Bladder
R. kidney
(removed^
After neph-
rectomy
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Bladder
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Testicle
R. kidney
L. kidney (?)
Prostate;
vesicles;
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Elbow
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and pulm. 1 be.
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h
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Little pus and colon bacilli from
both kidneys.
Pus and stophylococci from both
kidneys.
Probably extra-catheter flow from
L. side.
Other specimens gave equal urea %
from kidneys.
No operation.
Pus and blood in urine for 5 yrs.
From behavior of catheter flow,
most of bladder color thought
to come from L. kidney.
Had had Rt. renal colic. Voided
1600 cc urine in 24 hrs. — 1%
urea, 0.5^ (bulk) albumin, much
pus. On Jan. 14, R. nephrec-
tomy. Death 53 hrs. later (see
text). At autopsy, marked vas-
cular engorgement of remaining
kidney.
Frequency of urination; had hae-
maturia. Tuberculosis suspect-
ed— marked improvement on tu-
berculin.
Condition much better.
Bladder urine — trace albumin and
pus. No pus from L. kidney.
Later pyelotomy , followed by re-
nal sepsis, then R. nephrectomy.
Thereafter few casts in urine.
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A C LINIC AL STUDY OF REXAL FUNCTION 403
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cleared up,
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from R. kidney, 2.0', from L.
Excellent general condition. Re-
fused operation.
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Now pyuria and pain over re-
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404 THE AMERICAN JOURNAL OF UROLOGY
INFECTION FOLLOWING URETERAL CATHETERIZA-
TION
By A. Xelkex, M.D., Xew Orleans, La.
IN trained hands, catheterization of the ureters is, ordinarily, a
simple procedure, and it is indeed rare that any sequels more
serious than some pain or bleeding follows the examination.
In the early days of catheterization of the ureters, great
stress was laid upon the possibility of carrying infection up the
ureter in the passage of the catheter through the septic bladder.
One of the advantages claimed for the segregator was that it
avoided this danger.
The perfecting of the catheterizing cystoscope has made
catheterization of the ureters a routine procedure, and lias shown
this danger to be theoretical rather than real.
One who cares to consult the authorities on the subject will
conclude that such infection never occurs, for each writer, while
acknowledging the possibilities of such an accident, always ends
with the remark that he has never had it occur in his own experi-
ence.
Some years back the opinions of many of the prominent gen-
ito-urinary specialists of this country as to the danger of infec-,
tion following the use of the ureteral catheter were collected and
published, and, without exception, they all disclaimed having ever
seen it occur.
Indeed, so firmly fixed is the opinion among genito-urinarv
men that this operation is free from this risk, that I am afraid
that sometimes we are careless in the application of ordinary
surgical cleanliness. For one thing, asepsis during ureteral cath-
eterization can be only relative. Neither the cystoscope nor the
catheters stand boiling with any degree of safety to the instru-
ments. And it is difficult to keep the hands sterile during the
manipulation necessary to the introduction of the catheters.
But, granting all this, I believe that it is the common im-
munity from accidents that has led to the large degree of careless-
ness in the aseptic technique of this operation.
I report the following case to show that catheterization of the
ureters is not necessarily the safe procedure that a perusal of the
literature of the subject would lead us to infer, and that grave
infection can, and sometimes does, occur.
I think that I can claim for myself at least the ordinary de-
URETERAL C ATHETERIZATION
405
gree of care in the use of the cystoscope. All parts of the in-
strument that stand heat well are boiled ; the sheath and periscopes
are sterilized with carbolic acid and alcohol ; the catheters are kept
in formaldehyde vapor, and before being used are immersed in bi-
chloride solution (1-1000) for twenty to thirty minutes. The
bladder is thoroughly washed before cystoscopy, both to clean the
bladder and to get a clear field for examination.
I do not introduce the catheters more than three or four
inches up the ureters unless there is some special reason for it,
for then I am sure that that portion of the catheters within the
ureters has not come in contact with the hands.
The case I am about to report has several points of interest,
and I hope I may be excused if I go somewhat into detail.
Mrs. W., aged 31, one child 12 years ago.
Applied for treatment September, 1910. She gave a history
of constantly recurring attacks of bladder disturbance since child-
hood. Trouble became worse after menstruation was established.
She has consulted a number of physicians, but had never gotten
any permanent relief. Nine years previously her abdomen had
been opened for some pelvic trouble, but the operation gave no re-
lief to her bladder trouble.
The spells with her bladder come on at irregular intervals,
and last from a few hours to several weeks. They consist of fre-
quency, pain and tenesmus, and are as bad at night while in bed
as they are during the day.
Patient is a well nourished, healthy-appearing woman, with
no neurotic element apparent. Pelvic examination was negative.
Her urine showed a heavy deposit of pus, and the sediment,
stained, showed a Gram negative bacillus — probably the colon.
The peculiar history of her case and the fact that her bladder was
unusually intolerant to irrigations led to a careful search for the
tubercle bacillus, but they have never been found. A guinea pig
was inoculated, but the findings were negative.
Cystoscopy showed a diffused cystitis, with no ulceration.
After two weeks of irrigation with nitrate of silver solution,
her urine was clear, showing microscopically only a few leucocytes.
Symptoms relieved.
One week later, without any assignable cause, there was a re-
turn of all symptoms with a cloudy urine.
These relapses, following periods of complete relief from
bladder irritation, were of regular occurrence. At times, urine
406 THE AMERICAN JOURNAL OF UROLOGY
would be cloudy without irritation, and, again, she would complain
of her bladder when the urine was microscopically clear. As a
rule, however, when the bladder was troublesome the urine would
show a large quantity of pus.
After treatment with all sorts of solutions without any per-
manent results, I decided to catheterize the ureters, thinking it
posible that the bladder was being reinfected from above.
On January 17, her urine being clear, I went up both ureters
without difficulty. The specimens were sent to the pathologist
of the Touro, Dr. Gurd, for examination, and he reported that the
urine from the left side was sterile, while that from the right
showed a few colon bacilli.
Dr. Gurd made an autogenous vaccine from the bladder urine.
To this vaccine, in doses of 350 million or more, she always gave
a prompt constitutional reaction, temperature rising the evenings
of the injections to 100F.-101F.
But a fair test of the vaccine showed no improvement in the
local condition, and after a trial lasting over five weeks, it was dis-
continued.
I then decided to again catheterize the ureters, choosing a
time when the urine was cloudy, so as to determine whether colon
bacilli came from the right side or whether, as seemed more prob-
able from the few found, they were an accidental contamination
from the bladder.
On June 25, her ureters were again catheterized, the Brown-
Buerger instrument being used. The ureters were entered without
difficulty. The urine from the right kidney was watery, showing
only a few flocculi, which, under the microscope, proved to be
epithelium, probably brushed off by the catheter. The urine from
the left side was watery and gave no deposit on centrifuging.
The examination was done at the office, and the patient suf-
fered no immediate inconvenience of any sort.
On the fourth day following the examination, she complained
of pain in the left side, distinctly referred to the left kidney and
radiating down the left ureter. The following day pains were
worse, being especially acute on deep pressure over the left kidney.
She complained of pain at the waist line on deep inspiration, and
the whole course of the left ureter was tender to pressure. Maxi-
mum temperature 101F.
Severe pain over the kidney and along the course of the ure-
ter continued for six days. At times the pain was so extreme
FAILURE OF EXTERNAL URETHROTOMY
that it was necessary to administer opiates so that she could get
some sleep. Temperature ranged from 991 to 102 4-5.
A careful examination of the base of the left lung showed it
to he normal.
On the seventh day following the onset of the trouble, pains
were better, but temperature rose to 102 4-5 that evening. The
following day she was decidedly better, temperature not rising
over 99o, with very much less pain.
On the tenth day her temperature remained normal for the
first time, and there was only a slight soreness over the kidney
on deep pressure.
During the entire course of the attack, her urine was highly
cloudy, but it was only when she began to improve that her blad-
der began to trouble her again.
Her urine did not clear for a month after this attack.
Her subsequent history is a repetition of the past story. At
present her urine shows only a few leucocytes, and she is more
comfortable and for a longer period of time than usual. Cathe-
terization to verify the diagnosis of infection of the renal pelvis
was not done.
After her experience, the patient was not enthusiastic about
going through it again.
But the clinical picture was so clear that I do not believe any
reasonable doubt can be raised as to the diagnosis, and slight
question as to the exciting factor of the trouble.
Perrix Btildixg.
CAUSES OF FAILURE OF EXTERNAL URETHROTOMY
By H. A. Kraus, M.D., Chicago.
IT is a very noticeable fact that the most important urological
operations are not as well defined, as to execution and to re-
sults, as most operations in other fields of surgery.
This fact is best exemplified when we consider external ure-
throtomy performed for the relief of strictures. A careful survey
of the literature (which may be truthfully stated is meager
enough) shows that there is no unanimity as to the course of
operation and that also a dissensus of opinion prevails as to the
after treatment.
While exact statistics are not available, still one cannot be
misled from the conviction that the number of final good results
is not any too large.
408 THE AMERICAN JOURNAL OF UROLOGY
The failures of external urethrotomy should naturally divide
themselves into two groups : (a) Relapse at the original seat of
the stricture or strictures, (b) New formation of constriction in
places that were normal before operation, such places being ad-
jacent to the site of operation.
As to the degree these changes may vary is, from a slight
improvement of the patulence of the urethra to a decided deteri-
oration of the previous urethral status.
As one of the most striking instances I would like to quote
the not infrequent occurrence, that at the distal end of the in-
cision after the healing process is finished, there establishes itself
a new resilient stricture, which would call for urethrotomy, pro-
vided one could guarantee for the result. It seems that this new
formation, or constriction, is always due to an infection originat-
ing from the incision.
This is very probable, and, in my experience, I have never
observed such an occurrence if subsequent suppuration had not de-
veloped around the primary incision. I am led to believe that the
development of inflammatory changes at this spot is dependent
on two conditions: the establishing of a soil favorable to the
growth of pus producing germs and the subsequent infection by
infectious mine penetrating this soil ; this soil will be prepared
by hemorrhage into the tissue at the distant pole of the incision,
and by the urinary infiltration and infection due to the too early
removal of the drainage tube inserted into the bladder.
The recurrence of the stricture at the place of the incision
can be due to various factors.
The first one can be considered the incomplete severing of
the stricturing bands, or the incomplete exsection of stricturing
cicatricial tissue, that had practically supplanted the urethra.
Another cause may again be hemorrhage that teased apart
the surrounding tissue, leading in due course of time to the or-
ganization of the hematoma and to subsequent cicatricial re-
traction.
This phenomenon is more likely to occur if infection of these
hematomata has led to suppuration, extensive infiltration and
finally to new formation of fibrous tissue around the urethra.
The most frequent cause for these hemorrhages will be furnished
by injuries to the bulbus. If the hemorrhage occurs packing has
to be resorted to, which in turn may lead to infiltration and subse-
quent cicatrization.
CURRENT UROLOGIC LITERATURE 409
Another factor that may lead to postoperative relapse can
be furnished by the sutures applied, for closing part of the in-
cision.
If these sutures approximate in a frontal sense the edges of
the urethral wound too closely, the result of the operation will be
jeopardized because the centrifugal tendency of the union by
granulation is counteracted.
From these permanent relapses have to be differentiated those
forms of apparent, or, more exactly speaking, temporary relapses
which consist in temporary indurations around the seat of opera-
tion; these indurations will most frequently occur after extensive
exsection of the cicatricial tissue and as a rule yield in a rather
short time to antiphlogistic treatment ; any attempt at sounding
during the acute and subacute stage will increase the difficulty
instead of bringing relief.
Review of Current Urologic Literature
ANN ALES DES MALADIES DES ORG AXES
GeNITO-URINAIRES
Volume XXIX, Xo. 15, August, 1911.
1. Six cases of Cystitis with Incomplete Retention of Urine. By
M. Cealic and L. Strominger.
2. The Ejaculatory Ducts and the Sexual Function after
Suprapubic Prostatectomy. By F. Legucu and E.
Papin.
3. L'reterostomy as a Method of Functional Renal Diagnosis.
By G. Key.
Volume XXIX. Xo. 16, August, 1911.
L The Pathogenesis of Renal Tuberculosis. By P. Heresco,
and M. Cealic.
5. Remote Results following the Incision of Prostatic Abscess.
By M. Cealic and L. Strominger.
Volume XXIX, Xo. IT, September, 1911.
6. Syphilis of the Bladder and Upper Urinary Tract. By X.
MikhailofF.
7. Primary Tuberculous Cystitis. By Dr. G. La Virgin.
410 THE AMERICAN JOURNAL OF UROLOGY
2. The Ejaculatory Ducts and the Sexual Function
after Suprapubic Prostatectomy. In an exhaustive and
painstaking paper which includes both the results of anatomical,
post-mortem, and clinical research, the authors conclude: 1st,
that the ejaculatory ducts in hypertrophy of the prostate are
always situated behind the enlarged gland ; and 2nd, that after
the suprapubic method of prostatectomy, they should remain
intact, the sexual function being ordinarily preserved.
The prostate may be regarded as composed periurethral or
inter-sphincteric glandular tissue which does not extend beyond
the smooth-muscle sphincter, and of prostatic glands proper
that perforate this muscle to become distributed beyond its
limits. In front of the ejaculatory ducts there are both nitra-
and extra-sphincteric glands, but behind them we find only the
extra-sphincteric type.
Taking only the adenomas and fibro-adenomas into con-
sideration, the authors find that all specimens of hypertrophied
prostate have three characteristics in common. 1st, They are
all adherent to the urethra. 2nd, They are all situated in front
of the ejaculatory ducts. And 3rd, they all lie above the sum-
mit of the verumontanum. Thus we never find an involvement
of the middle of the prostate at some distance from the urethra,
nor is it feasible to enucleate the growth without tearing the
corresponding portion of the urethra. As the hypertrophic
process advances, the ejaculatory ducts are pressed downward
and backward, the verumontanum representing the lowermost
boundary of the tumor mass.
If we assume that the hypertrophic prostate finds its origin
in the region of the peri-urethral glands, we are accepting an
hypothesis that adequately explains botli the topography and
the ease with which enucleation can be done.
Considerable confusion still exists concerning what struc-
tures are actually removed in a so-called suprapubic prostatec-
tomy. In order to study this question the authors performed a
series of post-mortem prostatectomies on cases with moderate and
considerable enlargement of the prostatic gland, removed the
gland, ejaculatory ducts, vesicles and bladder in tofo directly
afterwards, and conducted thorough anatomical investigations of
the prostatic bed. The cavity left after extirpation is situated
below the bladder so as to give to the specimen the appearance of
a double sac, the smaller having contained the hypertrophic
CURRENT UROLOGIC LITERATURE
411
prostatic. The upper limit of the bed is formed by the incision
or tear in the vesical wall, which, in healed specimens, is repre-
sented by a transverse bar lying below the ureteral ostia. The
lower boundary line of rupture in the prostatic urethra, and the
tear, should here leave at least the lower half of the verumcn-
tanum intact, the latter resting as a sort of promontory on ti e
inferior urethral wall. As a rule the ejaculatory ducts are
intact. They can be traced in their common sheath under a
thin layer of tissue that lies in the wall of the prostatic bed,
and projects into it in the form of a median ridge. Histological
examination reveals prostatic glandular tissue in the wall of
the pouch, permitting of the conclusion (which had already been
arrived at by Wallace, Motz, and others), that the prostate
itself is left behind, the so-called prostatectomy being nothing
more than the enucleation of an adenoma or fibro-adcnoma.
As regards the condition of the sexual function after the
operation, the authors find that exact data are lacking in the
reports of most surgeons, for no special regard is taken of the''
fact that the following phases of the act may individually or
conjointly suffer alteration, namely, the sexual desire, the erec-
tion, the ejaculation and the orgasm. Reviewing 9 of the cases
whose subsequent histories could be carefully investigated to-
gether with reports of others, it was found that the sexual
appetite does not seem to be suppressed except in the very feeble
and aged. Ejaculation probably occurs into the bladder in most
cases and retention in the spermatic tract only takes place when
the ejaculatory ducts are torn. The orgasm is usually retained
which also points to the view that ejaculation into the prostatic
bed and bladder occurs.
5. Remote Resuets following Incision of Prostatic
Abscess. The authors have studied 71 cases operated on in the
service of Heresco in Bucharest. The patients had been either
recently examined or their replies to letters of inquiry were re-
corded.
As regards the indications for operation, the weight of opin-
ion expressed at the XI Meeting of the Urological Society of
France, seemed to favor intervention in gonorrhoeal prostatitis,
whenever there is a distinct abscess, when there is a suppurative
periprostatitis, or if small foci in the prostate give alarming
svmptoms. The authors' cases were all operated on by the
412 THE AMERICAN JOURNAL OF UROLOGY
perineal route, and the remote results were very gratifying.
After incision of a prostatic abscess we may expect healing
in 18 to 35 days, and a cure of the gonorrhoea in 15-40 days,
the proper local treatment having been given. As for post-
operative complications, untoward sequelae, and mortality, the
following have often been cited : perineal fistulae, sexual com-
plications, atrophy of the prostate, epididymitis, funiculitis, re-
tention and incontinence of urine.
The frequency of the occurrence, and the dangers of perineal
nsti^.ae have been exaggerated. Although the observations of
Segond, who records 10 cases of fistula in 114 operations, would
seem to speak for the frequency of their occurrence, more recent
reports and the last twenty cases of the authors seem to dis-
prove this. If the rectum or urethra be injured, or if there
already exists a potential communication due to perforation of
the urethra by the prostatic pus, a post-operative tract lead-
ing into the urethra and bladder may become established. Even
should this occur, the persistence would be unusual. Thus in
£2 cases, fistulae occurred but twice. One of these was due to
perforation of the rectum by a probe during dressing, the other
occurred also secondarily because of neglect in post-operative
treatment.
Lesions of the adnexa ought not to occur if the incision is
properly made. A carelessly executed transverse incision may
easily cut the ejaculatory ducts, so that a longitudinal direction
is to be preferred. Sexual complications could be of the follow-
ing types: Sexual impotence, total absence of ejaculation, pain-
ful ejaculation, and interrupted ejaculation. Such sequelae
may be the result of a uni- or bi-lateral lesion of the ejaculatory
ducts. Although slight temporary disturbances of the above
nature are seen in some instances, on the whole permanent sexual
changes are rare.
Atrophy of the prostate is encountered rather in the form
of a moderate diminution in the size of the gland, than in a total
or very marked degeneration of the organ. In one case there
was precipitate ejaculation, in two patients the act was re-
tarded ; slight pains were felt by three patients, a symptom
which lasted for some six months.
As regards epididymitis and funiculitis, we have no reason to
suppose that this is directly brought about by the operation,
except where a lesion of the ejaculatory ducts has taken place.
CURRENT UROLOGIC LITERATURE
413
In all the post-operative cases of epididymitis, the prostate was
very large and the symptoms were so severe that this complica-
tion was to be expected even without intervention.
Retention or incontinence of urine did not take place in any
of the cases observed by the authors, although reports of high
mortality are recorded. There were but two fatalities in the 71
cases. One of these patients had already a general infection,
the other succumbed to an extension of the suppurative process
from the pelvis into the peritoneum.
There is no doubt but that an infected prostate is often re-
sponsible for the persistence of the disease ; and particularly is
this true when the gland has become the seat of collections of pus.
But it is concerning the question as to whether massage or in-
cision gives the best final results that genito-urinary surgeons
are still at variance. When we consider that, even in the so-
called mild cases of prostatic suppuration, the lesion consists in
a number of miliary abscesses, which do not always become con-
fluent to form " surgical " abscesses, but which may become
encysted and remain as latent foci, ready to light up an acute
process, the rationale of a thorough operative cure becomes ap-
parent. Heresco considers prostatotomy indicated whenever
repeated attacks of suppurative prostatitis have occurred :
further in certain cases, that prove refractory to massage and
treatment of the urethra, even if the gland be small, and finally
where there is a frank abscess.
As to whether incision is superior to spontaneous evacua-
tion of the pus, the authors are emphatic in their opinion that
the former is incomparably better than the latter. In all of
the cases operated upon, the gonorrhea was completely cured.
Rupture of the abscess either into the rectum or urethra, is
usually followed by conditions that make for a persistence of
the inflammatory foci, leading most frequently to a chronic,
often incurable gonorrhea.
6. Syphilis of the Bladder and L'pper L'rixary Tract.
By means of cytoscopic examination confirmed by the Wasser-
man test and by the results of therapy, the author was able to
diagnosticate a case of syphilis of the bladder and kidneys. The
patient, a female 39 years of age, complained of a feeling of pres-
sure in both renal regions, of occasional hematuria during a
period of about five years. The kidneys were not palpable,
41 4 THE AMERICAN JOURNAL OF UROLOGY
tenderness was absent, and the total quantity of urine voided
in 24 hours did not exceed 600 c.cm. Peculiar lesions were
found with the cystoscope. Surrounding the ureteral ostia. as
well as scattered over the superior and lateral walls, there were
collections of small papules arranged in circular groups. They
were covered by grayish yellow clots, and each circle was sur-
rounded by a red annular band that formed a striking contrast
to the neighboring normal mucosa. Some of these areas were
suggestive of a cutaneous areola.
Catheterization of the ureters gave evidence of disease of the
left kidney, the ureteral orifice bing hyperaemic and excreting
cloudy urine with many pus cells.
The Wasserman reaction was positive, and, after the admin-
istration of mercury and iodide of potash, the improvement in
both the general and local condition of the patient was strik-
ing. Thus the total quantity of urine soon increased to 1500
c.cm., and after one month the aspect of the bladder had com-
pletely changed. The lesions over the superior wall had dis-
appeared and there only remained slight indication of disease
over the trigone and lateral walls in the form of rose colored
spots. The hematuria had ceased shortly after the anti-leutic
treatment had been administered and had not recurred.
ZEITSCHRIFT FUR GYNAEKOLOGISCHE UROLOGIE
Vol. III. No. 1, July, 1911.
1. Bacteriological Studies of the Value of Myrmalyd as a Urinary
Antiseptic. By P. Tsch.
2. Foreign Bodies in the Female Bladder. Bv O. Hoehne.
3. Ligature — Stones of the Female Bladder. By R. Know.
4. Pyelonephritis of Pregnancy. By E. Kehrer.
5. Tuberculosis of a Cystic Kidney. By A. Sitzenfrey.
4. Pyelonephritis of Pregnancy. From a study of the
literature and of six cases, Kehrer concludes as follows :
1. Pyelonephritis of pregnancy is rather common and often
follows exposure to cold. The case under consideration may have
originated during a previous pregnancy. About 70 of the cases
occur on the right side at about the middle of the term.
2. The colon bacillus in the infecting organism is 79% of
cases, probably reaching the pelvis of the kidney by the ascending
CURRENT UROLOGIC LITERATURE
415
route. Frequently cystitis of long standing precedes the pyelitis.
3. The hyperemia of the pelvic organs during pregnancy
leads to swelling of the ureteral orifices and a consequent atony
of the ureteral musculature. A tendency to antiperistalsis and
retention results. The antiperistaltic movements are elicited by
virtue of the irritation of the infected contents of the bladder, by
the pressure of the uterus, and possibly also by an increased vesi-
cal pressure.
4. The early treatment of the cystitis is an important
prophylactic measure.
5. Energetic conservative therapy gives good results. A
cure from the bacteriological standpoint cannot be expected to
occur until a considerable time has elapsed. The disappearance
of subjective symptoms is the rule shortly after labor.
6. Nephrotomy should be avoided.
7. In the severest cases only, when there is a bilateral af-
fection, when a general infection is threatened, is the interruption
of the pregnancy to be considered.
5. Tuberculosis of a Cystic Kidxey. A rather remarka-
ble specimen of cystic kidney completely converted into a cavernous
type of renal tuberculosis was obtained in the case of a woman
40 years of age, who clinically represented the picture of a large
tense fluctuating; lumbar tumor extending almost to the umbilicus.
The examination of the tumor showed a typical cystic kidney
plus an extensive tubercular process. The ureter was completely
stenosed as it passed through the bladder wall, but, according to
the author, because of congenital anomaly, and not due to the in-
flammatory process.
Radiography ix Urinary Lithiasis. ( Sur quelques Par-
ticularities de la Lithiase Urinaire, etc.) L. Bazy and Des-
terxes, La Presse Medicate, June 24, 1911.
The necessity for a thorough X-ray examination of the
urinary tract is dwelt upon by the authors, and some striking clin-
ical examples illustrating its importance in diagnosis are cited.
The salient features of their paper may be summed up as follows:
1. Pain may be the only symptom of urinary calculi, urinary
symptoms being absent. Thus a young woman 28 years of age
had an attack of severe abdominal pain for a long time without
a single functional sign pointing to the urinary tract. Roentgen
416 THE AMERICAN JOURNAL OF UROLOGY
examination revealed a small calculus in one of the calices of the
left kidney.
%. Urinary calculi may present paradoxical phenomena. A
female patient 40 years of age had experienced pain in the right
flank for a long time, the diagnosis of appendicitis having been
made. There was a calculus in the left kidney. In another case
of a young woman who gave all the usual symptoms of cystitis
colli and did not improve under treatment, the X-ray examination
revealed that the pelvis of one of the kidneys was filled with urin-
ary sand.
3. Urinary calculi may be present without symptoms. In
a boy 7 years of age who had developed a stone behind a congeni-
tal stricture of the urethra, a radiogram showed an immense cal-
culus in the lower part of the left ureter, without there being
any symptoms pointing to an affection of the ureter or kidney.
4. Urinary lithiasis may show multiplicity in its localiza-
tion. The case of a man in whom a calculus had formed behind a
traumatic stricture of the urethra, proved to have also a stone in
the right kidney.
5. Urinary calculi may be associated with other lesions.
Thus after the removal of a stone from the right kidney of a
young woman, convalescence was interrupted by fever and a per-
sistence of the preexisting pyuria. The kidney was the seat of a
chees}r tuberculous process.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor.
Vol. VII
NOVEMBER, 191]
No. 11
Contributed by the Author to The American Journal of Urology.
AN EXPERIMENTAL AND CLINICAL STUDY OF COLON
BACILLUS INFECTIONS OF THE URINARY TRACT*
HE pathogenicity of the colon bacillus in its attack upon
the urinary tract has placed these infections among the
most interesting and provoking that the urologist encoun-
ters.
