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Full text of "Urology; the diseases of the urinary tract in men and women, a book for practitioners and students"

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1}anlac^ flDebical Scbool 



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UROLOGY 



VOLUME I 






* ' V ■ 



1 ■ ;f 



UROLOGY 

THE DISEASES OF THE URINARY 
TRACT IN MEN AND WOMEN 

A BOOK FOB PHACTITIONERS AND STUDENTS 



KAMON gUITERAS, M.D. (Harv.) 

PBOFEHOB OT QBITITO-UKINAHY HDROEBV. KEW YORK POST-OBASITATE MEDICAL SCHOOL; TlaiTIIIO 
iOBQBOW TO THB COLUMBUS AND POi 
AND rmKSCII HOSPITALS; FOBHEI 

GTITBCOLOOV. POBT-GBADnATE MEDICAL W 



WITH NINE HUNDRED AND FORTY-^THREE ILLUSTRATIONS IN TEXT 
AND SEVEN PLATES 



VOLUME I 



NEW YORK AND LONDON 

APPLETON AND COMPANY 
1912 



Copyright, 1012, by 
D. APPLETON AND COMPANY 



PRINTED IN 
NEW YORK, V. 8. A. 



TO MY TEACHERS 



HENRY J. BIGELOW 
THEODOR BILLROTH 
ERNEST FINGER 
FELIX GUYON 
JAMES E. KELLY 
PRINCE A. MORROW 



FESSENDEN N. OTIS 
FREDERICK R. 8TURGIS 
ROBERT W. TAYLOR 
ROBERT ULTZMANN 
LEOPOLD VON DITTEL 
ERNEST VON BERGMANN 



THIS WORK IS DEDICATED 
AS A TOKEN OF RESPECT, ESTEEM 

AND GRATITUDE 



PEEFACE 



This work on Urology includes all the diseases of the urinary tract, both 
medical and surgical, in men and women. The upper part of the urinary 
tract, the kidneys and ureters, .is practically the same in both sexes. The 
middle part, the bladder, is also the same, although its relations are different, 
and, whereas bladder troubles in men are principally due to intravesical causes 
and obstructions in the prostate and urethra, the troubles in women are gen- 
erally due to extravesical causes in the pelvis. It is obvious, therefore, that 
it is the lower third of the urinary tract, the urethra, which principally differs 
in men and women. 

In men it has been thought advisable to consider the diseases of the genital 
tract together with the urinary, as the genital tract empties into the prostatic 
urethra and from this point to the external urinary meatus the two tracts are 
in common. In women, on the other hand, the urinary and genital tracts are 
separated from each other throughout their entire extent, meeting externally 
at the urogenital sinus in the vestibule. The internal genital organs are, how- 
ever, in close enough contact with the bladder to give rise to many disagreeable 
urinary symptoms, most of which have been carefully considered. If an attempt 
were made to consider the genital tract of the female as thoroughly as that of 
the male, it would necessarily embrace gynecology, which is not within the 
scope of this work. 

It has been my aim in writing the text to consider principally cause, diag- 
nosis and treatment and not to go as deeply into pathology as many writers do. 
The illustrations were chosen to show certain pathological conditions and to 
illustrate the steps of operations, and, excepting the purely anatomical and 
pathological drawings of specimens, they are principally diagrammatic and 
schematic. 

The first part of the book is preparatory to the second. It contains the 
anatomy of the urinary organs in the male and female and the* laboratory 
methods of examining the urine, discharges and blood. The different varieties 
of offices for this kind of work are then considered with their equipment, the 
instruments and apparatus recommended and the methods of sterilization of 
the apparatus and instruments. The technique employed in using the apparatus 
and the general instruments that compose the armamentarium of the urinary 
surgeon as well as the special instruments, such as the urethroscope and cysto- 

vu 



vm 



PREFACE 



scope, IS carefully described. A lengthy description of the general and special 
urinary symptoms and disturbances of urination are then entered into, and 
urinary fever is thoroughly discussed. 

The history and examination of the patient, showing the manner of arriv- 
ing at a diagnosis, are then taken up. This is followed by a chapter on uro- 
logical therapeutics in which drugs, exercise, diet and the use of water, inter- 
nally and externally, as well as by rectum, intravenous injections and hypo- 
dermoclysis, are fully considered. Asepsis and antisepsis and general and local 
anesthesia, such as are used in the various urological operations, are also care- 
fully described. A small section on the diseases of metabolism is here brought 
in and is a valuable addition to the work. 

The second part of the work is principally clinical and operative, and the 
diseases of the various organs of the urinary tract, the kidneys, ureters, bladder, 
prostate, urethra and the genital organs in the male have been taken up seriatim; 
and finally a chapter on lues was added. The most modem methods of exami- 
nation of the patient and diagnosis are here described in great detail. The med- 
ical and palliative treatment of diseases have, however, been gone into as care- 
fully as the surgical, and the details of such treatment are thoroughly explained. 
Lengthy historical data have been omitted and statistics have not been recorded 
and quoted fully. As the object of the book has been to make it a comprehen- 
sive work for the practitioner, the bibliography has not been given great promi- 
nence. 

Most of the teachings in the book are the same as I have advocated in my 
lectures during the last twelve years. They are my own views on the subject, 
some original and others taken from the teachings and writings of others that 
appeal to me as sound and worthy of recommendation. 

Having taught in the New York Post-Graduate Medical School and Uos- 
pital for over twenty years, I believe I imderstand the requirements of the gen- 
eral practitioner, and therefore, after repeated requests from many students, 1 
have endeavored to present the subject in a way which I believe will be satisfac- 
tory to them. 

I wish to thank Dr. H. T. Brooks, Dr. Faxton Gardner, Mr. K. K. Bosse, 
Dr. David Geiringer and Dr. F. Robbins for their assistance in the text, and 
Dr. David Geiringer for the illustrations he has made. 

For the remaining illustrations I wish to thank the various authors whose 
names appear on the legends. If in any case I have not given credit where it 
is due, it is on account of being doubtful whose name to inscribe. I wish par- 
ticularly to thank Drs. Ashton, Corner, Deaver, Kelly, Lewis, Lydston, Luys, 
Manson, Wallace, Watson and Cunningham and White and Martin for the kind 
permission to use their illustrations. 

Kamon Guiteras, 

80 Madison A^'enue, New York City, 



CONTENTS 



VOLUME 1 



PAOB 

I. — HisTOBT OF Diseases of the Urinary Tract 1 

n. — ^The Anatomy of the Urinary and Gen ito-Uri nary Tract .... 9 

III. — ^The Urine 70 

rv. — ^Discharges 117 

V. — ^The 'Blood in Relation to Urology 132 

VI. — Urological Equipment 137 

VII. — Sterilization of Instruments and Apparatus 153 

VUII. — ^Technique of Instrumentation 163 

IX. — Urethroscopy 188 

X. — Cystoscopy 198 

XI. — Special Urinary Symptoms 239 

XII. — Urinary Fever (Catheter Fever), Urinary Infection 289 

XI n. — ^The History of the Case 297 

Xrv. — General Symptoms 304 

XV. — Examination of Patients 308 

XVI. — Urological Therapeutics 323 

XVII. — Anesthesia in Urology 350 

XVIII. — Diseases of Metabolism 358 

XIX. — Methods of Examining the Kidney 369 

XX. — ^Anomalies of the Kidney 383 

XXI. — Kidney Injuries 390 

XXII. — ^Movable Kidney 403 

XXIII. — Nonsuppurative Nephritis 418 

XXIV.—Uremia 440 

XXV. — Chronic Suppurative Diseahkh of the Kii>nky 453 

XXVI. — TlTMORS OF THE KiDXEY 480 

XXVII. — Cysts of the Kidney 492 

XXVIII. — Nephrolithiasis 409 

XXIX. — ^Tuberculosis of the Kidney 525 

XXX. — Hydronephrosis 560 

XXXI. — Operative Surgery of the Kidney 570 

XXXII. — ^The Ureters 622 

XXXIII. — Operations on the 1'reter 646 

ix 



LIST OF PLATES 



VOLUME I FACING 

PAOB 

Plate I. — ^Ixdican Ck>LOB Reaction in Urine 86 

Plate II- — Bacteria Found in the Urine 110 

Plate II J. — Bacteria, Showing the Opsonic Action Increased by Proper Adminis- 
tration OF Bacterial Vaccines 112 

Plate IV. — Urethroscopic Conditions 192 

Plate V. — ^Ube?thbo8C0PI0 CJonditions 194 

Plate VI. — Shreds and Formations Passed in the First Urine without Massage . 316 

Plate VTI. — Formations Coming from the Vesicles after Massage .318 



XI 



LIST OF ILLUSTRATIONS IN TEXT 



VOLUME I 



no. PAQB 

1. — Anterior view of the opened genito-urinary tract in the male 10 

2, — Posterior view of the genito-urinary tract in the male 10 

3. — Posterior view of the relations of the genital and urinary organs in the male at 

the back of the bladder 11 

4. — Anterior view of the genito-urinary tract in the female 12 

5. — Posterior view of the genito-urinary tract in the female 12 

6. — Upper and middle portions of the urinary tract of the kidney 13 

7. — Lower urinary tract in the male on sagittal section, and also the internal and 

ejctemal genital organs 13 

8. — Genital organs and lower urinary tract in the female on sagittal section 14 

9. — Genito-urinary sinus in the male 15 

10. — Genito-urinary sinus in the female 15 

11. — Anterior view of the bony skeleton of the part of the body in which the urinary 

tract is lodged 16 

12, — Posterior view of the bony framework enclosing the urinary tract . ... 17 
13. — Space occupied by the urinary tract after it has been lined with its muscular 

layer 18 

14. — The ligaments and muscles helping to form the pelvic floor 19 

15. — View of the right side of the pelvic cavity as .seen after a sagittal section . . 21 

16. — The pelvic floor looking in from above 22 

17. — View of the internal genitals and the pelvic fascia in the male as seen from be- 
hind 23 

18. — Extraperitoneal sagittal section of the body to the left of the median line 24 
19. — Muscular layer of the perineum on the right side after the removal of the super- 
ficial fascia and on the left side after removing the muscular layer ... 26 
20. — Anterior perineal triangle after the removal of the muscles, the corpus spongeosum 

and the corpora cavernosa covering it 27 

21. — ^The outer layer of the triangular ligament of the right side, and on the left the 

space between the two layers of the ligament 28 

22. — The male perineum after the removal of the deep layer of the triangular ligament 29 

23. — The perineum in the female after the removal of the labia 30 

24. — Anterior layer of the triangular ligament in the female, after the removal of the 

external genitals, the superficial fascia and muscles 31 

25. — The deep layer of muscles forming the floor of the pelvis in the female from the 

outside 32 

26, — The posterior surfaces of the kidneys and their relations to the ribs .... 33 
27. — ^The relation of the kidneys and suprarenal capsules to the soft tissues in front 

of them 34 

28. — The relation of the kidneys to the soft tissues behind them 35 

29. — Median vertical (sagittal) section of the right kidney 35 

30. — The renal fascia after a sagittal incision through the kidney 36 

• • • 

xm 



xiv LIST OF ILLUSTRATIONS IN TEXT 

FIO. PAOB 

31. — ^The renal fascia after a horizontal incision through the kidney 37 

32. — Sagittal section of the kidney 37 

33. — Malpighian corpuscle • . 38 

34. — Scheme of the renal tubes and blood vessels 38 

35. — The renal artery and its branches 39 

36. — Schematic drawing showing the theory of the arrangement of the vascular arches 

over the pyramids 40 

37. — The relations of the ureter to the inferior pole of the kidney and to the blood ves- 
sels of this region . 41 

38. — A sagittal section of the pelvis to the left of the median line showing the ureter 

outside of the peritoneum 42 

39. — The relations of the ureter to the pelvic tissues 43 

40. — Ureter passing through the wall of the bladder 43 

41. — Schematic drawing of the relations of the ureter to the neck of the uterus and its 

vessels. 44 

42. — Shape of the right ureter 44 

43. — Bladder on sagittal section, showing its apex and base 46 

44. — Bladder on vertical transverse section, showing the trigone and the urethral 

orifices. 46 

45. — The peritoneal reflection on the side of the bladder 47 

46. — Diagrammatic drawing of the upper surface of the bladder in the male ... 47 

47. — The upper surface of the bladder in the female as seen from above .... 48 

48. — Diagrammatic drawing showing the base and sides of a dilated bladder from below 49 

49. — Change in the shape of the bladder while filling 49 

50. — Longitudinal muscular fibers of the bladder wall 49 

51. — Middle or circular layer of the muscular wall of the bladder 50 

52. — Deep layer of the bladder wall 50 

63. — Veins in the male pelvis connected with the bladder 61 

64. — Veins about a female bladder 62 

65. — Male urethra from the neck of the bladder to the external urinary meatus . 52 

56. — Curves of the urethra when the organ is flaccid, also the fixed portion of the canal 53 
57. — Curve of the urethra when the penis is erect or held in position for the passage 

of instruments 53 

58. — Membranous urethra and its relation to the triangular ligament .... 54 
59. — Genito-urinary sinus in the male, the prostate having been opened anteriorly into 

the urethra and its lateral lobes retracted 54 

60. — The natural dilatations and narrowings of the urethra 65 

61. — Transverse vertical (coronal) section through the female urethra .... 66 

62. — Cowper's glands 67 

63. — Vertical transverse (coronal) cut through the scrotum and penis (schematic). . 67 

04. — The tunica vaginalis opened, exposing the testis 58 

05. — Schematic drawing, showing the anatomical arrangement of the tubules in the 

testicle and the epididymis 69 

66. — Vertical section (sagittal) of the testis and epididymis, showing the line of reflec- 
tion of the visceral layer of the tunica vaginalis, the tunica albuginea with its 

septa, the rete testis mediastinimi, the epididymus and vas deferens ... 60 

67. — Blood supply of the testis and cord 60 

68. — Coverings of the testicle, seen from in front 61 

69. — The vas deferens extending through the inguinal canal and along the side of the 

bladder to the ejaculatory ducts 62 

70. — Profile view of the side of the unopened prostate 64 

71. — The lobes of the prostate and the perineal fascias 65 

72. — Sagittal section through the prostate, a little to the left of the median line . . 66 

73. — Penile urethra in the state of repose and erection 67 

74.— Roots of the penis 67 



LIST OF ILLUSTRATIONS IN TEXT XV 

na. 'Aa» 

75. — Maimer of union of the anterior end of the corpora cavernosa with the glans . 68 

76. — The end of the penis 68 

77. — Urine analysis chart 72 

78. — Squibbs urinometer with thermometer and cylinder 74 

79. — Saxe*8 urinopyknometer and cylinder 76 

80. — Esbach's albuminometer 77 

81. — The Laurent penumbra polarizing saccharometer 80 

82. — Lohnstein*8 saccharometer for undiluted urine 82 

83. — Einhom's saccharometer 82 

84. — Doremus ureometer 84 

85. — Doremus ureometer, improved form 84 

86. — Ruhemann's uricometer for the rapid estimation of uric acid 85 

87. — Hand centrifuge 92 

88.— Water centrifuge 92 

89. — The Purdy electric centrifuge 93 

90. — Crystals of uric acid 94 

91, 92, — Unusual forms of uric acid 96 

93. — Crystals of ammonium urates 95 

94. — Calcium oxalate crystals 96 

95. — Crystals of ammonium magnesium phosphate 96 

96. — Feathery form of triple phosphates 97 

97. — Crystals of calcium sulphate 97 

98. — Leucin crystals 98 

99. — Leucin and tyrosin crystals 98 

00.— CrysUls of cystin 99 

01. — Blood cells in the urine 99 

02. — Pus cells in the urine 99 

03. — Epithelial cells of genito-urinary tract 101 

04.— Hyaline casts 105 

05. — Granular casts 105 

06.— Epithelial casts 106 

07.— Blood casts 106 

08.— Pus casts 107 

09. — Fatty and other casts 107 

10. — Types of casts with a waxy matrix 107 

11. — Cylindroids or false casts 108 

12. — Manner of holding the slide in taking a specimen of urethral discharge in the male 117 

13. — Method of obtaining a specimen from the male urethra 118 

14. — Platinum wire to be passed down the urethra to take some discharge from its walls 118 

15. — Forcing the discharge out of the female urethra 119 

16. — Smears on slides 119 

17.— The slides together 119 

18. — Spermatic or BSttcher's crystals 120 

19.— Spirocheta pallida 122 

19. — A spirocheta as seen by Goldhom stain 122 

20. — Reflecting condenser 123 

21. — Reflecting condenser 124 

22. — Electrical arc lamp with hand feed for a current of 4 amperes 124 

23. — Plan of an oflice of one room with waiting room 137 

24. — Plan of an oflice of two rooms with waiting room 138 

25. — Plan of an oflice of three rooms with waiting room 139 

26. — Table in the examining room with glassware used in examinations .... 143 

27. — Counterbalance table in the position for examination of male patients 144 
128. — Difl'erent positions in which the patient can be placed in examining the abdominal 

organs, especially in kidney cases 146 



Xvi LIST OF ILLUSTRATIONS IN TEXT 

FIO. PAOB 

129. — Counterbalance table with a douche-pan on it 145 

130. — Allison table in the cystoscopic position 147 

131. — ^Appointment form 148 

132. — Three vertical files in which the envelopes containing the patients' histories and 

correspondence are kept 149 

133.— Plan of the clinic at the New York Post-Graduate Medical School ... 150 

134. — ^Willy Meyer steam sterilizer for the sterilization of dressings and instruments . 154 

135. — Rochester sterilizer, steam and dry heat 154 

136. — Schering-Glatz formalin sterilizer, used principally for woven catheters, piston 

syringes and cystoscopes 155 

137. — Snell's formalin sterilizer for sterilizing all catheters, but especially ureteral . 157 

138. — ^Method of flushing out catheters employed in author's office 158 

139. — Catheter and catheter tube 159 

140. — Glass sterilizing tubes with hollow rubber stoppers containing formalin 159 

141. — Straight catheter with single eye 163 

142. — Elbowed catheter with the eye on the side 163 

143. — Curved catheter of the woven variety 163 

144. — Straight olive-tipped woven catheter 163 

145. — ^Bi-coud6 woven catheter 163 

146. — Straight rubber catheter with velvet woven eye 164 

147. — Elbowed soft rubber catheter with eye on the side 164 

148.— Metal catheter 164 

149. — N^laton catheter 165 

150. — Retained catheter 167 

150o. — A more secure method of holding a retained catheter 167 

151. — Malecot's catheter 167 

152. — Another type of Malecot's catheter 167 

153. — Pezzer's catheter 167 

154. — ^Another type of Pezzer's catheter 167 

155. — Glass urinal between legs 168 

156. — Relative position of meatus and nozzle of the syringe 169 

157. — Manner of holding the nozzle of the syringe in the urethra 169 

158. — How the solution is held in the urethra 169 

159. — ^A large piston syringe (bladder syringe) used for washing out the bladder 

through a catheter 170 

160. — Cut-off, nozzle tip and shield with a tube passing to a douche jar . .170 

161. — Author's methods of suspending douche jars for irrigations in office, hospital and 

clinic 171 

162. — Author's apparatus for irrigating urethra and bladder by hydrostatic pressure . 172 

163. — Irrigating Kollmann dilator 173 

164. — Guyon's instillating syringe 174 

165. — Manner of giving an instillation of the urethra with the Guyon instillator . .174 

166. — Ultzmann's instillating syringe 175 

167. — ^Manner of injecting the posterior urethra by means of the Ultzmann instillator . 175 

168. — Curves of sounds recommended 176 

169. — French (Charri^re) sotmd scale, compared with English measurement . . 176 

170. — Sound curve preferred by author 177 

171. — First step of passing a sound 177 

172. — Second step of passing a sound 178 

173. — Third step of passing a sound 178 

174. — Beniqu^ sound with and without filiform guide 179 

175. — First step of passing a Beniqu6 sound 179 

176. — Second step of passing a B^niqu6 sound 180 

177. — Third step of passing a B^niqu6 sound 181 

J 78. — Fourth step of passing a Beniqu6 sound 181 



UST OF ILLUSTRATIONS IN TEXT xvii 

FHS. FAOB 

179.— Oberllnder dUators 182 

180.— Kollmann's dilators 183 

181. — ^Blades of a Kollmann dilator, opened and closed 184 

182, 183. — ^Rubber sheaths drawn over the dilators 185 

184. — Kollmann irrigating dilator 185 

186. — Guiteras urethroscope. 188 

186. — Light carrier for the Guiteras urethroscope 189 

187. — Portable battery for the Guiteras urethroscope 189 

188. — Wappler's controller for urethroscopy and cystoscopy 190 

180. — Case of intraurethral instruments 191 

18»a.— Urethra probe 191 

1896. — Cannula used for injecting glands and follicles 191 

180c.— Urethral knives ! . 191 

189d. — Gruenf ell's pol3rpus snare 191 

190. — Swinburne's posterior urethroscope 192 

191. — The Braim-Buerger cysto-urethroscope 192 

192. — Manner of introducing the urethroscope 193 

193. — Swabbing out the urethra 193 

194. — Position in examining the anterior urethra 194 

195. — Position in examining the posterior urethra 195 

19<L — Brenner's observation and catheterizing cystoscope 200 

197. — Nitze's observation cystoscope 201 

198. — Nitze's irrigating cystoscope 201 

199. — Nitze's operating cystoscope, showing the snare and lithotrite 202 

200. — Nitze-Albarran catheterizing cystoscope 203 

201. — A direct air cystoscope of American make 204 

202. — The Brown direct cystoscope 205 

203. — BierhoflTs indirect catheterizing cystoscope 205 

204. — Bransford Lewis cystoscope 206 

205. — Guiteras teaching cystoscope 206 

206. — Portable table used for cystoscopy in the clinic and at private houses .211 

207. — Patient's position for cystoscopy on Allison table 213 

208. — Washing out the bladder through the urethroscope, first step 214 

209. — Washing out the bladder through the urethroscope, second step 214 

210. — Looking into the bladder 215 

211. — Air cystoscopy 215 

212. — The cystoscope introduced into the bladder 219 

212o. — Inspection of the bladder with the indirect cystoscope 219 

2126. — Inspection of the bladder with the direct cystoscope 220 

213. — Phantom bladder for practicing cystoscopy and ureteral catheterization . 228 