Without pausing to consider the origin of colon bacillus in-
fections of the urinary passages I will briefly review some of the
cultural characteristics of the organism in question, so that we
may have some foundation for the working basis leading up to
the experimental portions of this paper. Thriving as this
organism does in the intestinal tract, its medium is under normal
conditions of a strong alkaline reaction. Artifically grown, it
curdles milk, which process probably depends on the fermenta-
tion of the lactose of the milk and the throwing down of the
casein by the resulting lactic acid. Litmus bouillon or gelatin
will soon give a slight acid reaction, when inoculated with the
colon bacillus. In short, the organism grows equally well on
media slightly acid and on those of an alkaline reaction. The
question arose, if it were possible to increase the acidity of the
habitat, what would be the effect upon the resistance and multi-
plying powers of the bacteria?
To increase the alkalinity was not considered because of the
fact that the usual habitat, namely, the intestinal tract, where
the colon bacillus best thrives is strongly alkaline.
Reviewing the literature on chemical therapeutics, it was
* Read at the Twenty-seventh Annual Meeting: of the American Urological
Association held in Chicago, Sept. -26 and 27, 1911.
By Irvin S. Koll, B.S., M.D., Chicago.
(From the Laboratory of the Michael Reese Hospital.)
4-17
418 THE AMERICAN JOURNAL OF UROLOGY
found that aluminum acetate had been very satisfactorily used
in surgical dressings for many years. Dreuw1 also used the
drug by internal administration for the reduction of excessive in-
testinal fermentation, and he claims to have ameliorated the
strangury of posterior gonorrheal urethritis by the same means.
BACTERIOLOGICAL EXPERIMENTS
Accordingly, the following series of bacteriological experi-
ments was undertaken: First, two sets of twenty-four hour cul-
tures of four different strains of bacilli were taken, one in
bouillon and one in urine. To each tube, which contained 5 c. c.
of the culture, was added 5 c.c. of a cZc/c suspension of the sub-
acetate of aluminum. One urine and one bouillon culture of each
strain were incubated respectively for 2, 5, 7, 10, 20, 30, 40, 50,
and 60 minutes ; then agar plates inoculated with one loop full
of the culture. At the end of 24 hours the entire four sets had
a countless number of colonies, thus showing the inertness of
the insoluble subacetate of aluminum. Next, the same technique
was used, substituting liquor aluminum acetate (N. F.)2 for the
insoluble subacetate. Beginning witli full strength, which is
nearly 80%, the experiments were carried down to a dilution
of 1%, each set \( \ lower than the previous, with a result
which showed that it required a %i [ dilution 50 minutes to com-
pletely destroy 5 c.c. of a 24 hour bouillon or urine culture.
Attenuation of the number of the colonies was constant in
proportion to the strength of the solution added, and the time
of incubation. Thus was proven the germicidal power of the
liquor upon the colon bacillus.
I was now curious to know what the effect would be upon the
other members of the colon group and upon the staphylococci.
Accordingly a series of experiments was gone through as above,
using different strains of para-colon, typhoid, and staphy-
lococcus pyogenes albus and aureus. The experiments, several
times repeated using controls, were uniform in their results,
namely, a cZ(/c dilution destroyed 5 c.c. of a 24 hour culture of
para-colon and typhoid in 50 minutes, but that at full strength
the staphylococci were unaffected.
Having established the germicidal effect, the antiseptic power
of the drug was next tried. To two sets of tubes of bouillon
and sterile urine were added sufficient quantities of the liquor to
make the correct percentage dilutions from 8 to 1 ; each tube
was inoculated with 1/10 c.c. of a 24 hour bouillon culture of
the different strains and different bacteria, as in the foregoing.
COLON BACILLUS INFECTIONS
410
These were then incubated 48 hours, plated and again incubated.
There were no growths on any of the colon, para-colon, or
typhoid plates, but all the staphylococci plates an infinite num-
ber. Thus a lc/c dilution was sufficient to prevent the growth
of the different members of the colon family, but the full strength
did not influence the staphylococci.
Acetic acid in the same percentage strength gave the same
results upon the colon group, and in 3* ft dilution completely
destroyed and prevented the growth of the staphylococci. The
acid reduced to the same degree of acidity as the L2( < liquor
aluminum acetate expressed in terms of n 10 NaOH again gave
the germicidal and antiseptic action upon the colon group but
not upon the staphylococci.
C HEMICA L E X PER] M E X T S
( /hemieally, some of my results were inconstant, namely, I
first tried to ascertain whether the internal administration of
the subacetate of aluminum would raise the total acidity of the
normal urine. Three grams per day were given to three in-
dividuals living about the same routine and upon the same diet.
Taking an A.M., noon, and P.M. specimen I titrated them with
n 10 NaOH, using phenolphthalein as an indicator. For the
seven days following the administration of the drug, compared
with the seven days previous to it, there was a total increase
in the 24 hour specimen of 18 calculated in terms of NaOH.
This is so small that I don't think we can attach much impor-
tance to it. There was no appreciable difference in the resisting
power of the urine with the increased acidity when inoculated
with a colon culture. However, urine that contained the higher
acidity did not become infected as rapidly when allowed to re-
main exposed to the air as a specimen from the same individual
previous to his taking the subacetate.
What is the effect of the liquor aluminum acetate upon the
healthy mucosa of the urinary tract was the next question to be
solved before putting the results obtained to clinical use?
ANIMAL EXPERIMENTS
To determine this a series of rabbits was used. A good sized
animal was prepared for operation, anaesthetized, both kidneys
exposed and brought up into the incision. The right ureter — -
control — was clamped about 5 cm below the kidney pelvis and
then the organ was replaced into the abdominal cavity. The left
ureter was injected proximally with a %% dilution of the liquor
aluminum acetate until the pelvis was distended. A clamp was
420 THE AMERICAN JOURNAL OF UROLOGY
then placed distal to the point of injection. Then 10 c.c. of
the 2% solution was injected downward through the ureter into
the bladder and the left kidney dropped back into the abdominal
cavity.
After the lapse of one hour, the animal being kept under
the anaesthetic for the entire period, the clamps were removed
and the incisions closed. Rabbit I was killed at the end of 24
hours ; rabbit II at the end of 48 hours. The pelves of both
kidneys, portions of the ureters and the urinary bladder were
then examined macroscopieally and histologically. There was
no change whatever in any of the cellular structures except a
certain amount of hyperemia produced by pressure upon
the ureteral vessels. Great care was taken to find some evidence
of necrosis or edema of the epithelium, but none could be found
in any of the tissues. Increasing strengths were then used, and
as soon as a greater concentration than 49f was reached,
changes began to manifest themselves in the epithelial structures
in the nature of a cellular destruction, which reached a true state
of marked general necrosis at a concentration of 7/f.
From these animal experiments we may conclude that a 2%
dilution of the liquor has no harmful effects upon the mucosa of
the urinary tract. Whether or not the same degree of acidity
in terms of NaOH of acetic acid will act in a . like manner is now
being determined. The penetration power of both the liquor
aluminum acetate and the acetic acid in addition to the histo-
logical study of experimental pyelitis and cystitis will be re-
ported in a subsequent communication.
CLINICAL OBSERVATIONS
The clinical application of these results was now undertaken,
and with such uniform and excellent results that I will report
somewhat in detail a few of the more interesting cases. The
cases are divided into three groups : First, those having unilateral
pyelitis : second, those having cystitis, and third, those having
urethritis — a total of 27 cases. In each case a bacteriological
examination by culture Mas made of the urine before the treat-
ment was instituted, and the colon bacillus found in every in-
stance except one in pure culture. In the urethritis cases the
discharge was examined bacteriologically and in every instance
cited the organism found in pure culture.
The pyelitis cases, 7 in number, were treated by lavage with
the 2c/c liquor aluminum acetate and three grams of the aluminum
Mibacetate made into one-half gram tablets, two tablets given
COLON BACILLUS INFECTIONS
after meals. The lavage was carried out in the usual way, wash-
ing until the return fluid came away clear, then injecting about
10 c.c. of the solution and withdrawing the catheter. The
treatments were repeated at intervals varying from 2 to 5 days,
depending upon the reaction produced by the introduction of
the cystoscope. The longest period of treatment was 3 months,
the shortest two weeks. In every case a culture from the urine
was sterile and the leucocytes cither entirely gone or reduced to
very few before the treatment was stopped.
Previous to the treatment the duration of the infection, judg-
ing from the patients' histories, varied from 1 to 8 months.
No unpleasant symptoms from the lavage developed in any case.
The usual pain associated with these infections disappeared after
the second or third washing. Only one patient was confined to
the hospital, on account of difficulty in urinating after the
cystosocopy.
Up to date there has been no recurrence, as I am in constant
touch with all of the patients. The first case was treated 13
months ago. Two cases permit me to report to you more in
detail :
I. Male, 27 years of age. Three years ago had a left nephro-
lithotomy. Uneventful recovery. Two years later, following
an attack of influenza, a severe pain developed over the left lum-
bar region. Temperature 101 . Urine very turbid, slightly
alkaline, loaded with pus, and a pure culture of colon bacilli ob-
tained. Patient was sent to the Michael Reese Hospital. Hot
fomentations applied, urotropin grs. v., given three times a day.
Auto-vaccines made and large doses given. No improvement at
the end of one week. Then left pelvis irrigated with 2/ % liquor
aluminum acetate, vaccines and urotropin stopped and the tablets
of subacetate substituted. Two days later a second irrigation
given. At the end of 5 days the pain and tenderness had en-
tirely disappeared, the urine was much clearer, though the colon
bacilli were still present. The patient left the hospital at the
end of the fourth week, having had 10 irrigations. Urine sterile
and showing only an occasional leucocyte. No recurrence at
the end of 12 months.
II. Male aged 47. Five years, ago an attack of acute nephritis
following a lobar pneumonia. Eight months previous to con-
sulting me patient had a constant pain over the right lumbar
region, and occasionally had chilly sensations. He thought this
was due to his "run down" condition from overwork and did not
422 THE AMERICAN JOURNAL OF UROLOGY
consult a physician. When first seen he had distinct rigidity
and tenderness over the right kidney. Temperature 100°.
Urine very turbid ; contained large casts of pus and a vigorous
colon bacillus culture was obtained. Pelvic lavage was at once
advised but. the patient would not consent. So he was put on
urotropin and autovaccines and kept on the treatment for 6
weeks, with little or no improvement "which could in any way
be attributed to the vaccine therapy," to use the words of
Geraghty.:} The patient was finally induced to submit to the
pelvic lavage and there was a most remarkable change in the
urine in 10 days. It took 9 treatments, however, extending
over 4 weeks time, before the urine became sterile. Eight months
have elapsed and the patient has remained quite free from any
urinary disturbance.
The cystitis cases 8 in all, varied in age from 24 to 84 years.
Duration of the infection previous to the treatment, judged
from the patients' histories, extended over a period varying from
one week to several years. The shortest time required to give
a sterile urine and complete cessation from symptoms was 10
days.
The treatment consists in irrigating the bladder with either
sterile water or boracic acid solution until the return washings
were perfectly clear. This was followed by an instillation of
from 60 to 120 c.c. of the %(/c liquor, which was left in the blad-
der until expelled by the succeeding urinary act. These irriga-
tions are carried out from 2 to 4 times in the 24 hours, accord-
ing to the severity of the inflammation, whether it is acute or
chronic, and in accordance with the length of time the patient
can retain the liquor. In addition to these irrigations the
aluminum subacetate is administered by mouth. Rectal sup-
positories of opium, belladonna, and ichthyol are used for
tenesmus and frequency. The Sitz bath and other measures com-
monly adopted in vesical inflammations are employed. In the
most severe cases there was a marked relief in 36 to 48 hours,
and the urine showed very rapid changes going back to normal
appearance in a very few days.
Two cases follow more in detail :
I. Male, aged 84. Had never had any urinary disturbance
up to about two weeks before I saw him, when he suddenly de-
veloped marked frequency and very severe tenesmus. The
urine was very foul smelling, strongly alkaline, full of pus and
pure culture of colon bacilli obtained. There was about 60 c.c.
COLON BACILLUS INFECTIONS
Remarks.
Nephrolithotomy three
years ago.
Urotropin and vaccines
tried unsuccessfully.
Right nephrolithotomy, 6
months previously.
Urotropin and vaccines
used ineffectually.
Advised nephrotomy.
Pain entirely gone.
Urotropin and vaccines
used unsuccessfully.
Urinalysis when Treat-
ment was Stopped.
Culture sterile.
Occasional leucocyte.
Culture sterile.
No leucocytes.
Culture sterile.
Occasional leucocyte.
Culture sterile.
Occasional leucocyte.
Pure culture staphylo-
cocci. Leucocytes, 15 to
20 to field.
Culture sterile.
Leucoctyes 6 to 8 to field.
Sterile culture.
No leucocytes.
Urinalysis before Treat-
ment.
Pure culture B. coli.
Very many leucocytes.
Pure Culture B. coli.
Very many leucocytes.
Pure culture B. coli.
Leucocytes 20 to 40 to low
power field.
Pure culture B. coli.
Leucocytes 20 to 40 to low
power field.
Leucocytes. Culture of colon
and staphylococci.
Pure culture B. coli.
Leucocytes.
Pure culture B. coli.
Leucocytes.
Duration of
Treatment.
Four weeks.
Two and a
half months.
Six weeks.
Three and a
half weeks.
Two months.
Two weeks.
One month.
Kidney
Affected.
Left
Right
Right
Right
Right
Right
Duration of
Symptoms
before treat-
ment was
started.
About four
weeks.
About eight
months.
Several
months.
Several
weeks.
Ten months.
Six months.
Few weeks.
Sex.
Male
Male
Male
Male
Female
Female
Female
Age.
fc- fcr © O M5 OS «5
©1 CO
6
%
rH CO Tj? >6 CO t-'
COLON BACILLUS INFECTIONS
425
residual. The median lobe of the prostate was encountered by
the prostatic catheter. Rectal examination negative. Sup-
positories, Sitz baths, urotropin and irrigation with 1 :10,000
oxy cyanide of mercury (this was before I began the use of the
aluminum acetate) relieved the condition after about two weeks.
The urine still gave a pure culture of colon bacilli. The patient
was discharged and told to notify me on the least sign of the
return of any symptoms, which he failed to do until several days
after an acute exacerbation. The other irrigations were then
started and in about three and one-half weeks the urine became
sterile and has remained so since.
II. Virgin, aged 24. Claims that she has had bladder symp-
toms since she was 14 years old, in the nature of frequency and
tenesmus more or less pronounced. During the day she uri-
nates every hour, sometimes every half-hour, and must get up
from one to three times during the night. The urine was very
turbid, full of pus and shreds of mucosa. Pure culture of colon
isolated. Cystoscopy had to be done under nitrous oxid
anaesthesia, because the bladder would not hold more than 30
or 40 c.c, without producing tenesmus. The picture was that
of a chronically inflamed, contracted bladder with numerous
punctate erosions. After 2 weeks of irrigations and general
treatment, the patient would go one and a half to two hours
without urinating. At the end of four and a half weeks the
urine was sterile, micturition not more often than two and a half
hours and seldom during the night was she disturbed at all. No
recurrence at the end of six and a half months.
Not less interesting is the group of 12 cases of urethritis.
The ages ranged from 19 to 38. Duration of discharge previous
to acetate treatment varied from 4 days to 8 years. In 4 of
the cases there was no history of gonorrhoea.' One patient pre-
sented himself with a profuse waterly discharge 4 days after
coitus. Microscopic examination and culture showed the colon
bacilli in great abundance, which disappeared in 36 hours fol-
lowing the injections.
The treatments consist in giving an anterior and posterior in-
stillation with either the Guyon or Ultzman syringe every other
day, and giving the patient a 1 to 2% solution to inject twice
daily, with the ordinary glass urethal syringe, instructing him
to retain the injection 15 to 20 minutes. If the case is stub-
born, any enlarged glands or inflammed points with full strength
liquor through the Vallentine urethroscope. As soon as the dis-
charge fails to show the presence of the bacilli, an astringent is
426 THE AMERICAN JOURNAL OF UROLOGY
substituted for the liquor. If the discharge is only the "morn-
ing drop" the patient is given a couple of slides to make a smear
which is examined the next time he presents himself for treat-
ment.
I. Eight years ago contracted gonorrhoea. Following the
disappearance of the gonococci there was intermittently a dis-
charge, sometimes profuse, sometimes only present in the morn-
ing. Frequently it was thick but white in color. First glass of
urine turbid and full of "tripper-faeden." Bacteriological ex-
amination showed the colon bacilli in abundance. Seventeen
days after the instillations were begun the patient was entirely
free from the discharge. Two weeks later no shreds appeared
in the urine and culture was negative. No recurrence after 6
months.
II. Eight months ago had slight attack of gonorrhoea which
lasted only 2 weeks. Discharge recommenced in a few days,
continuing constantly up to the time that the patient came to
me. Repeated examinations of the discharge taken at various
hours of the day showed only the colon bacilli, proven by cul-
ture. Twenty-seven days of treatment were necessary to pro-
duce a sterile urine, with no shreds and no discharge. No re-
currence at the end of 4 months.
SUMMARY
From the experimental work described, we may conclude that :
1. Liquor aluminum acetate in a dilution of cZc/c is an active
germicidal and antiseptic agent to the colon bacillus and the
colon group of bacteria.
2. Liquor aluminum acetate in %c/c dilution has no deleterious
effects upon the mucous membrane of the urinary tract.
3. The germicidal and antiseptic properties are due to the
acid radical of the drug, as proven with the experiments with
acetic acid.
4. Whether or not the acetic acid produces any untoward ac-
tion upon the mucous membrane of the urinary tract will be re-
ported upon in a subsequent communication.
5. The internal administration of the subacetate of aluminum
raises the total acidity of the urine, which is desirable in deal-
ing with the colon bacillus infections of the urinary tract.
The clinical observations lead us to believe that :
1. Colon bacillus infections of the kidney pelvis, urinary blad-
der and male urethra are more promtply ameliorated by the %%
428 THE AMERICAN JOURNAL OF UROLOGY
liquor aluminum acetate than by any therapeutic measure pre-
viously used.
2. The bacteria in the urethral discharge disappear in from
36 to 48 hours following the instillation with the liquor, but other
astringents may be necessary to "dry up" the discharge.
S. Care must be exercised in the preparation of the liquor
aluminum acetate as an excess of free acetic acid will produce
unpleasant subjective symptoms. The solution must not be
more than a week to ten days old when used.
4. The liquor aluminum acetate is of value only in those
cases where the presence of the colon bacillus is proven by cul-
tivation under the most careful aseptic precautions.
CONCLUSIONS
We all well know that in medicine more than in any other
branch of science facts, to be of value, must be based upon a
greater number of successfully treated cases than herein cited.
So I appreciate keenly, that 27 cases do not solve a problem that
has perplexed modern urology. I present the results of my ex-
perimental work and clinical observations for what they are
worth and ask those of you who are interested in this subject
to cooperate with me in the attempt to further prove or dis-
prove the value of the foregoing treatment in combating colon
bacillus infections of the urinary tract.
In concluding, I wish to express my gratitude to Dr. J. W.
Jobling, Pathologist to the Michael Reese Hospital, for his un-
tiring assistance; and to Dr. Sol Strouse? his associate, for his
many valuable suggestions.
In addition, I want to thank Drs. L. A. Greensfelder and I.
A. Abt for the privilege of utilizing their clinical material at the
Michael Reese Hospital.
1010 Coi-rMurs Memorial Builtoitg.
LITERATURE
1. Dreuw: Dent. med. Klinik, March, 1010.
2. National Formulary: Preparation of Liquor Aluminum Acetate.
3. Geraghty: Trans. Am. Assoc. Genito-Urinary Surgeons, 1910, p. 28 2.
4. O'Neil: Trans. Am. Assoc. Genito-Urinary Surgeons, 1910, p. 233.
5. Cabot, H.: Trans. Am. Assoc. Genito-Urinary Surgeons, 1910, p. 288.
G. Rostoski: Dent. med. Woeh., 1898, vol. 24, p. 235 and 249.
7. Bond: British med. Jour., 190T, vol. 2, p. 1639.
8. Stern: Muenck, med. Woch., Nov. 1, 1910.
9. Casper: Zeitschr. f. Urol., April, 1911.
10. Pedersen: N. Y. Med. Jour., March 11, 1911.
11. Abt: /. A. M. A., Dec. 14, 1907.
12. Brenneman: /. A. M. A., Mar. 4,- 1911.
FILARIA BANCROFT! INFECTION
429
UNILATERAL CHYLURIA DUE TO FILARIA
BANCROFTI INFECTION.
By David J. Kaliski, M.I).
Assistant in Serum Research, Mt. Sinai Hospital; Assistant in the Department
of Genito-Urinary Diseases, Mt. Sinai Hospital Dispensary, New York.
INVASION of the blood of man by the plana bancrofti is of
especial interest to the genito-urinary surgeon on account
of the frequency with which patients affected with this
nematode show lesions of and symptoms referable to the organs
of the genito-urinary apparatus.
Chyluria, chylocele, lymph-scrotum, elephantiasis of the
scrotum and varicose inguinal and femoral glands are more or
less common in tropical regions where filariasis is endemic, and
are occasionally encountered in temperate climates in natives of
the tropics who have emigrated. A few cases are on record as
occurring in Europeans who have never visited the regions where
infection with this nematode is common. In the past five years
the writer has seen five cases of plaria bancrofti infection ac-
companied by more or less grave involvement of one or more
of the genito-urinary organs.
A brief review of the life-cycle of plaria bancrofti will ren-
der the pathogenesis of the various lesions more intelligible.
The adult worms inhabit the lymphatics of the trunk and ex-
tremities. The sexes are usually found in conjunction, and the
embryos, termed by Manson the microfilaria, are born in the
lymph that bathes the parents. The embryos find their way
into the blood stream via lymphatics, traversing the lymph
nodes and thoracic duct. It is only at night that the micro-
filaria circulate freely, those born during the day presumably
finding lodgement in the lungs and larger blood vessels of the
thorax. The microfilaria commence to appear in the blood at
dusk, increase in numbers up to midnight, diminish in numbers
in the early morning hours, gradually disappearing from the
circulation before the individual arises. The embryos can read-
ily be found in a drop of blood from a needle-prick if examined
with an objective of moderate power. The blood is prevented
from clotting by adding a drop of normal salt solution or one
per cent, sodium citrate in normal salt solution. In individuals
who sleep during the daytime this periodieity is usually reversed.
In the case detailed below the microfilaria were found at night
when the patient slept at night, and on a number of. occasions
when in the alternation of his work as elevator-runner he worked
430 THE AMERICAN JOURNAL OF UROLOGY
at night and slept during the day, the embryos were found dur-
ing the day.
If a person harboring the parasite is bitten at night by
any of a number of species of mosquitoes, the microfilaria are
imbibed by the insect, and undergo further metamorphosis in
the body of the female. This process takes from six to twenty
days according to the observations of Manson, when the para-
site is ready for transfer to the human host by the insect. The
further development after it reaches this host through the bite
of the mosquito has never been described.
The microfilaria may circulate in the blood of a person for
years without giving rise to any appreciable symptoms, and ap-
parently without harm to the host. However, in a certain per-
centage of cases* " by an intertwining of a number of the parent
worms in the lymphatics or due to the stenosis caused by their
presence," in say, the thoracic duct, the latter becomes occluded,
and there occurs a rise of pressure and a stasis of lymph in the
lymphatics below this point. Relief is obtained by anastomosis
with the thoracic lymph vessels in a recurrent course by way of
the pelvic lymphatics, through the inguinal and upper femoral
vessels, and over the dorsal and abdominal regions of the bod}'.
This dilation, combined with rise of pressure in the lymphatics
may cause rupture. If it involves the renal or vesical vessels
chyluria results, while if the lymphatics of the inguinal or fe-
moral region, tunica vaginalis or scrotum are involved, varicose
inguinal or femoral nodes, chyloccle or lymph-scrotum respec-
tively ensues.
Elephantiasis is explained by Manson as due to prema-
ture birth of the embryo due to an injury to the part harboring
the adult worms. Instead of motile slender fully-grown em-
bryos, non-motile broader ova pass into the lymph stream, block
up the vessels and nodes in all directions, and combined with at-
tacks of local inflammation give rise to the condition of ele-
phantiasis.
Chyluria occurs in both sexes following strain or injury
and in women occasionally comes on after pregnancy. The
urine is turbid and milky in color. It is sometimes salmon-col-
ored or distinctly bloody (hemato-chyluria) , and from time to
time contains smaller and larger clots of coagulated urine with
or without an admixture of blood. In the passage of these
clots from the kidney or bladder the patient may experience all
Manson in Allbutt and Rolleston's System of Med.
FILARIA BAXCROFTI INFECTION
431
the painful sensations of an attack of renal or vesical colic.
Otherwise the only subjective symptoms are dragging and ach-
ing pain in the back, pubic region and loins, and these are only
very occasionally complained of. Spontaneous coagulation of
the entire bulk of urine in the bladder has occurred with com-
plete retention of urine. The urine may be turbid in the morn-
ing and clear up in the course of the day or the reverse. The
condition may persist for days, months or years. It may dis-
appear after months or years probably due to a closing of the
fistula between the organ and the lymph varix or on account of
the opening of collaterals, frequently reappearing from the in-
cidence of causes that originally brought about the rupture.
The daily fluctuation of chyluria and clear urine has been ex-
plained by Magnus-Levy on a mechanical basis. In about a
third of the cases cited by him the urine was turbid for the
greater part of the day, and in a majority of the remainder the
urine was turbid only at night or when the patient was in a re-
clining posture. A few presented chyluria only when in an up-
right posture. This may be attributed to an insufficiency of the
valves of the vessels when the body is reclining or to a closure
of the communication between the varix and the urinary organ
involved.
The point of opening of the chyle-fistula into the urinary
tract has been demonstrated during life by cystoscopic exam-
ination and ureteral catheterization and rarely by autopsy.
Havelberg found a communication between the bladder and a
lymph varix at autopsy and Liickes demonstrated a similar com-
' munication by means of cystoscopy. A number of observers
have shown by cystoscopy that the bladder was normal, the
chyle finding its way into the kidney pelvis or ureter on one or
both sides. In my case the communication was between the right
kidney as in the cases of Magnus-Levy and of Heuk. The break
probably takes place into the pelvis of the kidney rather than
into the ureter which is thicker-walled than the pelvis. In
Port's case the pelvis at autopsy was filled with chylous fluid.
In most of the cases of chyluria no renal involvement was made
out so that it is unlikely that the fistula enters into this organ.
At no time was I able to find renal elements or casts in the urine
of my case.
Chylous urine may contain as high as 3 to ^\c/c of al-
bumin, and on being voided may clot spontaneously. The fat
content depends to a certain extent upon the diet, usually being
432 THE AMERICAN JOURNAL OF UROLOGY
about one to two per cent., occasionally as high as 10 or 14%
as .in a case of Gallois. It also to a certain extent upon the
size of the fistual into the urinary tract and the hydrostatic
pressure causing the emptying into the urinary tract of lymph
from the lymphatics, rather than the damming back of chyle
from the thoracic duct. Besides these elements, the chylous
urine contains salts, especially NaCl, cholestearin and lecithin,
and occasionally some blood. On centrifugalization of the chyl-
ous fluid numerous microfilaria are usually found in the sedi-
ment, and finely granular lymph corpuscles or fine droplets of
fat. The total amount of chyle voided in tAventy-four hours
varies greatly ; reaching as high as one litre in a case of Franz
and Steyskal, or about one-third of the total amount passing
through the thoracic duct in a day (Magnus-Levy). Thus it
is apparent that the condition in persistent cases is apt to cause
marked debility and inanition, rendering the patient particu-
larly susceptible to invasion of an intercurrent infection as in
my case.
Most cases of chyluria are due to the presence of the filaria
bancrofti, but rarely cases are found due to the presence in the
kidney or lymphatics in this region of the Eustrongylas gigas.
Casper reported such a case in which the eggs of this parasite
were found in the urine, and the chyle found issuing from one
ureter. In some of the cases of European chyluria in which
the filaria could not be found either before or after death, the
communication was attributed to mechanical causes. In lipuria
due to dietetic causes fat is found in the urine, but the other
elements of true chyle are lacking, especially the albumin, and
the fat droplets are larger than the finely granular lymph cor-
puscles.
In lymph scrotum the part is enlarged and swollen, and on
the surface are found larger and smaller vescicles filled with
lymph in which the microfilaria may be found. Attacks of local
inflammation and fever often accompany the condition which
may subside or frequently recur, elephantiasis of the scrotum
eventually ensuing. The above condition may coexist with vari-
cose inguinal and femoral lymph nodes on one or both sides.
These doughy, lobulated masses may be mistaken for herniae.
Differential points are the following: the masses arc flat on per-
cussion and never tympanitic, they are not reducible on pres-
sure, there is usually no impulse on coughing, and finally aspira-
tion reveals the presence of lymph and often the microfilaria.
FILAR I A BANCROFTI INFECTION
433
The fluid may coagulate spontaneously and under the micro-
scope the finely granular fat globules are found and occasionally
the microfilaria.
Chylocele is simply a chylous hydrocele, the tunica vaginalis
being filled with the fluid frequently referred to above. The tu-
mor is opaque and doughy, and frequently coexists with varicose
inguinal or femoral nodes.
Before entering into a discussion of the therapy of these
conditions, I shall briefly recite the history of a case of fUaria
bancrofti infection in which persistent chyluria was the dom-
inant factor.
The patient was 34 years old, a native of the West Indies,
living in this city for about four years. The past history was
negative, excepting an attack of measles in childhood. About
eight years ago he noticed that his urine was milky and occa-
sionally slightly bloody. While resident in the tropics there
were periods of three to four months at a time when the urine
was normal in color. For the past four years while living in
this city the urine was milky the greater part of the time and
frequently was bloody and contained small clots. The patient
occasionally experienced aching pain in the lumbar region ra-
diating down into the pubic region and thighs. On a number
of occasions during the past few years he underwent severe at-
tacks of pain in the back and lower abdomen, radiating down
the thighs and into the penis, simulating renal colic. He felt
chilly frequently and often feverish. For the past year he was
slowly losing strength and weight.
An examination of the patient revealed an individual in
fairly good health, with a hemaglobin of 80r/r, 4,000,000 red
blood cells and 7,500 leucocytes. A differential count of the
leucocytes showed a normal relationship between the types of
cells with three per cent, of eosinophiles. On a number of occa-
sions I was able to demonstrate in the blood between the hours
of six p. m. and midnight the microfilaria nocturna, the embryo
of the filaria bancrofti. On a few occasions in which the patient
retired at noon, the microfilaria were found in the morning after
eight o'clock. The urine voided was usually quite turbid and
often distinctly blood-tinged and contained yellowish and red-
dish clots up to the size of small pea. The milky urine usually
cleared up on shaking with ether. It contained a varying
amount of albumin and usually a large amount of fat. The
urinary sediment contained besides the usual urinary elements,
434 THE AMERICAN JOURNAL OF UROLOGY
lymph corpuscles, a smaller or larger number of red blood cells,
and occasionally the microfilaria nocturna still actively motile
if the urine was examined soon after it was voided or motionless
if the urine was preserved for some time.
Cystoscopic examination of the bladder revealed a normal
bladder mucous membrane. The trigone region and ureter
mouths showed nothing abnormal. The efflux from the left
ureter showed clear urine. The efflux from the right ureter
can best be likened to a sudden puff of cigarette smoke blown
from between the tightly-pressed lips. The ureter opening was
visible for a few moments only, since the ejaculated turbid urine
soon rendered obscure the landmarks in the bladder. Two or
three spurts from the ureter were sufficient to cause this. On
catheterization of the left ureter I obtained a clear slightly
acid, light amber urine of a specific gravity of 1010 which was
normal on chemical and microscopical examination. Catheteri-
zation of the right ureter showed a typical chylous urine, free
from macroscopic blood, slightly alkaline in reaction, a part of
which coagulated spontaneously. No sugar was found. There
were a few red cells and leucocytes and a few microfilaria. In
three minutes about five cubic centimeters of milky urine were
obtained from the right kidney. The catheter was introduced
as far as the pelvis of the kidney, thus proving that the com-
munication was into the pelvis of the kidney or kidney proper.
In an attempt to control or modify the course of the in-
vasion of the blood stream by the parasite, I injected the pa-
tient with 0.6 gram, of salvarsan intravenously. Through the
courtesy of Dr. Goldenberg, the attending dermatologist of Mt.
Sinai Hospital, I was permitted to admit the patient for a day to
the dermatological service, for this purpose. Following the in-
jection there was a severe chill and rise of temperature to 1033,
but within a few hours the patient was as well as before the in-
jection. Within a few days after the exhibition of the drug the
embryos were found in the blood in about the same numbers as
before the injection. The urine cleared up, however, and was
free from all trace of chyle for about six weeks.
About one month after this procedure the patient was sud-
denly taken with a severe chill combined with fever and pain in
the right chest following exposure to cold. An examination of
the chest revealed a dry pleurisy which, in the course of a week,
developed into a full-blown sero-fibrinous pleurisy. About five
hundred cubic centimeters of a clear, straw-colored fluid was
FILAR I A BANC ROFTI INFECTION
435
aspirated from the chest. The effusion reaccumulated within
a few days, and the patient was admitted to the first medical
service of the Mount Sinai Hospital. I am grateful to Dr.
Rudisch, the head of this service, for permission to use the hos-
pital notes of the subsequent course of the case.
On admission to the hospital the physical examination re-
vealed a fluid exudate in the right chest. Except for a general
enlargement of all the palpable glands and of the prostate, the
remainder of the examination was negative. The temperature
showed irregular slight elevations between 99 and 100". A
marked Pirquet reaction was obtained. A litre of fluid was as-
pirated from the chest. Neither on this or the previous aspira-
tion could the microfilaria be found in the chest fluid. After a
stay of ten days in the hospital the patient was discharged with
no trace of the fluid exudate in the chest. For a period of about
two months, although free from all active symptoms, the patient
complained of a progressive loss of strength. The chyluria
returned soon after his discharge from the hospital and was as
bad as ever. He was readmitted to the hospital complaining of
progressive asthenia, night sweats and hemato-chyluria. Ex-
aminations revealed the signs of a small amount of fluid at the
right base and disseminated signs suspicious of tuberculosis
throughout the entire upper right chest. The temperature was
irregular and remittent in type, ranging between 100° and
103.6 . The hemoglobin had dropped to 51". The blood' cul-
ture was negative, aerobically and anaerobically. The patient
declined very rapidly in strength, and died of asthenia two weeks
later. On numerous occasions during both stays in the hospital
the microfilaria were demonstrated in the urine and in the blood.
A partial and unsatisfactory post mortem examination was
made, and unfortunately it was not possible to make an effort to
trace the communication between the urinary tract and the
lymphatics.
A general, disseminated miliary tuberculosis was found, all
the organs being riddled with small miliary abscesses. In one of
the small abscesses of the kidney tubercle bacilli were demon-
strated. No macroscopic or microscopic evidence of a chronic
nephritis was obtained. The bladder mucous membrane was
normal. The prostate contained a large caseous mass in the
left lobe.
As to the prognosis of the disease much depends upon the
severity of the complicating factors. It was stated above that
436 THE AMERICAN JOURNAL OF UROLOGY
the embryos may circulate in the blood for years without harm
to the host. The occurrence of any of the complications of the
disease puts a different aspect of the case before us for consid-
eration. Chyluria causes a severe drain on the system, and
eventually the sufferer may succumb to some intercurrent infec-
tion, e. g., tuberculosis, as in the case recited above. Chylocele
and varicose lymph glands may disappear spontaneously, es-
pecially if the " milky hydrocele " is tapped. Lymph scrotum
is usually a distressing condition lasting for years, rarely bene-
fitted even by radical surgical removal of the organ, which may
be followed by elephantiasis of the leg and chyluria.
The treatment of this disease is very unsatisfactory. It
was hoped that salvarsan might prove a useful weapon to de-
stroy the parent worms in their nidus in the lymphatics. A pre-
liminary favorable report by Pilchcr in a case in which the filaria
was not demonstrated in the blood (a condition of chylous-like
pleurisy with effusion), led me to use this drug in my case. The
results were unsatisfactory. More than one injection could not
be given on account of the extreme weak condition of the patient.
In robust individuals two or three injections each of 0.6 gram
may be tried. A warning should here be sounded against draw-
ing definite conclusions from the clearing up of the urine after
the injection of the drug. In my case the urine remained clear
for more than a month, but the patient had known similar periods
of clear urine in the absence of all treatment. The only definite
proof of the cure of the condition by the exhibition of this or any
other drug would be the continued freedom from symptoms or
signs of the disease and the absence of the microfilaria from the
blood for an extended period.
The recumbent position with the hips raised, as recom-
mended by Manson, for a long space of time, until the urine is
clear of chyle and free from albumin, even after giving large
amount of milk in the diet, may bring about a cure of the condi-
tion. Many drugs have been used without any beneficial effect
upon the disease. In the Indies turpentine is a favorite remedy ;
also thymol, salicylic acid and the salts of iron. The condition
of varicose lymph glands and lymph scrotum are best treated by
rest and general support of the part by a firm bandage. Sur-
gical intervention is rarely of an}' benefit. Chylocele may be
treated like hydrocele. These points in the treatment of the
disease from the work of Manson might as well be applied to
the cases of European chyluria in which the condition differs
PSEUDO-HEM APHRODITISM
437
only in the causative factor from tropical chyluria. The con-
dition is more apt to disappear spontaneously and less likely to
recur. Operative interference is almost useless on account of
the slight chance of finding the opening into the urinary tract
of the chyle-fistula. Konig performed a nephrotomy for the
removal of a Eustrongylus gigas from the kidney of a case of
chyluria in which tin- eggs were found in the urine. The para-
site was not found and the condition was uninfluenced for the
better by the procedure.
Literature.
Magkus-Levt -t- Zeitschr. fur Klin. Med. 66, 482, 1908.
K. Franz and K. V. Steyskal — Prayer Zeitschr. f. Heilk. 23, H. 11,
1 90-J.
Haveijierg — Virchow's Archiv. Vol. 89, 3C.5, 1885. .
Uevk — Dernuit. Zeitung, 15, 706, 1905.
Hevk — Dermaf. Zeitung, IS, 85, 19(H).
Port — Zeitschr. f. Kiln. Med. .39, 4.5.5, 19CG.
Gallon's — Jo urn. de. Pharm. et Chim. iv., 20, 561, 1904.
Ludke — M unch. Med. Woch. 1908, p. 1369.
Maxsox — Allbutt and Rolleston's System Med.
Pilch.er, P. M. and J. F., — N. Y. Med. Record. 1911, 79, ]). 434.
PSEUDOHERMAPHRODITISM— REPORT OF A ( ASK
By Henry .1. Scherck, B.S., M.D.
Of the Department of Genito-Urinary Surgery, St. Louis University School
of Medicine; Visiting Genito-Urinary Surgeon to the City and Missouri
Pacific Hospitals; Chief, Department Genito-Urinary Surgery, Jewish
Hospital Dispensary.
THE members of this association will, no doubt, be inter-
ested in the accompanying photograph and description of
the genitals of an individual who was brought to my at-
tention through the courtesy of Dr. Thomas A. Hopkins of St.
Louis.
The case is of such extreme interest to me that I feel cer-
tain that a brief report of the result of my examination will
prove a sufficient excuse for reporting it. He announced him-
self as a Miss (?) X., age 41: nativity, United States. The
individual since childhood has always been healthy and has suf-
fered only from the ordinary diseases of childhood. At 13 he
claims to have menstruated through the vagina, this continu-
ing until he arrived at the age of 18 years : since that time he
lias seen no sign of menstruation.
* Read before the American Urological Association, Chicago, September,
1911.
438 THE AMERICAN JOURNAL OF UROLOGY
He acknowledges having masturbated quite a great deal
for a number of years, and says that he has a distinct organ at
the sexual climax, discharging a quantity of " sticky " substance
from the meatus at that time. I have had the opportunity of
examining this discharge and find it free of spermatozoa.
He has always believed himself to be a female — his life has
been spent in those duties which are usually associated with the
female sex. This individual is about 5 feet 11 inches tall, rather
strong, though feminine; hair on head iron gray; no hair on
face ; his arms and legs are not distinctly feminine in conforma-
tion; on the contrary, they are rather inclined to the masculine
type : his hands and feet, very large. The conformation of the
pelvis is neither markedly masculine nor feminine. The breasts
are flat and masculine in appearance, though devoid of hair.
He states that one breast was for a time considerably larger
than the other, but that it has gradually shrunken until there
is now no marked difference between them. Beyond these points
there is nothing noteworthy in his conformation except what is
PSEUDO-HEM APHRODITISM
439
developed in the genital examination, which reveals the following:
The pubis is well covered with hair ; the upper margin is
horizontal and does not incline upward in the middle line, the
female type. In place of the clitoris is a well-marked penis, two
and one-half inches in length when in a flaccid condition : on
erection he states that it doubles in length ; the glans is well-
developed and the corona distinct, there is a marked hypospadias
of the glandular portion of the penis. The labia minora extend
downward only about two inches and cover the penis above, re-
sembling in appearance the normal prepuce. Below the penis
for 1-J inches is a space which leads to a rudimentary vagina
above and close to the opening of which is the urethral opening.
The vagina is only three inches deep and ends in a blind pouch
— no cervix can be felt — the rugae are well marked throughout
this rudimentary vagina. A rectal examination was then made
to determine the presence of a uterus, but I could not determine
any, though anterior to the lower portion of the rectum a small
body fixed in position about the size of a chestnut could be felt
which in every way answers the description of the prostate.
The anus and rectum are normal. As the labia majora de-
scend on either side they appear loose, resembling, when brought
together in the median line over the underlying vagina, an ordi-
nary scrotum. They contain testes of normal size and shape,
the right being larger than the left. The feeling of these two
organs is identical to the normal testicles. The vasa can be
distinctly felt running upward to the ring. On the posterior
surface of these two ovoid bodies in the labia majora can be felt
what resembles in every particular an epididymis. On the right
side he tells me that at one time it became very much swollen
and a modular epididymis can now be felt on that side.
He claims never to have undertaken or allowed sexual inter-
course with either male or female.
The case is one which judged from the sexual organs,
demonstrates the person a male, though this is doubted by a
competent observer in our city, who takes the position that the
bodies in the labia majora are ovaries, but we have yet to learn
how he explains the other definitely male development.
309 Century Building.
1U) THE AMERIC AN JOURNAL OF UROLOGY
Genito-Urinary Pathology
Pathology of Hydronephrosis. Joest, Lauritzen, Deger
and Brwecklmayer : (Beitrage zur Vergleichenden Pathologie der
Niere), Frankfurter Zeitschr. f. Pathol., 1911, p. 35. As part
of a comparative scries of studies of the pathology of the kidney,
the authors give the results cf a thorough investigation of the
subject of hydronephrosis in swine. Occurring not infrequently
in these animals owing to certain anatomical peculiarities in the
disposition of the neck of the bladder, ureters and symphysis
pubis, it was possible to collect quite a goodly number of spec-
imens at the Dresden slaughter house. Casts of the renal
pelvis and of the vascular distribution were made by injection,
and corrosion specimens were obtained. A careful microscopical
examination of both pelvis and parenchyma was also part of
their work. Moderate dilatation manifests itself first in a
flattening of the papilla, and in a broadening of the secondary
calices (calices minores). Later follow the changes in the
primary calices and pelvis. Thus the smaller calices become
elliptical and then spheroidal hand in hand with the expansive
phenomena in the pelvis. The compression of the papillae, so
that they even recede behind the columns of Bertin, and later
their excavation, are the most important primary changes. The
columns of Bertin tend to remain intact much longer than the
papillae and adjacent cortex, and in the higher degrees of hy-
dronephrosis, form the connective tissue septa separating the
spheroidal cavernous or cyst-like spaces.
Microscopic examination reveals the fact that a chronic
inflammatory process goes on in the parenchyma pari passu
with the mechanical pressure effects due to stasis. As a result,
the compression of the vessels (that is in part responsible for the
atrophy of the kidney substance) is thereby enhanced by a new
factor, resulting in a more rapid atrophy of the tissues, so that
finally a dense connective tissue envelope, representing a fusion
of the fibrous kidney capsules, and sclerotic fibrous parenchyma,
is all that remains to cover the expanded pelvis and calices.
Excellent plates of casts taken from specimens of varying
degrees of hydronephrosis accompany the author's paper.
They are worthy of careful attention since they give us valuable
hints in the interpretation of the pictures obtained by pyelo-
GENITO URINARY PATHOLOGY
441
radiography, a method that is already regarded as one of the
most important aids in the diagnosis of renal lesions.
Nephrolithiasis ix Infants. Joseph, H: Yir chow's Archiv.
1911, CCV, p. 335. Although many pediatrists agree that urin-
ary concretions are not infrequent in very young infants, and
Comby reports the finding of 100 cases in 600 autopsies, the au-
thor, stimulated by Ponfick (who has done such excellent work on
renal pathology), examined the kidneys of all the infants under
two years of age, in the post-mortem room of the Breslau
Pathological Institute during a period of one year. Joseph
found that 40 cases contained concretions. For the most part
these were yellow or yellowish brown granules or clumps varying
from a pin-head to hemp-seed in size. Their surface was rough,
their consistency not very hard, there often being masses com-
posed of loosely aggregated granules resembling sand. The
uric acid reaction was regularly obtainable. Microscopically
the kidneys showed no change nor did the clinical histories give
any reason to suspect that profound renal lesions were to be
expected. The microscopic examination revealed almost con-
stantly the presence of an exudative process in the capsules of
Bowman and in the convoluted tubules. An albuminous sub-
stance giving a tinctorial reaction allied to that obtainable with
fibrin, was found in the above-mentioned places. Supported by
the work of Ponfick and Kumita who detected renal changes in
many cases of lithiasis in infants, the author concludes that the
urinary concretions are in some way responsible for the exuda-
tive process in the parenchyma.
Polycystic Rudimentary Kidney. Reseno-w, G: (Polyzys-
tisches Nierenrudiment etc. J Virchow's Archiv, 1911, ccv, p. S18.
The author describes an interesting pathological condition that
was found in an autopsy on a foetus of 8 mos. Besides absence
of the anus, but slight indication of a scrotum, undescended
testes, and total absence of the right kidney and ureter, the left
kidney was remarkable. It was composed of a grape-like mass
of cysts measuring 2 cm. long, and f of an inch in the other
two diameters. The individual cysts were, transparent, closely
packed, and, for the most part, no larger than a lentil. The
bladder was represented by a strand of the thickness of a lead
pencil, and fused with the rectum, the ureter being absent.
Histological examination of the rudimentary kidney re-
vealed elements that indicated renal parenchyma, and the cysts
442 THE AMERICAN JOURNAL OF UROLOGY
must therefore be regarded as composing a degenerate kidney
anlage, or as a congenital rudimentary cystic kidney. The les-
son that can be drawn from this specimen is of considerable in-
terest from the embryological standpoint, for it is evident that
we have here a strong argument in favor of the view that the
kidney develops from two distinctly separate components. When
these fail to unite (as was the case here, since there was a total
aplasia of the lower component, the ureter being absent) then
the condition favorable for the development of a rudimentary
cystic kidney obtains.
Anomaly of the L'rixary Tract. Wooley, G., and
Broun, H.—John Hopkins Bull. July 1911 p. 221. The authors
describe in detail a specimen of unusual interest that was ob-
tained at a post-mortem examination. Extending from the
antero-mesial aspect of the upper pole of the right kidney, at
the normal site of the right adrenal, there was a distended tor-
tuous, sacculated tube which ran parallel with the right ureter,
finally entering the prostate and emptying into the posterior
urethra at the site of the sinus pocularis. Its average diameter
was about 2cm., measuring .5 cm. at the widest part. The. upper
part of this distended duct ended in a mass of tissue which was
taken (upon gross inspection), to be the remains of an atrophic
adrenal. There was no connection between the tubular struc-
ture and the kidney, ureter or bladder. Microscopic examina-
tion of sections from the sac showed that the wall was composed
of fibrous tissue with a minimal number of smooth muscle fibres,
and that there was a lining of low columnar or cuboidal
epithelium.
As to the explanation of the origin of this structure several
possibilities could be entertained. Usually we may have three
large openings in the posterior urethra, two belonging to the
ejaculatory ducts and a third being the opening of the united
Miillerian ducts. According to Pohlman the ureter may open
into the prostatic urethra. If this be true, then the mass of
tissue attached to the upper part of the tube may be considered
as the remnant of an atrophic or hypoplastic kidney, or, as the
remains of the Wolffian body. We would have to assume a mul-
tiplicity of kidneys, each with its ureter, one leading into the
posterior urethra. According to another assumption, the duct-
like structure may be the result of the persistence of the united
Wolffian duct and ureter. That we may be dealing with an
accessory ureter, is another view that deserves consideration.
CURRENT UROLOGIC LITERATURE
443
Current Urologic Literature
ZEITSCHRIFT PUR GYXAEKOLOGISCHE UROLOGIE
Vol. Ill, No. 2, September, 1911.
1. Modern Therapy in Diseases of the Uropoetic System. By
O. Kneise.
2. The Treatment of the Injured and Non-Injured Ureter After
Gynecological Operations. By W. Stoeckel.
3. Removal of Hair-pins from the Female Bladder. By P.
Hussy.
4. Notes on the above article of Dr. Paul Hussy. By W. Sto-
eckel.
2. The Treatment of the Injured and Non-Injured
Ureter After Gynecological Operations, In an exhaustive
and interesting paper, Stoeckel arrives at conclusions that may
be summed up as follows :
1. The so-called obstetrical ureteral fistulas are practically
unheard of at the present day. 2. Gynecological ureteral
fistulae are becoming more common. 3. In benign conditions in
the pelvis, injury to the ureters can be avoided with the use of
proper technic. 4. When we are dealing with malignant tumors,
injuries cannot always be avoided. 5. A healthy ureter may be
isolated for a considerable distance without injury: it may undergo
compression or kinking after such a treatment, but it does not be-
come obliterated. 6. The dissection of the ureter out of car-
cinomatous tissue is not advisable, for either secondary infection
and the establishment of a fistula results, or a recurrence of car-
cinoma in the ureter is to, bn.feared. 7. To overlook injury to
the ureter during an operation must be regarded as a .grave error
in technic. 8. A diagnosis can easily be made after the opera-
tion by means of ureteral catheterization. 9. A fistula should
be lecognized in the same way. 10. All partial ureteral fistulae
show marked tendency to spontaneous closure. 11. The fur-
ther course of cases of spontaneous healing warrants careful in-
vestigation to determine whether the patency of the ureter remains
permanently unimpaired. 12. As long as we are not certain of
the functional results of spontaneous healing, we should not take
the position of ultra-conservatism in treatment. 13. The methods
of vaginal plastic, of the extra peritoneal implantation, as well
±U THE AMERICAN JOURNAL OF UROLOGY
as implantation into the gut, should be given up. 14. Intraperi-
toneal implantation is the best procedure for all recent ureteral
injuries that are not situated too far from the bladder. 15. It
is important to make the hole in the bladder for the reception of
the ureter sufficiently large for implantation. Not a slit but a
veritable hole must be made, the bladder mucosa and bladder serosa
whipped over with suture, and the adventitia of the invaginated
ureter secured by two simple stitches to the peritoneal coat of the
bladder. Such a procedure prevents the occurrence of stenosis,
a consequence that is to be feared most. 16. Quite as important
as the preceding is the proper selection of the site of implanta-
tion, the attainment of sufficient redundancy of that portion of
the ureter which enters the bladder, and the employment of a
catheter a demeure. In selecting the site of implantation we
must do this with a view to bringing a part of the bladder wall
over and a part under the ureter. IT. Ureterorrhaphy is recom-
mended only when a small area is injured because extensive su-
ture is liable to be followed by stenosis. 18. An operative result
is to be judged as a success only from the standpoint of per-
manency. 19. A good result is one in which cystoscopy under-
taken three years after operation demonstrates a patent ureter and
normal urine. 20. Nephrectomy is indicated when infection of the
kidney has taken place. 21. The exclusion of the kidney with
ligature of the ureter and implantation of the latter into the ab-
dominal wall (where it can be opened if the ligature does not hold,
establishing a fistula) is the operation of choice when implanta-
tion into the bladder is impossible owing to extensive resection of
the ureter.
3. Removal of Hair-pins from the Female Bladdfk.
A simple method for the removal of these foreign bodies is
the use of a blunt hook which is introduced into the bladder with-
out general' anesthesia and manipulated until the operator suc-
ceeds in engaging the hair-pin at its closed end. The author
thinks that in most instances this procedure is to be preferred to
the more complicated one in which a cystoscope or Kelly tube is
employed.
(It may be permissible to add that this method is not a new
one, having been mentioned in the Handbuch der Urolog'w v.
Frisch and Zuckerkandl, vol. II, p. 689, and that it is best carried
out under the guidance of an observation cystoscope which can be
used in conjunction with the hook. L. B.)