214. — Catheterization of the ureters 228 

215. — The same position as in Fig. 214, to show the position of the hands in catheteriza- 
tion 229 

216. — Catheterization of the ureters by the direct method 230 

217. — Catheterization of the ureters by the indirect method 231 

218, 219. — Catheterization of the ureters, the catheters in situ 232 

220. — Diagrams of bladder used for keeping records 236 

221. — The outline of the abdomen in a case of retention 258 

222. — The Blasucci catheter, first step of catheterization 261 

223. — The Blasucci catheter, second step of catheterization 262 

224. — The Blasucci catheter, third step of catheterization 263 

225. — Paracentesis of the bladder 264 

228. — The method of wearing a urinal 270 

227. — Chart of acute urinary fever 292 

228. — Chart of acute recurring urinary fever 292 



xviii MST OF ILLUSTRATIONS IN TEXT 

no. FAOB 

229. — Chart of chronic urinary fever 293 

230.— Male history card 298 

231.— Female history card 299 

232. — Patient lying at full length, first step in the examination of the male . . 309 

233. — Examination of the kidneys, the patient lying flat 310 

234. — Examination of the kidneys, the patient in the sitting posture 310 

236. — Examining the kidney, with the patient lying on the healthy side . ,311 

236. — Position for examining the female genitals and urethra 313 

237. — Male patient urinating in a glass cylinder 313 

238. — The preparation of the finger prior to rectal examination 314 

239. — ^Rectal examination of the prostate and vesicles 315 

240. — Massage of the prostate 316 

241. — Examining the urethra with the bougie k boule 319 

242.— Filiform bougies 319 

243. — The examiner looking through the urethroscope 320 

244. — Method of obtaining specimens of urine from female patients 321 

245, 246. — ^Abdominal exercise 330 

247. — Back exercises 331 

248. — Front exercises 332 

249-252. — Chest and arm exercise 333, 334 

253. — ^Loin exercises • . . 335 

254. — Recto-genital tube 341 

255. — Rectal irrigations, patient in bath tub 342 

256. — Rectal irrigations, patient reclining in chair 342 

257. — Hypodermoclysis 347 

268. — Intravenous injection, first step 348 

259. — Intravenous injection, second step 348 

260. — Intravenous injection, third step 349 

261. — Syringe for local anesthesia 354 

262, — Method of holding the syringe 355 

263. — Method of making the blebs in intradermic injections 355 

264. — The subcutaneous method of anesthetizing an area to be operated upon 356 

266. — Minute tubercular abscesses of a single asymmetrical kidney 386 

266. — Single asymmetrical kidney, 8J inches long, removed at autopsy .... 388 

267. — Single asymmetrical kidney, markedly convoluted, removed at autopsy . 388 

268. — Shape of the abdomen in the case of a ruptured kidney 395 

269. — ^The rent in the kidney proper and pelvis of a ruptured kidney 397 

270. — Displacement of the kidney, showing the first, second, and third degrees of dis- 
placement 404 

271. — Kinking of the ureter in displacement of the kidney 405 

272. — ^Anterior view of the body divided into three zones, the upper, middle and lower, 

in people with movable kidney, as determined by Harris 408 

273. — Side view of the body and the lines corresponding to the antero- posterior diam- 
eters of the body index, predisposing to movable kidney 408 

274. — Pomeroy*s elastic abdominal support for patients with movable kidney . . . 415 

275. — Straight- front corset for movable kidney 416 

276. — How the corset should be put on in movable kidney 416 

277a. — ^Wide strips of adhesive plaster for supporting abdomen 416 

2776. — The adhesive plaster strips applied 417 

278. — Kidney pad to be buttoned on the back of a vest as a protection for nephretics 432 

279.— Southey*s tubes 437 

280. — Bleeding the patient in uremia 451 

281. — Pyelo-nephritis 457 

282. — Pyonephrosis, showing enlargement of the kidneys and their pelvis and kinked 

ureters 460 



LIST OF ILLUSTRATIONS IN TEXT xix 

na. PAQB 

283. — Cross section of a calculus pyonephrotic kidney, 7i inches long 461 

284. — Bulge in perinephritic abscess in left side of loin, front view 468 

285. — Characteristic bulge in a perinephritic abscess on the left side, back view 469 

286. — Posterior surface of left kidney in a case of a tubercular perinephritic abscess 470 

287. — Posterior surface of tuberculous kidney in a case of perinephritic abscess 471 
288. — Longitudinal section of same kidney, showing contracted pelvis now not much 

larger than the ureter 471 

289. — A bulging of pus in the groin and an opening in the thigh and groin made to drain 

a perinephritic abscess 472 

290. — A sharp-pointed calculus that was found sticking through the wall of the kidney 

in a case of perinephritis 473 

291. — Multiple disseminated abscesses of kidney 476 

292. — Chronic parenchymatous nephritis with acute exacerbation and suppurating foci 477 

293. — Chronic interstitial nephritis, the other kidney in the case 477 

294. — Carcinoma of the kidney 482 

295. — Sarcoma of the kidney 483 

296. — Hypernephroma, outside view 485 

297. — Hypernephroma, view on section 485 

298. — Papilloma of the renal pelvis 490 

299. — ^Large serous cyst of the kidney 493 

300. — Two large polycystic kidneys in the same individual 494 

301. — The larger kidney in Fig. 300 on section 495 

302.— Hydatid cyst of the kidney 497 

303. — Some large calculi removed from a pyonephrotic kidney 501 

304. — A pyonephrotic kidney in a state of acute renal retention 603 

306. — The renal pelvis of a pyonephrotic kidney filled with five stones of large size . 504 

306. — A cluster of stones in one kidney 510 

307. — A cluster of stones in both kidneys 511 

308. — A calculus concealed in the thick mass of fibrous tissue held open by the hook 

and not detected by nephrotomy 518 

309.— A renal calculus that was discharged through the wall of the kidney . .519 

310. — Clusters of tubercles on the outside of the kidney 528 

311. — The same kidney as in Fig. 310, shown in section 528 

312. — A case in which the tuberculous abscesses have broken into the pelvis, giving 

rise to pyelonephritis 529 

313.— Tuberculous pyelonephritic kidney 530 

314. — Tuberculous pyonephrotic kidney 531 

315. — A case of urinary tuberculosis involving both ureters and both kidneys 532 
316. — Tuberculous kidney in which the functionating renal tissue has been entirely de- 
stroyed by the disease 533 

317- — ^A vertical section of a tuberculous kidney removed by a secondary nephrectomy 549 

318. — Kidney with hydronephrosis 561 

319. — Hydronephrosis, first stage 563 

320. — Hydronephrosis, second stage 563 

321. — Hydronephrosis, third stage 563 

322. — Instruments used in operations on the kidney 571 

323. — Posterior kidney angle and triangle 572 

324. — Anterior kidney angle and triangle 572 

325. — Posterior vertical incision seen on the left and the short-curved incision on the 

right 573 

326. — Anterior vertical incision seen on the right side and the " modified " incision on 

the left 573 

327- — Transverse incision 574 

328. — Long curved lumbar incision, the position preferred in renal surgery . 574 

329. — Oblique lumbar incision 574 



XX LIST OF ILLUSTRATIONS- IN TEXT 

no. PAGB 

330. — Operating table with a transverse iron plate running across it that can be elevated 

to any distance for regulating the patient's position 575 

331. — Body holder for preventing the patient from rolling when lying on the side . . 576 

332.— The body hblder on the patient 676 

333. — Incision through the skin and superficial fascia, revealing Petit's triangle . . 577 

334. — Incision through latissimus dorsi muscle, showing the tissues beneath it . 578 

335. — ^Muscles cut through down to the lumbar fascia 578 

336. — Deep lumbar fascia cut through, showing the fatty capsule of the kidney . . 579 

337.— Freeing the kidney 579 

338.— Delivery of kidney 580 

339. — Delivery of the kidney, the lower pole first 580 

340. — Delivery of the upper pole of the kidney 581 

341. — Delivery of the kidney by inserting the entire hand in the wound .... 581 

342. — Examination of the kidney by pyelotomy 583 

343. — Operation for movable kidney; the fixation sutures are passed through the ab- 
dominal wall 584 

344. — Operation for movable kidney; the kidney is delivered and the whole of the 

fatty capsule behind the kidney is cut away 585 

345. — Operation for movable kidney; the capsula propria of the kidney slit through . 585 
346. — Operation for movable kidney; the kidney capsule on the back of the kidney is 

reflected halfway to the hilum 585 

347. — Operation for movable kidney; the posterior fixation sutures are passed through 

the doubled capsule of the kidney 586 

348. — Operation for movable kidney; the anterior fixation suture is passed between the 

capsule and cortex 587 

349. — Operation for movable kidney; the kidney is pushed back again into the renal 

fossa and the fixation sutures are again passed through the abdominal wall 587 
350. — Operation for movable kidney; the muscles and fasciee of the abdominal incision 
are closed by interrupted sutures, the fixation sutures are hauled taut and 

tied 588 

351. — Side view of the convexity after anchoring the kidney 589 

352. — Posterior view after anchoring the kidney 589 

353. — Anterior viej^ after anchoring the kidney . . .• 589 

354. — Nephrotomy; showing position of patient and loin incision 591 

355. — Nephrotomy; the long incision from pole to pole 692 

356. — ^Nephrotomy; the short incision between the poles 592 

357. — Nephrotomy; catheterization of the ureter from above 593 

368. — Method of passing sutures in closing the nephrotomy incision in the kidney . . 594 

359. — ^Appearance of the kidney after closure 594 

360. — Drainage tube in position 594 

361a. — Four-tailed bandage for controlling renal hemorrhages 596 

3616. — Four- tailed bandage in place 596 

362. — Nephrostomy; this is nephrotomy plus fixation of the sides of the kidney incision 

to those of the abdominal wall 598 

363. — Drainage in nephrostomy 599 

364. — Drainage by siphonage 599 

365. — Cup -shaped shield of Watson's apparatus for permanent renal drainage through 

the loin 600 

366. — The metal receptacle of Watson's apparatus 601 

367. — Method of clamping the pedicle and passing the pedicle ligatures in nephrectomy 602 

368. — Nephrectomy; ligatures in place ready to tie 603 

369. — Nephrectomy; second ligature 603 

370. — Albarran's method of securing the pedicle in a subcapsular nephrectomy . 609 

371. — Retraction of the capsule, allowing the operator to ligate the pedicle outside of it 609 

372. — Partial nephrectomy 610 



LIST OF ILLUSTRATIONS IN TEXT xxi 

PAOB 

373o. — ^Nephrectomy by morceDement ; the lower pole amputated 611 

3736. — Nephrectomy by morcellement ; the upper pole amputated 611 

373c. — Nephrectomy by morcellement; the remains of the isthmus between the two poles 612 

374. — Closing of the wound in nephrectomy by morcellement 612 

376. — ^Nephrectomy by the transverse incision; the kidney delivered 613 

37^ — Nephrectomy by the transverse incision; the vascular pedicle clamped . 614 
377. — Anterior or transperitoneal nephrectomy; the peritoneal cavity opened and the 

incision made in the mesocolon 614 

378, — Anterior or transperitoneal nephrectomy; the kidney being freed from the fatty 

capsule 615 

379. — ^Anterior or transperitoneal nephrectomy; the kidney delivered and pedicle clamped 

and ligated 615 

380. — ^Anterior or transperitoneal nephrectomy; the kidney removed and the wound 

closed 616 

381. — Hydronephrosis 616 

382. — Resection of kidney pouch below the ureter 617 

383. — Capittonage; the part of kidney pouch below the ureter is drawn up by a series 

of tucks or reefs 618 

384. — ^Albarran's method of suturing in capittonage 618 

385- — Cutting down the ureteral spur 619 

386. — Cutting down the ureteral spur; sutures passed uniting pelvic and ureteral walls 

on either side 619 

387. — Uretero-pyeloplasty ; the incision 619 

388. — Uretero-pyeloplasty; sutures placed so as to leave a transverse wound . 620 

389. — Uretero-pyeloplasty; sutures ligated 620 

390. — Lateral pelvic-ureteral anastomosis 620 

391- — Lateral pelvic-ureteral anastomosis; the wound united 620 

392. — Kinked ureter with adhesions amputated below 621 

393. — Two ureters emptying into the bladder, coming from a single unsymmetrical kid- 
ney on the right side 622 

394. — A double ureter coming from the left kidney, as seen by radiography 623 

395. — Vesical ends of the ureters prolapsing into bladder 624 

306. — A diverticulum of the part of the ureter passing through the bladder wall 624 

397. — Ureteritis and associated pyonephrosis 629 

398. — Dilatation of the renal pelvis and ureter in a case of acute ureteritis .... 630 

399- — Papilloma of the ureter 631 

400- — Cervix with a cancerous growth that has involved the ureter and bladder 631 

401. — Positions of ureteral calculi 633 

402. — ^Actual size of a stone giving rise to calculous anuria 635 

403. — Case of double ureteral calculus 638 

404. — Tuberculosis of the ureter 640 

406. — ^Thlckening, dilation, ulceration and strictures of the ureter that are seen in Fig. 

404, more clearly shown 642 

406. — Instruments for ureter operations 647 

407a. — Ureterotomy for stone; delivery of the ureter below the kidney .... 647 

4076. — Ureterotomy for stone; method of enlarging the field prior to operation 647 
408. — Ureterotomy for stone ; exposing the ureter as it crosses the pelvic brim and iliac 

vessels 648 

409. — ^Ureterotomy for stone in the Trendelenburg position. The same incision is seen 

and two ligatures about the epigastric artery 648 

410. — Ureterotomy for stone; shows a deep-seated calculus 649 

411. — Ureterotomy for stone; the delivery of the calculus, the clamping of the ureter, 

and the suturing of the ureteral wall 650 

412. — ^Ureterotomy for stone; a ureteral catheter as an aid in suturing the ureter 651 

413. — Incision through the broad ligament, exposing the ureter on one side 652 



xxii LIST OF ILLUSTRATIONS IN TEXT 

ria. PAQB 
414. — Perineal ureterotomy ; the vesicle and the vas pulled to one side and ureter hooked 

up and incised over the calculus 653 

415. — Patient in the gynecological position. An incision is seen in the vaginal wall, the 

ureter hooked up and incised over the calculus 654 

416. — Intravesical ureterotomy. The bladder opened suprapubically ; the part of the 

bladder wall through which the ureter passes and the stone are clearly seen . 655 

417. — Ureterotomy for stricture 656 

418. — Ureterorrhaphy 658 

419. — Poggi*8 operation for a ureteral anastomosis 658 

420. — Van Hook's operation of lateral anastomosis 659 

421. — Bov^*s method of end-to-end anastomosis 659 

422. — Transperitoneal method of uretero-cystotomy 661 

423.— Ureterocolostomy 663 

424. — Ileo-lumbar incision for nephro-ureterectomy 664 

425. — Nephro-ureterectomy 665 

426. — Showing Kelly's method of removing the ureteral stump through the vagina in 

nephro-ureterectomy 666 



ij R a L a Y 

VOLUME I 



CHAPTER I 



HISTORY OF DISEASES OF THE TRINARY TRACT 

Ancient Urology. — ^Diseases of the urinary tract have been known and 
treated, both in a medical and surgical way, for many centuries. Medical treat- 
ment was first recorded in the Papyrus of Ebers, written 1550 years b.c, 
in which were given many prescriptions for their cure. From this time until 
the present, various remedies have been used internally and externally by 
medical men, and by the monks during the ^Middle Ages, when the practice of 
n edicine was principally in their hands. 

The history of the progress of surgery has been interesting, although noth- 
ing was written upon it imtil the time of the " Ayurveda of Sucrutu," the great 
work of the Hindoos in India, which was brought out about one thousand years 
after the first recorded manuscript. The first operation spoken of in this later 
work was perineal lithotomy, which was then performed in practically the 
same way as it is to-day. The Hindoos at this time were also treating strictures 
by gradual dilation with sounds of metal or wood, and w^ere treating diseases 
of the urethra and bladder by injections. 

Hippocrates (about 400 b.c.) was the next great writer. Among other sub- 
jects, he was interested in vesical calculi, and described accurately how a stone 
grows gradually from a nucleus. He thought that lithotomy should be per- 
formed only by a lithotomist. He was the first to be interested in the surgery 
of the kidney, and taught that, as soon as a swelling appeared in that region, 
it should be cut down upon. He also wrote on the subject of urethral abscess and 
cystitis, and was the first to point out the change in the urine in diseases of 
the kidney and bladder. 

Cornelius Celsus, the great Roman medical writer w^ho lived at the begin- 
ning of the Christian era, was the next to write extensively on urinary dis- 
eases. He wrote on urethrotomy for impacted urethral stone; catheterization 
for retention of urine, especially in old men; vesical calculus and lithotomy, 
including after-treatment; and the care of wounds and fistula?. Perineal ure- 
throtomy was also performed for stricture by the Koman surgeons one hundred 
and fifty years later. 

1 



2 HISTORY OF DISEASES OF THE URINARY TRACT 

Galen was the next writer of consequence. He wrote upon incontinence 
and retention of urine, and described an " S-shaped " or curved catheter which 
he used for the relief of the latter trouble. 

Cffilius Aurelianus, at the beginning of the fourth century, was the next 
to interest himself in diseases of the bladder. He used a stone "searcher for 
the diagnosis of vesical calculus. 

Mediseval Urology. — We thus see that, in the beginning of the Middle Ages, 
diseases of the urinary tract had been treated medically for two thousand years, 
while surgical interference had been going on for a thousand years. Diseases of 
the urethra, prostate, bladder and kidney were already known, and many of them 
had been operated upon. It was strange therefore that at such a time a de- 
cadence should have taken place, that the practice of medicine should have 
fallen into the hands of the monks, and that surgery was attended to by the 
barber and charlatan. This condition existed until the fourteenth century, 
when scientific surgery again started up in Paris, at the College of Saint Come, 
founded by Jean Pitard, and thence slowly extended over Europe. The ad- 
vances along the urological line were evidenced by the discovery of movable 
kidney in 1497 by Mesure of Venice; the improvement in the technique of 
stricture operations by Ambrose Pare and Richard Wiseman ; the works of Git- 
tler of Leipsic on wounds of the kidney ; the rescue of lithotomy from the hands 
of the layman and the variation of its teclmique by Pierre Franco. 

Changes of the urine had been spoken of since the time of Hippocrates, 
but the first work of any scientific importance was that of Protospathori in the 
seventh century; for he not only described normal urine, but also, in a clear 
way, the various changes that took place in the urine of disease. Actuarius, 
a Turk, wrote the first extensive work on this subject in the twelfth century, 
and it remained an authoritative treatise for five hundred years. 

During the heyday of the Salemian School, near Naples, all the physicians 
were practically urologists, as they depended largely upon the urine for diag- 
nosis and prognosis, and the urinal became the insignia of the physician and 
the emblem of medicine. At this time, the examination of the urine was re- 
sorted to, not only by the regular practitioner and the university graduate, but 
also by the school of quacks, known as uromancers or uroscopists, who gravely 
inspected urine passed into a glass flask, guessed the illness and temperament 
of the patient, and dispensed miraculous cures. 

Paracelsus and Van Helmont, in the latter part of the sixteenth century, 
introduced the spagiric or so-called analytic methods of the diagnosis of dis- 
ease, which depended on the proportion in which the three elements of man's 
nature — mercury, sulphur, and salt — occurred in the urine. Boerhaeve and 
Bellini, in the seventeenth century, added to the study of urine. Boerhaeve 
distilled the urine and weighed the vapors. When the vapor occupied a certain 
part of the still, it pointed to disease in a certain part of the body. He was 



MODERN UROLOGY 3 

the first to discover the specific gravity of urine. Bellini advocated the study 
of the average urine of the healthy individual, the amount passed and the 
specific gravity as a standard with which the unhealthy urine should be com- 
pared. 

In the latter part of the eighteenth century, there was a decided advance 
in urinary analysis. Cotugno discovered albumin in the urine of diseased 
kidneys by boiling it. Koulle and Cadet discovered urea and isolated many 
salts of the urine, and Schule discovered uric acid. 

It will thus be seen that, at the dawn of the nineteenth century, a good 
working basis existed in the study of urinary diseases, especially in the line of 
urinarv examinations and the treatment of urethral and bladder diseases. 

Modem Urology. — Modem urological history may be divided into two 
periods, the first and second halves of the nineteenth century, the first of which 
was preparatory to the second. 

During the first half of the century the work was principally confined to 
improving and elaborating urethral and bladder work, urinary examination, 
and the study of pathology. 

In 1805, Bozzini of Frankfort, invented an apparatus for illuminating the 
urethra and bladder, which was the first of a series of crude attempts that led 
to our present knowledge of urethroscopy and cystoscopy. In urethral work, 
Desormeaux in 1853 improved the endoscope. Later a cooling apparatus was 
added, which finally was supplanted by the mignon or cold lamp introduced 
by Preston, an electrician of Rochester, X. Y., at about the dawn of the twen- 
tieth century, thus giving us the practical instrument of to-day. 

ilaisonneuve in 1853 invented the first of the modem urethrotomes, which 
is still used in internal urethrotomy to cut through small strictures from the 
front backward, and in 1872, Otis invented his dilating urethrotome for cutting 
strictures of large size from behind forward. Both of these, although there 
have been many modifications, exist to the present day. The dilation of 
urethral strictures by the dilators of Oberlander and Kollmann have since then 
superseded the use of sounds with many practitioners. The method of treating 
urethritis by the irrigation of Janet, and numerous new remedies for hand in- 
jections, have entered into our urethral therapeutics. 