CURRENT UROLOGIC LITERATURE
445
Specific Therapy of Renal Tuberculosis. (Weitere
Erfahrungen uber die specifische Therapie der Nierenttiberkulose ) ,
W. Karo, Mediz. Klinik, June 25, 1911.
Karo makes a strong plea for conservatism in the treatment
of tuberculosis of the kidney.. The end-results of nephrectomy
are not always gratifying, for an infection of the second kidney
is seen in many cases, and, further, the tendency to a repetition
of the tuberculosis process through the hematogenous route is
not prevented by the removal of a single focus. He therefore
recommends extirpation of the kidney only when cavernous ab-
scesses have already developed. The tuberculin treatment com-
bined with the administration of quinine lactate has given him
good results in the early cases. Of the 12 cases so treated, 11
were either completely cured, or much improved as far as the
subjective and objective signs are concerned.
FOLEY LTIOLOGK A
. Volume, VI, No. 2, July, 1911.
1. Interesting Renal Tcmors. By A. Calm.
2. Function of the Kidneys. By F. Cathelin.
3. Heminephrectomy for Horseshoe Kidney. By Th. L.
Koblinski.
Volume VI, No. 3, August, 1911.
4. Tubogonal and " Combination " Therapy in Modern
Urology. By A. Grave.
5. Pathology of Malignant Renal Neoplasms. By I. Scalone.
6. Technic of Posterior Urethroscopy. By H. Wossidlo.
7. Remarks on the Article of Prof. English on Urethral Fever.
By Bertelsman.
1. Interesting Renal Tumors. Three unusual cases of
renal tumor from the Israel Clinic (Berlin) are described by the
author. The first of these was a hypernephroma with metastases
of carcinoma in the ureter and the lung. The gross appearance
presented nothing extraordinary, but the localization of second-
ary growth in the ureter is worthy of note. Although the
question as to the origin of these tumors has been a mooted one,
(having been described by Grawitz and Bergstrands as hy-
446 THE AMERICAN JOURNAL OF UROLOGY
perncphroma, and by Lubarsch as hypernephroid tumors), since
Neuhauser was successful in producing typical tumors by in-
oculation of the kidneys of rabbits with young adrenals, there
can be little doubt but that they owe their inception to aberrant
adrenal rests. As a rule they partake of one or more of three
types: 1st. small, benign often multiple growths whose structure
resembles that of either the zona glomerulosa, fasciculata, or
reticularis of the suprarenal body: 2nd, a group that deviates
from the maternal type in that the characteristic cells are ar-
ranged in an irregular manner : and 3d, a very malignant form,
still farther removed from the type, in which there is either
an alveolar, carcinoma-like growth or such a proliferation of
the stroma that a sarcoma is simulated. The transition of hy-
pernephroma into carcinoma in certain portions of a tumor has
been observed by Neuhauser. The case in point is interesting
in that it shows the close relationship between this, really
epithelial tumor, and carcinoma.
Case c2 was a large round and spindle-celled sarcoma of the
capsule of the kidney, occurring in a man 59 years of age, whose
symptoms were the following: an increase in size of the abdomen
and oedema of the left leg. Upon extirpation the tumor weighed
10.5 kgm., measuring 40 cm. X 29 cm. X 15 cm. On section
it was composed of a large cystic portion and a smaller solid
fatty part enclosing small tumor nodules. The kidney itself
could be recognized as a small compressed organ, not involved
in the process. Tumors of the capsule are extremely rare.
Albarran and Imbert collected 72 cases in the literature, but of
150 tumors of the kidney removed by Israel, this is the only one
that arose from the capsule. The following types are recorded:
Lipomas and their derivatives, fibromas (n'bromyxoma etc.),
sarcomas, and mixed growths. Rather interesting is the fact
that symptoms are usually absent, a papable tumor with possible
increase in size of the abdomen being often the first indication
of their presence.
Case -'3 was an endothelioma of the kidney in a boy, 3 yrs. of
age. Hematuria, emaciation, abdominal pain and fever were the
clinical signs. A tumor, of the size of a child's head, of soft,
spongy consistency, hemorrhagic and cystic was removed by
Israel, although not without rupture during the operation.
Histological examination showed a very cellular stroma in which
there were nests, alveoli or tubules of various shapes, made up
of deeply staining cells. The presence of stellate cells in the
CURRENT UROLOGK LITERATURE 447
stroma and of numerous fine, partly degenerate capillaries
throughout, speaks for the assumption that the tumor was either
an endothelioma or perithelioma. Most of the so-called peri-
theliomas reported were probably various forms of hyper-
nephroma : a true angioblastic tumor must be regarded as a
rarity.
2. Function of the Kidneys. In his hospital service,
Cathelin proceeds to the examination of suspected renal cases
as follows: 1st. unilateral ureteral catheterization when this is
possible; 2nd. If not feasible, (a) the endovesical segregation of
the urines with the Cathelin apparatus in the male, and, in the
female, if the bladder is small: (b) the extra-vesical separation
of the urines in the female (Harris-Downes) , if the bladder is
large. Ke finds the different types of examination represented
in the following percentages in his own practice: Ureteral
catheterization in 50(/c of cases, Cathelin segregation in 2(K/c ,
Harris-Downes method in 20%, exploration not absolutely neces-
sary in 5%j and 5% in which the urgency of the cases makes
it permissible to dispense with all of these procedures. The
view elsewhere expressed that endovesical segregation of urines
is often successful when catheterization of the ureters fails, is
again emphasized by the author.
As to the value of cryoscopy, the methylene blue test of Al-
barran, experimental polyuria, and chromocystoscopy (Yoelcker-
Joseph), the author has scant praise for any of them, charac-
terizing them all as unreliable.
The importance of the excretion of urea and its proper
estimation is discussed at length. Varying from 2gm. to 50 gm.
per diem, an average of 20 gm. may be regarded as good.
Operation may, however, be performed even if the figures are
as low as 15 gm. or even 10 gm. The experience of the last 10
years has led to the formulation of certain physiological laws
that are of surgical value.
1st. The law of the value of the absolute quantity of urea
(per litre). The quantity of urea secreted by each kidney, as
estimated per litre, gives us valuable information regarding func-
tion.
2nd. The law of the excretion of the quantity of urea.
The excretion of urea is performed by the convoluted tubules
and in part by the loops of Henle. The quantity excreted is
an indication of the integrity of these parts.
448 THE AMERICAN JOURNAL OF UROLOGY
.'3rd. The law of the constancy of the quantity of urea.
This is exhibited with great regularity so that we can say that
whatever amount is excreted in 10 minutes will be a constant
secretory quotient, the same amount being delivered during all
subsequent periods of 10 minutes each. The quantity collected
in this time represents the maximum function of the parenchyma
of the kidney.
4th. The law of the immutability of the quantity of urea.
The quantity of urea collected oyer a given time remains the
same for the diseased kidney over a period of several weeks, as
shown by experiments in at least 16 cases.
5th. The law of the elimination of chlorides. Their quan-
tity depends upon the activity of the glomeruli. There need be
no relation between the amount of urea and chlorides.
In renal tuberculosis where there are miliary tubercles or
small discrete or conglomerate nodules, particularly if these do not
communicate with the pelvis, there may be no marked diminution
of urea. If, however, the amount of urea is diminished by one
half, we may affirm that the kidney is about diseased or destroyed
to that extent, and that it may be of the cavernous type. In ex-
treme cases, where the suspected kidney excretes say 3 gm. against
25 gm. delivered by the intact organ, a dead kidney or pyonephro-
sis is probably present.
Carcinoma of the kidney, even if extensive, may be attended
by but slight or no deficiency in urea output. On the other hand,
a calculus kidney will often show a marked inadequacy in its
ability to excrete urea, although a subsequent nephrectomy may
show plenty of good renal parenchyma. The author assumes
that the diseased portion exerts an inhibitory action on the healthy
part of the kidney, thus reducing its functional activity.
3. Hemixephrectomy for Horseshoe Kidney. Although
horse-shoe kidneys have not infrequently been seen as interesting
post-mortem findings, relatively few instances of operations on
such organs are recorded. Anatomically one of their peculiari-
ties is the presence of an isthmus that lies across the vertebral
column, bearing posteriorly the impression of the aorta and vena
cava. The isthmus contains either cortical substance and pyra-
mids, which may functionate as a third kidney, or, more commonly,
it is simply a bridge of parenchymatous tissue varying in thickness,
at times being only represented by a fibrous strand. Another
characteristic is the site of the hilus, which lies further anteriorly
than in the normal, the pelvis lying in front of the vessels.
CURRENT OTOLOGIC LITERATURE 449
Usually there are two single pelves and two ureters. A third
anomaly which is of clinical significance, is the emergence of the
ureter from the anterior wall, sometimes even from the upper
part of the pelvis. Thus the ureter passes over the anterior
surface of the kidney, even making a furrow across the isthmus.
These anatomical considerations explain the tendency to hydro-
nephrosis often exhibited by such kidneys.
In the author's case the diagnosis of intermittent hydro-
nephrosis was made. The patient, a male twenty-seven years of
age, complained of periodic attacks of abdominal pain for three
years. During the paroxysms the patient himself felt a tumor
in the left hypochondi ium. The associated symptoms were vom-
iting, constipation and meteorism. After three or four days he
would again feel perfectly well. Shortly after the patient was
admitted to the hospital, an attack was observed during which
a tumor on the left side became palpable. The indigo carmine
test showed that the right kidney was functionating normal,
whereas no urine was obtained from the left. Operation revealed
a large hydronephrotic sac involving the left half of the horse-
shoe kidney, the ureter lying anteriorly and arising from a point
considerably higher than the bottom of the sac. The isthmus-
was divided and the diseased organ removed. The technic differs
from the ordinary nephrectomy only in so far as there may be
more vessels to divide and in the section of the isthmus. It is well
to cut this after clamping, although some surgeons have used
the cautery. Albarran advises a cuneiform incision so as to per-
mit of easier suture. All in all, some 16 cases of heminephrec-
tomy for diseased horse-shoe kidney are recorded.
5. Pathology of Malignant Renal Neoplasms. In a
study of seven tumors of the kidney, Scalone makes observations
that may be summed up as follows : Carcinomata with cells of the
type belonging to the Malphighian layer of the epidermis occur
in the kidney. The origin of the growth in the author's speci-
men is to be sought in the pelvis which had undergone metaplasia,
or " leukoplakia," as the author calls it. A comprehensive resume
of metaplasia in the urinary tract is given, and the possible etio-
logical relationship between calculus, infection and leukoplakia
of the pelvis is discussed. The 4 cases of hypernephroma do not
seem to have brought out any strikingly new facts. A specimen
of hemangio- and lymphangio-endothelioma deserves mention be-
cause of its rarity. A remarkable example of papillary adenoma
is described in which the presence of giant cells is unusual.
450 THE AMERICAN JOURNAL OF UROLOGY
6. Technic of Posterior L^rethroscopy. Referring: to
his modification of the Goldsmith urethroscope already described in
a previous publication, Wossidlo claims certain advantages for his
instrument. Because of the peculiar situation of the fenestra and
the angulation of the beak (in which it slightly resembles the
" convex " type or Brenner type of sheath), the scope of the tele-
scope is enlarged. The illumination, is supposed to be superior in
that its source lies further forward. But it is especially in the
ease with which applications can be made that the author claims
to have improved upon the Goldschmidt models.
ANN ALES DES MALADIES DES ORGANES GENITO-
UR IN AIRES
Supplement for the Year 1911
1. The Estimation of the Amount of Hydremia in Cardiac and
Bright's Disease. By F. Widal, R. Benard and E.
Vaucher.
2. Contribution to Functional Diagnosis of the Kidneys. By
M. Heitz-Boyer.
3. Resistance of Nephrectomized Patients to Traumatism and
to Operations. By Pousson.
4. Pathology and Pathogenesis of Cysts of the Kidney. By
F. Legueu and Verliac.
5. Partial Nephrectomy for Tuberculosis of a Horse-shoe Kid-
ney. By Carlier.
6. Clinical Notes on Renal Calculi. By Rafin.
7. Prolapse of the Ureter into the Bladder. By P. Bazy.
8. Cystoscopic Diagnosis of Tumors of the Bladder. By
Marion.
9. Early Prostatectomy in Cancer of the Prostatic. By E.
Desnos.
10. Tertiary Syphilis of the Urethra and Urethral Fistulae.
By E. Michon.
11. The Gonococcus. By J. Janet.
12. Spinal Anesthesia with Novocain in Urology. By E.
Jeanbrau.
1. The Estimation oe the Amount of Hydremia in
Cardiac and Bright's Disease. — In a comparative study of the
body weight and the colloid content of the blood in the hydremic
state of cardiac and Bright's disease, the authors have sought to
determine the value of refractrometry. Bartels was the first to
CURRENT UROLOGIC LITERATURE
4ol
recognize that water is retained in the blood before it can find its
way into the tissues ; or, that edema is preceded by an hydremic
plethora. In this, both Conheim and Senator have concurred.
In a search for methods to measure the hydremic state, several
procedures have found favor at different times. Since the num-
ber of red blood cells diminishes proportionately with the aug-
mentation of the volume of the blood, the blood count could be
expected to give valuable information. However, this is not
always reliable, for vaso-motor disturbances may cause a tem-
porary variation in the number of erythrocytes in a particular
region of the body. Opposed to the variability of the cristal-
loids, is the constancy of the total quantity of colloids in the
blood. If there is an increase of water, that is, if hydremia oc-
cur, there is a diminution in the relation of the albumin to the
total quantity of blood. The serum becomes diluted. And con-
versely the concentration of the serum may increase.
The amount of colloid in terms of the weight of albumin
gives us a notion as to the degree of dilution or concentration
of the blood. Although the gravimetric method is exact, its
execution is laborious, necessitating the use of at least 5 to 10
ccm. of blood for each estimation.
A more simple method is one based upon the degree of re-
fraction that a ray of light must suffer in traversing a given
sample of serum. This procedure, known as refract rometrv,
permits us to obtain a rapid reading of the amount of albumin
in the plasma, and can be carried out with but a drop of blood
taken from a ringer. The authors used the immersion refrac-
trometer of Pulfrich modified by Reiss.
The reliability of this method had already been attested by
the investigation of Grober, Strubell, Tuffier and Maute, for in
the experiments of the last two workers, the difference between
the refractrometric and gravimetric procedures did not exceed
0, 023 in 100. Normally the albumin content of the blood
varies only from 76 to 84 grams per litre.
The scope of the author's study included a systematic in-
vestigation with the refractrometer of different types of the hy-
dropic state amongst which were cases of interstitial and
parenchymatous nephritis, cardiac cases and those in which both
heart and kidneys gave symptoms. The curve of the body
weight and the curve of the readings given by the refractrome-
ter were compared.
The conclusions of the authors may be summed up as fol-
452 THE AMERICAN JOURNAL OF UROLOGY
lows : — The refractometric method is a reliable one, giving us
data as to the dilution of blood. Simultaneous use of scales
giving us readings as to the infiltration of the tissues, is an im-
portant method of investigation. Edema of the tissues goes
hand in hand with increased dilution of the blood, but, as a rule,
a fall in weight precedes the rise of the refractrometric index.
Therefore, weighing is the superior method as far as the rapid-
ity with which data are obtained, and as regards its simplicity.
Refractrometry, however, supplies information which simple
weighing does not furnish. Thus the former shows us that the
process of dehydration takes place in two stages : first water is
eliminated, the serum remaining diluted ; and later the serum be-
comes concentrated whilst dethydration continues. If the body
be taking water, the weight rising and the refractrometric curve
falling, it is wise to restrict the salt-content of the food. If the
latter curve retain an equilibrium, a normal diet may again be
resumed. Although an estimation of the balance of chloride
daily gives us similar information, the readings of the refractro-
meter is a much simpler method.
U. Functional Diagnosis of the Kidneys. — According to
Heitz-Boyer our notions as to the methods of determining the
functional activity of the kidneys have undergone such change
during the last decade, that lie wishes to record his own ex-
periences during three years at the Necker Hospital in Paris.
What concerns us most in the pathology of the kidney is altera-
tion of the functions of the organ, i. e., the pathological physi-
ologv. As regards renal inadequacy, we deal with two phases :
the " chloruremic 99 syndrome, characterized by poor elimination
of scdium chloride, and the syndrome in which there is a dis-
turbance of the excretion of urea (azotemic). The former is seen
in acute or subacute renal disease, and corresponds to the "hy-
dropigenic " nephritis of Castaigne. The latter type is the final
stage in the history of renal lesions of long standing and of
slow development. The two may be clinically associated in
many cases.
Regarding the indirect methods for estimating the renal
working capacity, namely those based on the provocative elim-
ination of either coloring matter or phloridzin, these, although
simple of execution, can only give presumptive data. All the
-ul, stances used in the past, including methylene blue, indigo-
carmin, or phenolsulphonephthalein may lead to erroneous con-
CURRENT UROLOGIC LITERATURE
elusions. According to the work of Castaigne, their employ-
ment is only justified insofar as they give us a clue as to function
and stimulates us to investigating further with more reliable
methods.
Cryoscopy may be regarded as grossly inferior to chemical
tests, since it can only give us data regarding totals, being quite
unable to segregate urea and chlorides, a disassociation which
is indispensable for correct estimations. This method may
therefore be discarded at the present day.
Of the two conditions, the azotem'ic and the chloruremic,
the author discusses only the procedures applicable in the study
of the former. The azotem'ic (azotum=nitrogen) syndrome is
characterized primarily by poor excretion of urea, indicating a
retention of urea in the blood, and secondarily by the absence
of edema and by but slight albuminuria. Albarran had already
made mention of the small amount of albumin excreted by cases
with sclerotic kidneys in 1889. Large amounts of albumin usu-
ally mean the presence of lesions regularly associated with the
edemas. But it is the poor elimination of urea that constitutes
the most important feature of this syndrome. Widal has shown
that the amount of urea in the urine is no reliable index as to
the adequacy of renal function. The urea of the urine varies
according to the quantity of proteid ingested, and its estimation
is only of value insofar as it is compared with the amount of
urea in the blood. Expressed in a formula, the excretion of
urea in the urine varies as the square of the urea of the blood,
or, inversely, the urea of the blood varies as the square root of
the urea in the urine.
m f Quantity of urea in the blood) , ,. M _ ,
Thus: \ — ; ; — r is the constant A ot
I ]/ Output* of urea in the urine J
Ambard, a quotient which rises in accordance with the degree of
renal disease.
In actual practice, for the genito-urinary surgeon, this
method of computing the ureapoetic function is valuable since
the separated urines can be tested. In addition to an estima-
tion of the kidneys work under normal stress, we may. in the
manner proposed by Albarran, impose additional labor on the
organ, by virtue of the action of an increased fluid intake, pro-
ducing thereby a so-called experimental polyuria.
It was found that three general laws are maintained after
the induction of the polyuria. 1st. The two kidneys, if
* In twentv-four hours.
454 THE AMERICAN JOURNAL OF UROLOGY
healthy, do not excrete continuously in a constant qualitative
and quantitative manner. Therefore a duration of 2 hours for
examination is advisable, and the sum total of the work during
this time must be taken into account, the individual temporary
aberrations of function being neglected. 2nd. The diseased
kidney functionates in a more constant fashion than the normal.
-'3d. The exaggerated activity produced by stimulation mani-
fests itself more markedly in the healthy than in the diseased
kidney. Thus the healthy will respond more readily to the test
of experimental polyuria.
The author's technic is as follows : — Precautions having
been taken to obviate the occurrence of polyuria at the outset
of the examination, and the patient having fasted for at least 5
hours, two ureter catheters of large calibre (preferably No. 8
Fr. ) are inserted, the cystoscope withdrawn and a catheter is
put into the bladder. It is advisable to wait 15 or 20 minutes
before collecting specimens for functional tots, since the mere
presence of the catheters frequently provokes temporary reflex
inhibition or even polyuria. An injection of 4 cm. of a one-
half per cent, phloridzin solution is then given. Two specimens
(left and right) are collected during the first \ hour and then
three glasses of water are given, the three following specimens
from each kidney belonging to the period of experimental
polyuria.
During the first J hour 30-40 gm. of blood are drawn off
and the urea estimated. The samples of urine are examined
separately and the quotient K, which is normally about 0,040,
is determined : 0.600 is not being incompatible with life, al-
though 0,100 indicates profound functional derangement.
Besides the constant K, the concentration of urea in the
urine is of value. Thus we expect a healthy kidney to deliver
10-20 gm. of urea per litre. When the concentration falls to
3-6 gm., the kidney is probably the seat of old lesions of
" uremigenic " nature (that is of the type interfering with the
secretion of urea). The diseased organ furnishes urine in which
the concentration is distinctly deminished. When we calculate
from the total urea eliminated in 2 hours, both the average out-
put, and increased secretion of urea during the period of poly-
uria, give still further valuable information.
4. Pathology and Pathogenesis of Cysts of the Kid-
x fy. — The author's study includes specimens of the following:
bilateral polycystic kidney of the adult type, partial polycystic
CURRENT UROLOGIC LITERATURE
455
kidney (infantile), large serous cysts, cysts of nephritis and tu-
berculous cysts.
As regards the nephritic cysts, authors are almost unani-
mous in the opinion that by virtue of an interstitial sclerosis,
certain uriniferous tubules are compressed, retrodilatation oc-
curs, resulting in the formation of cysts. However certain ob-
jections to this view merit consideration. Thus ligatures placed
so as to cause interference with the outflow of secretions from
a gland, lead to atrophy, although this may be preceded by a tem-
porary dilatation of the gland. In hydronephrosis, we fail
to see the production of cysts in spite of an evident obstruction.
The renal papillae have been experimentally cauterized by Tol-
lens, without the formation of cysts in the corresponding renal
parenchyna.
There are two types of cysts that may be associated with
nephritis. (a) Those which frequently accompany adenoma-
tous formations. They are believed to originate in tubules that
are probably foetal remnants of the Wolffian body. (b) Glom-
erular cysts represent a second variety, and are produced by di-
latation of the capsule of Bowman due to some obstacle to the
outflow of urine occurring during the course of an interstitial
nephritis. (c) Cysts derived from dilated renal tubules may
owe their formation to the isolation of certain portions of the
tubules through some unknown process, the epithelium retain-
ing its secretory function.
Of the two large serous cysts of the kidney studied by
the authors, one occupied the outer border of the organ making
a globular prominence antero-externally, and forming a hemi-
spherical cavity that almost extended to the pelvis of the kid-
ney. A congenital origin must be assumed for this specimen.
The polycystic kidneys too are the result of some congenital
malformation.
Two types of false cysts may be confused with those just
discussed. One of these probably results from an extravasation
of blood, and the other is a psuedo-cyst of tuberculous origin.
The tuberculous cysts appear macroscopically to be simple
cysts, microscopically they are healed caverns. The study of
three cases has led the authors to conclude as follows :
1. The caseous type of renal tuberculosis may result in
the formation of cysts.
2. Tuberculous cavities may be evacuated, their pelvic out-
4f56 THE AMERICAN JOURNAL OF UROLOGY
let may become obliterated and their walls converted into con-
nective tissue, producing thin-walled cysts.
3. Such a process is usually accompanied by other evi-
dently tuberculous lesions, which may show no such tendency to
cicatrization.
1. When the psuedo-cysts are not associated with other
evidences of tuberculosis, they may be confounded with serous
cysts of the kidney.
10. Tertiary Syphilis of the L'rethra and Urethral
Fistueae. — Perforation of the urethra as a complication of lues
usually necessitates a plastic operation even after energetic
medical treatment is instituted. Tertiary syphilis of the urethra
is rare, as shown by the statistics of Fournier who found the
urethra involved in but 19 out of 151 cases in which the lesion
was located in the penis ; and even in most of these instances,
there was a gumma in the immediate vicinity of the urethra
implicating the latter secondarily. As a rule, a point near the
external meatus or the distal end of the pendulous urethra is
the seat of the gummatous process. We may divide these
lesions of the urethra into the following:
1st. Extensive destruction of the pendulous urethra due
to tertiary phagedenic process. These are not of great sur-
gical interest since operative restoration is impossible.
2d. Involvement of the inferior wall of the balanic portion
of the urethra. There may either occur a total disintegration of
the lower wall of the fossa navicularis with the establishment of
a veritable pathological and acquired hypospadias, or a band of
tissue limiting the meatus may remain producing a fistula.
When the hiatus is not too large, closure ma}* be obtained by
paring of the edges and suture.
3d. Fistulae of the anterior urethra may occur, the site
of predilection being just behind the corona or in the first few
centimeters of the penile urethra. Michon had the opportunity
of studying two such cases. In one patient there was an ulcer
near the corona interiorly, communicating with the urethra and
lasting for a year and one-half. The induration about the ul-
cer disappeared rapidly under anti-luetic treatment.
1th. Perineal fistulae are rather rare. Fevrier has re-
ported such a case and M. Renault has recorded the occurrence
of a gumma near the bulb, that was followed by perforation of
the skin.
GENITO URINARY SUGGESTIONS
457
Genito-Urinary Suggestions
When complications arc imminent in acute gonorrhea, the
administration of atropine in the form of suppositories tends to
counteract the tendency to spasmodic reflex muscular contrac-
tions of the sphincters and other urinary muscles, and is often
of great service in ameliorating the course of the disease.
Alypin and Novocain in 2 per cent, solutions are the safest
anesthetics for use in the urethra. As a rule at least ten min-
utes are necessary for the production of a good local effect.
* * *
In cases of subacute anterior gonorrhea that fail to re-
spond to treatment, we should suspect that the patient is not
holding the fluid injections properly. Lubrichondrin (tube
form) in which protargol or albargin is incorporated, will
often give excellent results, since the semisolid nature of this
form of medication permits of long and thorough contact with
the urethral mucous membrane.
* * *
Medicated bougies are often useless in the treatment of an-
terior urethritis because the vehicle, when softened and liquefied,
prevents the absorption of the silver salts. When they are made
up of starch, sugar, dextrin, and glycerin, however, they are
readily soluble, and the medication can act for a prolonged pe-
riod. As a rule, however, medicated bougies are disappointing,
and do not yield the results which one would expect of them —
a priori.
* * *
Lesser thinks that in using salvarsan the aim should be,
not to kill all the spirochetes at one stroke, but to tone up the
organs and enable them to manufacture the necessary antibod-
ies. Therefore he gives small doses. He uses salvarsan just
as the insoluble mercurial salts are employed, giving injections
of 0.1 gm. once a week, in suspension in oil of sweet almonds.
After the sixth injection the Wassermann test is applied. If
positive the treatment is continued. When permanently nega-
tive the disease may be regarded as inactive or cured.
* * *
Concealed chancres of the male urethra are not very rare.
Failing to bear this fact in mind may lead to grave errors in
diagnosis.
458 THE AMERICAN JOURNAL OF UROLOGY
Casper's Lubricant (Katheterpurin) has the following
composition :
Hydrargyri oxycyanidi 0.246
S Glycerin 20.0
Tragacanthae 3.0
Aquae clest. stcriliz 100.0
To be put up in collapsible tin tubes. This lubricant re-
mains sterile eight days after being exposed to the air; cathe-
ters and sterilizers smeared with it will therefore remain per-
fectly aseptic.
It is well to bear in mind that exanthemata occurring in
the course of a gonorrhea to the drugs which have been admin-
istered, namely, copaiba, cubebs or oil of santol ; but they may
also be due directly to the gonotoxin ; for they occur also in
cases in winch no drugs have been administered.
Strictures of the urethra are met with much more rarely
nowadays than was the case three or four decades ago*. This
may be safely ascribed to improvement in the treatment of gon-
orrheal urethritis.
* * *
Calcium sulphide (1 grain) and arsenic iodide (1/60
grain), 3 to 6 times daily arc extremely useful in gonorrheal
arthritis.
The symptoms of stricture are: 1. Gleet; c2. Changes in
the urinary stream — in form, size and force: 3. Premature ejac-
ulations and imperfect erections ; 4. Increased frequency of
micturition. When all four symptoms arc present, stricture is
pretty sure to be present. But any of these symptoms may be
absent ; and there are strictures which give practically no symp-
toms and are discovered only on passing a sound.
Oil of sandalwood is a valuable but not an indifferent rem-
edy. Well marked renal congestion may follow daily doses of
one dram. As a rule 10 min. 3 to 4 times is sufficient. And
the oil must be the purest obtainable.
THE AMERICAN
JOURNAL OF UROLOGY
William J. Robinson, M.D., Editor
VOL. VII DECEMBER, 1911 No. 12
Contributed by the Author to The American Journal of Urology.
TUBERCULAR EPIDIDYMITIS ; AN ANALYSIS OF 158
CASES*
By J. Dellixger Barxey, M. D.,
Assistant Surgeon to the Genito-Urinary Out-Patient Department, Massa-
chusetts General Hospital; Assistant in Genito Urinary Surgery,
Harvard Medical School.
THE cases on which this investigation is based occurred at
the Massachusetts General Hospital. Although the pa-
tients numbered 120, they offer for consideration 153 tu-
bercular epididymes.
The subject is of importance for two reasons: First, we do
not, as yet, know the genesis of epididymal tuberculosis ; second,
healthy testicles are daily being removed under the impression
that cure is more likely to follow. It is believed that the study
of so large a number of cases will throw further light on the sub-
ject.
The patient with tubercular epididymitis is generally young,
between twenty-five and thirty-five years in 45% of cases. But
that every rule has its exception is shown by the fact that the
age of occurrence tapers off on the one hand to a baby of eighteen
months and on the other to a seventy-three-year-old iceman.
Incidentally, 60% were married. Not that this is strange,
for matrimony usually claims this number. But as it has been
stated that the disease may be conveyed by coitus, I note that
in not one of this number was there anything to suggest that
marital relations were the cause of contagion.
As the left side is usually guilty when it is a question of
* Read at the tenth annual meeting of the American Urological Associa-
tion, Chicago, 111., Sept. 27, 1911. Appears simultaneously in The Boston
Med. and Surg. Jour.
459
460 THE AMERICAN JOURNAL OF UROLOGY
varicocele or gonorrheal inflammation, it is noteworthy that in
tuberculosis its fellow is involved in exactly the same number
(S6^c ) of cases, while both were diseased at the time of entrance
to the hospital in nearly 30%.
As to the duration of his trouble, the patient can give no
definite answer. In this respect it is strikingly different, with
rare exceptions, from the epididymitis of gonorrhea, with its
sudden onslaught. The tubercular process builds slowly, often
without arousing suspicion of its presence, till finally the victim
awakes to find himself hopelessly entangled in its meshes. The
answer to our question of " when " is, therefore, to be taken,
not as the time of actual onset, but as the moment when consider-
able advance has been made.
Fifty-three per cent noted the presence of the disease within
the six months preceding their appearance at the hospital ; in a
few it was only a matter of days. Thence the time lengthens till
five or six years have elapsed since the process began, and dur-
ing which the smoldering fire has more than once broken into
flame, only to be quenched with a poultice or a bag of ice. More-
over, out of 95 patients, ¥3 acknowledged the performance of
more or less minor surgery in a vain effort to stamp out the
disease. This interference was usually the tapping, often re-
peatedly, of a hydrocele, which so frequently accompanies the
tubercular process. In a larger number than one would like "to
see, the family doctor had merely lanced the abscess, thus pre-
maturely giving birth to the sinus which is so common.
As possible exciting causes, gonorrhea and trauma were in-
quired for. Of the former, cut of a possible 95, only S4 ('35' . )
confessed infection. This percentage would undoubtedly be
greater were it not for deception and ignorance. With one ex-
ception, no case showed definite evidence that the tubercular in-
vasion of the epididymis followed a gonorrheal inflammation.
This, together with the fact that most of these patients had never
had venereal .disease, inclines us more strongly than ever to the
belief that there is little if any connection between the two.
Trauma also is of small import, as a history was obtained
in only 18 out of a possible 92.
Coming now to the results of the disease, subjective and ob-
jective, what do we find? Firstly, that 80rr of those ques-
tioned on the subject had lost weight, an indication of the in-
sidious and far-reaching nature of the disease. In some the de-
TUBERCULAR EPIDIDYMITIS
461
pletion of flesh and strength was extreme, even in the absence
of demonstrable lesions other than those in prostate and epididy-
mis. On the other hand, one is struck by the fact that a few
(5) men had put on weight in spite of their affliction.
Pain was a symptom in 60%. In striking contrast to the
agony of a gonorrheal process in the same location, it is usually
mild, often trifling. During one of the characteristic " flare-ups,"
pain is intense, abating with rupture of the abscess and the es-
tablishment of fistula, or by absorption of its products. Its
usually mild character may be explained perhaps by the slowly
progressive nature of the inflammation, with simultaneous soften-
ing and absorption.
As an accompaniment we find tenderness, not intense, bar-
ring always the very acute cases, but, generally speaking, of only
a moderate degree, its intensity doubtless regulated by the same
factors which produce pain.
An adherent scrotum, with or without fistula, was noted in
67% of the epididymes, while sinuses were observed in 53%.
These, then, are important factors in diagnosis and may be con-
sidered true " earmarks " of tuberculosis in this region. More
often than not the fistulse were active ; in others, the sinuses
showed a volcanic intermittency. We have seen scars of old
sinuses healed for years, and found under them an epididymis
containing pus and likely to erupt at any moment.
Conspicuous by its absence is fever. In only 10 cases was
the temperature over 100° F. before operation, the epididymes
in these being in the stage of acute exacerbation. Tubercular
epididymitis, as commonly seen, and uncomplicated, does not,
therefore, produce temperature.
Whence the epididymal infection? Is it primary, is it sec-
ondary to tuberculosis of the prostate, or is it one of the points
of exit of a general genito-urinary tuberculosis? It is the
writer's belief that the disease is secondary to prostatic tuber-
culosis, and that a concomitant general infection of the genito-
urinary tract is rare, at least at the outset. The evidence em-
bodied in the material at hand seems to justify this belief.
In 112 cases definite data are at hand on the question of
past or present tuberculosis in other organs than prostate or
epididymis. In 72, or 61%, there was no demonstrable evidence
of its presence at time of entrance elsewhere than in the organs
mentioned.
462 THE AMERICAN JOURNAL OF UROLOGY
Tubercular infection in the past, and presumably cured, was
found in only 7, or 6%. Its distribution was lung 3 cases, bone
2 cases, larynx and kidney (nephrectomy six years previously)
each 1 case. In these patients either the fire was still smolder-
ing, enough at least to light up the epididymis or prostate, or
else these organs became involved at the outset and remained
quiescent for years.
Active tuberculosis was noted in 29%, its distribution being
as follows : Lung, 20 cases ; bone, 8 cases ; kidney, 3 cases ; lar-
ynx, 2 cases ; cervical or inguinal glands, 2 cases ; peritoneum,
1 case; meninges, 1 case; ischio-rectal fossa, 1 case. In the
majority the disease had " staid put " in the organ in which it
began, whereas, in the cases analyzed by Keyes 1 it was always
" flitting between bone and lung and urinary tract " as that
writer so poetically describes it.
In Keyes' series renal tuberculosis occurred eleven times,
whereas it was demonstrated before or at the time of entrance of
our cases in only three.
Thus it is clear that the majority of patients do not have
demonstrable tuberculosis in organs other than those for whose
treatment they present themselves, and- it is equally clear that
epididymal tuberculosis is not an index of a general genito-
urinary infection.
As evidence that the prostate is responsible for most of the
epididymal infections, we find that in two-thirds of the cases
(67%) this gland is clearly tubercular, with the probability that
at least a portion of the remaining prostates are more or less so.
Examination of the seminal vesicles tells the same story, for here
also 63% are unquestionably tubercular, and the condition of
the remainder may well be regarded with suspicion.
Now if the prostate is to be considered the guilty party it
should produce vesical symptoms and an abnormal urine. This
is found to be the case, for in as many as 38% of a possible 76,
vesical irritability of varying intensity was observed. Running
parallel to this it is found that out of 104 urines, 43% con-
tained blood or pus, sometimes both, and that in 7 out of 8 cases,
the guinea-pig test showed the presence of the tubercle bacillus.
An inquiry into the sexual life of these patients was made in
22. In 15 there was no diminution of appetite or potency: the
others had yielded to the enemy more or less completely. In his
i Ann. Surg., June, 1907.
TUBERCULAR EPIDIDYMITIS
463
admirable paper, Keyes has intimated that azoospermia will be
found in men with one tubercular epididymis, indicating a similar
process in the prostate. The evidence that we can furnish, to-
gether with that which Keyes submits, forms a firm foundation
on which this theor}' can rest. In 4 cases, each with one tuber-
cular epididymis and with a prostate that could only be classed
as doubtful, the semen was sterile. On the other hand, one pa-
tient, a physician, writes me that since the removal of his afflicted
member he has become a proud father, while our friend the ice-
man mentioned elsewhere, and now in his seventy-third year,
claims to have become a father four years previously, even though
his disease began four years before that happy event.
Again, the prostate is indicated on the evidence furnished
by the well-known tendency to involvement of the second epididy-
mis, after removal of the first. In this group it had become so
infected nineteen times, the patient returning for operation on
the second side. In 10 of these the infection had occurred within
a year of the first operation, the others hanging fire for periods
of time up to four and one-half years in one case.
A more intimate view of the prostate was obtained in 3
cases dying after operation of a general miliary tuberculosis, and
coming to autopsy. In 2 there was an invasion of practically
every organ, including prostate and vesicles. In the third the
infection was as general, but, strangely enough, it skipped blad-
der, prostate, vesicles and remaining epididymis in its haste to
complete the task. This case is to be regarded as important and
will -doubtless be seized upon with avidity by those who believe
that the epididymal process is primary. None the less, no abso-
lute proof is at hand, nor is it likely to be, but, taken as a whole,
the case against the prostate is bad. If the epididymal process
is primary, then its extension to the prostate is so early that no
clinical means can detect it.
In the hope that microscopic examination of the epididymes
would shed some light, our clinical pathologist, Dr. Milliam F.
Whitney, kindly looked over a large number of sections for us.
Generally speaking, the tubercular process was intertubular, in-
volving only the surrounding connective tissue and leaving the
tubules intact. This would suggest that whether the primary
process is prostatic or epididymal its extension in either direc-
tion is by the lymphatics or blood vessels and not by the vas
deferens. This opinion is not to be taken as final, and further
work in this direction is contemplated.
464 THE AMERICAN JOURNAL OF UROLOGY
Two patients died in the hospital within a month of opera-
tion, of general miliary tuberculosis. That the scalpel served
as a torch there can be no question, the situation being com-
parable to the fatalities sometimes seen after excision of tuber-
cular cervical glands.
The fly in this ointment lies in the operative treatment.
Let me take the plunge and say at once that from 114 patients
there were extracted 92 testicles, 4 of them double. As if to
justify this useless slaughter of essentially innocent organs, the
records state that the testicle itself appeared to be involved in
60c/c. So be it. Pathological and clinical experience do not,
however, bear out this statement. In 71 cases in which a patho-
logical report was given, 21 were definitely free from tubercu-
losis ; 50 were described as tubercular, but as the records make
no distinction between epididymis and testicle, it is impossible
to draw any conclusions from them. The writer's experience
and that of others has been that a very small percentage of testi-
cles in such cases are invaded by the tubercle bacillus to such an
extent that orchidectomy is indicated. It is a fact, to which
most will agree, that even when the testicle is affected, and that
to a considerable degree, the fire burns itself out when the fuel
furnished by the epididymis is removed. As proof of this we
offer the records of 50 epididymectomies, single and double, with
and without vasectomy. Of this number, not one has returned
for subsequent orchidectomy, and in an investigation of the end
results of these cases, to be published later, no relapse in the
testicle itself has been found. We have recently seen a case
which seemed to be the exception. A tubercular epididymis had
been removed some months previously. The patient reappeared
at our clinic recently with an acutely inflamed scrotum, and every
evidence of orchitis. Operation showed the testicle itself to be
perfectly intact, the seat of the trouble lying in the tunica and
peritesticular tissues. We recognize the possibility of an inva-
sion of the testis, especially in the later cases, and do not deny
that the removal of an organ which the patient, at least, regards
as ornamental, if not useful, may be necessary. But such an
event is rare, and even a partial orchidectomy generally serves
the purpose, as shown in 5 of our cases.
That epididymectomy may cause the tubercle bacillus to
hasten its step toward the other side we do not deny, but that
the march is rapid in any event is equally true. Of 33 un-
PREPUTIAL REDUNDANCY
465
operated double infections of the epididymis, the second side be-
came involved in 18 (55c/c ) within one year of the time of in-
vasion of the first side. Among the operated cases, as stated
elsewhere, 10 out of 19 (5%c/c ) returned for operation on the
second epididymis within one year after removal of the first.
In the case of the second epididymis it seems to be " Heads I win,,
tails you lose."
We have all seen the serious mental derangements which
have followed the old operation of castration for the relief of
prostatic hypertrophy. We all recognize the importance and
power of the internal secretion of the testicle. If the influence
of this secretion is essential for a grown man, how much more
is it for a baby or growing boy. In the face of these indisput-
able facts, and knowing that the invasion of the second epididy-
mis is more than likely, no surgeon is justified, with rare excep-
tions, in removing a testicle.
Epididymectomy, with vasectomy, when properly done, is;
so simple a procedure, so devoid of risk and reaction (in only
24 cases did the temperature exceed 100° F. after operation) y
and so much a source of satisfaction to the patient, who, as it
were, has his cake and eats it too, that its performance is amply
justified. Furthermore, knowing the life history of the disease,
and finding the patient already sterile, as we shall in a very large
majority of cases, we feel justified in advocating the removal of
both epididymis and vasa at one sitting.
Contributed by the Author to The American Jolrxal of Urology.
PREPUTIAL REDUNDANCY: AN OPERATIVE TECH-
NIQUE FOR ITS CORRECTION.
By William Warrex Towxsend, M.D., Rutland, Vermont.
IT is not the purpose of this paper to discuss the subject of
Phimosis, nor is the technique to be described recommended in
congenital or acquired Phimosis.
A review of the works on surgery relative to pathologic con-
ditions of the prepuce discloses the fact that little reference
is made to a class of cases in which there is marked redundancy
of tissue and wherein, owing to the size of the preputial orifice,
it is perfectly possible to retract the foreskin over the glans into
the coronal sulcus. This type of case is well shown in Fig. 1,
and aside from cases of congenital phimosis, it is this type that
comes most frequently to operation.
466 THE AMERICAN JOURNAL OF UROLOGY
Where reference is made to this condition the orthodox
operation of circumcision, with its usual technique consisting of
the removal of both layers of the prepuce, is advised; and it
is recommended by most authors to ablate the inner layer to
within a fraction of an inch of the corona. When as little
Fig. 1.— Type E.
Showing a long puckered prepuce, but with an orifice large enough to al-
low of its retraction into the coronal sulcus, forming a muco-cutaneous roll
therein: " a misfit."
• • ; , .
Fig. 2.
Showing the position of the artery clamps after picking up an esthetized
area of skin in the midline of the upper and lower sides of the muco cutaneous
roll with the prepuce drawn forward so as to cover the glans.
tissue as that is left the contraction following healing leaves
the corona and the glans without protection, — which is con-
trary to what nature apparently intended.
PREPUTIAL REDUNDANCY
467
Some authors sound a note of warning regarding the re-
moval of too much foreskin, but only in connection with its
interfering with erection ; hence in the operation of circum-
cision for phimosis and in performing it for redundancy, the
question naturally suggesting' itself is : How much foreskin is
it anatomically correct to remove? Each individual operator
decides this point arbitrarily. This is not to be wondered at,
as there is no anatomical standard that governs the length
of a normal prepuce. Anatomists describing it are brief and
Fig. 3.
Showing the artery clamps drawn forward invaginating the preputial ori-
fice. The circumcision clamp when applied is in front of the orificial ring.
ambiguous, for example to quote from Gerrish. He says : "Just
behind the cervix the integument leaves the surface of the penis
and is continued forward for a varying distance, forming the
outer layer of the prepuce ; then it turns backward within it-
self, forming the inner layer and rejoins the surface at the level
of the cervix." From this quotation and other descriptions re-
viewed and from our observations, it evident that nature intended
that some covering should protect the sensitive nerve papillae
in the mucuous covering of the glans and corona.
Just how much of the glans nature intended to protect we
have tried to determine, and it was with a view of gaining some
definite knowledge as to the average length of the prepuce
that we inaugurated a practice of observing, in the course of the
468 THE AMERICAN JOURNAL OF UROLOGY
Fig. 4.
Showing the cutaneous collar attached to the under layer, which remains
uncut when the section of skin is resected.
routine physical examinations of prisoners, in a penitentiary in
which I have a service, the length of the foreskins of the un-
circumcised, and classified them as follows :
Fig. 5.
Showing the eversion of the mucous membrane that occurs when the col-
lar is drawn back to be sutured to the retracted skin of the sheath.
PREPUTIAL REDUNDANCY
469
TYPE A.
Those in which the skin of the shaft of the penis joined the
mucous membrane at the cervix, thus affording no covering what-
soever to the plans : Cervical.
TYPE B.
Those in which the prepuce covered the corona and part
of the glans when the organ was in the flaccid state: Semi-Pro-
tective.
TYPE C.
Those in which the prepuce covered all of the glans, but
allowed a view of the meatus and tip of the summit through
the preputial orifice, which was large and distensible enough to
permit of a retraction of it into the coronal sulcus; as Protective.
TYPE D.
Those cases in which there was a quarter of an inch or
more of puckered, redundant tissue projecting beyond the tip
of the glans and a preputial orifice sufficiently large to slip
over the glans into the coronal sulcus, but when retracted would
bunch up into a muco-cutaneous collar: Redundant.
TYPE E.
Those cases in which conditions were as described in Types
C and D, but in which retraction was impossible, typical cases
of congenital phimosis: Phimotic.
We made these observations in a series of two thousand
adult examinations with the following results :
Type A, 163 cases, 8.15 per cent.
Type B, 510 cases, 25.5 per cent.
Type C, 880 cases, 44.0 per cent.
Type D, 420 cases, 21.0 per cent.
Type E, 27 cases, 1.35 per cent.
Or 1810 instances in the 2000 observations in which the glans
was protected when the penis was flaccid.
From these observations our conclusions were that nature
in her effort to protect the sensitive nerve endings in the mucous
membrane of the glans, provided a covering, which when the
penis was flaccid afforded full protection, and when the organ
became erect and the glans engorged, slipped back into the
coronal sulcus and was on a plane with the skin covering the
shaft of the organ, leaving the sensitive nerve terminals of the
glans exposed and open to receive the stimulus necessary to con-
summate the sexual act.
470 THE AMERICAN JOURNAL OF UROLOGY
This supposition is rather strengthened when the anatomy
of the prepuce and penis of the lower animals is studied. It
would also seem that the coronal sulcus was by nature placed
so as to receive, during the turgidity of the penis, the foreskin
which had so well protected the highly elaborated nerve terminii
from friction of the wearing apparel when the penis was in the
flaccid state.
Hutchinson long ago pointed out the fact that in circum-
cised individuals "the integument of the glans became of a horny
character." From the standpoint of prophylaxis we can ap-
preciate that the hornified epithelium offers resistance to the
spirochetae and pyogenic organisms and in that way affords a
Fig. 6.
Showing the suture line.
certain amount of protection to the promiscuous; but does not
the hornified and less sensitized epithelium bear some relation to
the complaints of individuals who come to us for relief from
feeble erections and the inability to complete the sexual act by or-
gasm?
We have no records to prove or disprove this hypothesis,
but offer it simply as a possible etiological factor to be studied
in cases of this description.
Why should we inaugurate a change in the epithelium of
the glans which nature provided, by removing all of its covering
in the operation of circumcision?
PREPUTIAL REDUNDANCY
471
It is not within the scope of this paper to discuss the in-
dications for circumcision, but in conditions of redundancy our
technique has proven a most satisfactory method of correction,
when correction was indicated.
Von Zeissl in 1883, suggested and published an operation
for paraphimosis; and Klotz in 1902, published a method of
circumcision applicable to cases of congenital and acquired phimo-
Fig. 7.
Showing suture line fifteen days after operation. The prepuce is re-
tracted into the coronal sulcus where it "fits." It will also be noted that the
suture line is away from possible chance of urinary wetting or contamination.
sis. Both advised in their publications the preservation of the
inner layer of the prepuce and as far as I can ascertain, these
gentlemen are the only ones who have published techniques which
serve to shorten the sheath of the penis by resecting rather than
by amputation, as is done in the method I beg to present here
and which is as follows :
TECHNIQUE.
The patient is prepared as for any ordinary circumcision ;
a constrictor is applied at the root of the shaft and an estimation
of the amount of superfluous prepuce is made, and the amount
it is to be shortened is determined by retracting it so that the
preputial orifice lies anterior to and midway between the tip of
the glans and corona. This manipulation will cause the re-
dundancy of prepuce to roll up behind the corona.
Into the middle of this roll inject the selected local anes-
thetic and repeat the injection at a point corresponding to the
superior injection, on the inferior side at the raphe, which is us-
ually in the midline. The object of anesthetising these two areas
472 THE AMERICAN JOURNAL OF UROLOGY
being, that when they are picked up by the artery clamps
(Fig. 2) there will be no pain experienced. The clamps are then
■drawn forward and thus invaginate the preputial orificial ring.
An ordinary circumcision clamp or medium seized pedicle
clamp is then applied so that the invaginated ring is behind it
(Fig. 3). The cutaneous tissue lying in front of the clamp is
infiltrated with the anesthetic in the usual way and the redund-
ancy amputated with a scalpel or scissors, close to the clamp.
When the clamp is removed it will at once be observed that a sec-
tion of integument has been resected, leaving the under layer of
mucous membrane, the loose areola tissue and blood vessels that
lie between the layers, and a collar of skin uncut (Fig. -I).
The skin retracts on the shaft and the collar is drawn back
so that the cut edges of it and the retracted skin are brought
into apposition and held there by long guy sutures, which are
later used to hold on the turban gauze dressing.
It will be found necessary to hold the edges in closer ap-
pcsiticn than is done in a muco-cutaneous suture line, as the skin
shows a tendency to retract and pucker so that more interrupted
sutures are necessary than is customary.
When the collar is drawn back it turns on itself and the
mucous membrane becomes everted and later passes through a
transitional state, whereby it becomes like the stratum corium
of the true skin.
The advantages of the method we believe to be:
First, it accomplishes the purpose of shortening the pre-
puce by resecting a section of integument, preserves the normal
preputial orifice, leaves a covering for the glans and removes
the redundant tissue ;
Second, it does not interfere with the frenum, — its blood
or nerve supply ;
Third, the line of union is so far removed from the meatus
(Fig. 7) that it does not become soiled during urination, thus
favoring an aseptic wound. The line of union being on the shaft,
the post operative pain is nil, and patients suffer no inconven-
ience whatsoever in walking about immediately after operation.
The line of union shows well in Figure 7. The photograph
was taken fifteen days after the operation and in a short time
the cicatrix becomes absorbed and lost in the normal folds of the
integument.
We have had no patients complain of constriction caused
by the cicatrix during erection, after the first month, and all
Iiave been satisfied with the results.
Contributed by the Author to The American- Journal ok Urology.
SUPRAPUBIC OR PERINEAL PROSTATECTOMY
By A. C. Stokes. M.D., Omaha, Neb.
THE purpose of this paper is to arouse an expression of
opinion from the members of this Association as to the
method most commonly used by them for the removal of
the prostate gland. You are all familiar with the ordinary ar-
guments for and against both methods ; a few of these argu-
ments, however, I wish to review. Personally, I have done about
as many operations by the suprapubic as by the perineal route ;
employing the Goodfellow and Albarran- Young procedures when
taking the vesical route, and using the Belfield-Ayer method
when approaching by way of the perineum.
(1) We entirely abandoned the Goodfellow method because
we could not see enough, for in eleven operations performed in
this manner, I was not sure that we had removed the obstruct-
ing portion in any case. At about this time we happened to
meet three cases in which the Goodfellow operation had been
performed, but in which the cystoscope showed the presence of
obstructing prostatic tissue. If one could be sure of entirely
removing the prostate by this medium, this operation would of-
fer the advantage of a minimum of dissection, a minimum of
post-operative shock, and of the largest percentage of operative
recoveries. Yet, despite the fact that Ferguson, May, Wat-
son and other most excellent surgeons perform this operation
by means of the so-called intra-urethral perineal operation, our
experience points to a certain rather large percentage of
cases in which the prostate is not entirely removed, the real
obstruction remaining or returning after the operation. It is
not true that the eye in the end of the finger is as accurate as
the eye in the head in distinguishing kinds of tissue. We have
long held to the principle in surgery that " blind " surgery is
bad surgery, and we see no reason why an exception should be
made in the surgery of the prostate gland. The enthusiasm of
surgeons for their particular method of operation often carries
them beyond the point of conservative statement and careful ob-
servation regarding their methods and their results. Men whose
ability gives them phenomenal results are apt to leave the im-
pression that it is the particular operation which yields such
wonderful results rather than the skill and knowledge of the
operator.