In bladder work, the efforts to improve the diagnosis of pathological con- 
ditions by vision, led to the gradual development of the illuminating instru- 
ments, the first marked improvement being that of Briick, a dentist, who called 
his instnunent a diaphanoscope. Improvements were slow and unimportant 
until 1876, when Xitze, Brenner and Leiter perfected their cystoscopes, giving 
us our present knowledge of cystoscopic diagnosis. These were rendered more 
practical three years later (1879) by introduction into them of the incan- 
descent lamp, w^hich enabled the urologist to employ it instead of the hot 
and less luminous platinum wire hitherto used, with a cooling apparatus. 



4 HISTORY OF DISEASES OF THE URINARY TRACT 

Further improvemerit, due to the use of smaller and colder lamps, ren- 
dered the use of cooling devices — irrigation with water while examining — 
unnecessary. 

In bladder surgery, Civiale (1817) performed the first successful lithotrity, 
the crushing of a vesical calculus, with an instrument which served as a pro- 
totype for the modem lithotrite. His lithotrite was modified by Weiss, Hodg- 
son, Ferguson and Sir Henry Thompson, and finally by Bigelow (1877) who 
combined the operation with evacuation of the fragments of stone by means of 
an aspirator in one operation, litholapaxy. His evacuator for emptying the 
bladder of the last fragment of stone consisted of a very large hollow sound, 
with a large eye in its concavity, connected with a rubber bulb, between which 
and the sound was a bottle into which the fragments fell when sucked out by 
squeezing and releasing the bulb. While suprapubic lithotomy in this country 
has largely superseded Bigelow's operation, his method stands to this day in 
all parts of the w^orld as the procedure best employed for the removal of stone 
in the bladder in a selected class of cases. 

In the work on the kidney, that of Eichard Bright (1827) was the founda- 
tion of our present knowledge of the medical diseases. Bright's investigations 
showed that many patients with dropsy and albumin in the urine had diseased 
kidneys, and although Catugno, the discoverer of albumin, had made it known 
a century before and Allison in 1823 had reported the occurrence of dropsy 
with albuminuria in kidney disease. Bright found the profession more recep- 
tive to scientific advances than did Catugno, and through his writings received 
such recognition that the name of Bright's disease was applied to pathological 
conditions of the kidney accompanied by albuminuria. In 1823, Scudmore of 
London had found that the urine of patients with albuminuria contained less 
urea than that of normal persons. The discovery of urinary casts by Viglia, 
some ten years after Bright's publication, added another important link to 
the chain of our present knowledge of urinary findings in nephritis. From 
these early studies sprang the elaborate researches of later years, as recorded 
in the text-books of Johnson (" Diseases of the Kidneys," London, 1852), Jo- 
hann Fogel (1856), Eosenstcin (1863), Senator (1896) and others. 

In renal surgery, Paeslee performed the first nephrectomy (1868) by ac- 
cident, in a case the diagnosis of which had been an ovarian tumor. Simon, 
the following year, removed the first kidney purposely in a case of calculous 
pyonephrosis, and took advantage of this step to write his important monograph 
on the kidney, in which he gave a definite classification of the surgical 
affections of the organ, thus stamping them formally for the first time as 
surgical. 

Catheterization of the ureters, which now is one of the most important 
urological procedures, owes its birth to the efforts of Pawlik and Bozeman, 
who w^ere the first to catheterize the ureters in women. The development of 



MODERN UROLOGY 5 

this important procedure was, however, due to the cystoscopists. They added a 
compartment to their cystoscopes for the passage of a small woven catheter, 
then, by looking at the mouth of the ureter, they could push the catheter into 
the bladder until its end entered the ureter. The first catheterizing cystoscopic 
instrument was that of Brenner (1892), then followed those of Nitze (1895), 
Casper (1895), Albarran (1897), etc. Later they added to their instruments 
a double catheterizing apparatus which enabled them to catheterize both ureters 
at the same time. 

One of the most important discoveries in urology, as in all other diseases, 
was the role of the microorganism as the causative agent of fermentation, de- 
composition and disease, by Louis Pasteur, described in a work called " La 
Generation Spontanee," which appeared in 1859. He took up in particular 
the Micrococcus ureae, which causes urinary decomposition by splitting up urea 
into ammonia and other by-products, and suggested that the bacteria enter the 
bladder with dust particles that adhere to unclean instruments. 

In 1879, Neisser announced the discovery of the gonococcus, a microorgan- 
ism which has since then been found as the constant cause of blennorrhagic in- 
fection. Then followed rapidly the discoveries of the several important specific 
germs: The tubercle bacillus by Robert Koch, in 1882; the staphylococcus, the 
chief germ of suppuration, by Rosenbach, in 1884; and the colon bacillus — 
so often found in cystitis, pyelitis, etc. — by Escherich, in 1885. These dis- 
coveries changed many of our previous etiologic concepts and created entirely 
new therapeutic view points — antisepsis and asepsis. The development of a 
plate-culture method by Koch had a great deal to do with the later and more 
accurate studies on the bacteriology of cystitis, pyelitis, etc. 

The amalgamation of the diseases of the urinary tract into the modem 
specialty has taken place through the combination of the work of numerous 
internists, surgeons, pathologists and bacteriologists at different times and in 
different ways. 

A knowledge of diseases of the urethra and bladder and their treatment has 
existed since the earliest writings, and of diseases of the kidney since the days 
of Hippocrates. The diseases of the kidney, however, were not considered in 
common with those of the bladder and the urethra, but were rather in the 
hands of internists and general surgeons. 

Bright was the first thoroughly to consider diseases of the kidney from 
the point of view of an internist, and Rayer and Simon as surgeons; while 
Civiale, Thompson, Mercier, Guyon, Maisonneuve, Ricord, and others were 
working on the bladder and urethra in both a medical and surgical way. 

The laboratory men were principally engaged in the work of urinary anal- 
ysis imtil Pasteur's discovery of bacteria and microbic infection, followed later 
by the discovery of the gonococcus, the tubercle bacillus and streptococcus, 
colon bacillus and others of the important forms of infection. 



6 HISTOKY OF DISEASES OF THE URINAKY TRACT 

Cystoscopy in the hands of Nitze and Brenner was perhaps the final step 
of an amalgamation ; for it allowed the surgeon who had examined and passed 
through the urethra to see with certainty the condition of the bladder wall, 
and to diagnosticate in many cases between bladder and kidney hematuria and 
pyuria, and in case of renal origin to see from which side the pathological urine 
had come. 

The further investigations of the microbic causes of disease showed that 
the same germs that give rise to infectious bladder diseases were also the cause 
of suppurative renal disease: also that practically the same diseases existed in 
both organs ; that is, tumors, tuberculosis, stone and suppurative inflammations. 
Furthermore, it was then learned that in cases of disease of the urethra, pros- 
tate and bladder, the infection may pass to the kidney directly up the ure- 
ters, or by the blood current or the lymphatic channels. 

The catheterizing cystoscopes then came as another step in the relation 
between the two kidneys. In urinary cases, the analysis could tell us of disease 
of the bladder, or kidney, or both. The cystoscope could show us, in a bladder 
case, the degree of disease in this organ; while in a kidney case, the urine, 
withdrawn by the ureteral catheters, could tell us which of the kidneys ex- 
creted the urine that gave the pathological appearances to the general specimen. 
By this means, direct connection between the bladder and the kidney was es- 
tablished, and the study of the urinary tract from the bladder up was consid- 
ered just as important, if not more so, than from the bladder down. Conse- 
quently, the direct reason for including the entire urinary tract from the 
capsule of the kidney to the external urinary meatus in both sexes can be better 
understood. 

Having considered some of the principal direct steps taken in modem urol- 
ogy toward its advancement and development into the present specialty, we 
must consider a few important factors in general and special surgery that have 
an important bearing on the subject. 

The acceptance of the fact that germs are the cause of surgical infections 
led to the consideration of the best way to be rid of them in surgical work; 
that is, the study of antisepsis and asepsis. 

In 1859, Lemaire found that carbolic acid was the active constituent of 
coal tar and advocated it as the best antiseptic. It was thought that fermenta- 
tion and putrefaction were due to the access to the woimds of particles from 
the air that could be destroyed by boiling, heat and chemical agencies. Among 
the latter the best agents were carbolic acid and bichlorid of mercury, in which 
wounds could be washed and dressings soaked. 

The title " antiseptic method " was given by Lister to a form of wound 
treatment founded on certain definite principles and commenced by him in 
1865. His studies were founded on the results of Pasteur's researches on 
spontaneous generation, which served as a guide in systematizing his invest iga- 



MODERN UROLOGY 7 

tioiL Working on the hypothesis that the particles of dust-bome germs en- 
tered the wounds at the time of operation, he devised the carbolic spray as a 
means of rendering antiseptic the operative field in surgical operations. Asep- 
sis then succeeded antisepsis, as it became apparent that it is better to exclude 
germs by having everything connected with the operation sterile, than to have 
germs present at the time of operation and then try to render them inert by 
the use of strong solutions. The sterilization of instruments, dressings, gowns, 
etc., beforehand, and the wearing of rubber gloves, proved more simple and 
effective than the more cumbersome methods of trying to sterilize after the 
operation had begun. For the technique of asepsis we are much indebted to 
another English surgeon, Lawson Tait. 

Anesthesia was another great discovery for urinary surgery. In the years 
18 11 1 7, the three chief methods were discovered in rapid succession and 
at once began to exert an important influence upon the development of painless 
major urological operations. The discovery of nitrous oxid gas as an anes- 
thetic by Wells gave us an invaluable aid for brief operations and for examina- 
tions that require perfect relaxation. The discovery of ether anesthesia by 
Morton in 1846, and of chloroform anesthesia by Simpson in 1847, gave us 
the most useful means of rendering patients unconscious that have yet been 
discovered. Ethyl chlorid and cocain, as brought out by Koler, are of great 
value as local anesthetics, and the great majority of urological operations can 
be performed under the influence of the latter. 

In 1895, Conrad Roentgen discovered the X-ray, the perfection of which 
has brought to the urologist another valuable means of diagnosis in suspected 
cases of stone in the kidney, the ureter and bladder. 

Laboratory experiments through the inoculation of small animals, have also 
been of great service to us in determining the presence or absence of tubercu- 
losis in disease of the kidneys. 

A few years ago, the determination of the relative efiiciency of both kid- 
neys, and especially of each kidney separately by various methods, was consid- 
ered as one of the important diagnostic and prognostic criteria by surgeons and 
urologists in the study of renal diseases. The first of these methods employed 
to test the functional capacity of the kidney was cryoscopy, which consisted of 
freezing the urine. This was introduced in 1897 by Koranyo of Budapest, 
but has been little used in this country. The methylene blue test, popular with 
the French School, came next, the function of the kidney depending upon the 
early or late appearance in the urine of the blue or chromogen color after its 
injection into the body. The phloridzin test was advocated by Casper and 
Richter in 1900 and was the favorite method of the German School, but re- 
quired more care on account of the frequent necessity of testing the urine for 
sugar. 

It is difficult at the present time to see along what lines the progress in 



8 HISTORY OF DISEASES OF THE URINARY TRACT 

urology will extend. The steps in diagnosis at present seem to be quite com- 
plete, and I think that progress will probably be along the lines of improved 
technique. At present, what is most needed is better cooperation between the 
patient and the surgeon in the study of the cases, and the continuation of medi- 
cal treatment and careful observation before resorting to operation, except in 
urgent cases. 



CHAPTEK II 

THE ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 

The urinary tract in both sexes is arranged in a series which begins at the 
kidneys and ends at the external urinary meatus. The various parts are the 
kidney, ureter, bladder and urethra. The kidneys and ureters are the same 
in both sexes, while the bladder is practically the same, differing only in re- 
gard to its external relations. It will thus be seen that the urethra is the part 
which differs the most in the two sexes. In women it is short and entirely in- 
dependent of the genital tract in its functions and in its relations until it 
reaches the external meatus in the sinus uro-geni talis. In men, from the open- 
ing of the common ejaculatory ducts to the external meatus, the genital and 
urinary canals form a single passage. In both the male and the female the 
urinary organs meet the genital organs at the sinus uro-genitalis, which is 
found in the prostatic portion of the urethra in men and in the vestibule in 
women. At this point in the male the urinary tract commimicates with the 
ejaculatory duct, the vesicular seminales, the vasa deferentia and the testes; 
while in the female it communicates at the sinus with the clitoris, the vulva, 
the vagina, the uterus, tubes and ovaries. In men the combined relations and 
functions of the urinary and genital tracts in the urethra, where they are in 
common, has given rise to the expression geniio-urinary tract in their combined 
consideration. 

In women, on the other hand, except in foetal life, the genito-urinary 
organs are divided into two distinct tracts, the genital and the urinary. These 
are separated from each other throughout their entire course, and although 
they are in close contact with each other, they are never in conunon in a nor- 
mal condition; for which reason they are not spoken of as the genito-urinary 
tract 

In the female the genital and urinary organs bear a definite relation to 
each other, the urinary being in front of the genital except where the ureter 
passes behind the broad ligament. 

In the male, the urinary tract is also placed anteriorly as far as the 
urethra, but from the internal to the external meatus the urinary tract is sur- 
rounded by parts of the genital tract — namely, the prostate, the corpus spon- 
giosum, and corpora cavernosa — the urethra being the common canal for the 
discharges from each. 

9 



10 ANATOMY OF THE URINARY AND GENITO-TTRINART TRACT 



The following ilhiatrations will give an idea of the relation of the genital 
and iirinary tracts to each other when removed from the body : 



, 1. — Antewob View OF THE Opened Genito- Fio. ; 


J.— PoBTEHioB View op ibe GsNrro-UBi- 


U8IMABI TBACT in the MaLE. 


HARY TkACT IH THE MaLS. 


pe, the pelvis o! the kidDcy. 


K. kidney. 


cor, the cortci, the part between the cortex 


pt, pel\i8. 


and the pelvU beiog the medullary portion. 


V, ureters. 


PUT, pyramid. 


B. bladder. 


ca, the calicfiH. 


V, vas deferens. 


U. the ureters. 

B. the bladder. 

o.u, the ureteral openings. 

i,u.m. the internal urinary meatua. 


a. ampuUa, 


».t, senainal vesicles. 

P. prostate. 

c. Cowper's glaiida. 


o.e.d, the openinea of the ejaeulatnry du<'ls in 


T, testicles. 


the prostatic urethra. 


E, epididymis. 


IJ.u.i, the genilo-urinary ainufl. 


b.u, bulb of urethra. 


t.m. the vcru montanum. 




b.u, the bulbous urethra. 




d.c, opcoingB of the ductii at Cowper's glands. 


C. glans penis. 










H, urethra. 








t.u.m, citernal urinary nieutUH. 





ANATOMT OF THE URINARY AND GENITO-UEINAKY TRACT 11 

Fig. 1 gives the anterior view of the genito-urinary tract in the male, 
and Pig. 2 the posterior. In Fig. 1 it can be seen how the urine excreted 
into the tubules of Uie kidney ia carried down through the calices, the renal 
petvia and the ureter into a reservoir, the bladder, where it accumulates and 
from which point it entera the urethra tlirough which it is discharged from the 
body. In examining the first part of the urethra as it passes through the pros- 
tatic gland, we see the opeuings of the ejaculatory ducts that bring the secre- 
tions of the testes and seminal vessels into the urethra; also the openings of the 
prostatic ducts that discharge the prostatic fluid ; while lower down the bulbous 
portion will be seen the mouth of the ducts of Cowper's glanda, that are the 
last to contribute to the formation of the combined fluid known as semen at 
the time of its ejaculation. 

In Pig. 2 it can be seen how the spermatozoa formed in the testes are 
carried up through the epididymis and vas deferens to the seminal vesicles 
where they are stored and from which point, mixed with the secretion of the 
vesicles, prostate and Cowper's glands, they are discharged from the urethra, 
as has already been shown in Fig. 1. 



Fiti. 3.— PoBTEHioH View of the Relations op the Genital and L'hinarv 
Ohoanb in the Male. 
/, ureters. 7. bladder. 

S, vaas defcrciitia. A, outer muscular layer of bladder. 

5, right Beminal vesicle laid open. B, middle muspular laj'er of bladder. 

i. right vaa deferens laid open. C, inner muscular layer of bladder. 

5, pro9tat«. D, mucous membrane of bladder. 

6, left seminal vesicle. 

Fig. 3 is a view of the posterior aspect of the bladder prostate, seminal 
vesicles, ureters and vasa defercntia. The right vesicle and vas have been 
laid open. 



12 ANATOMY OF THE TJKINARY AND GENITO-TJRINART TRACT 

Fig. 4 represents an interior view of the geni to-urinary tract in tlie 
female; tlie kidney and ureter on right side are split, and the bladder and 
uretlira below. 

Fig. 5 represents a posterior view. The tubes, uterus and vagina are 
split Here the genital tract is scon to be behind the urinary, excepting where 
the ureters pass behind the adnexa. 



Fig. shows the side view of the kidney, ureter and bladder in an an- 
terior posterior section as it is found in either man or woman. If this is 
placed above either the male or tlie female urethra chart in such a way that the 
urethral opening of tlie bladder is placed at the beginning of the urethral canal, 
it will be seen that the bladder answers for either sex as well as the kidneys 
and ureters. 

Fig. 7 represents a central anterior posterior vertical scctifin through that 



AITATOMT OF THE URINAKY AND GENITO-URtNABY TRACT 13 



r^ 



/•^■^ 




Fio. a. — Uppbr anb MiDDue Ponnoda or thb 
Urisaht Thact, thb Kidney. Uheteii and 
BUDDEB OF ErTBEB Sex OH Saoittai. 3bc- 



t,*b»»e.' 

e.u, cystic orifices of ureter. 



Fia. 7. — Lower Ubinary Trmtt in the Male 

ON Saoittal Section, and also the Internal 

AND EXTEBNAL GeNITAL ORQANS. 

V. vas defcif ns. 

S. v., Bcminiil vesicle. 

□. ampulla. 

e.rf, ejapulatory duct. 

£, epididymis. 

ir-Tn. globus major. 

ff.min, globus minor, 

b, body of the epididymis. 

T, testicle. 

P, prostate. 

T.L.. triangulat ligament. 

C, Cowpcr'g glaod. 

U, urethra. 

p.u, prostatic urethra. 

b.u. bulb of urethra. 

/,n, fossa Davicularis. 



14 ANATOMY OF THE URINARY AND GENITO-TJRINARY TRACT 



part o£ the genito-urinary apparatus of the male that is in common, namely, 
the penis, prostate and urethra; besides which it shows the male atlnesa on. 
one side, that is, the seminal vesicles, vas 
deferens, epididymis and testis. 

If Fig. 6 was placed on Fig. 7 in 
siicli a way that the opening of the blad- 
der was to fit that of the urethra, and 
the seminal vesicles and the vas deferens 
with their ampullie were properly ad- 
justed, they would he seen to lie on the 
back of the bladder as in Fig. 2. 

Fig. 8 depicts an anterior posterior 
vertical section through the central part of 
the female genitals, namely, the vesti- 
bule, clitoris, vulva, vagina and uterus. 
There is also a similar section through 
the urethra in the same line. The Fal- 
lopian tube and the ovary are also shown, 
although somewhat out of position. The 
place for a dilated bladder corresponding 
in size with that of Fig. 6 is indicated 
by dotted Hues. If Fig. 6 was placed 
over Fig, 8 in such a way that the blad- 
der would fit in the space indicated by 
the dotted lines, it would be seen that the 
uterus would lie in a plane posterior 
to the bladder, and tliat the tnbes and 
ovaries, in case the bladder were empty 
or hut moderately distended, would also 
lie in a posterior plane. 

These figures show the great similar- 
ity in the upper three quarters of tiie uri- 
nary tract in the two sexes and also how 
much closer related the lower quarter of 
the urinary tract is to the genital in the 
male than in the female. 

This intimate relation in the male has 
been the reason why the troubles of the 
genital tract have been called " genito- 
urinary" in men, instead of " andro- 
logical," which would correspond to the 
term " gynecological " in women. 



Fio. 8. — Gemitai, Orqanb and Loweb Ubi- 
NABT Tract in the Fbuale oh Saoittai 
Section. 

F. fallopiaa tube. 

f.e, fimbriated ratremity. 

0. ovary. 



R, rectum. 



r pauing aloDgside uterus. 



S. symphysis pubis. 

V, vagiiia. 

H, clitoris. 

Ve. vpBtibuIe. 

e.u.o, external urethral orifice. 

L.M, labium major. 

L.Min., labium minor. 

I.V, introitus vagiuee. 

F.B, perioeBl body. 



LOCATION OF THE GENITO-URINARY TEACT 



15 



The arogenital sinus is the point where the urinary tract joins the genital 
and is differently located in the two sexes. 

Fig. 9 shows the urogenital sinus in the male. It is situated in the 

prostatic urethra at the point where the ejaculatory ducts open into the canal 

about one inch below the vesical open- 



Fla. 9. — GEHrro-iTBiKABT SiHDS ni the Male, 

IBB PBOWATE having BEEN OpBKBD ANTE- 

uost-T AND rrs Latekal Lobes Retracted. 
(TeWut.) 

At thia point, tbe posterior uretlira is seen in 
direct coauDuaication yrith the Uaddet, bqU with 
the e)acui&tory ducta. 
1. the tdadder. 
e, urethn. 

3, prostate. 

4. veru montanum. 

6. frenum of the veru montaDimi. 

6, uretbral crest. 

7, prostatic utricle. 

8, orifices of the ejaculatory ducts. 

9, prostatic foesette. 

10. lateral dcpressioDS of the veru monta- 



F:0. 10. — GBNITO-ritWABT SlNDB IN THE 

Feuale. 

The labia minora ot the eitenisl seuitsls are 
seen to be retracted. showinK the uretbral meatus, 
tfactcnntDatioDof the urinary tract, and juat below 
and behind it the vaginal opening, the tenninatioD 
of the genital tract. 



Fig. 10 shows it in the female. 
It is situated in the vestibule of the 
vulva, where the urethra and the 
vagina open. 



LOCATION OF THE GENITO-URINARY TRACT 

The genito-urinary tract in its whole course has au extensive location, being ■ 
partly within the body cavity and partly without. The inside part extends 
from the costal diaphragm to tlie pelvic diaphragm (levator ani muscle) below, 
while the outside part is a continuation of tlie part within through the pelvic 
diaphragm and the perineum, to end in the external meatus in the male and 
the vestibule in the female. The bony framework which incloses it may be 
said to consist of the two lower ribs, the last dorsal and the lumbar vertebrte, and 
the bones entering into the formation of the pelvis. These are bound togetlier 
by ligaments, especially important in assisting to make a smooth pelvic cav- 
ity out of an irr^ular bony framework. (See Figs. 11 and 12.) 



16' ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 



.. — Antbbiob View op the Bontt Skeleton of the Part of the Boot in Which tb 
Urinari Tract ib Lodoed. 

7, anterior common ligament, ,j. Ei^sser sacro-Bciatic ligament. 

S, ilio-lumbar ligament. S. obturator foramen and membrane. 

3, greatcc sacro^ciatic Ligament. 0, anterior pubic ligament. 



LOCATIOX or THE OENTTO-miNAET TRACT 17 

Both kidneys and tlie upper five and one half inches of tlic ureter are 
witliia the abdominal cavity. The bladder, seminal vesicles, the lower four 



Flo. 12. — POBTEBiOR View of the Bony Fbauework Enclosing the Urinary Tract. 
t. posterior Uio-lurabar ligameut. 3, Icsacr eacro-sciatic ligametit. 

t. posterior Bacro-iliac ligament. i, greater sacro-eciatic ligament. 

:inii one liiilf inches of the ureter, the prostate gland, and part of the vas dnfer- 
MU are within the pelvic cavity; -while the penis, testicles and part of the 



18 ANATOMT OF THE URINAEY AND GENITO-TJRINAEY TRACT 



I. 13. — Space Occdpibo b 



E Umnabi Tract aftbr It h 



I It« MoscDLAa 



diaphrsgm. 
inferior vena cava. 
right cnis of diaphragm. 
pectineuB. 
esophagus. 

T. left erua of diaphragm. 

8. quadratuH lumborum. 

9, traiuveraalis fascia. 



pnoas parvus. 
iliacua. 

psoas magtiua. 
pyriformifl. 

obturator e 
obturator membrane. 
obturator juternua. 



THE PELVIS 19 

urettra are outside the body cavity. The kidneys are on the posterior abdom- 
inal wall on either side on the last dorsal and upper three lumbar vertebne. 
They are behind the peritoneum, and rest behind on the twelfth rib, crurse of 
the diaphragiu, psoas and qnadratiis litniborum muscles (Fig. 13), The ab- 
dominal portion of the ureter is also behind the peritoneum, lying upon the 
psoas and running downward and inward as far as the brim of the pelvis. 

The intrapelvic and extrapelvic portion of the tract is so intimately re- 
lated to the various structures in the pelvic cavity and perineum, that, in order 
to give an adequate idea of their location and relations, a brief description of 
the pelvis and perineum as a whole must be given. 

THE PELVIS 

The pelvis consists of a surrounding framework of bones and ligaments, 
the inner surface of the bones being covered, for the most part, by muscle, while 
a sheet of muscle arising from either side of the bony wall meets in the middle 



Fk). 14. — Thi LioAHENTa HBU>iHa TO Form the Pelvic Floor on the RioaT and on 
FtasT Latbb or the Mubclib Above Covehino Them and the Spaces Aboot 
/, aoUrior common ligament. 7. obturator membrane. 

t, ilio4umbeu' ligament. 8, levator ani. 

S. anterior Bacro-iliac ligament. 9. obturator internus. 

i. pealer tacro-Bdatic ligament. 10, pyriCormis. 

5. laser sacro-sciatic ligament. II, coccygeuB. 

0, Y ligantent of Bigelow. 



20 ANATOMY OF THE IHIINARY AND GENITO-URINARY TRACT 

line, to close the space below. The muscles are covered with fascia, constitut- 
ing the various layers described as pelvic fascia. This has attachments to the 
prostate, bladder, vagina, vesiculie seminales and rectum, and forms folds 
which are described as ligaments of these organs. The whole cavity so formed 
is lined by a complete layer of peritoneum. 

The bonv wall consists of the sacrum behind and the os innominatum on 
either side, meeting in front at the symphysis pubis. The ligaments and struc- 
tures which complete the framework of the pelvis are the sciatic ligaments 
which extend over the sciatic notch, the obturator membrane closing the ob- 
turator foramen, and the triangular ligament which bridges across the space 
between the rami of the ischium and pubes. These cover the irregular open- 
ings in the bony framework, and transform the lower part of the interior into 
a cylindrical cavity with more or less complete walls, as already mentioned. 
The muscular structures which pad the inner surface of this framework are 
the pyriformis and obturator internus. They cover the inner surface of the 
bones on their lateral and posterior aspects, and obliterate the irregularities of 
the bony wall, thus rendering the interior a comfortable location for delicate 
organs. 

The space inclosed by these various structures is known as the pelvic cav- 
ity, and may be likened to the short segment of a hollow cylinder, deeper be- 
hind than in front. It is closed in below by the levator ani and coccygeus 
muscles, which are known as the pelvic diaphragm, but the coccyx and trian- 
gular ligaments must also be looked upon as forming part of the true floor of 
the space. 

Levator Ani. — This arises from the back part of the pubic bone from a 
line of fascia (white line. Figs. 15-16) extending from the back part of the 
pubes and from the inner surface of the ischial spine. The anterior fibers 
extend do^vnward and inward by the side of the prostate, meeting those of the 
opposite side. The intermediate fibers slope downward and inward and sup- 
port the rectum and bladder. At the junction of the rectum and anal canal, 
they form a collar round the gut, which extends downward on its lateral walls 
as far as the external sphincter. The posterior fibers are inserted into the ano- 
coccygeal raphe and the sides of the coccyx (Fig. 15). In the female, that 
portion of fibers which surrounds the prostate in the male are attached on 
either side to the vaginal wall. The nerve supply for this muscle comes from 
the fourth and fifth sacral, some branches of the same nerves going to the 



coccvffeus. 

4/ O 



Coccygeus Muscle. — This is a small fan-shaped muscle which arises from 
the spine of the ischium, extending backward and inward to be attached to 
the sides and anterior surface of the coccyx. The levator ani and coccygeus 
thus form one continuous sheet of muscle, which make, as it were, a bed and 
support for the viscera (Fig. IC). They are both the remains of the tail 



THE PELVIS 



muscles. In quadrupeds the various coraponeuts of the levator an! arise from 
tile brim of the pelvis, and are inserted into the coccyx or caudal vertebrir. 



to 



11 



10 



16 



14 



Cowper's glands, 
transveraus perinei muscle- 
sphincter ani extern us. 



Fig. 15. — View or the Riort Side of the Pelvic Cavttt as Seen apteii a Sagittal Sbction, 
The asenim 'a seen above and the pubis below, while between a. 
nuke ap the peliic walla and floor. The urethral orifice ia seen jua 
the itump of the rectum: extending from the coccyx, t* 

/ , cut Buriace of the sacrum. 

S. pyrif oralis. 

S, ilio-pectioeal line. 

.j, obturator iatcrniis. 

S, obturator foramen. 

G. urcthml opening. 

7. bulbo-cavemosUB muscle. 

8, corpua spongiosum. 
O. deep layer of triangular ligament. 

lO, superficial layer of triangular ligament. 

With the assumption of the upright posture, the muscles become modified to 
furiu one sheet, their origin sinks downward, while thoy acquire their various 



22 ANATOMY OF THE URINARY AND GENITO-FRINARY TRACT 

insertions and increase in strength, to support the viscera which tend to sink 
downward from gravity, the effect of gravity being markedly increased in the 
upright position. In man, traces of the former attachment of these muscles 



Fro. 16. — Thb Pelvic Floor Lookino in from Above. 

The pubis is seen in front, the vertebra behind and the ilium and pubes on cither aide. 

1, syiuphysia. 6. obtumtor intcmus. 

g, prostatic urethra. 7, levator ani muscle. 

5. seminal vesicles. S. coccygeus. 
4. rectum. 9. pyriformis. 

6, cut Burface of iliac bone. 10, prostate glanil. 

can often be found, Tlie cnccygeus and suiall sciatic ligaments are the rejire- 
scntatives of the Jachio coccygeus, the lateral flexors of the tail in lower ani- 
mals (Keith's "Embryology"). 

Pelvic Fascia. — This can be best understood by considerinff the dcvelojv 
ment of fascia in general. This structure is never develojicd in sheets, as is so 
connnonly described, but is merely the portion of mesoblast left over after 
atnictures have formed within it. Thus we see that fascia must form a con- 
tinuous attenuated spongework, in wliieh the interstices arc filled with struc- 
tures which have become differentiated. We can now un<Ierstand the intimate 
relations of the fascia covering the levator and its connections with the pros- 
tate gland, bladder, the vesicula; seminalis, uterus, vagina and rectum. With 
the above considerations in mind, we see that the parietal layer of pelvic fascia, 
so called, is merely the internal sheath of tlie pyriformis and obturator in- 
temus muscles. The visceral layer, laterally and behind, is tlic upper portion 
of the sheath of the levator ani, while in front the visceral layer is really tho 



THE PELVIS 23 

posterior layer of the triangular ligament, which is itself the posterior portion 
of the sheath of the compreaaor urethra. The fibrous covering of the prostate, 
bladder, vesicula seminales, vagina, uterus and rectum are thus continuous 
with these muscle sheaths, and form the fascia described as the vesical, recto- 
veaical, and rectal layers of pelvic fascia (Fig. 17). The internal and ex- 
ternal capsules of the prostate are so called because a partial line of cleavage 
has been made by blood vessels developing in the inesoblastic spongework. The 



17 9 

Tia. 17. — ViBw o» THE Intbrhai. Genttalb and the Pelvic Fascia ik the Male as Seen ebou 
Bebind. ArrER the Rectum has been Separated and Pulled Down. 

i, bladder. ?;, wWIp line faecia. 

*, vaa derereoa. It. obturator faacia. 

5. ureter. IS. anal faacia. 

4, scDunal veaicle. 14, recto-vesicBl fascia coveriog levator ani 

6, obturator iDtemus milsde. muacle, 

6. proatate. is, recto-vesical tam^ia split and reflected from 

7. Alcock'a canal. bladder, prostate and seminal vesiclea. 

8. levator ani muselc. IS, recto-vedcal fascia forming capsule of 

9. rectum drawn down. prostate. 

10. pdvic fascia. 17, recto-vesical fascia reflected from rectum. 

anal fascia covering the perineal surface of the levator ani is merely the sheatli 
of the under surface of the muscle. 

Peritoneum. — Internal to the fascial lining of the pelvic cavity is a com- 
plete covering of peritoneum. This lines the sides of tlic i)elvi8, being contin- 



24 ANATOMY OF THE UBINABY AND GENI TO-URINARY TRACT 

uouB witli tlie peritoneal lining of the abdominal cavity, and ia reflected on to 
the floor of the space, covering more or less of the pelvic viscera (Fig. 18). 
The peritoneal coverings can be heat understood by imagining the peritoneum 
83 extending down into tlie pelvic cavity as a closed sac, and the viscera as 
having been pushed up from below, evaginating portions of the bottom of the 



Fra. 18. EXTHA PERITONEAL SaOITTAL SECTION OF THE BODT TO THE LbFT OF THE MEDIAN LiNB. 

The ureter is seen eiteading down until it cnten the bladder. The vas deferens with the peritoneum 
above aud extraperitjjDeal portion of the bladder below is seen mnninB horiiontBlly toward the ureter 
and passing in front of it to become an ejaculatofy duct. The prostate is seen below the bladder aod 
between its base and the ureter on the posterior wall of the bladder the stump of the seminal vesicte is 

sac and not having been pushed up far enough to get complete coverings. Thus 
the bladder is covered on its superior surface as far as the apex, on the upper 
part of the lateral surface, and covering over the basal surface far enough to 
cover one third of tlie vesicnlic seminales. In front, from the apex of the 
bladder, it is reflected on to the anterior abdominal wall. Behind from the 
base of the bladder it passes backward on to the rectum in the male, forming 
the reeto-vesical pouch. In the female, it covers the uterus above, in front and 
behind, the two layers meeting laterally to form the broad lipament. From 
the uterus it is reflected on to the rectum, forming the utero-sacral pouch or 
pouch of Douglas. It covers the middle third of the rectum on the anterior 



THE PERINEUM 25 

surface, extending backward and upward over the sides to the upper third, 
which is covered in front and on the side, thence blending with the parietal 
laver. 

The blood vessels in the pelvis run beneath the peritoneum. The larger 
trunks, internal iliac and its lateral branches, are found on the side wall of the 
pelvis, superficial to the fascia, while the visceral branches run inward to their 
distribution between the peritoneum and fascia. The sacral nerves, with the 
exception of the obturator, are found beneath the fascia, the obturator is super- 
ficial, running beneath the peritoneum, and leaves the pelvis through a special 
opening in the parietal fascia at the upper part of the obturator foramen. 

THE PERINEUM 

The perineum is a lozenge-shaped space between the pelvic floor above and 
the cutaneous surface below. It is bounded on the sides by the rami of the 
pubes and ischium, the ischial tuberosity, and the great sciatic ligament, in 
front by the symphysis pubis and behind by the coccyx. The superficial fascia 
covering this space presents certain characteristics of surgical importance (Fig. 
19). It is fatty behind, muscular in front, where it extends over the scrotum, 
the muscular fibers being known as the dartos, and accounts for the rugosities 
in the skin of the scrotum. The middle portion is divided into two layers, the 
superficial layer, continuous with the superficial fascia of surrounding parts, 
and a deep layer known as the fascia of Colles. This is attached on either 
side to the pubic arch and behind winds round the posterior border of the trans- 
versus perinei muscle to form a firm attachment to the anterior layer of the 
triangular ligament. In front it is continuous with the fascia of Scarpa on the 
anterior abdominal wall. This fascial connection is very important, as it de- 
termines the direction of extravasated urine in cases of rupture of the urethra 
anterior to the triangular ligament. The perineal space is arbitrarily divided 
into two portions by a line extending transversely across the space between the 
two ischial tuberosities. This line passes just in front of the rectum, and 
forms the urogenital triangle in front and the rectal triangle behind. 

The Rectal Triangle. — This contains the rectum with its sphincter mus- 
cles, and on either side of it is the ischio-rectal fossa. The latter is a pyram- 
idal-shaped space filled with fat which is derived from the superficial fascia. 
Crossing the space from without inw^ard, are the inferior hemorrhoidal vessels 
and nerves, which come oS from the internal pudic artery and nerve as they lie 
on the inner surface of the ischium, in the fascial sheath known as Alcock's 
canal. The fourth sacral nen^e is found in the posterior part of the space, 
while the two superficial perineal nerves arise from the internal pudic and 
run a short distance in the anterior part of the space before they pierce the 
triangular ligament and enter the urogenital triangle. 



26 ANATOMY OF THE TJRrSART AND GENITO-I'RINART TRACT 

The Urogenital Triangle. — The two layers o£ the superficial fascia having 
been described, we come next to tlie various muscles beneath this, which meet 
in the central part of the triangle. This is called the central point of the 



On the left side the niUHriilar layer hae been removed, ahowitiR the eorpus apongioBUin with its butb 
and the roots of the norporn eavemoHa, whereas below the aupcrficial layer of the deep fascia (the tri- 
aDEular ligament) is »een. 



bulbo-cavernoauB (accel 


rat 


orurin 


ffi) 


muaclc 


10. addurtor muscle of thiah. 


ischio-cavemosua or ere< 




penis 




selc. 




ischio-cavemoBUH or cro< 






muscle. 


IS, anterior or superficial layer of triaogutar 












ligament. 
13. tuber ischii. 


^hinetor ani e;.trrnus. 










14. obturator iiitcrnus. 


cori)us sponnioHiini. 










l.t. levator ani. 


corpus cavernosimi. 












CoUeii' fascU reflected. 










/*, CIWClTt. 



perineum, or perineal body. It is merely a fibrous sciitiiin situated a little in 
front of the amis, into which are attiiclied the anterior portion of the sphincter 
ani, the bulbo-cavernosiis, the anterior fibers of the levator ani, and the trans- 
versiis perinei raiiack's. 



THE PERINEUM 27 

Spni:»cTER Asi. — T)ie sphincter ani is a band o£ muscle fibers extending 
from tbe coccyx beliind to the perineal body in front. It forms a muscular 
wllar round the lower part of the anal canal. 

TRAssvERsra Perirei, — These fibers extend from the ascending ramus of 
the ischium near the tuberosity horizontally inward to be attached to the cen- 
tral point of the perineum. 



Flu. JO. — Antebiob Ferine ai. TniAHai^ aftbb the Removal of toe MrscLKa.THB Cobpus Sponoe 

Oei7lfl AND THE CoRFOKA CAVERNOSA CoVERIHd It, 

The urethra ia seen near the middle of the triangle. 
J. corpus spongiosuni. S, sphincter aoi pxtcraus. 

3, rorpus cavcmoaum. S, levator ani. 

3. dorsal vein to penis. 10, gluteus maiinius. 

4. riorsal artery to penis. 11, urethra. 

5. adiluctoT muscle of thigh. IS, tuber ischii. 

6. superficial layer triangular ligampnt. 13, anus. 

7. artery, vein and nerve to bulb, li. urethra. 

Bri.RO-CAVERXosrs.— The bulbo-caveruosus is a muscular sheet covering 
the Imlb and extending on to the corpus spongiosum. It arises from the central 
point of the perineum, aud from a tendinous septum formed by the union of 



28 ANATOMY OF THK URINARY AND G EN ITO-l" BINARY TRACT 

the two muscles. Some of the fibers completely encircle the bulb, meeting 
those of the opposite sitle; others exte»<l forward and enclose the corpora cav- 
ernosa; while the posterior fillers are attached directly to the triangular 
ligament. 

IscHio-CAVERNOSLS 11 T SCI. PIS.- — These mu.sclcs arise on either side from the 
inner surface of the ischial tuberosity. They e.'itend forward, completely eov- 



—The Outer Lateh of the Trianul-lar 


,:gam 


ENT OH THE RlUHT StDE, 


THE Space Between the Twt 


LaIEHS or THE LlUAUENT. 


D. dorsal nerve of penis. 




B. internal pudic artery 


E, dorsal arUiry of penis. 




C. internal pudic vein. 


F, dorsal vein of pcnU. 




/. vein of corpus cavern 


(/, urethral opening. 






T. antorior layer of triangular liganieut. 




3, nerve of corpus cave 


L. posterior layer of triangular ligament. 




X, nerve of bulb. 






Y, artery of bulb. 


G, Cowper's gland. 




Z. vein of bulb. 


K, duet of Cowper'« gland. 




P. pubic rami. 


A. internal pudic nerve. 







ering the crura of the penis and nre attached to the corpora cavernosa. These 
variotis muscles divide tlie urogenital triangle into two Icssur perineal triangles, 
the boundaries of wliich arc the bn!bo-cavcrnosns muscles on either side and 
the transvcrsus perinei muscles behind (Fig. 19); At the bottom of this 
perineal triangle is found a dense fibrous structure on which these muscles seem 
to rest. This fibrous structure is the anterior layer of the triangular ligament 
(Fig. 20). As we have seen before, this is on the same plane with the bony 
wall of the pelvis, and is attached firmly to the rami of the pubes and ischium, 



THE PERINETTM 29 

wliile bebind it receives a finn attachment to tlie fascia of Collea (Fig. 20), 
It is perforated at its posterior part by the urethra, and a sliort distance on 
either side of this the artery of the bulb comes through. About half an inch in 
front of the urethral opening, it is pierced by the internal pudic artery and 
ilursal nerve of the penis, while the superficial perineal vessels and nerves enter 



Fig. 22. — Tbb Male PBBrNEDH after the Removal of the Deep Later or tbb TftlANOULAH 

Here we ace th« other eidc of the levator ani muscle to that Bhown in Fik- 16- 
I. urethra, H. Rluteus maximus. 

?. triangular liRament. T, great sacro-sciatic ligament. 

S, obturator intemua muscle. S. dorsal vein of penis. 

4, levator ani muscle. 9, renlo-vGaical fascia. 

5. sphincter ani eiternua. 10, rap'sulc of proatale gland. 

tlie urogenital triangle by piercing its base (Fig. 21), The deep or superior 
layer of the triangular ligament, as v:e have seen, is merely a portion of the 
[jelvic fascia, but between the so-called superior and the anterior or trlangidar 
ligament proper is a definite space. The stnietures found in this interval are 



30 ANATOMY OF THE UHINART AND GENITO-TTRINART TRACT 

the urethra, svirroimdod bj' the eomprossor urethra! muscles, Cowper's glands, 
the internal pudic artery and dorsal nerve of the penis, the artery to the hnlb, 
and the dorsal vein of the penis wliich haa entered this space by passing back- 



Fio. 23. — The PcRiNEru w the Female after the Removal of the Labia. 
On the right beneath the deep layer of the Bupcrtioial fascia the muscular layer ia seen, and on the 
left side, after removiiig the muscular layer, the corpus oavcrnosum, vaginal bulb and the superficial 
layer of the triangular ligament are seen. 



Collea' fascia reflected. 

bulb of vagina. 

corpus cavcrtioBum. 

opening of vagina. 

adductor muscle. 

cavemosum muscle — ischio-cavemosus. 

superficial layer of triangular ligament. 

tuber iachii, 

levator aiu. 



II. obturator intemus. 
IS, gluteus maiimus. 
IS, coccyjt. 

14, urethral opening. 

15, ischio-bulbosus (aphioctcr vagioie). 
I>i, vagina. 

17, corpus cavornosus muscle. 



SO, sphincti 



ward through a small opening between tlie anterior triaugitkr ligament and the 
subpubic ligament (Fig. 21). 

CoMPKEssoR Ukethr.k. — This arises from the inner side of the ischio- 
pubic rami on either side, the two niu.scles meeting in the mid lino and inclos- 
ing the urethra. The larger body of the muscle is inserted behind the urethra. 