473
474 THE AMERICAN JOURNAL OF UROLOGY
We believe it impossible to tell exactly the point at which
separation of tissue is taking place in a dissection made at the
end of the index finger, and within the urethra. To remove a
gland whose anatomical definition at best is not clearly discern-
ible from the adjacent tissue must necessarily be fraught with
danger. There seems to me to be no good rule to prevent one
from removing parts of the sphincter, the trigone of the blad-
der, the seminal vesicles or the ejaculatory ducts rather than
the prostate under such circumstances. In our experience this
operation cannot be recommended, either from the standpoint
of thoroughness of removal of the gland nor can it be regarded
as being free from the chances of injury to adjacent organs.
Certainly the method is inadequate when we are brought face
to face with complications such as vesical stones or a carcinoma
of the prostate. The prostatic urethra is often badly torn and,
therefore, the operation possesses no advantages so far as con-
servation of the posterior urethra is concerned. A minimum
of post-operative shock and the infliction of a comparatively
small amount of traumatism in the perineal dissection, these seem
to be the only arguments in favor of this method of procedure
over the open methods.
(2) After reading the reports of Dr. Young, we made
larger incisions and more complete dissections, finding thus that
a very much better approach to the prostate could be obtained.
By the aid of the tractor we were able, in most cases, to bring
the prostate well up into the perineal wound. We cannot but
believe, however, that the diagramatic sketches found in the
fourteenth volume of the Johns Hopkins Hospital Report are
somewhat overdawn in this particular, and leave an impression
that the bringing of the prostatic gland into the wound is more
simple than our experience justifies or than I have ever seen any
other operator succeed in doing. In some cases we have been
unable to raise the prostate into the perineal incision at all, even
with the most extensive dissection, which the anatomical area
justifies, and with the most expert use of the tractor which we
were able to command.
In a certain number of cases we have found the perineum
so deep and the space between the tuber ischii so narrow, that
we have had considerable difficulty in dissecting down to and
around the prostate without injuring the surrounding tissue.
We were never quite sure that the entire obstructing lobe of the
SUPRAPUBIC OR PERINEAL PROSTATECTOMY 475
prostate was removed, for the tractors often slip about and
away from the obstructing lobe in a manner which is misleading
and confusing. They do not always sink into the center of the
intra-vesical projection so beautifully as the illustrations show.
The enucleation is, therefore, often very difficult because of
our inability to hold the prostate in position and at times we
have been compelled to remove the retractor entirely before we
were able to determine the exact position of the remaining frag-
ments or lobe of the gland.
We believe the traumatism to the cut-off muscle cannot
help but be great, and, as shown by Ruggles (Annals of Surgery,
April, 1905), this is an important factor in determining the de-
gree of vesical control. This muscle is certainly severely in-
jured in a number of cases. The nerve supply of this muscle,
the perineal nerves and vessels are doubtless injured in a cer-
tain number of cases, resulting in incontinence.
We have never been quite sure just what has happened to
the urethra at the time of operation, especially when the pro-
static bar had developed up into the bladder. In some cases
we are sure the prostatic urethra was torn and considerable
portions of it removed. In one case, at least, a portion of the
trigone was also removed. We have not been quite sure that the
ejaculatory ducts on both sides were intact even when we have
attempted to do the conservative perineal operation of Young.
Examination of the prostate gland made after removal shows
portions of the urethra in nearly every case, and in six of twenty-
three, we have found portions of the ducts.
The position of the patient as described by Dr. Young is
a difficult position to obtain in most of our ordinary hospitals
and unless one has a rest constructed especially for this opera-
tion it is often difficult to obtain such a sharp angle in the back
of the patient so that the perineum is parallel with the plane of
the floor. If the Trendelenburg position is used, the weight of
the intra-abdominal organs draws the prostate, if anything,
deeper into the perineum.
We are advised to be careful to pass the instrument of
cleavage into the correct layer of the capsule. We have never
been able to choose the correct layer and we have always been
compelled to follow the path of least resistance, whether this
was the correct layer or not. We were often compelled to re-
move a number of small fibrous adenomata which were in the
prostatic struma and practically none of the prostate itself.
476 THE AMERICAN JOURNAL OF UROLOGY
In the removal of the median bar we have been compelled
to tear the urethra often low down toward the vesico-reetal fas-
cia and were unable to remove the lobe with the skill which some
of the more dexterous operators describe with such eloquent and
attractive diagramatic sketches. The use of the finger as a
tractor has been found, in most cases, impossible. We have
nearly always been compelled to divide the recto-vesical fascia
in a rather wide manner and to leave large pockets behind the
same. These must necessarily interfere with sexual relations and
form acceptable areas for the formation of localized abscesses.
Our results on twenty-three operations on the prostate by
the perineal route have been as follows :
One case died two days after operation. In the same case
we perforated the rectum in the dissection. These cases have
extended over a period of six years, and I am only able to find
seventeen of them alive. One case had a fistula two years after
the operation and at the time of his death. The cause of his
death was pneumonia. We have had no cases of incontinence,
and none of dribbling or stricture, as far as I know.
Despite all the above named technical difficulties I believe
this operation offers the following points of advantage:
1. It is the operation which so far offers the nearest ap-
proach to an " open operation " for prostatectomy.
2. The sexual apparatus may be preserved.
3. Less of the urethra i>> dot ro ved than in the suprapubic
operation. The part injured, if any. is farther from the blad-
der, lies nearer to the posterior layer of triangular ligament and
is less liable to be followed by untoward results.
4. It offers the best possible drainage for the bladder.
5. It is particularly applicable in cases of small fibrous
prostate, in which this organ obstructs rather by contraction of
the vesical orifice than by enlarging the prostatic mass.
6. It is best adapted when the obstructing neoplasm pro-
jects down into the perineum or against the rectum.
7. The mortality is less than in the suprapubic operation.
In addition to the technical objections elaborated above one
may add :
1. It requires more experience and a better understanding
of the anatomy and physiology of this region than does any
other operation for removal of the prostate.
2. It opens a large number of blood vessels and lymphatics
SUPRAPUBIC OR PERINEAL PROSTATECTOMY 477
in the dissection. It necessitates a great deal of traumatism,
possibly in some cases affecting the perineal nerves and leaving
the external sphincter paralyzed.
The suprapubic method is recommended and done by Moiny-
han, Mikulicz, f reyer, Israel and many others.
We have done fourteen operations all told in this way with
one death. The technical difficulties of this method have been
comparatively few in our cases. Once I opened the peritoneal
cavity and this case died, but not until about three weeks after
the operation. Whether this had anything to do with the death
or not I do not know. There were no signs of peritonitis. In
these fourteen cases we have not met with dangerous hemor-
rhage. The recoveries have been as rapid as the perineal, and,
as I believe, the results as good. In one case I found that the
patient had trouble after removal of the prostate, the principal
complaint being pain in the urethra. In two cases it was neces-
sary for the patient to use the catheter after the entire prostate
had been removed. These were both men over seventy-five years
of age, and in both an atonic bladder was present. I do not
feel that the removal of a portion of the tortuous and elongated
prostatic urethra is a very serious matter, and in no case was I
able to find any urethral obstruction caused by the injury to
the urethra.
Old cases of chronic cystitis, which had existed several years,
usually continued to have pus in their urine even when the kid-
neys were healthy ; in one case it was observed for five years.
The presence or disappearance of pus does not depend upon
either the suprapubic or perineal operation. It followed both
operations equally so far as I am able to judge. It did not dis-
appear in the old cases following either the suprapubic or peri-
neal method. My experience in this regard may be unique and
differs from many of the reports in the literature.
The technical difficulties are few, but other more dangerous
difficulties more than offset this advantage.
A large cavity is left in the region of the neck of the blad-
der. The drainage must necessarily be up-hill for some two or
three inches and the large pocket from which the prostate was
removed forms an ideal position for the deposit of micro-organ-
isms and urinary debris. Many advocate a boutonniere in the
perineum as not adding much shock and it seems to be a rational
procedure. Ranshoff's trocar should in all cases be condemned
478 THE AMERICAN JOURNAL OF UROLOGY
as dangerous and unscientific. The opening into the bladder
should be made well up into the fundus and not under the sym-
physis. The same point is made by Squier {Surgery, Gynecol-
ogy and Obstetrics, September, 1911).
Drainage tubing in the bladder whether large or small, sin-
gle or double, is, in my opinion, contra-indicated. The large
hole in the base of the bladder is packed with iodide of bismuth
gauze at the close of the operation and the serum and urine al-
lowed to drain through this gauze. This prevents hemorrhage
and infection, drains the serum rapidly from the wound and
when it is removed it leaves a clean granulating surface.
After removal of the prostate, and before the bladder is
packed with gauze, normal salt solution at a temperature of 120°
is passed through the urethra by hydrostatic pressure without a
catheter until the bleeding ceases. The bladder is then packed
and the patient returned to bed, and in three days the pack is
removed. No cases of secondary hemorrhage have appeared in
our fourteen cases.
The following are extracts from a discussion on this subject
in the American Surgical Association for 1909.
Dr. A. H. Ferguson, of Chicago. (Perineal Prostatectomy.)
This is one of the most interesting subjects in the fie]d of sur-
gery. At the present time surgeons are divided in their opinions
as to the best method of removing the prostate gland.
My first work was done suprapubically in 25 cases. (I must
explain that at least 4 of these should not have been operated upon
by any method.) I lost 8 out of the 25, one from hemorrhage.
After this experience I determined to attack the prostate through
the perineum. In over 125 cases operated upon by this route, my
mortality has been less than three per cent. I prefer the median
perineal incision. The rest of the operation I carry out as I de-
scribed it at the American Medical Association meeting in Boston, in
1906.
The prostate, which is most adherent at the neck of the bladder,
must not be torn any when resistance to enucleation is met with ;
but the gross mass should be cut away with knife or scissors, leaving
a layer of prostatic tissue, which is removed bit by bit with my pros-
tatic biting forceps. Since the prostate is also more or less firmly
adherent to the prostatic urethra, the same precautions must be taken
to prevent injury to the latter.
Even supposing you have to destroy two-thirds of the prostatic
urethra, in nearly all cases you can preserve the anterior portion. I
SUPRAPUBIC OR PERINEAL PROSTATECTOMY 479
think the prostatic urethra can be more conserved by the perineal
route, and, in fact, I know it. The finishing up of the operation is
important. I sew up the perineum and prostatic urethra in all cases
where the urine is not septic; and in about 25 per cent of these I
get union by first intention without any leakage through the peri-
neum at all. It is difficult to do this close to the neck of the bladder.
A small drain should be placed at the lower angle of the wound, and
a catheter though the penis. Experienced men who have followed
the improvements of perineal prostatectomy do not injure the blad-
der, nor have they a fistulous tract, except possibly in septic cases,
and not always in these. If there are stones and diverticuli present,
the condition of the bladder can be found out through the perineum
and the bladder by the subpubic route. Better drainage is thus
obtained. The mortality, moreover, is twice as high by the supra-
pubic route.
Dr. Maurice H. Richardson, of Boston. (Perineal Prostatectomy.)
I, like most of the members of the Association, come here to
learn the experience of others, and I, therefore, welcome this dis-
cussion. I have seen a good many operate upon the prostate but
never yet a man who knew exactly what he was doing with refer-
ence to the uretha. My training has been that of an anatomist I
have never been able yet, by the suprapubic or the perineal route, to
be sure whether in prostatectomy I was injuring the urethra or not.
I have asked other operators, and they acknowledge that they do
net know either. When I take out the prostate from above, I can-
not believe that there is much left of the prostatic urethra.
As an anatomist I prefer vastly, in suitable cases, the perineal
route. As Dr. Moore has said, the case is to be treated from above
or from below, according to the results of the digital examination.
Sometimes the suprapubic route has proved of the greatest possi-
ble ease, and the operation has teen one of great rapility, and has
been followed by little if any shock.
What appeals to me and what interests me in these discussions
is the experience of the different Fellows of the Association, and
what interests me still more is the frank admission that these opera-
tions do have their drawbacks, and that patients seventy or eighty
years of age occasionally die. I look upon this operation as an ab-
dominal one, and it becomes, therefore, a considerable part of my
work. I select methods and routes according to the case in hand ; I am
not bound in every instance to follow a certain method or a certain
route.
Dr. John B. Murphy, of Chicago. (Both Methods.)
The operation of prostatectomy was approached by me first by
the perineal route, and then by the suprapubic route, the reverse of
480 THE AMERICAN JOURNAL OF UROLOGY
Dr. Ferguson. The difficulties that I encountered in some of the
perineal cases caused me great anxiety, so I changed to the supra-
pubic. Finally, after I had felt fairly secure in the suprapubic route,
I encountered more difficulties, and then I concluded that both routes
had adyantages. Finally, after an experience of 123 cases, I haye come
to the conclusion that the small, firm, hard prostate can be taken out
easily and more accurately from below. The large, thick, juicy
prostate I can take out with greater ease and safety from above.
Whether you make a little larger incision in the perineum makes lit-
tle or no difference, because the deep excavation, if you take out the
same amount of tissue, must be the same by both routes, and it is
the deep structures which are the important ones. It is essential
in operations from both positions to keep within the capsule.
A number of malignant cases can be recognized before the opera-
tion by the hard, ligneous nodules palpable by procteal examination.
However, if all specimens are put through the microscopic examina-
tion, one will often find, to his great surprise, malignancy in a case
in which he has not suspected it. To your gratification, a year or
two later you will find your patient doing very nicely, and then, as
is but to be expected, in another year or two he succumbs. But
where the malignant disease has penetrated the capsule and invaded
the connective tissue, the patient is worse from the day of the opera-
tion, and continues the downward course until he dies. The circum-
scribed carcinomata cases do very well after the operation, and the
surgeon feels repaid for doing them.
Deaths in prostatectomy result from causes independent of the
operation oftentimes, as sepsis, pneumonia, renal insufficiency, and
sudden collapse in an old person from lowering the arterial tension;
but if you are ready in such cases to at once fill the patient's veins
with salt solution, you will be surprised how quickly he will rally.
It should be administered, however, before the patient leaves the
operating table. Experience aids one in selecting the time for opera-
tion and in guiding one to the proper preparation of the patient be-
fore operation, materially lessening the mortality.
Dr. Moore.
As I stated, my paper was only suggestive to bring out discus-
sion, and it has certainly had the desired effect. Dr. Bevan, as we
all know, is a man of positive convictions, and has the courage to
back them, so I expect in five years he will come in and read a
paper before this Association on the complication and sequels of su-
prapubic prostatectomy. He is very positive in his statements as
to the superiority of the upper operation, but you will notice that
there are a gcodly number who are equally positive and have equally
good reason for the lower operations. You will agree with me that Dr.
SUPRAPUBIC OR PERINEAL PROSTATECTOMY 481
Murphy stands on solid ground, fitting the operation to the case in
hand.
Dr. Richardson asks how we are going to tell when the urethra
is injured, and I say examine the specimens after operation.
Dr. Bevan. (Perineal Prostatectomy).
I think the situation can be summed up as follows: That the
evidence is quite conclusively in favor of the suprapubic operation
from the standpoint of the completeness of cure and freedom from
complications. That would be the opinion of the majority of sur-
geons. Then I think that probably the majority of surgeons would
feel that the suprapubic operation was one that carried greater mor-
tality than the perineal. Is it not possible to reduce the mortality
rate of the suprapubic operation until it is as low, or lower, than
that of the perineal? I think it is, and that the point brought out
by Stillman has been well exemplified in some of my own recent
work, that is, in an infected case making first a suprapubic drainage
under nitrous oxide gas. Nothing has been more satisfactory than
the secondary prostatectomy ten days, two weeks, or three weeks
later, when the patient was in good condition, the operation being
performed without any instruments whatever, simply through the fis-
tulous tract with a gloved finger, with the patient under nitrous oxide
gas. If that method is adopted and the badly infected cases first
drained and prepared for prostatectomy, the suprapubic operation
will have as little or less mortality than any other case, and the re-
sulting cure will be more satisfactory^ and more complete.
RESUME
Age seems to be the reason for the greatest dangers in pros-
tatectomy. The mortality relation of different operations shows
in perineal prostatectomy six to eight per cent, in the supra-
pubic between nine and eleven. With the constant increase in
knowledge of the technique of this operation and the widening ex-
perience, the mortality suffers gradual reduction. Freyer re-
ports 644 suprapubic prostatectomies with 39 mortality, about
six per cent, and Young 238 perineal prostatectomies with a
mortality of 2.9. His last 128 operations showed no mortality.
Each of the operative methods has its advantages. The
suprapubic possesses the superiority of easier technique and
greater rapidity. It is astonishing how often very large pros-
tates can be removed by the suprapubic way in a few moments,
particularly if one can shell out the prostate by starting in the
right layer. The perineal method has the advantage, that each
step is more perfectly under the control of the operator, but the
482 THE AMERICAN JOURNAL OF UROLOGY
technique is more difficult. The chief drawbacks of suprapubic
prostatectomy are bad drainage and a large round wound hole
in the deepest part of the bladder, which assists in causing re-
tention of the wound secretion and tends to the production of
dangerous after effects*. This is doubtless responsible for the
higher mortality.
Most patients lose their potency after a total prostatec-
tomy. This appears to be much less frequent in the case of the
suprapubic prostatectomy than in the perineal. It may be men-
tioned that Young and Fuller have both observed an increase in
the potency after suprapubic operations.
Many operators prefer one method at one time and one
method at another, depending on whether the prostate is enlarged
down towards the rectum or whether the tumor mass extends up
against the bladder. I believe that this is the proper position
to take and it is better that the operation be made to fit the case
rather than the case to fit the operation. The suprapubic is for
me the easiest to perform. The short time of the operation, the
rare appearance of complications, the ability to deal with com-
plications, such as stone, and the short period of wound healing,
are the deciding factors. The healing of the perineal prosta-
tectomy requires from six to eight weeks. When a fistula occurs
it may last several months. Fistulae after suprapubic prosta-
tectomy, in my experience, close about a week sooner. In one
of my last cases the suprapubic wound was entirely healed in three
weeks.
My first suprapubic operation was done because I was un-
able to pass any guide whatever into the urethra, fearing it would
require considerable time to find the urethra by the perineal
route. I decided to do the suprapubic operation and was pleased
with its results.
In spite of the many opinions to the contrary given in this
paper I believe the suprapubic operation is slowly gaining ground
among the American surgeons. In German}' and England it is,
now, almost the only operation done, while in France, I under-
stand, Albarran and Legueu are also doing the suprapubic more
commonly than the perineal.
We are now using a retractor for suprapubic operation
upon the end of which an electric light is placed in such a manner
as to illuminate the entire base of the bladder. By the use of
this instrument the steps in the enucleation are more clearly seen.
SUPRAPUBIC OR PERINEAL PROSTATECTOMY 483
In certain cases the two step suprapubic operation has
proved advantageous. I believe, however, it is but rarely neces-
sary.
I have attempted to summarize the present situation in the
surgery of the prostate as I see it in America. I have laid stress
on the difficulties and complications met with rather than upon
the simplicities and successes, for I feel that already in Amer-
ican literature the operation of prostatectomy is too lightly re-
garded, and, therefore, often attempted by those whose training
has not fitted them for this work, with disaster to the patient, to
themselves and to the discredit of a very valuable surgical pro-
cedure in proper cases.
484 THE AMERICAN JOURNAL OF UROLOGY
EDITORIAL ANNOUNCEMENT
Enlargement of the Scope of The American Journal of
Urology.
A publication like The American Journal of Urology is
net, and, as those familiar with special medical journalism know,
cannot be a money-making venture. That the journal may pay
for itself, leaving perhaps a margin for further improvement, is
all that can be expected. The editor's and collaborators' work
is generally a labor of love.
When we took charge of The American Journal of L'rol-
ogy four years ago — how time does fly — it was, considered from
every point of view, in a deplorable condition. Financially it
was ruined, its subscription list was meager and its text pages
did not shed any glory on American Urology.
We had uphill work, and while we have not achieved all we
hoped to achieve, there has been considerable improvement. At
any rate, we have succeeded in building up a subscription list,
which now justifies us in attempting to realize our original in-
tention, that is, to make The American Journal of L'rology
the best L'rologic Journal in existence; if not the superior, at
least the equal of any Journal published in any foreign language.
There is a field for such a Journal. Neither in this coun-
try, nor in Great Britain or any of its dependencies, is there a
single Journal, with the exception of The American Journal
of Urology, devoted to the important branch of genito-urinary
and venereal diseases.
Beginning with the New Year the scope of this Journal will
be so enlarged that it will become indispensable to the genito-
urinary specialist, as well as to the general practitioner treating
venereal diseases. It will comprise the following features :
1. A comprehensive review of all the foreign Urological
Journals. Every Urologic Journal: Folia Urologica, Zeitschrift
fiir Urologie, Annates des Maladies Genito-U rinaries, Annates
des Maladies Veneriennes, Rirista Urologica, will be fully and
comprehensively reviewed, so that subscribers to The American
Journal of L'rology will practically have no need to subscribe
for any other L'rologic Journal.
2. Comprehensive abstracts of all the important L'rologic
EDITORIAL ANNOUNCEMENT
485
and Venereal articles appearing in the general medical Journals,
English and foreign.
3. Reports of the meetings of all national, foreign and in-
ternational Urologic and Venereal Congresses.
4. Original articles from representative Urologists in this
country and abroad.
5. A special department of genito-urinary pathology.
6. Diagnostic and therapeutic points for the general prac-
titioner.
7. And probably a special Department dealing with the
vast problems of our sexual life.
Without in any way encroaching on the domain of the
genito-urinary specialist, additional space will be set aside for
contributions which will be of interest and value to the general
practitioner. We have many general practitioners on our sub-
scription list, and it is in compliance with their oft-repeated re-
quests, that we institute a general department, incorporating
brief clinical cases, the treatment of gonorrhea and syphilis,
diagnostic and therapeutic suggestions, etc.
Dr. Leo Buerger of New York will be actively associated
with us in the editorial management of the Journal and it is
confidently expected that henceforth the Journal will be a credit
to American Medical Journalism and to the Urologists of the
country.
We look forward to the co-operation of all genito-urinary
specialists, and we trust that in the near future our hope to make
the Journal so good that there will be " No Urologist without
The American Journal of Urology," will have become a
reality. w. j. r.
Of the Original Articles which are to appear in early issues of
The American Journal of Urology, we will mention the fol-
lowing:
"Pyelitis Exfoliativa" Howard A. Kelly, Baltimore, Md.
Common Sources of Error in the Diagnosis of Renal and Ureteral
Calculi Hugh Cabot, Boston, Mass.
The Value of the Irrigating Cystoscope for the Electric Illumination
of the Bladder, with the Presentation of a New Instrument
Willy Meyer, Xew York
Mucous Cysts of the Bladder Producing Symptoms of Obstruction
Willy Meyer, Xew York
486 THE AMERICAN JOURNAL OF UROLOGY
Distention of the Renal Pelvis for Purposes of Diagnosis
O. S. Fowler, Denver, Col.
A Case of Fracture of the Pelvis with Extraperitoneal Laceration of the
Bladder J. F. McCarthy, New York
The Bladder during Pregnancy .... Samuel Brickxer, New York
Traumatism of the Bladder During Delivery . H. N. Vixeberg. Xew York
Echinococcus of the Kidney .... Braxsford Lewis, St. Louis, Mo.
Carcinoma of the Prostate Removed Through a Suprapubic Incision.
Longquiescence . . Howard Liliexthal and W. Leightox, Xew York
The Medical Aspect of Hematuria . H. Elsxer, Syracuse, X. Y.
The Diagnosis and Treatment of Pyelitis . . Arthur Steix, Xew York
Roentgen Rays in Urology Leopold Jaches, Xew York
The Present Day Diagnosis of Acquired Cutaneous Syphilis .
Walter Heimaxx, Xew York
A Xeglected Principle in Cystoscopy . W. F. Braasch, Rochester, Minn.
Renal Calculus W. Wayne Babcock, Philadelphia, Pa.
Report of Bladder Tumors Treated by Fulguration
D. A. Six clair, Xew York
The Treatment of Sexual Disorders in the Male
William J. Robixsox, Xew York
Gonorrhoeal Arthritis in Children Sarah Welt, Xew York
Bladder Diverticula G. Warrex, Xew York
Observations on Disturbances of the Bladder Function in Diseases of
the Brain and Spinal Cord C. A. Elsberg, Xew York
A Two Way Catheter Robert L. Dickixsox, Xew York
Diagnosis of U/rinary Lithiasis H. Bugbee, Xew York
Surgery of Urinary Lithiasis J. B. Squier, Xew York
Urinary Lithiasis: Etiology and Chemistry . . F. E. Soxderx, Xew York
The Modern Therapy of Syphilis .... Walter Heimaxx, Xew York
Litholapaxy J. R. Haydex, Xew York
The Kidney in Syphilis W. B. Brouxer, Xew York
Mixed Tumors of the Kidney Y. C. Pedersex, Xew York
Cystitis and Pyelitis in Children Dr. H. Schwarz, Xew York
Phosphaturia and Oxaluria F. E. Soxderx, Xew York
Clinical Studies of the Prostatic Urethra . John A. Hawkins, Pittsburg, Pa.
Vesical Calculus with Multiple Recurrences . . . A. Hymax. Xew York
Renal Functional Diagnosis Victor Blum, Vienna, Austria
Operative Treatment of Gonorrhoeal Epididymitis
Louis Schmidt, Chicago, 111.
An Operating Cystoscope Leo Buerger, Xew York
Obscure Fever of Renal Origin . . . . D. X. Eisexdrath, Chicago, 111.
Analysis of 62 Cases of Lues Treated with Salvarsan
* Louis Gross, San Francisco, Cal.
The Clinical Significance of Horseshoe Kidney . Arthur Steix, Xew York
Special Problems in Cystoscopy Leo Buerger, Xew York
The Unrecognized Influence of the Prostate on Man's Physical and
Mental Condition William J. Robixsox. Xew York
Lectures on Diagnosis of Renal Disease . . Victor Blum, Vienna, Austria
CURRENT UROLOGIC LITERATURE 487
Review of Current Urologic Literature
FOLIA UROLOGICA
Vol. VI, September, 1911
1. The End-Results of Nephrectomy for Renal Tuberculosis.
By J. Israel.
2. Calcification in the Pelvis Simulating Ureteral Calculi in
the Radiogram. By B. Alexander.
3. Contribution to Renal Surgery. By G. Bonzani.
1. The End-Results of Nephrectomy for Renal Tu-
berculosis.— The indications for the operative treatment of
renal tuberculosis have completely changed during the last ten
years. Whereas, years ago, retention of pus, pain, emaciation
or perinephritic abscess, and hematuria were the usual signs
for intervention, we now take the view that early nephrectomy,
done when the process is in its incipiency, gives the best results,
regardless of the extent of the pathological process.