THE PEEINEITM 31 

Just IkIow this muscle is a groii]) of muscle fibers arising from the ramus of 
the iachium and continuous with the compressory urethra at its insertion; this 
is called the transversus perinei profundus. Sometimes muscular fibers (com- 
pressor veme dorsalis) from the anterior portion of the bulbo-cavemosus mus- 
cle pass obliquely outward and forward, inclosing the entire circumference of 
the root of the penis and the dorsal vessels, 

IxTERNAi, Prmc Akteky. — The internal pudic artery arises from the an- 
terior division of the internal iliac, passing out of the pelvis throngh the small 



Phi. 24. ANTEBtOB I.AVER OF THE TniAKQm.AR LlOAMENT IN THE FeMALE. AF 

iBE External Genital8. the SuFEHnciAL Fascia and Mubci 
The urinary and vaginal passages are seen. It coircspoads to Fig. 20 

(, urethral opemoK. G, levator ani. 

i, vagiiiB. 7, sphineter ai 

S, tuber ischii. 8, Klutcua 

4. adductor musclen of thigh. 9, corryx. 

B, auperficial layer of triangular ligament- 
sciatic notch; it crosses over the spine of the ischium and enters the perineal 
space, running along the ischial tuberosity in the fascial Hheath known as Al- 
eock's canal. This is situated about an inch and a half froni the lower border of 
the ischial tuberosity. It ascends to the inner surface of the ramus of the puhes, 
and about one half inch below the symphysis pubis pierces the triangular liga- 



32 ANATOMY OF THE UKINARY AND GEN I TO-URINARY TRACT 

ment and is continued onward to the dorsal artery. Its branches are inferior 
hemorrhoidal, superficial and transverse perineal, artery to the hnlb, and artery 
to the corpus cavernosns, 

Ihteknal Pudic Nkkve. — Tliis arises from the sacral plexiis and follows 
the same course as the artery, the nerve being situated usually above. As it passcn 
over the ischium, it divides into two branches, the perineal, and dorsal nerves of 
the penis. The perineal nerve breaks up to supply the small perineal mnscles 
previously described, and the two superficial perineal nerves supply the skin over 
the part as far forward as the scrotum. The dorsal nerve of the penis is contin- 



Fio. 26. — The Deep Later op Mdscleb Forming the Floob of the Pelvib im tee Femai.e fkoh 

THE OUTBIUE. 

The urethral and vagiaal opemnga are seen. It meembleB Fig. 22 in the male. 
/. urethra. 6, coccyi. 

S, adductorv. 7. sphincter ani, 

3, tuberosity of ischium. 8. levator ani. 

4, obturator intcmua. 9, great sacro-sciatic ligament. 

5, giuteuB maiimuB. 

ned onward with the interna! pudic artery and dorsal artery of the penis, Fig. 
22 shows a deep dissection of perineum after removal of triangidar ligament. 

Female PeriQetun. — In the female the perineum is divided into urogenital 
and rectal triangles, as in the male. The rectal triangle does not differ in any 



THE lODNEYR 33 

way from that found in the male. In the urogenital triangle the vagina makes 
some alteration in the relation of the parts. The ischio-bulbosus muscle is 
found in two separate parts covering over the bulb as it lies at tlie sides of the 
vagina (Fig. 23). The vagina also makes a cleft in the triangular ligament, 
which structure in the female is of less density than in the male (Fig. 24). 

Fig, 25 shows a deep dissection of female perineum after removal of tri- 
angular ligament. 

THE KIDNEYS 

The kidneys are the glands which secrete the urine. They are situated on 
the posterior abdominal wall behind the peritoneum, between the upiier border 



FiQ- 28. — Thk Pobteuob Sohfacbb of the Kidnets and their Relations to the Ribs. 

(Rocaniior.) 

of the twelfth dorsal and middle of the third lumbar vertehrro (Fig. 26). Tlie 
right kidney extends to the lower border of the eleventh rib ; the left is placed 
somewhat higher, and its upper pole may rest on the eleventh rib. Below, they 
are both separated by a short interval from the crest of tlic ileum. The kidney 
is a bean-shaped body, four and one half inches (11.2 cm.) in length, two and 
one half inches (6.2 cm.) in breadth, and one and one half inches (3.7 cm.) in 
thickness. Its weight is about four and one half ounces. 



34 ANATOMY OF THE URINARY AND OENI TO -URINARY TRACT 

Belations of the Kidney. — The kidney haa an anterior or viscera] surface, 
a posterior or muscular surface, an internal border or hilus, and an external 
border. The upper and lower ends of the kidney are called respectively the 

upper and lower poles. 

The anterior surface of the kidney looks forward and slightly outward, and 
is partly covered by i)eritoneum. On the right side, it is in relation above with 



1, caval area. 9, duodena] area (nonpcritoncal). 

£, gastric area (peritoneal), 10, colic area ol spleen. 

S, hepatic area (nonperitoneal). II, mesocolic arc?u. 

i, gastric area of spleen. IB, eolie area (nonpcritooedj. 

S, duodenal area (nonperitoneal). 14, mesocolic area. 

e. splenic arteij-, 16, meter. 

7. hepatic area (peritoneal). 18, aorta. 

S, pancreatic area (nonperitoneal). SO, vena cava. 

the right suprarenal body, which extends farther down the anterior surface on 
the right than on the left (Fig. 27). The outer throe fourths of the upper 
half of the kidney lies behind the liver and is covered hy peritoneum. T'.:e 
outer three fourths of the lower half, just below the hepatic area, is behind the 
ascending colon and the mesocolic area and is not covered by peritoneum be- 
neath the colon. The inner quarter of the organ is behind the duodenum, and 
is nonperitoneal as is its colic area. The small area on the internal aspect of 
the anterior surface of the upper third of the kidney is in relation with the 
inferior vena cava. 

The anterior surface of the left kidney is in relation ahove, for a small 
space, with the left suprarenal (Fig. 27). The upper fifth of the anterior sur- 
face lies behind the stomach, and is covered by peritoneum. The middle two 
fifths is behind the pancreas, nonperitoneal. The lower two fifths lies behind 
the colon and mesocolon, the latter being peritoneal. A narrow atrip of the 



THE KIDNEYS 



35 



anterior surface in its outer part is in apposition with tte renal surface of the 
Epleen, and connected to this organ by the lieno-renal ligament. 

The posterior surface on both sides in its upper third rests upon the 
diaphragm, the twelfth rib crossing behind this (Fig. 28). Between the dia- 
phragm and the lower ribs, the pleura extends for a considerable distance be- 
hind the kidney. The inner third of the lower two thirds lies upon the psoas, 
the middle third on the quadratus hunborum, and the outer third rests upon 
the tendon of the transversal is. The last dorsal ilio-hypogastric and ileo-in- 
guinal nen-es pass in a direction downward and outward behind the kidney 
on both sides. The external arcuate ligament and transverse processes of the 
npper three lumbar vertebra! lie 
immediately behind the muscular 
bed of the kidney. 




Renal 
Renal 



Tic. 28. — The Relation or the Kidnets 

TO THE T1S8CK8 BEHIND ThEU. (MoITUI.) 

1, tranevRse proceaaes o[ the first and bcc- 

oad lumbar vertebne. 
t, line mdicatiDg outer border of quadratus 

lumborum. 



la. 29. — Median Vertical Section c 
Kidney. (Poirier.) 
The reoal artery and vein, the iatiri 
is, colicea, the ureter, the papilla and 



The inner border of ihe kidney in its middle part consists of an anterior 
and posterior lip, forming a fissure wliicli is known as tlic hilinii. In a space 
between these lips, which e-ttenda into the kidney substance for a short dis- 
tance, is the renal sinus, and here the blood vessels and ureter enter the kidney 
(Fig. 2^). These vascular structures arc kno«-n as tlie pedicle. 

The relations from before backward are vein, arterj', ureter. From above 
downward the relation is artery, vein, ureter. The upper pole of the kidney 
supports the suprarenal body posteriorly. It is in relation with the inner sur- 



36 ANATOMT OF THE mUNARY AND GENITO-TJBINARY TRACT 



face of the twelfth rib, or on the left side may lie in front of the eleventh. The 

diaphragm and pleura intervene between the kidney and the bone. The lower 

pole reaches about two inches from the iliac 

crest and is situated farther from the median 

line than the upper pole. 

The external border of the kidney is 
formed by the meeting of the anterior and 
posterior surfaces, and rests upon the tendon 
of the transversal is. The kidney is closely in- 
vested by a fibrous capsule, which, winding 
round the lips of the hilum, lines the renal 
sinus and also sends prolongations over the 
vessels and ureter. 

The Pelvig of the Kidney. — This arises 
from the kidney sinus by a series of small 
tubes, eight to twelve in number, called caliees, 
surrounding one or more papillte. These fuse 
into one, two or three larger ducts, which in 
turn nnite to form the pelvis. This cone- 
shaped duct extends inward and downward, 
decreasing rapidly in size to become continu- 
ous with the upper end of the ureter (Fig. 



Perirenal Tissue. — When the kidney de- 
velops, it grows out as an evagination from 
the Wolffian duct. This diverticulum extends 
into the surrounding mesoblastie tissue, a por- 
tion of which becomes differentiated to form 
the kidney cortex. The part of the mesoblast 
that remains outside the cortex forms the peri- 
renal tissue. This remaining spongework be- 
comes filled with fat and surrounds the kidney, 
being thickest above, behind and externally. 
As we see from this mode of formation, no 
special ligaments are developed to hold the kid- 
ney in place, although by special dissection 
some of the fibrous tissue may be described as 
such. 

This surrounding tissue above is car- 
ried upward to the diaphragm (Fig. 30), 
infernally over the spinal column (Fig. 31) to the opposite kidney, while 
below it extends on the posterior abdominal wall as far as the iliac fossa. 



Fia. 30. — Tbb Henal Fascia AnxE 

A. SAOriTAI. InCISIOK TRItODOH THS 

KiDNET. (Testut and Jacob.) 
1, kidney with iU sinuB. 
i, Euproreiial capaule. 

3, perirennl fascia in front of kidney. 

4, perirenal fascia behind kidney. 

5, common insertion of its two leaves 

into the diaphrasm. 

6, fatty capaule. 

7, pararenal fascia. 

8, openiog below the two layers of 

perirenal fascia. 

9, diaphragm. 

10. twelltb rib. 

11, quadratus lumbonim muscle. 
IB, crest of ilium. 
IS, parietal peritoneum. 
14. adipose and cellular tisBue in ths 

iliac fossa. 



THE KIDNETS 



37 



Below it does not form so markedly a closed sac as it does over the upper part 
of the kidnev. This is due to the fact that the kidney originates below and 
travels upward as it develops. The chief agents in maintaining the kidney in 
its normal position are the intra-abdominal 
pressure, the attachments to the various vis- 
cera, and to some extent the perirenal tissue. 



Fin- 31.— Thb Renal Fascia i 



XX, the ineduui line. 
/. the Iddney. 

f . inferior vena cava. 
S. periiukal fascia. 

4. posterior le&flet of perire- 

nal Tasria. 

5, anterior leaflet of perirc- 



N Throdgb the Kidnet. (Teetut.) 



I HOBIZONTAL In- Flo. 32.— Saohtal Sbction 1 



6, 6. fatty capsule. 

7, pararenal fat. 

8, parietal peritoaeum. 

to. psoaa muscle with its a 



KiDNET. (Hente.) 
u.(. uriniferous tubes. 
c.t, cortex with pyrainidi of Ferrein. 
tn, pyramids of Malpighi. 
1. GoluniD o( Bertini. 
p, papilla. 

c, calyx embracinB papilla. 
m.r, medullary rays. 

Stmetnre. — The kidney on section shows an outer cortical layer called the 
cortex, and an inner called the medulla (Fig. 32). The medulla consists of 
pyramidal masses, eight to twenty in number, with their base toward the cor- 
tex, called pyramids of Malpighi, Their apices form small prominences (renal 
papilhc) which project into the renal calicea, and contain the orifices of the 
kidney tubules. Between the pyramids are found the columns of Bertini ; 
these are processes from the cortex and contain blood vessels, lymphatics and 
nerves. 

At the bases of the pyramids in the cortex, are seen the medullary rays 
which are made up of the cortical portions of the straight collecting tubules, the 
descending and ascending limb of Henle and blood vessels. The areas of cortex 
between these rays are known as the labyrinth. The pyramids of Ferrein are 
seen at the periphery of the cortex and lie external to the medullary rays and 
Jabvrinth. 



ANATOMY OF THE TTRINARY AND G EN ITO-U BINARY TRACT 



The kidney substance is made up of small tubules, which consist of a base- 
ment membrane lined with epithelium and separated one from the other bv 
connective tissue. The tubules 
UN7 Vessel begin as blind dilated extrem- 
>?/■*/• V '^^^^ "^ *''® labyrinths and 
form what is called the cap- 
sule. This is surrounded by 
looped capillary blood vessels, 
which in turn are covered 
by a thin reflected layer of 
the capsule. The capillaries 
are thus inclosed between the 
Fio. 33.— Malpiqbian ciorpdscle. two layers and the whole is 



'erulus. 






Fio. 34.— Scheme of the Renal Tdbbs *nd Blood VESsEla (fro 






oiirac of thG urimferoufl tubulcs. 




.«, veniE Btcllatff of Verheyen. A, cortei. 


5. descending limb of looped 




tubule of Henle. 


.r, venre rcctie. C, papillary lone of medulla. 


6, bend. 


ni.r, veins of medullary part, a.a', superficial and deep layetB 






10. irresular tubule. 


i.i. intcrlobulnr arteiy. i, Malpighian capsule. 


;/, second convoluted tubule. 


•}. glomerulus. «, neck. 


78, junctional tubule. 


n.r, arteriff rertiB. 3. first convoluted tubule. 


IS, 14. collectins tubule. 


a.m. arteries of medullary pari. 4. spiral tubule of Schaehowa. 


15, excretory tubule. 



THE KIDNEYS 



39 



mHwI a Malpighian corpuscle (Fig. 33). The first part of tlie tubule lead- 
infT from tbe capsule is the first convoluted tubule; it passes through the 
lahvriath to the medullarj' ray and becomea the spiral tubule. Thence it passes 
into the intermediate zone, then straight through the pyramid toward tlie apex. 
This part is known as the deseendiug limb of Henle's loop. Near the apex 
it bends around, forming the loop of Henle, and passes upward through the 
pyramids, through the intermediate zone into the medullary ray, as the ascend- 
ing limb of Henle's loop. It now continues its course to the labyrinth as the 
irregular tuhule, becoming more uniform within the labyrinth; this portion 
is known as the second convoluted tubule. 
This ends in the junctional tubule which, 
passing into the medullary ray, joins 
the collecting tubule. The collecting tu- 
buk is made up of several renal tubules 
and pursues a straight course to tbe apex 
of the pyramid. Here several unite to 
form one excretory duct, which opens 
at the renal papilla; in tbe kidney sinus 
(Fip. 3-1). 

Blood Supply. — The kidney is sup- 
plied with blood by the renal artery, Tbe 
chief function of this artery, however, 
is not to nourish the gland but to allow 
tlie various products of metabolism in the 
systemic circulation to be acted upon by 
the kidney. 

The Ren.vl Artery. — In the sinus, 



Fio. 35.— Thb Renal Ahtert and Itb 

B RANCH Efl. (TffllUt.) 

Right kidney. Sagittal section seen from 
the a^tcr^' subdivides into a fan-shaped the front. 



t. pyrspiida of Malpighi, 

5, S. columni of Bertioi. 

4, renal artery. 

B. ila poflterior branch. 

6, its anterior branch bifurcating. 

7, peripyramidal arteries. 

5, renal pelvis. 



plexus, as seen in Fig. 29, and the ter- 
minal branches enter the projections pro- 
duced by the columns of Bertini (Fig. 
35). On entering these, at their cen- 
ters, the arteries at once bifurcate, so 
that each division skirts the boundary of 
a pyramid. Each pyramid is supplied with four or five arteries which travel 
along its surface until the base is reached (lobar or peripyramidal arteries). 
At the bases, they give transverse arched branches whicli anastomose witli 
Mmilar branches from other lobar arteries, and form the suprapyramidal arch 
or plexus. The meshes of this network surround the base of a pyramid 
transversely like a collar. From this network arise a number of arteries 
ihrecteil toward the fibrous capsule, usually between two pyramids of Ferreiii 
(Fig. 36). 



40 ANATOMY OF THE TJEINARY AND GENITO-URINARY TRACT 



These arterioles, known as the interlobular vessels, end in the capsule in 
" capsular branches," some of which perforate into the perirenal fat. The in- 
terlobular vessels, however, give off lateral branches all along their route 

through the parenchyma, 
which end in the afferent ves- 
sels of numerous Malpighian 
tufts. 
5 The glomerular capillaries 

are twist«(l around each other, 
forming the lobulated tuft de- 
scribed above, and end in an 
efferent arterial capillary. 

Leaving tlie glomeruli, the 
efferent eapillaries pass toward 
the convoluted tubules and 
the pyramids of Ferrein, and 
form a network which sur- 
rounds and supplies all the 
cortical tubules. In the me- 
dulla, the straight tubules are 
found accompanied by parallel 
capillaries — the artcriie recta; 
— ^which are probably also de- 
rived from tlie efferent capil- 
laries of the glomerulus. The 
arterito recta' form a rectangu- 
lar network about the papillary 
orifice of the collecting tubule. 
Abnormalities of the Kidneys.- — (1) Complete absence of one kidney. 

(2) One kidney very small and atrophied, the other hypertrophied and 
very large, 

(3) Lobulation, such as is seen in the fcetua and in some of the lower 
animals. 

(4) Horseshoe kidney, the two kidneys being fuse<l together at the lower 
Ijole. 

(5) Abnormal position, one kidney, usually tlie left, may be placed very 
low, opposite the sacro-iliae synchondrosis, this being the kxration of its early 
origin. 

(6) ifore than one renal artery may be present, or the main artery may 
break up before it enters the sinus. 



Fio. 36. — ScHBMATic Dbawinq Showino the Tbeort 

THE ASRANOEUENT OF THE VaSCVLAB ArCBEB OVER 1 

Pthamiim. (Teetut.) 

I, S, two Malpishian pyramids. 
g, sinuB of the kidnpy. 

3, coiumnH of Bcrtini. 

4, arterial archea. 

5, venous arches. 

6, branches of the renal artery. 

7, branchea of the renal vein. 

8, interlobular arteries. 
B. interlobular veins. 

10, direct (straight) veins. 



THE UHETER 



THE URETER 



The ureter is a fibro-miiaeiilar canal, whicli conducts the urine from the kid- 
nev to the bladder. When in aitn it measures about fifteen inches (37 cm.) 
(Fig. 37). 



On botli sides, it lies on the psoas muscle behind the peritoneum (Fig. 38), 
and is crossed obliquely by ovarian or spermatic vessels. The genito-crural 
ner\'e passes behind it on both sides, in a direction from within downward and 
(lutward. On the right side, the duodenum lies in front of its commencement. 
Lower down it is crossed by the ileo-coHe artery and tiie root of the mesentery. 
On the left side, the left colic artery and the mesentery of Ihe pelvic colon pass 
in front. 



42 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 

Crossing the pelvic brim at the bifurcation of the common iliac or at the 
coimnenoement of the external iliac (Fig. 39), it passes down from the side 
wall of the pelvis in a cun-ed direction, the convexity of the cun-e being back- 
ward. It passes over the obturator nerve and artery and obliterated hypogas- 
tric artery, ns they run forward on tlie side wall of the pelvis. At the spin© 
of the ischium, it crosses inward over the floor of the pelvis and is crossed by 
the vas deferens near its termination. As it enters the bladder, it lies in front 
of the vesiciibe aeminales and is surrounded by veins continuous with the 
vesical and prostatic plexus. As they enter the bladder, the two ureters are 



Fia. 38.— A Saoittal Section of the Pelvib to the LErr of the Median Line. (After RartmaDn.) 

On the risht the peritoneum is seen iotact with the ureter outside of it, wheresH on the left the eitr« 
pcriloncaL tisnue and Ihe (Mmmon iliac branching into the Eit«rnHl and internal iliac braocheH are seen. 
If the two aides were brought tOKctber the ureter would oceupy the spaee at the bifurcation of the 



])laced about two inches (5 cm.) apart They run from the bladder wall in 
an inward direction for three quarters of an inch (1.87 cm.) (Fig. 40), and 
open on the internal surface by two valvular slitlike orifices which in the empty 
bladder are about one inch (2.5 cm.) apart. In the female, the pelvic portion 
of the ureter has somewhat different relations. As it runs down on the side 
wall of the pelvis, it produces a ridge in the peritoneum, which forms the pos- 
terior boundary of a small fossa (fossa ovarica) in which the ovary lies. The 
upper and anterior boundary of this fossa are formed by the external iliac. It 
tlien passes inward underneath the broad ligament, passing over the vault of 



THE URETER 
10 11 IS IS u 



19 SO 21 

39.— The RELATioNit of the Vreteb to the Pelvic Tishves. (After Duval.) 
Tho ureter ia aeeo to iiusa jiut below the bifurcation of the cummoti iliac. 



/. sscendioR colon. 



•, «>d of ileu 

S, appendix held up. 



S, miperior hemorrhoidal. 



lA. left ui 



I-'i, psoBB muscle. 

Itl, left Mgmoidal artery. 

/7. internal iliac. 
: artery. 18, colon. 

>. risht sigmoidal. 19, anterior layer of pelvic mesocolon. 

7, middle WRinoidal. 20, posterior layer of peritoneum. 

S, iDtemal iliac. Bl. posterior layer of pelvic mesocolon. 



/Mucous Co^T. 

T^HiOlxR Cam 
/fusct/hd CoAl 



44 ANATOMY OF THE URINARY AND GENITO-URINABY TRACT 



the lateral fornix of the vagina about a quarter of an inch (0,6 cm.) from the 
lateral border of the cervix uteri, Near its termination it is crossed by the 
uterine artery {Fig. 41). Its course within the 
bladder is the same as in the male. 

Structure. — The wall is composed of an 
outer fibrous layer, then a middle muscular 
layer, the muscular coat being in three strata. 