The question naturally arises as to whether spontaneous heal-
ing is possible. Thus far no anatomical proof of this has been
forthcoming. As fcr the effects of tuberculin, we have also
failed to have obtained thus far definite evidence pointing to
its value in causing a disappearance of the lesions of the kidney.
In spite of temporary improvement in subjective symptoms, the
pathological changes progress, so that we are not justified in the
present state of our knowledge to procrastinate, immediate sur-
gical intervention being the only proper procedure.
Israel's experience is based on 170 operated cases, and his
conclusions are drawn from a consideration of his own cases
and of data furnished by quite a number of surgeons whose
opinions on this subject had been requested and given. By late
results the author means the condition of the patient after 6
months have elapsed. Thus in 1023 cases (170 his own), there
was a mortality (occurring after 6 months) of 10 to 15%, and
an early mortality (in first 6 months) of 12.9%? meaning that
about 25% of the patients are saved by operation. The mor-
tality in males is considerably greater than in females, usually
because of chronic tuberculosis of the lung in the late mortal-
ity, and because of an acute miliary process when death occurs
early.
488 THE AMERICAN JOURNAL OF UROLOGY
■ The most important causes of late death are pulmonary
tuberculosis and disease of the second kidney. Acute miliary
tuberculosis occurs twice as often during the first post-operative
year as in all the other years, being in most cases a direct se-
quela of the operation.
More than cne-half of the late mortality ocurs before the
end of the second year, including as causes, pulmonary tuber-
culosis (45.27c), renal disease (35.9%) and acute miliary tu-
berculosis (l-Lc/c ) .
Cf the renal diseases responsible for late mortality, the
author distinguishes two varieties, the non-tuberculous and the
tuberculous. To nephritis may be attributed the greater part
cf the deaths, kidney lesicns being at fault in almost a third of
these who succumb late.
After nephrectomy, we expect as a rule, to find an improve-
ment in the second kidney, which, before operation, may have
been the seat of a toxic process. From the standpoint of in-
dications, it is important to be able to distinguish between a
true chronic nephritis cf the second kidney and a transitory
tcxic lesion. Save for increased arterial tension in Bright'a
disease, we have no reliable data upon which to base a differen-
tial diagnosis. Nephrectomy is only permissible in the pres-
ence of Eright's disease, if we estimate that the effect of the
presence of the tubercular process is more dangerous than would
be the removal of the functioning parenchyma contained in the
affected kidney.
Tuberculosis of the second kidney usually causes death
within two years after operation ; later mortality of renal ori-
gin signifies that the second kidney was already diseased at the
time of operation. Of all the cases of nephrectomy only 1.6%
develop renal tuberculosis.
Nephrectomy, is only allowable in bilateral affections, if
there be severe hematuria and ungovernable pain and colic, and
provided that the process in the other kidney be in its incipi-
ency.
The removal of the tuberculous organ diminishes consid-
erably the chances of involvement of the healthy second organ,
since infection from an extravesical source is rare.
The tubercle bacilli disappears from the urine after neph-
rectomy in three-quarters of all cases, and their persistence de-
pends upon the extent of the involvement of the bladder before
operation. The absence of the bacilli in smears must be con-
CURRENT UROLOGIC LITERATURE 489
trolled by animal inoculation. The presence of the bacilli is
not incompatible with the enjoyment of good health, there being
records showing that 17 years may elapse where tubercle " bacil-
lus carriers " (in urinary tract) are apparently well and with-
out having an affection of the second kidney. The bacilli may
be present even though the urine contains no albumin. Of those
cases in which bacteria disappear, the great majority become
free frcm pain, and in 75%. of cases the frequency of micturi-
tion become normal.
There is also an improvement in weight even where the
urine contains bacilli, and some patients become " bacillus car-
riers " (as do typhoid cases) without symptcms.
The urine fails to become absolutely normal in more than
75%. of cases; albumin remains in 5S.4%, usually only in traces;
red blood cells in 48.8% ; leucocytes in 46.5 % ; and casts, usu-
ally hyaline, in 23.%c/c .
The cystoscope reveals a cure of the bladder in 43.59c ,
partial involution in 45.1% ; either no change or progression
of the pathological lesions in 9% • The bacilli disappears be-
fore the visible alterations cf the bladder mucosa, although a.
large part of the apparent lesions are no longer of tubercu-
lous nature. As a rule, the amelioration of urinary symptoms
takes place pari passu with the improvement in the condition of
the bladder, as attested by the cystoscopic findings. When the
frequency of micturition becomes worse after operation, having
previously been normal, the assumption of disease of the second
kidney is admissible and usually correct.
The mere extensive the bladder lesions, the less often does
the pain disappear. The absence of painful micturition after
nephrectomy occurs oftener than a complete cure of the blad-
der.
The ureter usually heals spontaneously ; although there
may be ureteral fistulae in 11.5%, even these heal within 4 years.
The operative treatment of the stump does not seem to influ-
ence the final result appreciably.
The body weight increases in 93.9% . Pregnancy does not
affect the second kidney after nephrectomy in any different
manner than the kidneys of healthy people. Consent to marry
should be given only after permanent disappearance of the
bacilli.
All in all, the conclusions of the author speak in favor of
early nephrectomy for unilateral renal tuberculosis.
490 THE AMERICAN JOURNAL OF UROLOGY
ZEITSCHRIFT FUR UROLOGIE
Vol. V, No. 6, 1911
1. Endourethral Operative Work in Chronic Proliferative
Urethritis. By H. Lohnstein.
2. The Inadequacy of the Indigo-Carmine Test; By Max
Roth.
3. The Regeneration of the Prostatic Urethra after Prostatec-
tomy. By A. Wischnewsky.
L Double Renal Pelvis, One Infected, the Other Normal. By
W. Stark.
Vol. V, No. 7, 1911
5. One Hundred and Forty-five Litholapaxies. By M. Kreps.
6. Syphilitic Disease of the Bladder. By P. Asch.
7. Hemorrhage after Nephrectomy. By H. G. Pleschner.
1. Endourethral Operative Work in Chronic Pro-
liferative Urethritis. Lohnstein feels convinced of the fact
that the superficial proliferations of the mucous membrane are
often responsible for the failures of cases of chronic gonorrhea
to respond to treatment. When the. lesions are confined to the
anterior urethra, subjective symptoms may be entirely absent.
A recurring discharge containing a preponderance of epithelial
elements makes it probable that hypertrophic changes are pres-
ent. In the posterior urethra, however, such lesions are usu-
ally accompanied by some of the following symptoms : — dull
pain in the perineum, rectum, in the cords or testicles, peculiar
sensations in the pelvis or lumbar region, associated at times
with alterations in potency, premature ejaculation, phospha-
turia, sexual neuroses and even neurasthenia. Even recurring
epididymitis seems to depend in a casual relationship, on the
presence of papillomata of the verumontanum ; for, the author
has observed three cases in which the destruction of these
growths was followed by cure. The roof of the prostatic ure-
thra often harbors glands in which thick secretion is retained.
Expression of these by means of the endoscopic curette results
in a disappearance of urinary shreds.
Lohnstein has constructed several ingenious devices that
can be manipulated through the Goldschmidt urethroscope, for
the operative treatment of the urethra. Four of these are used
in routine work : a curette, a flat cautery, a cautery loop and a
CURRENT UROLOGIC LITERATURE 491
Bottini knife. The curette is applicable in the case of the ses-
sile type of epithelial hypertrophies, in the polypoid excrescences
and in occluded glands of the posterior urethra. Papillomata
are destroyed by means of the cautery instruments. Such op-
erative treatments tax the patience of both physician and pa-
tient at times, because a number of seances may be necessary.
Thus a cure may not be effected until months have elapsed, be-
cause the sittings cannot be carried out at short intervals.
The author's Bottini incisor enables exact work under control
of the eye.
Lohnstein does not proceed to operative measures through
the irrigation urethroscope until the usual methods, including
dilatation, have failed. In 10 cases the use of the curette was
indicated. Two varieties of urethral affection call for the appli-
cation of this instrument; 1st, circumscribed lesions in the bulb,
that are difficult to attack with the dilators, and 2d, the ca-
tarrhal processes in glands lying in roof of the prostatic ure-
thra. Seven of the ten cases belonging to the latter type were
cured by curettement. The three failures are attributed by the
author to neglect on the part of the patient to come regularly
for treatment.
In the author's series of observations, there were 12 cases
in which villi or polypoid growths were regarded as being re-
sponsible for the chronic gonorrheal process. Cauterization
was followed by marked improvement in all of the 8 patients who
applied regularly for treatment.
The papillomatous growth showed a marked tendency to
recur in four of the cases, but even here complete cure may be
the result of assiduous work and perseverance.
6. Syphilitic Disease of the Bladder. In a thorough
paper cn the symptcmalogy and the diagnosis of syphilis of the
bladder, the author calls attention to the scarcity of published
data on this subject and attempts to stimulate us to a better
recognition of this condition. Even Guyon in 1894 dismissed
the subject in his lectures with scant mention, saying that the
urinary tract seems to escape luetic infection. Neumann was
the first to appreciate that secondary syphilitic involvement
of the bladder was not uncommon. He also describes a condi-
tion which he called luetic paracystitis. Matzenauer seems to
have recorded the first observations cn the appearance of syphi-
litic lesions of the bladder with the cystoscope in a case of vesi-
cal gumma.
492 THE AMERICAN JOURNAL OF UROLOGY
Most of the reports in the literature describe an involve-
ment of the bladder during the tertiary stage. Gummata oc-
cur that may often be mistaken for papillomata, their true na-
ture remaining concealed unless luetic ulcers or other tertiary
manifestations elsewhere in the body occur simultaneously. Ul-
cers should create the suspicion of being syphilitic in origin,
if the bacteriological examination for tubercle bacilli is nega-
tive. Luetic ulcers are distinguished from simple and tubercu-
lous ulcers by their markedly infiltrated and prominent mar-
gins. The gummatous processes usually give the symptoms of
a neoplasm, causing hematuria throughout the whole duration
of the act of micturition, whereas vesical ulcers are more apt
to produce terminal hematuria. At times the accompanying
pyuria may be quite marked. The subjective symptoms depend
greatly upon the location of the disease, being most intense when
the neck of the bladder is affected. In rare cases, retention of
urine occurs.
More unusual are the casts of secondary luetic manifesta-
tion in the bladder. In these pollakiuria and pyuria are promi-
nent symptoms, the cystoscopic examination revealing swelling
and redness of the mucosa with mucous plaques.
There is a considerable number of luetic patients with urin-
ary disturbances in which we encounter symptoms referable to
lesions of the nervous system, such as cases of bladder palsy
due to progressive paralysis and tabes. The tabetic changes
in the bladder are of importance ; they often appear in the very
earliest stages of the disease. The recognition of the trabecu-
lated bladder described by Nitze, Hirt, Boehme, Walker and the
author, is of considerable aid therefore in diagnosis. The
vesical alterations are the manifestation of an attempt at com-
pensatory hypertrophy and are unattended by the usual causes
such as stricture and hypertrophy of the prostate.
As for therapy in tabetic conditions, improvement may re-
sult if energetic antiluetic treatment be instituted.
CURRENT UROLOGIC LITERATURE 4*93
ZEITSCHRIFT FUR UROLOGIE
Vol. V, No. 8, 1911.
1. The International Urological Congress in London.
2. Symptoms, Diagnosis and Treatment of the Horse-shoe
Kidney. By T. Rovsing.
3. Congenital Hydronephrosis. By J. Verhoogen and A. de
Graeuwe.
4. The Conversion of Bladder Epithelium into Secreting Cy-
lindrical Epithelium. By O. Zuckerkandl.
5. Pyelolithotomy as a Preventive against Secondary Hem-
orrhage after Nephrolithotomy. By P. Kusnetzky.
6. Non-Prostatic Senile Urinary Retention. By M. W. Ware.
7. Neuralgia of the Bladder due to Varicocele. By B. Ma-
raini.
8. Remarks on Urinary Secretion. By P. Heresco.
9. Metastatic Carcinoma of the Ureters with Anuria. By F.
Schlagintweit.
10. Traumatic Hydronephrosis Healed by Pyeloneostomy. By
H. Wildbolz.
11. The Origin of Prostatic Hypertrophy. By Marion.
Vol. V, No. 9, 1911.
12. Gonococcus Carriers. By P. Asch.
13. Prostatic Lipoids and Prostatic Concretions. By H. L.
Posner.
14. Syphilis of the Bladder. By N. Pereschiwkin.
15. Congenital Diverticula of the Urethra. By J. P. Haberern.
16. A Cystoscope for Teaching Purposes. By W. Batzner.
17. Renal Tuberculosis Complicated with Parametritis. By J.
Voigt.
18. Psychic Onanism. By M. Porosz.
Vol. V, No. 10, 1911.
19. Experimental Studies of Tests for Renal Function. By J.
Wohlgemuth.
20. An Endovesical Method of Operating for Tumors of the
Bladder. By V. Blum.
21. The Intramural Portion of the Ureters, the Trigone, and
Their Variations. By W. N. Schewkunenko.
2. The Symptoms, Diagnosis and Treatment of Horse-
shoe Kidney. — Whereas the diagnosis " horse-shoe kidney " was
494 THE AMERICAN JOURNAL OF UROLOGY
formerly only made at autopsy or at operation, clinical observa-
tions that have accumulated during the last few years, and a
study of four cases by the author, point to the possibility of
clinical recognition of this anomaly, particularly since character-
istic symptoms given by even an uncomplicated or a healthy
horse-shoe kidney may be identified. The frequency of the in-
cidence of this malformation in autopsies is given as 1 in 1100
by Kiister, but Rovsing's investigations would tend to make the
figures much higher, namely 1 in 500 cases. Our interest in
this condition should be stimulated by the hope of cure offered
by operative measures, for relief can be expected even in those
cases where a simple, uncomplicated horse-shoe kidney is re-
sponsible for the symptoms.
The history of four cases are given by the author. The
symptoms were typical and did not vary essentially in the cases
reported. Dull pain either of pressure or of tension across the
small of the back and in the lower abdomen was regularly pres-
ent. Rest seems to dissipate all discomfort and pain, whereas
exercise (particularly when it necessitates hyperextension of the
vertebral column) aggravates the feeling of distress to a marked
degree.
A rational explanation of the subjective symptoms is to be
sought in the mechanical effects of extension of the vertebral
column upon the isthmus of the horse-shoe kidney and the aorta,
vena cava and nerves underlying it. Whenever the vertebral
column is bent backward, the kidney must be stretched inasmuch
as the upper poles are fixed. Not only does the kidney paren-
chyma suffer pressure and tension, but the vessels and nerves are
compressed against the bodies of the vertebrae. The occurrence
of shock in one case may be attributed to the same cause.
The diagnosis must naturally be based mainly upon the
presence of the above symptoms and upon palpation of a trans-
vertebral mass. Sometimes the lower pole of one or the other
kidney can be traced towards the median line where, for some
reason or other, its further course becomes lost to the examining
finger.
In short, we are justified in making a presumptive diagnosis
of horse-shoe kidney when the following picture is presented: —
Dull pressure, pain across the back and on a level with the kid-
neys, with the history of total disappearance of all discomfort
in the supine position : marked aggravation of the pain after ex-
CURRENT UROLOGIC LITERATURE
495
ercise and on bending the trunk backward ; the absence of a float-
ing kidney; and the presence of a mass stretching across the
spine. Occasionally, retroperitoneal tumors, especially of the
pancreas and mesentery and even a hydrops of the gall bladder,
may give a picture that may tax our diagnostic skill.
As regards the therapy, complete rest will alleviate the
symptoms ;• a cure, however, can only be expected from operative
procedures. The best method is the division of the isthmus, fol-
lowed by suture of the cut ends of the respective organs. The
most accessible approach is a transperitoneal one with division
of the peritoneum outside of the colon and duodenum. When
the isthmus is fibrous, we need only cut between two clamps and
ligate either side. Where we are dealing with a thick parenchy-
matous mass, it is well to use the angiotribe of Roux, and then
to cut through and sew up the crushed band of tissue.
3. Congenital Hydronephrosis. — Under this term the au-
thors include not only those varieties of hydronephrosis that are
already present at birth, but also those in which the cause only
is congenital, there being a gradual post-natal development of
the lesion. The pathogenesis of this last type is not as yet com-
pletely understood, although it is admitted by many that incom-
plete obliteration of the lumen of the ureter at some point or
other in its course, may be the cause. Verhoogen and de Graeuwe
have seen a number of instances in which hydronephrosis could
be attributed to atresia of the upper end of the ureter, and were
able to make careful anatomical studies in three of the cases.
Authorities are at variance as to what anomalies are re-
sponsible for congenital hydronephrosis. Rayer was the first to
ascribe the condition to some organic lesion, having cited a case
in which there was an abnormal coarctation of the upper end of
the ureter. Since then the following peculiarities have been held
responsible by different authors : torsion of the ureter, kinking,
valve formation, and faulty insertion into the pelvis. The as-
sumption that anomalous implantation into the pelvis is a com-
mon cause is denied by those who hold that this condition is the
result of dilatation of the pelvis rather than the cause. Kiister
is in accord with this view, maintaining even that repeated at-
tacks of pyelitis may lead to hydronephrosis. Still others be-
lieve that compression of the ureter by reason of its anomalous
course or by the renal veins is a frequent etiological factor. The
496 THE AMERICAN JOURNAL OF UROLOGY
four cases of the authors are alike in strengthening the hypothe-
sis, that an aplastic condition of the ureter may account for fche
pelvic dilatation.
The author's first case gave a clinical picture so closely re-
sembling that of appendicitis that the appendix was removed.
At times there were attacks of pain simulating renal colic with
nausea and vomiting. Nephrectomy was done and the kidney
proved to be hydronephrotic, its parenchyma atrophic, the ureter
implanted 1 centimeter above the lower pole and so narrow and
thick-walled that its lumen (3 mm.) scarcely admitted a fair-
sized needle. Sections of the ureter at its attenuated portion
showed papillary ingrowths of the mucosa and submucosa, re-
ducing the lumen to a narrow slit, and a sclerotic process of the
submucous connective tissue.
Case II, a boy 16 years of age, was admitted to the hos-
pital with severe pain in the left lumbar region and hematuria.
Such attacks had recurred periodically since the age of two.
Extirpation of the kidney revealed a hydronephrosis due to stric-
ture of the ureter. The cortex was found reduced to the thick-
ness of 1 centimeter. The calices broadened and the pelvis di-
lated. The ureter measured only 4 mm. in diameter, and opened
in the lower part of the pelvis by a minute opening. Microscop-
ically it presented a picture similar to that of Case I.
The disease in Case III had lasted four years, being char-
acterized at the time of patient's admission to the hospital by at-
tacks of severe pain in the sacro-lumbar angle, desire to urinate,
pollakiuria, and painful micturition. The extirpated kidney was
enlarged, hydronephrotic, the pelvis much dilated. The ureter
entered the pelvis at its lowermost point and its lumen was hardly
enough to admit a fair-sized needle.
Seeking an explanation for the stenosis of the ureter with
the consecutive hydronephrosis and renal sclerosis, the authors
are able to rule out lithiasis in all of their cases. The theory of
Virchow, which presupposes an intra-uterine inflammatory proc-
ess, is untenable, since it is only applicable to those instances in
which the affection manifests itself soon after birth, and would
hardly be in accord with the histories of the cases in question.
It would seem more plausible to assume (with Klebs and Eng-
lisch) that the strictured zone in the ureter represents the re-
sult of anomalous or faulty development. It is well known that
until the fourth month of intra-uterine life, the ureter is not
CURRENT UROLOGIC LITERATURE
smooth-walled, but is narrowed by plication of its mucosa in a.
manner similar to that found in the authors' cases. These folds;
are encountered especially in the upper, middle and lower por-
tions of the canal. This peculiar conformation disappears later,
perhaps by virtue of the pressure of the urine or perhaps by
reason of normal development. The plications at the uretero-
pelvic junction may persist and lead to local stenosis.
The following is the mechanism accepted by Verhoogen and
de Graeuwe, as being in harmony both with the pathological find-
ings and the clinical picture. The foetal narrowing of the ure-
ter at the renal pelvis remaining after the fourth foetal month,
and the development of the kidney continuing, the means of out-
flow for the urine finally become inadequate, so that hydronephro-
sis and hypertrophy of the renal pelvis result. Whenever the
congestion (which the constant intrarenal pressure brings forth)
in the kidney is increased either by exposure to cold or through-
excessive drinking, complete closure of the ureter may ensue.
Thus are to be explained the symptoms of pain, nausea, vomiting-
and hematuria, on the basis of the occurrence of acute retention.
4. The Conversion of Bladder Epithelium into Secret-
ing Cylindrical Epithelium. — Reviewing some of the theories-
that have been put forth in explanation of cyst formation in the
bladder, Zuckerkandl concludes as follows :
1. The epithelium of the bladder may become converted
into cylindrical epithelium by virtue of the action of constant and
intense irritation.
2. The lesion usually designated as cystitis cystica and
glandularis is produced by epithelial proliferation with consecu-
tive metaplasia into secretory epithelium.
3. Cystitis glandularis and C. cystica are analogous proc-
esses, the secretion remaining rudimentary in the latter.
4. We may look to the metaplastic phenomenon, therefore,
for the explanation of the primary development of neoplastic
glands in the bladder, and we need no longer resort to the as-
sumption of the presence of aberrant fetal rests.
10. The Origin of Prostatic Hypertrophy. — In a criti-
cal review of the studies of other authors on the origin of so-
called prostatic hypertrophy, and from investigations of his own,
Marion concludes that in this condition we are dealing with ade-
nomas or fibro-adenomas of periurethral glands, the prostate it-
49$ THE AMERICAN JOURNAL OF UROLOGY
self not being implicated except through contiguity. The pars
prostatica of the urethra contains two varieties of glands, those
belonging to the prostate, and those grouped about the urethra,
the periurethral glands. The former lie outside, the latter in-
side of the sphincter.
In his exposition of his investigations on the genesis of " hy-
pertrophy " Marion considers separately the origin of the so-
called middle and the lateral lobes. Middle lobes may represent
merely adnexa or off-shoots of lateral lobes ; or, more frequently,
their inception is submucous, somewhere within the sphincter
muscle. Thus in some specimens, the hypertrophic lobe is seen
to be surrounded by a collar of sphincter muscle, and may be re-
garded as a nodule wholly outside of the prostate.
As for the pathogenesis of the lateral lobes, it is somewhat
more difficult to come to a definite conclusion. Of the many
arguments in favor of the view that the lobes have their origin
in urethral glands, the following may be cited :
1. In suprapubic prostatectomy the gland is apparently
covered only by mucous membrane, a fact that speaks for a sub-
urethral origin, since a muscle layer should intervene if the proc-
ess had its inception in the prostate. Further, the new growth
is usually easily extirpated without injuring the prostatic plexus,
or ejaculatory ducts. These facts may be taken also as favor-
ing the view that we are dealing with adenomas and not with
hypertrophy.
2. The new-formed lobes encroach on the urethra both an-
teriorly and posteriorly. The tissue of the lateral prostatic
lobes, however, lies behind a transverse line posterior to the ure-
thra. Hypertrophy of these lobes should cause expansion up-
ward and posteriorly where there are no dense neighboring tis-
sues to obstruct neoplastic advance.
3. If the prostatic gland were responsible for the hyper-
trophy, we should expect a general elongation of the prostatic
urethra, whereas in reality only that posterior portion bearing
the verumontanum suffers this change.
4. If we were dealing simply with adenomas of the pros-
tate, we should encounter instances in which isolated tumors
could be removed without injury to the urethral canal.
5. Numerous examinations of the prostatic bed after pros-
tatectomy bear testimony to the view that the prostate is left
behind after prostatectomy. This fact strengthens the assump-
CURRENT UROLOGIC LITERATURE 499
tion that we are dealing with adenomas and not with true hy-
pertrophy.
6. Cross-sections of that portion of the vesico-urethral
region which is extirpated in prostatectomy demonstrate the
presence of the new glandular growth directly beneath the mu-
cous membrane. A fibro-muscular capsule surrounds the neo-
plastic tissue and crowds away the prostate. The muscular ele-
ments of this capsule speak strongly against the view that we
are simply dealing with an adenoma originating in the prostate.
The absence of displacement of the prostate in forward and
lateral directions, and the singular crowding backward of this
organ, indicate that the capsule is something more than the mere
covering of an adenoma.
7. The fact that the growth takes place within the sphinc-
ter (which is easily demonstrable in the early stages of " hyper-
trophy "), is one of the most reliable proofs of the correctness
of the assumption that its origin is not in the prostate.
8. Finally, it is noteworthy that we never encounter ure-
thral glands within the hypertrophied masses, or between these
and the urethra, a fact which is not compatible with the hypothe-
sis that the " hypertrophy " begins in the prostate.
Although we cannot conclude that true prostatic adenomas
do not exist, the data adduced above bear eloquent testimony to
the correctness of the author's view that in most cases, at least,
the prostate gland takes no part in " Prostatic Hypertrophy."
13. Prostatic Lipoids and Prostatic Concretions. — Un-
til a short time ago the recognition of the lipoid sujbstances was
based entirely upon their appearance in the polarization micro-
scope. They differ from true fats in their double refraction,
but resemble them in micro-chemical reaction, in that they take
up the Sudan III, and Scharlach R. stains, as well as osmic acid.
The recent introduction of Ciaccio's method for differentiation
of the lipoids from fats was therefore most welcome. This pro-
cedure depends upon the insolubility of lipoids in alcohol and xy-
lol after fixation in chromic acid solution, demonstrating the
lipoid bodies even after imbedding in paraffin by means of the
Sudan stain. What Fiirbringer called " lecithin " some thirty
years ago is now grouped together with other fatty bodies, un-
der the caption " lipoids."
The presence of lipoids in prostatic secretion having been
definitely proven by polarization and tinctorial reaction, Pos-
500 THE AMERICAN JOURNAL OF UROLOGY
ner sought to corroborate these findings by applying the Ciaccio
method to sections of the gland. Of the 13 prostates examined,
all but two (taken from very young children) showed lipoids. The
cells of the acini are particularly rich in these bodies, the base
of the cells being the favorite site of numerous granules of vari-
ous sizes. One gains the impression from the stained specimens
that the lipoid granules are the specific substances elaborated
by the epithelial cells. In the lumina, too, there are granules,
and even the cells that lie free and detached are often filled with
them. In the presence of an inflammatory process, the leuco-
cytes also take up the lipoid bodies, and certain authors assume
that there is a positive chemotactic influence which determines
the inhibition of lipoids by the wandering cells.
14. Syphilis of the Bladder. — Pereschiwkin calls atten-
tion to the sparsity of observations of leutic lesions in the blad-
der other than gummata, and cites the histories and findings in
three cases with secondary manifestations.