UreteraiarUry-^ 
VrtUrnl aritrv ^ 

Vino'-Kwiiiiit plciu^ 







FlO. 41. — SCHBHATtC DBAWlNOOrTHB RsLAIlONB Of THE UnE- 

TERTOTHE Nece OF THE Utebub AND Itb Vbssbi^. (Poirier.} 
L.L. ia a line drawn just bdow the uterioe isUunus. The 
Btriations below this represeDt the vagjaal wall. The outline o[ 
the cervix uteri ia indicated io this area by a dotted line. An 
arch ia (ront ot the cervix and va^na represents the outline of 
the bladder wall through the sides o[ which the ureters arc seen 
to extend. On the right side of the cervix about the urettr, the 
uterineand vaginalartcrieBHiidveinBareBeen. The ut«rine artery 
and vein paaa in front of the ureter. 

The middle fibers are circular, the outer and 
inner longitudinal. Inside of the muscular 
coat is the mucous membrane, the epithelium 
of which is the same as that found in the 
bladder. 

Caliber of the Ureter. — The caliber of the 
ureter ia not uniform throughout its extent. 
At its junction with the pelvis, its diameter 
is about 3.2 mm. From this point on it gradu- 
ally dilates until it reache.-s a diameter of S mm. 
As it passes from the abdomen into the pelvis, its diameter is alMiut 4 mm. 
From that point to its termination there is a slight gradual de<>reasc in its 
caliber (Fig. 42). 

Variations. — The ureter is sometimes double at its commencement; smut- 
times it is double throughout its course. In rare cases, one ureter may oi)en 
into the vagina or urethra. 



F:a. 42. — SiiAPEor THE RiobtITre- 

TEB AFTER 1t HAS BEEN InJKCT- 

ED WITH Tallow. (T(»tul.) 
pelvis of kidney. 
infundihul urn- 
narrowing. 

wide or abdominal portion, 
bend at pelvic brim. 

widening in pelvic portion. 

9. eiteroni iliac artery and \Tin. 

\'eairal orifice. 



THE BLADDER 



THE BLADDER 



The bladder ia a muscular pouch which acts as a temporary reservoir for 
die urine. Its capacity varies in different individuals, but an average is about 
twelve ounces. It is situated in the anterior part of the pelvic cavity, behind 
the symphysis pubis and the retro-pubic pad of fat, and in front of the rectum, 
from which, in the male, it is separated by the vesieula; seminalea and the ter- 
minal portion of the vas deferens. In the female, it is separated from the rec- 



Fuj. 43. — BiiUiDaB But Sughtlt Dilated on SAotTTAi. Section. Sbowxno Its Apex 
AHD Babe. (Poiiier.) 
I. vu deferens. S, seminal vesicle. 

t, Retnua space. S, prostata. 

3, plexus of Santorini. 7, transverse dvep perineal muscle. 

i, retro-vesicBl told. S, transvcrae BUperScial perineal muBcle. 

turn by the uterus and upper part of the vagina (Fig. 47). It presents varying 
forms and relations according to whether it is distended or empty. 

SeUtions. — The bladder has an a]>ex and five surfaces ; they are a superior 
or abdominal, a postero-iuferior or basal, antero-inferior or pubic and two lateral 
(Figs. 43 and 44). 

The apex looks upward and forward and is connected to the abdominal wall 
bv a fibromusciilar cord, the urachus. On either side of it are the obliterated 
hypogastric arteries which pass upward from the sides of the bladder. 

The superior or abdominal surface is entirely covered by peritoneum an<I 
Miends antero-po3teriorly from the apex to the base. Laterally it ia separated 
from the sides of the bladder by the obliterated hypogastric arteries (Fig. 45). 

The antero-inferior or pubic surface (Figs. 46 and 47) is that part of thp 
bladder in relation with the symphysis pubis, the triangular ligament, internal 
oltturator muscles and the anterior portions of the levator ani. It looks down- 
ward and forward, and is not covered by peritoneum. 



46 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 

The base or fxindus (diagrammatic view) looks downward and backward 
(Fig. 48). In tlie male, it is in relation to the rectum, from which it is sepa- 
rated by a reflection of the recto-vesical fascia. In the female, the base lies in 
contact witli the upper part of the anterior wall of the vagina and the cervix 
of the uterus. 

The lateral surfaces or sides (Fig, 48) are in relation to the levator ani 
and obturator iutemua muscles with their fascial coverings. The sides are 



Vbrtical TRAJisvBRfli: Section o 


r Pelvib j 


JST [N Front of the Internal Meatds 


IHO THE Trigone and 




HRAL OiuFicEB. (Poirier.) 


I.neckof liladder. 




(/, extension of ischio-reftal fossa. 


S. ureteral orifice. 




li. internal pubic artery. 






13, deep trans verw! perinei muscle. 


4, lateral liKoment. 




14. ischio-pubie ramus. 








e. levator ani fascia. 




le. isrhio-caver[ioau8 muscle. 


7, obturator intronuH muscle. 




17. bulbo cavemosuB artiry. 


8. levator aoi muBcle. 




IS. bulbo cavernoBUB Tnusclc. 


ff, pelvic layer of faacin. 




19. membranous urethra. 



tf, peivic layer oi laaein- jft, niemuraiiuus uretii 

10, lateral prostatic fascia (capsule). SO, bulb o( the urethra. 



crossed obliquely from below, upward and forward, by the obliterated hypo- 
gastric artery. Above and behind this cord, the bladder is covered by peri- 
toneum, while below and in front, it is covered by rccto-vesieal fascia. 

That portion of the bladder immediately around the internal urethral 
orifice is called the " neck." In the male, it rests upon the prostate and 
connects with the urethra passing through it, but has no definite anatomical 
limits. 



THE BLADDER 



47 



The Distended Bladder. — When the bladder is distended, the various boi^ 
ders and surfaces are obliterated so that the bladder assumes an oval shape 
(Fig. 49). The superior sur- 
face, upper part of the infra- 
lateral and upper part of the 
basal surfaces, take most part in 
the distention, and the lateral 
and posterior borders are oblit- 
erated. The superior surface, 
from being almost a flat plane, 
assumes varying degrees of con- 
vesitT until it comes to represent 
a segment of a sphere (Fig. 49). 
The peritoneal reflection from 
the apex is carried upward with 
increasing distention until it may 
be from one to two inches (2J to 
5 c.c.) above the symphysis, thus 
markedly increasing the area of 
the prevesical space, or space 
of Retzius. Laterally, the peri- 
toneal reflection from the side 
wall of the pelvis is also elevated. 
Behind, its alteration in position 



CStit 01^ 

Yla. 45. — The Pehitoneai. ItEru:(7TioN om the Side or 

THE Bl.ADDEI( ALONO THE COVItSE OF THE HvPOOAa- 

TtucAfiTEHl.AaSEEHiNTaE Newborn. (Teatut.) 
Thisartery in the adult is obliterated in the groater 
part of its counc. forming a. cord. 

A. superior posterior part f, vesico-rectal poriloneum 
ot the bladder covered forming cul-de*ac. 
by peritoneum. t, right ureter. 

A', inferior anterior part of 3, right vas deferens, 

the bladder not covered A, aorta, 

by peritoneum. S. right iliac artery. 

B. seminal vesicle. 0, right internal iliac. 

C. rectum. 7, right umbilical. 



-The 






obliler- 



fto- <6. — DuaRAVHATic Drawino Sbowino the Upp 

StniFACK OP TBB BI.AHDBR IN THE MaLE AS SkEN rS 

Above When Lookino Down into the Pelvih. 
V. upper surface of bladder. &. sacrum. 
P, syDiphyiDs pubis. /. ileum. 



is very slight, but the recto- 
vesical space is relatively in- 
creased. In depth, the urethral 
orifice and lower part of tlie 
bladder remain fairly constant 
in position, the orifice descend- 
ing slightly. The distended 
bladder comes into more inti- 
mate relation with the side wall 
of the pelvis, being in apposi- 
tion with the hypogastric artery, 
the obturator vessels and nerves, 
and the vas deferens; while a 
large part of the organ becomes 



48 ANATOMY OF THE URINARY AND OENITO-rRINARY TRACT 

intra-abdominal and is in relation to the anterior abdominal wall for a vary- 
ing distance. 

Ligaments of the Bladder. — The ligaments are described as true and false. 
The false ligaments are merely folds of peritoneum. A reflection of peritoneum 
from the apex over the urachus is called the anterior false ligament. This 
forms the upper part of tlie posterior wall of the space of Retzius. The peri- 
toneal reflection from the side wall of the pelvis to tlie lateral borders and 
superior surface of the bladder are the lateral false ligaments. They dip down 
slightly into the space between the bladder and pelvic walls, which is called the 



H THE Otheb Pelvic 

paravesical fossa. Behind, two distinct folds of peritoneum cover the vas 
deferens and are described as posterior false ligaments ; these correspond to the 
folds of Douglas in the female, and form the lateral boundaries of the recto- 
vesical pouch. 

The true ligaments consist of the urachus extending from the apex .to the 
anterior abdominal wall; the lateral processes of pelvic fascia firmly fix the 
lower part of the bladder in position. In front, two folds of this fascia extend 
from the symphysis over the prostate to the inferior surface of the bladder — 
the pubo-prostatic ligaments. Within these folds are strands qf muscular fibers. 
The lateral ligaments are the pelvic fascia as it passes from the levator ani to 



THE BLADDER 



tlie bladder. The basal surface ia fixed in its lower part by the fascia sur- 
rouoding the vesiculic seiniDales and termination of the vas deferens. This 




I TBI SHAHt 
E Bl~tt>DER WHIU: FlLUNQ. 

(Poirier,) 



iO. 48. DlAGRAHUATIC DiUWINa SHOWING THE BaBB AND 

Sides or a Dii.ated Bladdeh in a Pelvis fboh Which 
THE Flook and tbe Tusceb Constitutinu rue Pesihedu 
IIatk Been Reuoveo. 

surface ia just socn. The 



contains some muscular fiber and extends back- 
ward, jraiuin^ attachment to the rectum and the 
frfiDt of the sacrum, 

Stntetnre of the Bladder. — The serous or 
peritoneal coat, as we have seen, only gives a 
partial covering to the viscns. The muscular 
wrtit 13 very thick and is disposed in three laj'errt, 
which are aomewhat irregular. The outer coat 
ia disposed for the most part in a longitudinal 
or vertical direction, some of the fibers from the 
inferior surface being continuous with the mus- 
culature of the prostate, while in front they are 
otntinuons with the muscle fibers in the pubo- 
prostatic ligament (Fig. 50). The middle coat 
i^ not found as a complete layer, some ot the 
filters l>eing horizontal (Fig. 51) and some longi- 
tudinal. Over the trigone it forms a continuous 
layer, the fibers running transversely, while near 
the urethral orifice they are dispersed in a cir- 



Fiu. 50.— 

Fibers of the Anterior Layeh 
OF THE BUAimER Wall. (Sapppy.) 

longitudiniil fibers of ihc anterior 
wall. 

S, the same fibers which arc continu- 
ous at the to|) of the bladder with 
those of the opposite side. 

the uraebu^ surrounded by the 
middle Bnlerior fil«TS. 

(croup of fibers iletaehing themselves 
from the principal bundle to sprend 
over the lateral ve«ieal wall. 

lateral libera extending out from 
the lonRitudinal. 

antero-lateral loneitudinal fibers. 

aponeurosis by which the lonai- 
tudinal medium fibers attneh 
theiUBolvcs to the inferior part of 
the symphysis pubis. 



50 ANATOMY OF THE FRINAKT AND GENITO-ITIINARY TRACT 

culftr maimer. The inner coat is a thin stratum, the fibers of which nin longi- 
tudinally, forming the internal sphincter (Fig. 52). The suhmiicoiia coat 
separates the mucous membrane from the inner muscular layer. This forms a 
definite layer, except over the trigone of the bladder, where the mucous layer 
is firmly adherent to the underlying muscidar surface. 



Fia. fil. — Middle or Cibcitimii Later of the 
Mdbcular Wall or the Bladder. (Sappey.) 
I, I, circular or transverse Gbera of the bldddi-r 

forming bundles which fit into one another. 
£, muscular fibers of the urachus. 

3, 3, sphincter of the bladder embracing the be- 

ginning the prostatic portion of the urethra. 

4, cut thmuKh the vesical sphincter showing its 

thickness. 



Fio. 52.— Deep Later of thb Bladdkb Walu 

(Sappey.) 
/, /, /. streaked bundles of fibers extending (rtm 

the top tovard the neck of the bladder ulv!.!- 

ing and uniting with one another. 

5, 2. e, elliptical meshes in the longitudinal axis re- 

sulting from the union of these bundles. 

3, muscular fibers at the urachus separating below 

and continuous with the other fibers. 

4, fibers of this layer forming a cylindrical sheath 

which extends along the urethrsl mucosa. 

6. sphincter of the bladder. 

8. cutsection of the prostatic portion of the i:r> 
thra. 



The mucous layer is a continuous membrane lining the whole internal sur- 
face of the bladder, and is continuous with that of the ureters and urethra; 
it is disjKiscd in folds and is loosely attached to the bladder wall, except over 
the region of tlie trigone. The epithelium is a transitional stratified type, the 
same as that lining the ureter. 

Cavity of the Bladder.^ — In the empty bladder, tliis is said to assume the 
shape of the letter " Y " (Fij;. 43), The stem of the Y is represented by the 
beginning of the prostatic urethra in the male. Xoriiially in the living body, 
the interior of the bladder probably never possesses tliia shape, but would be 
better represented as a slitlike cavity extending from the apex almost directly 



THE BLADDER 51 

backward to the internal meatus. In the distended bladder, the cavity assumes 
an oval shape (Fig. 49), 

The Orifices. — On the inner surface, three openings may be seen : Above and 
behind, the two openings of the ureters, while at the lowest part is the urethral 
internal meatus or urethral orifice (Fig. 44). Lines joining these orifices 
would form the boun<]aries of an equilateral triangle, the aides measuring about 
au inch (2.5 cc.) in the empty bladder. This triangular area is called the 
trigone. 

Vessels and Nerves. — The blood supply of the bladder comes from the su- 
perior and inferior vesical arteries. The veins (Figs. 53 and 54) form a dense 



I 



p 

IS 



i 



I 



Fic 


53.- 


-Veins 


IN THE Mai* 


Pblyib Arr 


EH THE Rectum has 


B 


EN RbUOVED a 










■Pri.(.ED Down. 


(HcDle.) 










/ 


ven« cava. 








7 


pleius of Santor 






S 


dtenudaUc 










vaa deterena. 






s 










9 


dorealis penis. 






4 


gluteal. 








10 


internal pubic. 






5 


sciatic. 








" 


bladder. 



a THE Bladder 



plesus about the base of the bladder just above the prostate and surrounding 
the entrance of the ureter. This plexus communicatos freely with the pros- 
tatic ple.xus and empties into tributaries of the internal iliac veins. The 
lymphatics go to the iliac glands. 



52 ANATOMY OF THE URINARY AND GENITO-TJRINAEY TRACT 

The nerve supply is derived from the pelvic plexus of tlie aynipathetic 
and the tliird and fourth sacral nerves. The former supplies the upper por- 
tion and the latter its neck 



. ,. - F'l. 55. — Entthb Length of tbe 

The male nretlira is a canal extending from Male Urethra rnoii the Neck 

the hladder to the external meatus. In the male it oftheBladdertotheExtebnal. 

Lrinart Meatcb, (Taylor.) 

measures about eight inches in length, and parwes 

through the prostate, compressor urethra? muscle and corpus spongiosum of the 
penis (Fig. 55). In its course from the bladder as far as the suspensory liga- 
ment, the urethra forms a continuous curve with the convexity backward. At 
this point a reverse curve appears when the penis is flaccid. The whole course 



TTTE TTKETHKA 



of tilt' canal thus reseiublfs the letter "' S " (Fig. 56). When the penis is 
em-t or iiehl iu position for the passage of an instrument, the reverse curve is 



Fiii. 



E Vw 



I. 3>inphj-Eis pubis. 
i. Dock of bladder. 
d, lowest poiiit of the bulb of 

the uicthra. 
j. angbr of tb» peoio. 
S, Madder cavity. 
''\ prostate. 
7. cas deferens. 

Od tbe right of the figure is t 
out rapidly the distance in a vp 

••hi iterated, tlie anterior 
h'mb of the posterior 
ciin-e being prolonged 
forward and upward 
(Fig. 57). 

The urethra is di- 
vided into three portions 
for descriptive piirposes : 
the prostatic, the mem- 
hranous and the spongy 
portion. 

The Prostatic Ure- 
thra. — This part extends 



10 

HRA When tbk Oboan is Flaccid. 
Cahal, (Testut.) 
a, eJBCuUtory duct. 

9. veni montBDum. 

10, bulb of urethra. 

a, a. tbe plane of the superior 
strait of the pelvis. 

b, b. ads of the symphysis. 

c, c, horiaontal line drawn through 
the neck of the bladder. 



o THE Fixro Portion ok thb 

d, d, horiiODtal line paasinK through 

the lowest edge of tbe sym- 

e, e, borisontal line drawn through 

the penile angle. 
/, /. horizontal line draivn through 
lowest part of tbo membranous 



54 ANATOMY OF THE TTRINARY AND GENITO-URINARY TRACT 

through the prostate gland, an<I is slightly curved in direction, the convexity 
of the curve being backward (Fig, 58), It is one and one quarter inches (3,1 



of the sinus poeularis, a small enl-de-sac 
which extends into the jirostate for about 
one quarter of an inch, and is aimlogons in 
the male with the uterus in the female. On 
either side of its opening into the urethra, 
are the openings of the common ejaculatory 
ducts. About the vem montanum, are the 
openings of the <Iuct8 of the prostate, while 
on either side is a groove called the prostatic 
sinus. 

The Membranoas Portion. — This part 
extends from the prostate to the bulb of the 



"la, 58. — Genito-umnabt Rinub in the 
Male, -tbb Pbobtate Havinq Dren 

Opened Anteriori.t and Its Lat- 

EBAL LoBEB RkTBACTED. (Tcstut.) 

At this point, the posterior urethra is 
^n in direct comniutiicBtiun with the 
ladder and with the ejaculatory ducts. 
1, the bladder. 
i. urethra. 
3. proBtate. 



5, rrenun of the veru montanum. 

?, urethral crest. 

f, prostatic utrirle (sinus pocutaria). 

!, orificea of the ejaculatniy ducts. 

9. prostatic fossette. 

7, lateral depressions of the veru moi 



THE UBETHEA 55 

penis. It is about an inch (2.5 cm.) from the symphysis pubis, and lies 
between the two layers of the triangular ligament. The anterior wall is 
about one half inch in length, while the posterior wall is a little more. This is 
due to the fact that the urethra opens into the bulb by an oblique o[)ening. It 
is completely surroundetl by the compressor urethne muscles, while on either 
side are Cowper's glands. At its commencement, it is immediately in front 
of the rectum, but in its course it curves forward while the rectum curves back- 
ward ; hence at its termination there is an interval of about half an inch be- 
Jween the two. At its termination 
the anterior portion has passed 
through the triangular ligament be- 
fore entering the bulb, and here « 
there is a small area with no im- 
mediate covering and it can be eas- 
ily punctured by an instrument 
(Fig. 58). 

The Spongy Portion. — The 
spongj- portion extends from the an- 
terior layer of the triangular liga- 
ment to the meatus and is about six 
inches (15 cm.) in length. It is sur- 
rounded by the erectile tissues of the 
corpus spongiosum, the greater part 
of the tissue being behind the urethra 
in the bulb, and in front and on the 
side of the glans. The caliber of " 4- 



out (Fig. CO), thus it is larger in 

the part surrounded by the bulb, be- e. neck of blmider. 

comes smaller in the corpus spongi- ^' ^''^^' ""^ '^^■ 

OSam, and as it enters the glans it The natural dilatatioas are: 

Incomes markedly dilated, the di- JSltS""' 

lated portion being known as the 7, of the fossa navicuiaris. 

fossa navicularis. The external 
meatus is vertical in direction, and is 
the narrowest and least dilatable por- 
tion of the whole canal. Therefore, it will be seen in Fig. 60 that the 
three dilatations of the canal are the fossa navicularis, the bulb and the 
prostate. 

The Stmetnre. — The urethra consists of a muscular, submucous and mucous 
layer. The external coat is a thin layer of unstriped muscle, continuous with 
the musculature of the bladder and prostate. The siibmucous layer consists 



56 ANATOMY OF THE URINARY AND GENITO-TTRINAEY TRACT 

of vascular and erectile tissue. This is found not only in the spongy portion 

but also in the membranous and prostatic portions. The mucous membrane 

is a thin delicate layer lined by transitional epithelia continuous with the 

bladder and urethra. The supertieial epithelium of the mucous membrane is 

columnar, except at the meatus and fossa navicular 19, where it becomes 

squamous. The membrane ia disjKised in folds during the flaccid condition of 

the organ, and on the internal surfaee 

are the orifices of nimierous glands. 

Some of tliese in the membranous and 

the first i)art of the spongy portion 

are called the glands of Littre. The 

ducts of Cowiier's glands ojk'U into 

the bulbous iwrtion near its eonimeucc- 

mcnt. 

The urethra in the female (Fig. 
01) is a short canal about one aud one 
half inches (3.7 cm.) in length, im- 
bedded in the anterior vaginal wall. 
The external meatus is situated be- 
neath the clitoris and has the shajie of 
an inverted " V." The whole urethra 
in the female morpliologically repre- 
sents that portion of Ihe prostatic ure- 
thra in the male which is situated be- 
tween the bladder orifice and the sinus 
jiocularis. 

The Blood Supply. — The prostatic portion is supplied by branches of the 
middle hemorrhoidal artery, the membranous portion by the inferior hemor- 
rhoidal and transverse perineal arteries, the spongy portion by the arteries 
which go to the penis. The venous return Is in part by the dorsal vein of the 
penis, and in part directly by the prostatic plexus. The lymphatics of the 
membranous and spongy portion go to the inguinal glands, while those of the 
prostatic portion go to the iliac glands. 

The nerve supply of the urethra is from the superficial perineal and dorsal 
nerves of the penis, and also branches from the hypogastric plexus. 

COWPER'S GLANDS 

These are two small bodies about the size of a pea, placed on either 
side of the membranous urethra, between the apex of the prostate and the 
bulb of the corpus spongiosum (Fig. 62). The gland consists of numerous 
branching tubules, which are arranged in small lobules. The excretory duct 



SCKOTUM 



57 



of each gland passes forward between the urethra and the substance of the 
bulb for about an inch (2.5 cm.), opening by a minute orifice on the floor 
i>f the urethra. The glands of 
Bartholin, in the female, are 
ibe analogues of the glands of 
Cowper in the male. They are 
slightly larger than the iatrer 
glands, and open outside of and 
external to the hymen just be- 
neath the labia minora. 



Fio. 62.— Cowpeb'b Glamdb. 

(After Testut and Jacob.) 

1 , anterior layer of the deep perineal fascia (triangular liea- 

rnenl). 
g, the faacin inriscd and drawn down. 

3, Cowper'a gland on the right Bide freed and delivered. 

4, arteiy of Cowper'a gland. 

5, Cowper'a gland on the left aide covered by fuscia. 

6, membranous urethra cut through . 

7, bulbo-urettaisl artery. 



Fig. 63.— Schematic Vkhtical Than»- 
TKisE Cut tbbocgh the SCKOTtlll, 
Saowma the Foiuutioh of the 
Sac. (Poirier.) 

I. akin. iatcKument. 

!. enter layer of dartoa. 

I, inner layer of dartos. 

i. areolar (cellular) tisaue. 

S. middle apennatic or cremaateric laypr. 

S. intcnia] apcrmatio or fibrous tunic. 

7. wUular tissue between the two sides 
of tbe KTOtum. 

S, penile dartos sheath. 

>. auspeoMiry ligament of penis. 



SCROTUM 

The scrotum is the bag in which the 
testes and a part of the spermatic cord are 
contained (Fig. (i.l). Its outer surface is 
wrinkled in appearance, light brown in color 
and is divided in two halves by an elevated 
narrow band called a raphe. 

Septom Sto'oti.— The two aides of the 
scrotum are further separated above by a 
continuation of the dartos sheath around the 
testes and up their inner sides to the penis, 
iu which intervening space is a layer of cel- 
lular tissue. 

Above the penis is the suspensory liga- 
ment which binds tbe organ to tbe pubos. 

The scrotum is comjiosed of several 
layers, and within it are the testes and 



58 ANATOMY OF THE URINARY AND GENITO-URINAKY TRACT 

their epididymes, the former surrounded by a tunica vaginalis. The layers of 
the tunica vaginalis are not, properly speaking, a part of the scrotum. The 
scrotal layers are : 

Tlie skin (integument). 

The darto3 sheath, which ia a red layer of fascia continuous with the dartus 
sheath of the penis and with the sniierfioial fascia of the perineum and abdomen. 
It contains elastic tissue and unstriped muscle fibers. 

The cellular tissue layer. 

The outer layer of spermatic fascia which is the extension downward of the 
lutereoIumDar fascia. 

The middle layer of spermatic fascia, which is the extension downward of 
the cremasteric muscle and fascia. 

The inner spermatic fascia, which is an extension of the transversal is and 
is pushed down diiring the descent of the testes. 

Tunica Vaginalis. — This consists of a parietal and visceral layer of serous 
membrane, forming a closed sac. The visceral layer invests the body of the 
testicle except behind, where the ducts and vessels are attached, being here con- 
tinuous with the parietal layer that lines the inner wall of the scrotum. 

TESTES 

The testes are two oval-shaped bodies situated on either side of the scrotum 
(Fig. 64) ; they are separated from one another by a partial septum extending 
across the scrotum from before backward. 
They are about one and one half inches 
(3.7 cm.) long, one inch (2.5 em,) in diam- 
eter from before backward, and three quar- 
ters of an inch (1.87 cm.) from side to side. 
Their long axis extends from below upward 
and slightly outward and forward; the left 

Tunim v«ginaii4, is normallv lower than the right. On the 

paridal (ajw. ,' ■ i , i- , 

upper and posterior borders, extending also 

slightly on to the outer surface, is placed a 
crescen tic-shaped body called the epididymis. 
The enlarged upper end of this is the globus 
major (head), and the lower end is the globus 
minor (tail), the intermediate portion being 
known as the body of the epididymis. The 
globus major is attached to the testes by the 
B Testib with visceral layer of the tunica vaginalis, and 
™e V.8CERAL LATER CovBiuNQ It gi^Q ^^ ([^ ^ ^ cmergiug from the testes 
.\ND THE Parietal Layer LiNTNOTHB . ' " - ■- 6 "& ^ >-- .v 

ScROTAi, TisaoBB. (Gray.) at its upper end (vasa efferentia). The 



TESTES 59 

jclobus miDor is attached to tlie loner part of the testes by areolar tissue and 
the visceral layer of the tunica vaginalis. The intervening portion or body is 
separated from the posterior border of the testes by an infolding of the tunica 
between it and the testes, forming the digital fossa, seen from the outer aspect. 
From the upper end of the testes near the globus major, are usually found two 
si»all bodies — one sessile, and one j>eduncnlated. The former is a remnant of 
ihe Wolffian tubules, corresponding to the parovarium in the female. Tlie 
|ie(Iunculated one is derived from the Wolffian duct, representing the epoophoron 
in tiie female. 

The Timica.^ — The scrotiun is lined by a serous sac <Iorivpd from the perito- 
neum (tunica vaginalis). In the posterior part of the scrotum, this is reflected 
on to the epididymis and tes- 
ticle, Burroimding them ex- 
cept where they are in con- 
tact with each other, and pos- g 
teriorly where the vessels 
pas^ to or from the testes and 

epididymis. The part of the • -* 

sac lining the scrotum is i 
called the parietal layer anil 
the part covering the testes 

is called the visceral layer -4 

(Fig. 64). 

Structure. — The testis 
has a complete fibrous cov- 
ering, the tunica albuginoa, * 
which forms the thickened 
ridge on the posterior border 
(mediastinum). From this 
fibrous Tid?e, septa pass into 

, , ijj-.j ■ ■ f^'^- ^- SCHIMATIC DlUWIHO. Showino trb Anatohical 

toe glands and divide it into Abranobuent op the Testicle and tub Epididtmui. 

compartments (Fig. 65) ; tlio (Tratut.) 

1 <....;„a albuginia. 

>(?p(B of the testis, 
a lobule of the teatin eodiiig ia a straight duct. 



body of HishmorF with the rete vsaculoaum ti 

efferent cani4<. 

duct of the epididjitiis. 

aberrant vaa of Haller, 

vsB deferens. 



glandular structure is found 
it these compartments and 
consists of a great number of 
minute ducts called semin- 
iferous tubules. These unite 
tci form the tubuli recti, 

which pass into the mediastinum, where they enter a complicated canal 
work called the rete testis. From this canal system, fifteen to twenty small 
ducts pass into the globns major. In the globus major these small ducts be- 
come markedly convoluted, forming conii vasculosi, and finally open into one 



60 ANATOMY OF THE UKINART AND OENITO-URINARY TRACT 

duct called the canal of the epididjmia. This in its course is greatly convo- 
luted and coiled upon itself to fomi the Imdy and especially the globus minor. 
If stretched out, it would measure about twenty feet. The canal of the epididy- 
mis emerges from the globus . minor 
as the vas deferens {Fig, 06), 



Fio. 66. — Vehticai 
Ep:did 



F TBK Testis a 



Fig. 67.— Bu 



J. Showinq the Line of REn.Ec- 

TION OP THE VlSCEBAl. LaTER OP THE TUNlC* 

Vaoinalis, the Tunica Albuqinea with Its 
Septa, the Rete Testis, Mediastinoh, 

THB EptDIDTMIB AND VaS DBPERENS. (After 

Gray.) 



ID SnPPLT OP Ta» Tbstjs A1 

(After Charpy.) 



artery ot the vas. 

anterior group of veioB. 

posterior group of veins. 

venous anastomosis with the sup«r6cial vi 



Blood Supply. — The testicle is supplied with blood by the spermatic artery. 
This vessel has a long course, arising from the aorta just below tlie renal ar- 
teries; it extends downward in the abdominal cavity to the internal abdominal 
ring, thence passing down the inguinal canal in the spermatic cord; it enters 
the testes at the upper part of its posterior border (Fig. 67). Within the 
gland it is distributed along the fibrous septa and beneath the tunica alhuginea. 

The spermatic vein forms a plexus, the pampiniform, at the posterior part 
of the testis and epididymis which passes upward and forward to the front 
part of the cord, where it is most marked. The vein then passes through the 
external abdominal ring, the ingiiinal canal and the internal ring and empties 
into the vena cava on the right side and the renal vein on the left. 

The Spermatic Cord and Vas Deferem. — The spermatic cord is about four 
inches in length, and extends from the globus minor of the epididymis to the 



TESTES 



61 



internal abdominal ring, at which place they separate. It is made up of the 
vas deferens, or excretory duct of the testicle; the spermatic artery from 
the aorta; the artery and 
vein of the vas deferens; 
tilt' eremasterjc artery from 
the deep epigastric; the 
spermatic veins; the sper- 
matic nerve plexus; 
branches of the ileo-iiiguinal 
and geni to-crural nerves, 
and lymphatics. These 
sirnctiires are bound to- 
p'lher by loose fibrous and 
fatty tissue, and are in- 
vested by the fasciw, already 
B|Kiken of in considering the 
anatomy of tlie scrotum, 
that are carried do\vn by 
the testicle in its descent. 
The vas deferens lies below 
ami behind the larger an- 
terior group of veins and 
the spermatic artery. The 
mass of veins on the front 
of the cord, called tlie pam- 
(liuiform plexus, unites into 
a single tnmk, the sper- 
matic vein, on the right side 
jiassing into the inferior 
vena cava and on the left 
side into the left renal vein. 
The artery of the vas defer- 
ens, derived from the in- 
ferior vesicle, is in direct 
relation with it ; whereas the 
itpennatic artery follows a 
mrtiious course through the 
cord. The nerves are dis- 
tributed throughout the cord, 
with the exception of fila- 
ments from the hypogastric 
plexus, which invest the vas 



FlO. 68. COVEOINOB OP TBE TESTES, SkBN rSOU IN FrONT. 

(Alter TcBtul.) 
On the right aide the scrotum and dartos liave been removed 
to show the cremaatcric tnustle and faacia. On the left side 
the sheath of the cord and the tunica vaeinalis have been cut 
through over the testis and retracted showing the gland and 
its epididitnia: whereas higher up another incision shotrs that 
the peritoneo-vagiDal process has not closed at this point. 
. of the organ pulled 3, skin of organ. 



upward. 


4. dartos layer. 


a. urethra. 


o, darlos of septum. 




C. cellular layer. 


B. inguinal canal on the right 


7, internal and eilernal bun- 


side. 


dles of cremasteric muscle. 


C. scrotum on the right side. 


8. cremasteric Isyer of scro- 


D. scrotum on the left side. 


tum. 


E. and F. testis and epididj- 


9. fibrous la>-er. 


mU on the left side. 


10. parietal layer of tunica 


C, spermatic cord. 








«, dftrtos. 


eesopen. 



62 ANATOMY OF THE URINARY AND GENITO-URINARY TRACT 

in a rich network. The lymphatic vesaela empty into the glands surrounding 
the lower part of the aorta and one gland lying over the external iliac artery. 



E El. 

the testis. 

the mule orRan. 

the epididiitiis. 

the erector penia. 

vas deferens. 

superior ramua cif the pubes. 

Hpex of the bladder. 

parietal peritoneum. 

obliterated hypogaatro-mnbilical artery. 

peritoneum over bladder. 

body of the bladder. 

seminal vesicle. 

iliac artery. 



ampulla of the vaa. 
reoto-vesieal space, 
sacral flexure of the rectum. 
diaphragm of the pelvis (leva 
external sphincter muarle. 



IS of the ischium. 



THE PROSTATE GLAND 63 

The spermatic cord (Fig. 68) derives its coverings from different layers in 
the abdominal wall, from within outward, the process of peritoneum, called the 
funicular process, being continuous below witJi the tunica vaginalis. Out- 
side of this is the infundibuliform or transversalis fascia, the cremasteric 
fascia from the internal oblique, and the intercolumnar fascia from the ex- 
ternal oblique. 

The vas deferens (Fig. 69) is a small duct which conveys the semen from 
the testes to the urethra. It can be felt as a small, cordlike structure running 
up the posterior part of the spermatic cord ; its appearance is white and glis- 
tening. A small portion of its course is within the scrotum, where it ascends 
on the inner side of the epididymis. It then passes through the inguinal canal 
with the other constituents of the spermatic cord to the internal abdominal ring. 
Here it winds round the deep epigastric artery, passing downward and back- 
ward on the side wall of the pelvis ; it crosses the obliterated hypogastric artery 
and obturator vessels and nerves. Crossing inward to its termination, it 
raises in its course a fold of peritoneum, crosses the ureter just before the ter- 
mination of the latter, and then turns downward in close apposition to the 
base of the bladder to the inner side of the vesiculffi seminales, to the base of 
the prostate, where it terminates by joining the duct from the vesiculae seminales 
to form the common ejaculatory duct 

The Vesicnla Seminales (Fig. 3). — These are situated on the basal sur- 
face of the bladder, extending from over the lower part of the ureter above to 
the base of the prostate below, running external to the terminal portion of the 
vas. The vesicle forms a convoluted mass about two inches (5 cm.) in length, 
and in reality is a single tube, coiled upon itself and held together by con- 
nective tissue. When opened out, it measures five or six inches in length. The 
vesicuke seminales lie almost in apposition at their lower end but above are 
widely separated and spread outward almost horizontally between the base 
of the bladder and the rectum. The lower ends open into the vas to form the 
common ejaculatory duct. They are developed as diverticula of the vas deferens, 
as the gaU-bladder is developed from the common bile duct. 

Common Ejaculatory Duct. — This duct is a short canal, three quarters of 
an inch (1.8 cm.) in length, extending downward in a cleft of the prostate 
gland to the urethra where it opens into or at the margins of the sinus pocularis. 
The sinus pocularis is a small depression just below the highest part of the 
veru montanum, and is the analogue, in the male, of the uterus in the female. 

THE PROSTATE GLAND 

The prostate gland is situated in the male pelvic cavity beneath the bladder, 
and completely surrounds the orifice of the urethra. It is about one and one half 
inches (3.7 cm.) in its transverse diameter, about an inch (2.5 cm.) from be- 



64 ANATOMY OF THE URINART AND GENTTO-tTRINART TRACT 

fore backward, and about one and one quarter inclies (3.12 cm.) from above 
downward. In shape it is said to resemble a Spanish chestnut, and has a base 
directed upward, an apex directed downward, a posterior, an anterior, and two 
lateral surfaces. The base is firmly fixed to the under surface of the bladder 
(Fig, 70), the musculature of the one being directly continuous with that of 
the other. There ia only a shallow groove between the circumference of this 
surface and the bladder where thty are not structurally continuous. This 
groove ia filled by several large veins. 





P:a. 70.— Phofile View op the Side ok 




1. pubis. 


S. sphincter ani muscle. 


a 




to. deep transvprsc perinei muscle. 


3 


subpubic ligament. 




4 


root o/ corpus CBvernosum. 


12. cut-off muscle, compressor urethm o 


s 


seminal vesicle. 


muscle of Guthrie. 




rectutn. 


IS, accelerator muscle. 


7 




14. prcproslatic layer of peli-ic fascin. 


8 


compreBSor urethra musclo. striated mus- 


IB, transverse pcl"c ligament. 


cle of Henlc. 


la, muscle ot Wilson. 


rE 


— The muscles of Guthrie, Wilson and Heol 


are all ansociated and tbeir fibers arc connected. 



The apex is the lowest portion of the gland, and rests on the su])erior or 
deep layer of the triangular ligament The ]K>sterior surface is somewhat tri- 
angular and is separated from the rectum by pelvic fascia, Tlie lateral surfaces 
are convex from behind forward and from below upward. They are covered 
with pelvic fascia which separates them from the levator ani. The anterior 
surface ia narrow and rounded in its lower part. In front and a little aWve 
(n© apex on this surface, the urethra leaves the gland. The anterior surface 
vcenpies the space between the two levator ani muscles, and is covered by pelvic 



THE PROSTATE GLAND 65 

fascia, a portion of which forms the piibo-prostatic ligament. The common 
ducts enter the prostate at the upper part of the posterior surface, running 
downward and forward to open into the prostatic urethra. The triangular por- 
tion of the plflud lietween these duels and the urethra ia called the middle lohe 
(Fig. 71). 



Fig. 71. — The Lobes or the Phostatb and the Pbhinbal Fahciab. (Albarran.) 
The sQ-caUed middle lobe ia seen clearly behind the urethra and in front at the ejnculBtoiy duct. 
Thii pan of the gland bounded by tbe bladder, urethra and eJBculatory duels ia supposed to be the 
phacipal part of tbe gland involved in prostatic hypertrophy. It is Bimply the portion of the lateral 
loba Above tbe ejaculatory duct. 

1, preproststic layer of pelvic fascia. 8, transverse ligament ot perineum. 

t, eiternal sphiocter, prostatic segmont. 7 and 5. leaflets of the aponeurosia of Denou- 

3, subpubic ligament. villiera. 

4, dorsal vein. 9, compressor uretbne or cut-oR muscle. 

5, lupraurethral fascia. 10, infraurethnU layer of fascia. 

The Selations. — It lies in front of the rectum and one and one half incliea 
(3.7 cm.) from the anna. It is situated behind the lower part of the syiiipliysis, 
ai a distance of about an incli. The bladder ia above it, tlie superior layer of the 
triangular ligament below it, and the levator ani muscle on either side, Innue- 
diately surrouuding it la pelvic fascia forming a thick layer, A line of cleavage 
i? mude in this layer by the prastatic plexus of veins which surround the sides 
and base of the gland (Fig. 72). The jiortion of fascia outside of these veins 
is Jescrilwd as the external ca()sule. A thin portion of fascia ia foiuid inside the 
veins between the latter and tJie true capsule of the jirostate. The gland itself is 
siim.unded by a fibrous capsule except at the base, where it adjoins the bladder. 

Strncttire. — It consists of two lateral lobes and a middle lobe. The lateral 
Iiilies are developed as two separate portions and in some of the lower animals 
muain distinct. In man, they unite together to form one mass. The so-called 



66 ANATOMT OF THE URINARY AND GENITO-URINARY TRACT 

middle lobe is merely the portion of gland between the urethra and common 
ejaculatory duct and is not marked off by any distinct separation from the 
lateral lobes. A true middle lobe with a distinct line of cleavage is often present 



Fio. 72. — SAaiTTAL Sbctioh tbrouoh the Probtat«, a Little to the Lett of ihe Median Jake. 
Note the remaini of the ejuculalory (common) duct, the vedcal sphincter and the pleiusea of veiiil 



n thig regioD. (Testut.) 

1, aymphj-sifl publB. 

S. bl&dder. 

f, neck ol bladder. 

nor bladder ligament. , 
(. umbilico -pre vesical aponeiiroais. 
S. prevesical space. 
9, rectum. 

^ recto-vesical space. 
S, prostate. 



ejaculatory duct on the l«ft side cut oblique 

vas deferens of right side. 

inferior layer of triangular ligament with Guthrie's museli 



pelvis fascia behind prostate. 

IS, external sphincter. 

Cowper's gland. 

bulb of urethra. 

spongy portion of the urethra. 

corpora cavernoBft. 

suspensory ligament of the organ. 

deep dorsal vein. 

plexus of Santorini. 

perineum. 



The gland consists for the greater part of muscle fibers, that portion in front 
of the urethra being altogether muscular. Elsewhere, the glandular structure 
is found imbedded in the muscular compartments. This consists of minute 



XHE PENIS 



67 



tubules lined with columnar epithelium. These open by about twenty ducts 
into the urethra on either side of the veni montanum. 

Blood Supply.— The prostate is supplied with blood by the inferior vesi- 
cal and inferior hemorrhoidal arteries. The blood is returned by the prostatic 
plexus of veins, which empties into the vesical plexus. 

LjmidiatiCB. — The lymphatic return goes to the iliac glands. 

Netres. — The nerve supply of the prostate comes from the hypogastric 
plexus. 

THE PENIS 

The penis consists of three longitudinal columns of erectile tissue; two of 
the columns, the corpora cavernosa, nrach larger than the third, are placed side 
by side, while the third cohmm, the corpus spongiosum, is placed on the under 
surface in a groove between the other 
two. It is through this portion that 
the urethra passes (Fig. 73). 



Fm. 73.— PENI1.B UBBTHSA is THIl StATB 01 

Repose akd Ebbction. (From Poirier.) 

I, FuCancaMu layer. S, urethra, 

t, ionai vein, flanked 6, corpus aponjiOAUin 

OQ each nde by dor- 7, dorsal vcId. 

nl aileiy and aerve. S, artery of corpus csvi 
3, lunini albugiiiea. noaum. 

i. artery of the corpus 9, venous plexus. 



Fio. 74. — Roots op tbe Penib. (From Poirier.) 
I, the annular Sbera of tbc Buapensory ligamont. 
S, pubis. 

3, the fibers of the BUspcnsory UxaineQt descending 

4, the erector penis muscle. 

5, the bulb of the corpora spongiosum. 

0, the central Sbrous tendon of the perineum. 