In Case I the bladder mucosa was normal save in the imme-
diate neighborhood of the left ureter where there were a few
small ulcers with deep red floors.
Cystoscopic examination in Case II revealed four minute
red areas in the vault of the bladder.
The third case showed ulcers of various size and shape,
oedematous ureteral ostia, and internal sphincter. All these le-
sions rapidly disappeared after a few injections of salycilate of
mercury.
15. Congenital Diverticula of the L'rethra. — Accord-
ing to seme authors, there are valve-like formations in the ure-
thra during foetal life, that prevent the outflow of urine. Kauf-
mann believes that these valves are not the causes of diverticula,
but rather that developmental anomalies are responsible. Only
eighteen instances are recorded in the literature. The author
cites the case of a boy eight years of age who presented a pocket
inferiorly behind the fossa navicularis of the urethra. During
the act of micturition this sac-like process filled up and became
almost as big as a walnut. A plastic operation, with incision
of an oval piece of the mucous membrane, was performed, result-
ing in complete cure.
19. Experimental Studies of Tests for Renal Func-
tion.— Wohlgemuth endeavors to point out the reliability of his
CURRENT UROLOGIC LITERATURE
501
Diastase Test for renal function, and compares the results ob-
tained by it with some of the other well-known methods. His
procedure depends upon the premise that a diseased kidney will
excrete less diastatic ferment than a normal organ. A study of
a series of urines of nephritics by the author, and the more re-
cent reports of other workers, seems to point to the correctness
of this assumption. If we take a set of test tubes in which the
ferment containing fluid (urine) is put in a decreasing series of
amounts, and then add equal quantities of a 1% starch solution
to each tube, we will be able to estimate the quantity of ferment
after incubation at body temperature, if we then test with a
drop of a 1/10 normal iodine solution. In those tubes in which
digestion is advanced a yellow or reddish color is found and
where there is not sufficient ferment to act, a blue or purplish
tint will appear.
The author concludes that his method can give valuable in-
formation as to the comparative function of the two kidneys.
In interpreting results we must compare the concentration of
diastatic ferment in the specimens of urine collected simultane-
ously from the two kidneys. If the figures drop very low, the
assumption of profound renal lesion is warranted, except in the
presence of polyuria. The presence of blood, too, may vitiate
the results, since the serum activates the ferment, giving, there-
fore, higher values to those specimens that contain blood in
appreciable quantities. On the whole, Wohlgemuth believes his
method to be very simple, convenient and reliable.
20. An Endovesical Method of Operating for Tumors
of the Bladder. — Blum describes his instruments and method
of treating benign tumors of the bladder and records the results
obtained in 52 cases. All work is done either through the sin-
gle or double Nitze catheterizing cystoscope.
A steel spring (1.8 mm. wide) is wound into a spiral cathe-
ter of a calibre of 6 Fr. (Charriere), and serves for the passage
of a snare made of aluminium-bronze. The vesical end of the
wire snare is attached to the corresponding end of the canula,
the free end being manipulated by its external projecting por-
tion. In addition, the armamentarium includes grasping for-
ceps, a hook and a cautery. The latter is somewhat heavier
than the other instruments, measuring 7-9 Charriere.
After injecting 4* cubic centimeters of a 5% novocain solu-
tion into the urethra, the bladder is filled with 150 cubic centi-
502 THE AMERICAN JOURNAL OF UROLOGY
meters of J % boric acid solution, the quantity of the filling fluid
being made to vary acording to the site and accessibility of the
growth.
Having located the tumor, the wire loop is made to encircle
it, the steel canula carrier being pressed against the bladder wall.
The snare is then drawn tight, the cystoscope removed, and the
snare and catheter allowed to remain in situ for 24-48 hours.
The removal of the snare is then easy, since the tumor becomes
rapidly necrotic.
One or two weeks after endovesical avulsion of a papilloma,
a circular spot with necrotic deposit is all that remains in evi-
dence. In uncomplicated tumors of moderate size, the technic
as given, can be carried out in the office in one sitting, and with-
out the loss of an appreciable amount of blood. If it is difficult
to encircle the pedicle, a double catheterizing cystoscope is used
carrying a grasping forceps and the snare. After pulling the
growth forward with the forceps, the snare is easily passed.
Larger tumors may require several seances for complete removal.
Society Proceedings
NEW YORK ACADEMY OF MEDICINE.
Section on Genito-Urinary Surgery.
Stated Meeting, Held November 15, 1911.
A SERIES OF CASES OF GONORRHEAL RHEUMATISM CURED BY SEMINAL
VESICULOTOMY
Dr. Eugene Fuller presented several patients on whom he
had operated. He regards the operation of seminal vesiculotomy
as serious because it requires careful technique. The cases were
kept in the hospital about three weeks. Sometimes there was
atrophy of the muscles in association with the joint symptoms,
and this called for massage, especially in the chronic cases ; in
the acute cases, however, the repair was very quick if operation
was done without any delay. The results as demonstrated by
the presentation of the following cases, were very good.
Case 1 was a man who for seven years before operation
had to use crutches when up and about. He was 26 years of
SOCIETY PROCEEDINGS
503
age and had his first attack of gonorrhea nine years ago. Since
then he had had gonorrhea six times. In 1907 he had a severe
attack of gonorrheal rheumatism and was treated for nine months
before there was any apparent improvement in his condition.
The right shoulder, both hips, one knee and ankle were involved.
He could not walk at all. On October 11, 19ll, he was operated
upon and he feels well to-day. The pains he had before opera-
tion left him the day following the operation.
Case % was twenty-three years of age, and had his first at-
tack of gonorrhea five years ago, in the early part of May. In
the latter part of that month his joints became infected and he
entered the City Hospital. The right shoulder and knee, also
the wrist of the same side, were involved; the left knee was but
slightly affected. On October 21st he was operated upon.
Eighteen hours after the operation all the joint pains left him.
Since Dr. Fuller had .been doing seminal vesiculotomy he
had become very enthusiastic because of his results. Although
some cases do get a certain amount of relief after the em-
ployment of vaccines, this method is not as reliable as the opera-
tion for drainage of the vesicles.
Case 3, a man thirty-four years old, had an attack of gonor-
rhea fifteen years ago ; since then he had six attacks. The left
knee and right ankle were very much involved. He could walk
with great difficulty. Immediately after the operation the pain
left him, and to-day he complains of no pain whatever.
Case 4?, a patient twenty-three years of age, had his first
attack of gonorrhea three years ago ; since then he has had three
other attacks. His left knee, ankle and arm were so involved
that the slightest touch caused him agony. He was operated
on October 28th, was up and around in a few days, and a few
days later was able to leave the hospital. At present he has only
a little stiffness in the knees.
Case 5 was a patient who had an attack of gonorrhea eight
years ago and another attack last May. The joints were very
much involved as well as both shoulders. While in the hospital
he lost as much as sixty pounds in weight. To-day, after the
operation, he was able to be about and to do much work around
the hospital. He has been improving right along since the op-
eration.
Case 6 had very severe joint manifestations which were
relieved by the operation.
504 THE AMERICAN JOURNAL OF UROLOGY
Case 7, a patient operated upon October 18th, had been
•discharged from the United States Army because he was unable
to use his hand at all. In this case Dr. Fuller did not gain as
much as he expected from the operation. There was partial
anchylosis and it was necessary to break up the adhesions forci-
bly. Dr. Fuller thought that in two months the patient would
be able to do everything necessary in his calling.
Case 8, a patient thirty-five years of age, almost completely
bedridden, had to use crutches when he wished to leave his bed.
His muscles were so atrophied that it was hard to distinguish
the condition from neuritis or progressive muscular atrophy.
He was operated on 1-J years ago, and he has improved grad-
ually since.
Discussion of Dr. Fullers Presentation
Dr. Schmitter, U. S. A., said that he had some experience
with the Fuller operation. In the army many men are discharged
because of gonorrheal joints. Only one month ago there were
two men about to be discharged from the Army because of dis-
ability : one patient had his ankle involved and the other his
wrist. Within twenty-four hours after the operation the pains
disappeared. The operation saved them for the service.
Dr. Eugene Fuller in closing said that when he first per-
formed this operation, he was often asked what bacteria were
found in the seminal vesicles and whether cultures were taken
at the time of operation. It should be remembered that the op-
erative wound is three or four inches deep and that it is a very
difficult thing to make a smear and get cultures. He therefore
gave up attempting to make cultures from the vesicles.
THE MICROCOCCUS CATARRHALIS AS A CAUSE OF INFLAMMATION IN
THE GENITO-URINARY TRACT
Dr. Ayres desired to show that the micrococcus catarrh alis,
first, is capable of causing a urethritis of more or less severity ;
second, that if it is not recognized early and treated properly it
is a dangerous infection ; third, that if handled with proper care
it is of slight pathogenicity : fourth, that an urethritis caused
by the micrococcus catarrhalis presents an entirely different clin-
ical picture from that of an acute gonorrhea : and fifth, that in
the internal genital of the female it is a dangerous infection and
not an organism of slight pathogenicity.
Under the first heading Dr. Ayres stated he had seen six
SOCIETY PROCEEDINGS
505
cases of micrococcus catarrhalis during the year and his paper
included the detailed history of three.
Under the second, Dr. Ayres recited the history of one case
which had been treated as a gonorrhea, who developed
prostatitis, seminal vesiculitis, cystitis, epididymitis and pyelitis
all because the infection was not recognized early.
Third : — In two of the cases reported, the diagnosis had
been made early and the history of the progress of the disease
showed the mildness of inflammation under proper treatment.
Fourth : - — Dr. Ayres claimed that a micrococcus catarrhalis
urethritis always began as a subacute inflammation and differed
decidedly clinically from an acute gonococcic urethritis. He
further stated that gonorrhea rarely began as a subacute
urethritis.
Fifth : — Dr. Ayres reported two cases of pyosalpinx due to
the micrococcus catarrhalis. In both cases laparotomy had
to be performed and recovery was decidedly tedious.
Dr. Ayres claimed that it was impossible to distinguish the
gonococcus from the micrococcus catarrhalis morphologically
and showed many smears taken from patients infected with mi-
crococcus catarrhalis which to every appearance were true gono-
cocci. He claimed that the only method of differentiation was
by culture, stating that the micrococcus catarrhalis would grow
on nutrient agar at room temperature, while the gonococcus
would not. He claimed this to be an easy and accurate method
of diagnosis, as, in gonorrhea, it was generally admitted that
the gonococcus was the only germ to be found in the early stages.
A subacute urethritis containing Gram negative diplococci in
the pus cells was subjected to this test. If a catarrhalis growth
appeared on the median gonococci were absent, but if no growth
appeared, the germs found in the discharge were gonococci.
Such a test was not sufficient from a medico-legal standpoint.
Dr. Ayres believed that infection could take place both by
direct contact and through a hematogenous route. In support
of the latter theory he cited the case of one patient who had not
had intercourse in over fifteen months ; and furthermore both
cases of pyosalpinx cited, appeared to be of hematogenous origin.
In regard to treatment, the author had little to say. He
suggested that cultures should be made from all cases beginning
subacutely and nothing but an antiblenorrhagic be given until
the result of the culture was known. If the micrococcus catarrh-
506 THE AMERICAN JOURNAL OF UROLOGY
alis was found, the treatment was the proper one and should
be continued for a week with no local interference. If at the
end of a week there was still a discharge, some very mild astrin-
gent should be used.
Dr. Ayres warned against making a diagnosis of micro-
cocus catarrhalis infection simply because the urethritis began
as a subacute or chronic inflammation. Gonorrhea is decidedly
too serious an infection to be excluded without thorough investi-
gation.
Of the first eighteen cases tested by culture at the Post-
Graduate Dispensary, fifteen contained Gram negative diplococci
in the pus cells. Of these fifteen one proved to be an infection
due to the micrococcus catarrhalis. The author thought that
the proportion of cases of micrococcus catarrhalis infection to
that of gonococcic infection would run fully as high when a suf-
ficient number of cases had been studied.
Discussion of Dr. Ayres' Paper
Dr. Schmitter, LT. S. A., said that he had been working on
the gonococcus for about two years and had cultivated the mi-
crococcus catarrhalis several times. He believed that this diplo-
coccus could become Gram-positive in the agar cultures. He
thought that the extra-cellular forms were more likely to be
micrococcus catarrhalis, the organisms varying also in their
morphology, being much larger in recent cultures ; smaller, and
at times Gram-positive, in old cultures.
Dr. Eugene Fuller said he was very much interested in the
paper just read by Dr. Ayres because it tended to show that
we must be careful in diagnosticating gonorrhea. Several years
ago Dr. Fuller read a paper entitled : " Is the determination
of the gonococcus as simple a matter as was commonly sup-
posed? " It seemed that every medical student was abso-
lutely confident of his ability to recognize gonococci. Medical
men and even bacteriologists are a little more conservative to-
day than they were years ago. Personally he did not think that
the statement made by Dr. Sondern was entirely correct. Dr.
Sondern spoke of there being an error of about five per cent.
(5%) ; Dr. Fuller thought that twenty per cent. (20%) of error
would be nearer correct.
Dr. Leo Buerger said that it was exceedingly interesting
to note that the micrococcus catarrhalis occurred in such a large
SOCIETY PROCEEDINGS
507
number of cases of non-specific urethritis ; for, although he had
not been wont to examine the secretion of his urethritis cases by
cultural methods in a routine way, he had the impression that
the organism in question occurred rather rarely. Indeed, he had
found the micrococcus catarrhalis in but one instance during
the last five or six years, and in this case it certainly was not
the organism responsible for the infection. It must be remem-
bered that there are a great number of bacilli normally in the
urethra and that many of these may cause an inflammation.
Thus the pseudo-diphtheria bacillus may at times be the cause
of urethritis. One should be very careful in drawing conclu-
sions as to the etiology and pathogenicity of an organism found
in the secretion from a case, and careful work must be done be-
fore we can decide as to whether any particular organism is re-
sponsible for the inflammatory process.
Regarding the isolation of the micrococcus catarrhalis, he
did not believe that it was sufficient to cultivate the organism in
agar tubes in the manner employed by Dr. Ayres, for mixed
cultures must necessarily result from the author's technique.
It is preferable to employ plates when we wish to make a study
of the bacteria present in any given secretion, and in his own
work he was accustomed to use Petri plates containing serum
agar, upon which the fluid to be examined is streaked so as to
bring out isolated colonies. Thus it may very well have hap-
pened that in some of Dr. Ayres' series the presence of other
organisms, such as staphylococci, may have influenced the find-
ings. Thus, Dr. Buerger had pointed out some seven years ago
that pneumococci, when grown in symbiosis with certain bac-
teria, would take on extraordinary morphological and cultural
characteristics. Although he did not doubt the occurrence of
the micrococcus catarrhalis in the cases reported, he wished to
call attention to the fact that in future corroborative work a
more careful bacteriological method ought to be employed.
Dr. Frederic E. Sondern said he was much interested in the
paper just read by Dr. Ayres, as he thought the expressed views
may change opinion on the value of the ordinary determination
of gonococci in spreads by their appearance. It has generally
been believed that a Gram negative, chiefly intracellular, diplo-
cocCus found in spreads of a urethral discharge is the gonococ-
cus, admitting 5% error in medicolegal practice. The micro-
coccus catarrhalis, while Gram negative, has usually been found
508 THE AMERICAN JOURNAL OF UROLOGY
somewhat larger than the gonococcus and chiefly extracellular.
In the specimens containing the micrococcus catarrhalis he had
examined through the kindness of Dr. Ayres, it was, however,
not possible to state that these organisms were not gonococci.
Dr. Ayres' statement that a micrococcus catarrhalis infection is
found once to about every fifteen cases of gonococcus infection,
may possibly contain the 5c/c error admitted in the diagnosis of
gonococci without culture. In event of a question concerning
the differential diagnosis in these infections, cultures are cer-
tainly necessary, and in this connection it is well to remember
that a growth of gonococci is not invariably obtained even on
suitable media, particularly in chronic casts.
Dr. V. C. Pedersen said he had not had any personal experi-
ence with the micrococcus catarrhalis in the genito-urinary tract,
but he had with another organism, the streptococcus brevis.
The patient in question was a physician who contracted gonor-
rhea twenty-two years previously, and both elbows and ankles
became involved. Every winter he had exacerbations of the
trouble. A specimen was secured from his urethra and a micro-
scopic diagnosis of gonococcus was made. He was given stock
vaccines with benefit. He received many millions of dead gono-
cocci in a period covering several months. Then without any
known cause the knees, too, became attacked. A specimen was
sent to a laboratory where a diagnosis of gonococcus was made
by cultural means. L^pon further examination, the diagnosis
was changed to streptococcus brevis. Autogenous vaccines were
then administered for three months. To-day the doctor is able
to go about his professional work and able to crank his auto-
mobile.
Dr. Winfield Ayres. in closing the discussion, said that he
had also observed old cultures of the micrococcus catarrhalis
that were Gram-positive. In his work he had aimed at obtain-
ing a reliable method that could be used in office practice, some-
thing that would be simple and which would entail the using of
nothing more than tubes of nutrient agar. In some of his cases
the diagnosis was corroborated by Dr. Sondern.
Infection of the L'rixary Tract by the Bacillus Lactis
Aerogexes. — J. A. Leutscher (Bull, of Johns Hopkins Hosp.),
October, 1911. In a comprehensive review of cases of infection
of the urinary tract possibly due to the bacillus lactis aerogenes,
CURRENT UROLOGIC LITERATURE 501)
the author includes two cases of his own where the bacillus was
positively identified in culture. In one case, a female 28 years
of age was attacked during the second month of pregnancy with
urinary symptoms among which frequent micturition, tenesmus
and bearing down pain, were the most prominent. The urine
was acid containing leucocytes and an occasional red blood cell.
Each of two catheterized specimens taken ten days apart showed
the B. lactis aerogenes in pure culture. The condition persisted
for four weeks with a marked tendency to recurrence whenever
urotropin was omitted.
The second case, the husband of the above, developed a
urethritis accompanied with a watery discharge that contained
a few pus cells but no gonococci. The symptoms of an acute
cystitis followed, the temperature rising to 103° F. after four
days. There was marked prostration, headache and some nau-
sea. Fifteen days after the onset epididymitis developed. The
prostate was not enlarged or tender. A bacteriological exam-
ination of the urine was made on the ninth and fourteenth day
of the disease, and in both the B. lactis aerogenes was found in
pure culture.
From a study of his own cases and a review of the litera-
ture the author concludes as follows :
1. The B. lactis aerogenes is a rare cause of cystitis.
2. The great majority of infections (of the bladder) are
due indirectly to the introduction of instruments.
3. Infections of the bladder, in cases where no instruments
have been introduced, are very frequent in women and rare in
men.
4. In infections of the bladder in women, without a history
of the introduction of the instruments, the route of infection is
usually an ascending one and due to the direct invasion of the
bacteria from the urethra.
5. Such direct invasion of the bladder also occurs in the
male, and probably much more frequently than is usually sup-
posed.
6. The introduction of a catheter or instrument into the
bladder is a very serious procedure, since it may produce a
pyuria if the local conditions are favorable, or a bacteriuria
which later may be converted into a pyuria when the local con-
ditions become favorable.
510 THE AMERICAN JOURNAL OF UROLOGY
Pyeloradiography after Dilatation with Oxygen. — A
V. Lichtenberg and H. Dietlen (Muench. Med. Wochenschr.,
June 20, 1911). Improvements in our methods of the diagno-
sis of renal and ureteral calculi are still to be sought since even
X-ray examination fails to show a shadow in at least 2-3 per
cent, of the cases. Furthermore, even the localization of renal
stones as to their position in the pelvis or calices is of no little
importance in aiding the surgeon towards a rapid decision of
the method of approach. In this regard, the method of collargol
injection has been of but scant assistance, and the authors,
therefore, investigated the utility of oxygen for the purpose of
intensifying the relative density of structures in the renal pelvis
and ureter. Three cases were studied, two of which were nega-
tive. In one case in which there was a large coral-like branch-
ing calculus in the renal pelvis, the plasticity of the radiographic
picture was greatly enhanced by the injection of oxygen, the
stone shadow being more intense, the empty portions of the pel-
vis showing as clear areas.
The following technic is suggested. A ureteral catheter
(No. 5-6 French) having been placed in the renal pelvis, an oxy-
gen apparatus, in which the pressure is low, is attached and the
gas allowed to flow for 2 or 3 minutes, after which the picture is
taken, the current of oxygen continuing. When the procedure
is properly carried out, the authors believe the method to be safe
and of distinct value in the recognition of calculi.
Local Anaesthesia for Renal Operations. — A. Lawen
(Muench. Med. Wochenschr. , June 27, 1911). Lawen recom-
mends the following procedure where the kidney is to be attacked
under a local anaesthetic. Four points are selected, each about
an inch above the crest of the ilium and equidistant from each
other. After directing the needle towards the bone, withdraw-
ing it 1-2 centimeters and pointing it upward, 20 cubic centime-
ters of a 0.5% novocain solution are injected at each of these
sites. Similarly four other points are taken, each -1 centime-
ters from the mid-line of the back and corresponding to the 12th
dorsal and 1st, 2d and 3d lumbar nerves. Here 10 cubic centi-
meters of a lc/c novocain solution are injected. Finally the line
of incision is infiltrated and after fifteen minutes the kidney may
be exposed without causing the slightest pain.
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Vol. VII
January, 1911
No. 1
The American
Journal of Urology
DEVOTED TO
Genito-Urinary and Venereal Diseases
EDITED BY
WILLIAM J. ROBINSON, M.D.
OF NEW YORK
G. A. DE SANTOS SAXE, M.D., New York
ASSOCIATE EDITOR
COLLABORATORS:
Leo Buerger, M.D., .... New York J. N. Vander Veer, M.D., . . Albany
Chas. Chassaignac, M.D., New Orleans A. L. Wolbarst, M.D., . . New York
Louis Gross, M.D., . . San Francisco Prof. W. Watson-Cheyne, . . London
F. M. Johnson, M.D., .... Boston Dr. David Newman, . . . Glasgow
F. Kreissl, M.D., Chicago Prof. Dr. L. Casper, ....... Berlin
Bransford Lewis, M.D., . . St. Louis Prof. Dr. C. Posner, .... Berlin
Granville MacGowan, M.D., Los Angeles Prof. Felix Legueu, Paris
H. F. Nordeman, M.D., . . New York Dr. E. Desnos, Paris
V. C. Pedersen, M.D., . . New York Prof. Tedenat, ..... Montpelier
H. J. Scherck, M.D., ... St. Louis Prof. A. Pousson, .... Bordeaux
Victor G. Vecki, M.D., . San Francisco Dr. E. Loumeau, .... Bordeaux
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A popular treatise on the three venereal diseases; their
nature, cause, course, symptoms and prevention
By WILLIAM L. HOLT, M. D.
Edited by WM. J. ROBINSON, M. D.
The only work of its kind in the English language
EVERY PHYSICIAN AND LAYMAN SHOULD
READ IT
Paper Bound, 25c.
Cloth Bound, 50c.
Ufye Social Evil:
Its Causes and Cure
By WILLIAM L. HOLT, M. D.
A remarkable thought-provoking booklet. Goes
to the root of the evil.
Price 10 Cents
Address all orders to
THE ALTRURIANS
Publishers of Books that enlighten, uplift and ennoble.
12 Mount Morris Park West,
NEW YORK CITY
THE POMEROY CORSET
A. Surgical Corset made hy a
dealer in Surgical Appliances
For MOVABLE KIDNEY, ENTEROPTOSIS,
GASTROPTOSIS. POST-LAPAROTOMY,
and any other condition requiring :: -
ABDOMINAL SUPPORT
SM This Corset
should be put on by
the patient while
in a recumbent
position .
The Pomeroy Corset is not an experiment. It is the successful result of
our many years' practical experience in fitting corsets for surgical uses.
The Pomeroy is a specially designed abdominal corset that meets the
demands of physicians for one that will successfully support displaced
organs and improve the figure on lines in keeping with the latest mode
POMEROY COMPANY, Makers of Surgical Appliances,
34 E. 23d Street, NEW YORK
BOOKLET AND ORDER BLANKS SENT ON REQUEST
IT DOES \
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^Saline
Laxative
THE season of bowel troubles has arrived. Now, more than
ever, the doctor will have need for Saline Laxative.
No other evacuant compares with it— no substitute is quite so
pure and so regular in action.
In bowel infections and summer toxemias choose this best-of-
all saline. It will flush out the intestinal tract quickly and
completely, leaving it clean and clear of toxin-breeding, bac-
teria-feeding residue.
Saline Laxative affords all the goodness of pure, full-strength
epsom salt without its vile taste and drastic effect. It yields with
water a sparkling, cooling draught no patient will refuse. It
operates energetically yet gently. It never gripes — never nauseates.
See that your druggist has it or order a dozen medium-size
packages; $4.00— delivery prepaid when cash comes with the
order.
trial can jree if you have not had one.
The Abbott Alkaloidal Co.
CHICAGO
NEW YORK TORONTO SEATTLE SAN FRANCISCO
For further information, full directions
concerning the use of CYTONE, prices,
etc., address:
is respectfully offered to the medical profession for
the systemic treatment of chronic eczema, late
syphilitic and tuberculous ulcers, malig-
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ilar affections.
CYTONE is not a secret remedy and con-
sists of a specially selected and modified creosote,
combined with terpenes and inert soluble oils.
It is used hypodermatically and is a powerful
systemic antiseptic, with marked antitoxic and re-
constructive properties.
No extravagant claims are made for CYTONE,
but in the hands of competent physicians it gives
results in relieving pain, arresting discharge and fetor,
controlling ulceration and promoting the normal
processes of repair, that give it a unique place in
modern therapy.
The internal antiseptic value of creosote has
long been recognized, but H is only through
the agency of CYTONE that doses sufficient-
ly large to arrest ulceration and effect tissue
metamorphosis can be safely administered.
THE CHEMICAL MFC. CO., OF NEW YORK
50 Church Street, New York City
if
The Last Word in
Samples on Request
Silver Therapy
At last, the ideal preparation of silver — possessing all of
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older salts, with none of their drawbacks.
I
"MILK OF SILVER IODIDE"
The most effective silver producr at the command of the pro-
fession—absolutely clean, does not stain the skin, clothing
or dressings and never irritates the most sensitive tissues.
Invaluable in acute and chronic urethritis, cystitis, vagi=
nitis, nose and throat diseases, otitis media and all acute or
chronic infections of the mucous membrane.
ANTISEPTIC
GERMICIDAL
HEALING
THE SILVODIDE CHEMICAL CO., 1215 Market St., Philadelphia
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