Soots of Penis. — The corpora cavernosa arise from the ascending ramus of 
the ischium on either side, and are covered by the ischio-cavemosus muscle 
(Fig. 74). They extend forward and inward, uniting with one another and the 
corpus spongiosum to form the body of the penis. The corpus spongiosum at 
its origin consists of an expanded portion called the bulb, which is covered by 



68 ANATOMY OF THE URINARY AND GENI TO-URINARY TRACT 

the iscliio-bulbosua miiacle and rests against the triangular ligament, the middle 
of the urogenital triangle. This proceeds forward in the mid line of the peri- 
neum to join the corpora cavernosa. At its distal extremity tlie corpus spongi- 
osum becomes expanded and forms a cap which fits over the conical extremities 
of the corpora cavernosa. This is known as the glans penis {Fig. 75). It 
slightly overlaps the corpora cavernosa and this projecting border is knoMTi as 
the corona glandis. At the smnmit of the glans and slightly on its under sur- 
face, is the meatus urinarius or external oijening of the urethra (Fig. 76), 
The three columns of the penis are 
bound together by fibrous tissue, each 
of the parts having a separate cover- 
ing. Between the corpora cavernosa, 
the fusion of this covering forms an 
incomplete septum — the septum pec- 
tinifonna;. 



FlQ. 75. — Manner of Union op the Anteriob 
End of the Corpora Cavernosa with the 
Glans. (After Testut.) 
Tbe aaterjor Ijjiameut has becD cut through and 

the eIbus pulled to one aide. 

I. anterior extremity of the corpus apongioauni. 

S, sntcrior ligaments. 

5, urGthral gutter between tbe corpora 

4. S. glans with posterior capsule. 

6, the cleft iii ita lower part. 

5, corpus spongiosum of the urethra. 



Fio. 76.— The End of th( 
(From Poirier.J 
/, the meatus. 
S, thetreoum. 
3, fOHsa beside the fre- 

num. 6, prepuce. 



The penis is covered with skin, 
which is loose and freely movable, to 
allow for expansion of the organ. 
It is continued over the glans as a 
thin, firmly attached layer, resembling mucous membrane, and frequently de- 
scribed as snch. From bcliind the corona glandis, a double fold of delicate skin 
is formed which covers over the glans in the flaccid condition of the jJcnis, This 
is known as the prejiucc, and disappears in the erect condition, Tlie skin over 
the body and glans then appears in its true continuity. From just below the 
meatus, a small fold of skin, the frenum preputii, passes to the nnder surface of 
the prepuce. The inner surface of the prepuce and posterior ])ortion of the skin 
over the glane contains sebaceous glands which secrete smegma. 



THE PENIS 69 

Suspensory Ligament. — A band of fibrous tissue extends from the symphysis 
pubis to the penis, and is attached to its fibrous capsule. This is the suspensory 
ligament. At its attachment it separates into two parts and through the space 
thus formed pass the dorsal vessels and nerves. 

Stmcture. — Each column of the penis is made up of fibrous covering con- 
taining many elastic fibers, and within this capsule an irregular spongework 
of fibrous trabecular are formed. The interstices of the spongework consist of 
blood spaces lined by endothelium and empty directly into the veins. Hence 
the size of the organ is subject to great variation, depending upon the amount 
of Wood contained within this spongework. 

Blood Vessels. — The arterial supply comes from the branches of the in- 
ternal pudic; these are the artery to the bulb, the arteries to the corpora cav- 
ernosa, and the dorsal artery of the penis. The glans is supplied by the 
dorsal arterv' which is a continuation of the internal pudic. The veins empty 
directly into the prostatic plexus or into the dorsal vein, which itself empties 
into the prostatic plexus. On the upj)er or dorsal surface, in a groove between 
the corpora cavernosa, the dorsal vein is situated. On either side of the vein 
are the dorsal arteries and just outside of these are the dorsal nerves. 

Lymphatics. — These go to the inguinal glands. 

Nerves. — The dorsal nerve and superficial perineal nerves from the in- 
ternal pudic nerve supply the skin, while the hypogastric plexus, indirectly 
through the prostatic plexus, supplies the erectile tissues. 

In the female, the clitoris is the analogue of the penis. It is very small in 
comparison, and consists of only two columns, the corpora cavernosa. The bulb 
of the vagina is the analogue of the bulb of the penis; it is, however, split 
in two by the passage of the vagina, and has a separate ischio-bulbosus muscle 
covering each part. The bulbs of the vagina imite in front between the urethra 
and clitoris to form a venous plexus, which is continuous vnih the glans 
clitoridis. 



CHAPTEK III 



THE URINE 



In treating of the subject of urine, it is not my intention to give it the 
comprehensive and exhaustive consideration demanded by a text-book on urine 
analysis. The examination of the urine will be gone into chiefly with reference 
to its bearing on pathological conditions noted in genito-urinary surgery. I 
shall, however, not lose sight of tTie importance of so-called medical pathol(^cal 
conditions, because we find that the kidney diseases heretofore considered 
strictly within the domain of medicine have begun to enter the surgical field. 
Moreover, in the surgical diseases of the kidney due to pressure, irritation, new 
growths or pathological deposits, an associated nephritis is wont to occur. 

Diseases of metabolism do not come within the scope of this work, except- 
ing so far as they may be considered associated with the subject or must be dif- 
ferentiated from diseases having symptoms in common with them. 

We will briefly discuss the characteristics and the constituents of normal 
urine before proceeding to take up the various pathological changes. The card 
used in my laboratory will serve as a guide, as it indicates the point of view 
from which we regard the subject We will give the tests used in our routine 
work and mention the others only by name, in order that they may be studied 
in text-books on urinary analysis, if the reader desires. There are many topics 
not mentioned on the card that will be spoken of and their importance briefly 
considered. 

I, GENERAL CONSmERATIONS 

The normal urine is a transparent fluid of an aqueous consistency, of a pale 
yellow color, with a characteristic odor and acid reaction, and a specific 
gravity of from 1.018 to 1.025 at 60° F. Few of these characters are so fixed 
that a slight variation signifies disease. The diet, the w^eather, the occupation 
of the patient, may change the features of the urine within certain limits in 
health. On the other hand, great and persistent departure from the above 
standard usually means that either the kidneys or the other urinary organs are 
diseased, or that the organism as a whole is deranged. 

70 



COMPOSITION AND PKOPERTIES OF THE URINE 71 

n. COMPOSITION AND PROPERTIES OF THE URINE 

The constituents of the urine are derived from two sources: from the 
catabolism of the tissues of the hody and from the waste of ingested food and 
Uquids. 

The following table (from Parkes) shows the composition of normal 

urine, together with the amount of each constituent excreted in twenty-four 

hours : 

• 

Water 1,500.00 gms. 50 oz. 

Total solids 72.00 " 1,110.96 grs. 

Uric acid 0.55 " 8.4 " 

Hippuricacid 0.40 " 6.1 " 

Creatinin 0.91 " 14.04 " 

Pigment and minor organic matters 10.00 " 154.00 " 

Sulphuric acid 2.01 " 31 .00 " 

Phosphoric acid 3.16 " 48.75" 

Chlorine 7.80 " 108.01-123.44 " 

Ammonia 0.77 " 11.88 " 

Potassium 2.50 " 38.57 " 

Sodium 11.09 " 171.11 " 

Calcium 0.26 " 4.01 " 

Magnesium 0.21 " 3 .24 " 

Sdection of Specimens of Urine for Examination. — For accurate urinary 
analysis, either the total amount of urine passed in twenty-four hours or a 
sample taken from the entire quantity, is collected in a clean half -gallon hottle, 
kept in a cool place, well corked. In either case, the quantity eliminated in 
twenty-four hours should be measured. If this is impossible, a four-ounce 
specimen of the night and morning urine should be obtained. The urine passed 
in the morning after a night's rest, is least likely to contain albumin or sugar. 
Voided urine, if allowed to stand warm and in an open vessel, becomes opaque 
in from twenty-four to forty-eight hours by the multiplication of bacteria, which 
change the urea to ammonium carbonate. 

Preservation of Specimen. — Urine should be examined in as fresh a state 
as possible. If it has to be kept more than a few hours, some antiseptic must 
be added. The best method in the author's hands, has been the addition of a 
crystal or two of thymol. The addition of an ounce of saturated solution of 
boric acid, or two five-grain tablets of the same to a quart of urine, is preferred 
by some ; others recommend five grains of salicylic acid to four ounces of urine. 
A drachm of chloroform to four ounces of urine is also effective. Formalin is 
sometimes used, but cannot be recommended, as it interferes wdth the ex- 
amination. 

Physical Properties of the Urine. — Amount in Twenty-four Hours. — 
The amount of urine voided in twenty-four hours by a healthy adult averages 
from 1,200 to 1,600 cc, the mean figure being about 1,400, forty-eight fluid 



72 



THE UKINE 



Laboratory of Dr. Ramon Guiteras, 80 Madison Ave. 



Urine of 



Address 



Date 



Report to be sent to 



Amount in 24 hours. 
Color. 
Reaction. 



Albumin. 
Sugar. 
Urea. 
Uric acid. 
Diacetic acid. 
Bile pigment. 
Chloridi. 



Phtsical Examination. 

Spontaneous. 

Odor. 

Specific gravity. 



By Catheter. 
Transparency. 
Total solids. 



Chemical Exabanation. 

Serum. Nucleo. 

Fehling test. 
Per cent. 

Urates. 
Aceton. 

Other organic elements. 
Carbonates. Phosphates. Sulphates. 



Quantitative. 
Quantitative. 
Grains to ounce. 

Indican. 



Amorphous deposits. 

Crystalline deposits. 

Red blood corpuscles. 

Pus. 

Mucus. Tissue. 

Epithelia. 

Casts. 

Cylindroids. 

Microorganisms. 

Diagnosis from urine analysis. 

Remarks: 



Microscopical Examination. 

Leucocytes. 
Shreds. 

Other elements. 



Fat globules. 



Fig. 77. — Urine Analysis Chart.^ 



ounces, or three pints. Roughly speaking, the kidneys secrete two ounces an 
hour, that is, one ounce each. Children pass relatively larger amounts than 
adults. One kilo of the body excretes on the average of 1 c.c. of urine per 
hour. Women pass smaller quantities than men, on account of their smaller 
average size. By taking violent exercise, by abstaining from drinking water, 
etc., and by promoting free perspiration, the excretion is diminished, but the 
density is increased. The amount is sometimes markedly increased after emo- 
tions (joy, grief, fright), and varies also at different times during the day. 
The largest amoimt of urine is usually passed in the afternoon, a moderate 
amount in the forenoon, and the smallest amount at night. In warm weather, 
much smaller amounts are passed than during the cold months. 

Color. — The color of urine varies considerably even in health. The color 
is due to the presence of urochrome and urobilin. Diluted urines are usually 
pale; concentrated urines are dark. The color may be changed by drugs, the 



* The accompanying charts are used by the author in recording urinary examinations. They 
may be kept printed in blank form, as illustrated, and filed with the history of the case. 



COMPOSITION AND PROPERTIES OF THE URINE 73 

amount of water drunk and the other factors influencing quantity, and some- 
times by the quality of the food. 

The color of the urine is markedly pale and forms a diagnostic feature in 
chronic interstitial nephritis, diabetes mellitus and insipidus. 

In acute fevers and in congestion of the kidneys it is highly colored, due to 
concentration of the urine. A dark brownish-red color is often characteristic 
of hemorrhage from the kidney. Hemorrhage from the bladder or ureters gives 
the urine a bright-red color. 

Odor. — The odor of the urine is characteristic and cannot be compared with 
any other. Certain variations from the normal are significant of disease. If 
freshly voided urine is putrid or ammoniacal, there must have been decompo- 
sition in the bladder or above this organ, as is often the case in pyelitis and 
cvstitis. 

When large quantities of pus are present, the odor is sulphuretted, owing 
to the decomposition of the albuminous substances. In diabetes mellitus, the 
urine usually has a peculiar aromatic odor. Certain foods and drugs, such as 
asparagus, garlic, the balsams of copaiba and Peru, turpentine, saffron, etc., 
impart easily distinguishable odors to the urine. 

Transparency. — Normal urine, freshly voided, is always perfectly trans- 
parent On standing a few minutes, a faint cloud often appears, known as 
the nubecula, which floats in the center or sinks to the bottom. It consists of 
mucus, bacteria and epithelial debris. In women, vaginal mucus is mixed with 
the urine and may cloud it considerably; and in catarrhal and other inflam- 
matory conditions of the genito-urinary tract, the normal mucous cloud may 
also be increased. The urine is then cloudy from the first on being voided. 
The normal mucous cloud is distinct from other causes of turbidity to be 
mentioned. 

Cloudiness in urine may result from (1) bacteria, (2) phosphates, (3) 
urates, (4) pus, and (5) fat. The following table shows the shortest methods 
of differentiating the causes of cloudiness by means of simple reagents. 

Differentiation of the Principal Causes of Turbidity in the Urine. 

(1) Heat the urine for a few seconds: 

(a) Turbidity increases or precipitate forms: bacteria, mucus, phosphates 
or pus. 

{b) Turbidity disappears : urates. 

(2) Add acetic acid: 

(a) Turbidity unchanged: bacteria, urates. 

{b) Turbidity increased or precipitates: mucus or pus, or both. 

(c) Dispelled at once : phosphates. 

(3) Add potassium hydrate: 

(a) Turbidity or precipitate disappears: urates. 
(6) Is changed to a gelatinous coaguhim: pus. 



74 



THE URINE 



Reaction. — In lierbivora, tlie urine is alkaline; in camivora, acid. In 
man, on a mixed diet, it is normally acid. The acidity depends upon the food 
ingested and is due chiefly to the presence of acid sodium phosphate and hip- 
piiric acid. The acidity varies at different times of the day in regular sequence; 
diminishing soon after meals, it changes in about three or four hours, when the 
urine may become alkaline. Alkaline salts or vegetable acids in the food in- 
crease the alkalinity, the acids being converted into carbonates (alkaline salts) 
in the blood. An excess of meat in the diet will increase the acidity, while a 
vegetarian diet produces alkalinity. 

The acidity is tested by means of red and blue litmus paper; the blue turns 
red in acid urine; the red turns blue in alkaline urine. 

Specific Gravity. — The specific gravity of normal urine is between 1.013 
and 1.024; the standard normal average 1.020 at 60° F. It varies in health, 
according to the time of day, the meals and the amount of exercise, the amount 
of fluid drunk and the total amount of urine passed daily, as welt as the amount 
of solids excreted. Therefore, to measure specific gravity accurately, allowances 
must be made for the conditions of diet, exercise, etc. 

The specific gravity of urine is increased by an excess of nitrogenous 
food, by sweating and muscular exertion. A lower specific gravity with 
absence of albumin or sugar, means less urea ; it also means an increased 
quantity of urine, except in heart disease and in the last stages of chronic 
Blight's disease, when combined low quantity and specific gravity is a grave 
sign. 

Delcrminaihn. — The specific gravity is best determined by means of a 
special liydrometer, known as a urinometer. (See Fig. 78.) Before testing, 
tlie urine should be allowed to cool to room temperature, for when just voided, 
it has abont the temperature of the body. A suffi- 
cient amount of urine is filtered into the cylinder 
accompanying each instrument, and the uri- 
nometer, carefully cleaned and aired, should be 
immersed gently with a alight spinning turn, 
which prevents its adhesion to the sides of the 
vessel. Any foam on the surface of the urine 
may be removed by means of filter paper. To 
read the urinometer, we must read the line at 
the level of the lower portion of the meniscus, 
formed at the contact of the urine with the stem. 
Fw. 78.-s<imBBH Ubinohbteb. -^° instrument for the estimation of the 

WITH Thehmometbb AND CiL- spoclfic grsvity of about 3 c.c. of urine with clin- 
ical accuracy, * was devised by De Santos Saxe 
while working in my laboratory, principally with the object of estimating 
specimens of urine taken from the kidney by the ureteral catheter. It ia known 




COMPOSITION AlfD PROPERTIES OF THE URINE 75 

as the pyknometer.' This coDsists of a flask with a well-fitting glasa stopper, 

tiie head of which tears a small bead of mercury. (See Fig. 79.) This flask is 

fixed to one pole of a small spheric bulb, to the other pole of 

which is attached the stem of the instrument. The mark 1,060 

is at the top of the stem, and the mark 1,000 at the bottom, so 

that the instrument ia graduated in reverse order as compared to 

die ordinary hydrometer. When the flask is filled with distilled 

water up to the mark " M " and when the instrument is 

dosed and immersed in distilled water, it reads at 

1,000. When urine is poured into the flask instead of 

distilled water up to the same mark, the instrument 

sinks in distilled water in proportion to the specific 

gravity of the urine, which is then read on the scale in 

the same way as the ordinary urinometer. 

ToT.vL Solids. — The anioimt of total solids in 
the twenty-four hours' urine determines the specific 
gravity. The specific gravity, as a rule, varies in pro- 
portion to the amount of solids, but in certain diseases 
the watery element of the urine predominates, without 
any marked change in the amount of solids in the 
tnenty-four hours' specimen. ^'°- 79— Saxi'b Ubinoptk. 

■^ Hnur.TER AND CtLIWDBB. 



For clinical purposes, the amount of total solids in (Elmer 4 Amend.) 
the twenty- four hours' nonnal urine can be determined 

approximately by multiplying the last two figures of the specific gravity by 
Eaeser's coefficient, which is 2.33, and thus obtaining roughly the number of 
grams of solids in 1,000 c.c. (1 liter) of urine. This number, multiplied by 
the number of c.c. passed in twenty-four hours and divided by 1,000, gives in 
grams the amount of solids eliminated in twenty-four hours. 

A much more accurate method of determining the amount of solids is to 
ei-aporate a given amount of urine in a previously weighed porcelain dish, dry- 
ing the residue, cooling and weighing repeatedly until there is no further 
loss of weight from drying. 

The average amount of excretion in twenty-four hours by a person weighing 
145 pounds (66 kilos), is 045 grains (G1.25 grams). This applies to an 
nnlinary diet of mixed food and to a liealthy man taking ordinary exercise. 
One third should be deducted for persons who have fasted for two days or 
I'jiiSer; one eightli if the diet bo spare; one tenth for perfect rest; one twen- 
tieth for comparative rest. According to Parkcs, the amount of solids ex- 
creted begins to diminish after forty and sinks to fifty per cent of the normal 
above seventy years of age. 



* Mode by Eimcr & Amend, New York City. 



76 THE UKTNE 

m, CHEMICAL EXAMINATION OF THE URINE 

The Proteids 

The proteids found in the urine under various conditions are : 
Serum albumin. Fibrin. 

Nucleo-albumin. Albumose. 

Serum globulin. Peptone. 

Albumin 

Serum albumin is the most important abnormal proteid foimd in the urine. 
Albuminuria has reference to the presence of serum albumin of the blood in 
the urine, and serum albumin is usually significant of deranged renal function 
or pathological changes in the kidney. Serum albumin is occasionally found 
in certain individuals under apparently perfect normal conditions. Traces 
may also appear in healthy individuals after excessive exercise, overindul- 
gence in meats or a diet of eggs. 

Nucleo-albumin is a compound of a proteid and nuclein contained in cell 
protoplasm. In the urine it is derived from the nuclei of epithelial cells and 
leucocytes. The organic debris of normal urine includes more or less of this 
cellular element and consequently it is possible by delicate tests to detect 
minute traces of nucleo-albumin in normal urine. In inflammatory condi- 
tions of the urinary tract where there is considerable amount of pus and 
epithelium present, nucleo-albumin is abundant. Where this is the case and 
when at the same time the urine is to be examined for possible evidence of 
kidney derangement or disease, it becomes very important to differentiate the 
serum albumin from the nucleo-albumin. Under the tests for albumin, a 
method of procedure will be given. 

Qualitative Tests for Albumin. — Xitric-Acid Test (Hellers). — Pour a 
small quantity (5 to 10 c.c.) of nitric acid in a test-tube. Hold the tube in 
a slanting position and with a pipette allow about an equal amount of filtered 
urine to slowly trickle down on top of the acid. If albumin is present, a white 
line appears at the junction of the two liquids. If the amount present is large, 
there is at once a wide band formed. This test is quite sufficient for ordinary 
purposes. It is not only reliable in determining the presence or absence of 
albumin, but it also gives evidence as to the presence of other properties, 
to wit : 

Excess of indican: purple band. 

Bile pigment: green band. 

Uric acid : faifit waving ring above the juncture of the liquids. 

Mucin: a cloudy band still higher up above the acid. 

Should the above test give doubtful reactions, the following sensitive tests 
can be employed. 



CHEMICAL EXAMINATION OF THE URINE 77 

Potassiom-Ferrocyanid Test. — To a test-tube of filtered urine add five 
to ten drops of acetic acid and a few drops of a ten-per-cent ferrocyanid-of- 
poiassiuni solution. If albumin is present, a cloudiness will at once appear. 
Very delicate in doubtful cases. 

TRitiiu»RA(KTic-Acii> Test. — This is one of the moat delicate tests known. 
It is often possible to demonstrate minute traces of albumin, with this test, 
in urines containing a few casta wlicn the common tests fail to show any reac- 
tion. To a test-tube containing the filtered urine, add with a pipette 1 or 2 c.c. 
of a solution of trichloracetic acid, depositing the reagent carefully at the 
boitom of the tube beneath the urine. (Specific gravity of the reagent equals 
1.147.) A white zone at once forms at the junction of the two liquids if albu- 
min is present. Albumose and excess of uric acid also show a reaction, but the 
former disappears on boiling and the latter on heating. 

Serum-Albl'mix Test. — Reference has already been made to the fact that, 
in genito-urinary work, it becomes necessary frequently to differentiate the 
niideo- from the seruni-albuniin. This can be done very readily by the following 
method : 

"Xucleo-albumin is not precipitated by heat and acid in highly salted 
urines. To prove serum albumin, therefore, to the urine add one fifth volumo 
of saturated sodium-chlorid solution, heat the upper one third, 
add t\vo to five drops of fifty-[)er-cent acetic acid, heat a second 
lime. A iiersistent cloud equals serum albumin." ' 

Quantitative Estimation of Albumin. — The absolutely ac- 
curate quantitative methods of testing for albumin are entirely 
too elaborate for clinical work. They will be found described 
in the handbooks on urinary analysis. 

EsB.wii's Methoik— This is a convenient method of quan- 
titative estimation, which is sufficiently accurate for clinical 
purposes. The apparatus is a graduated glass tube (albu- 
minometer. Fig. 80) which is filled with urine to the letter 
" L".*' Esbach's reagent is added up to the mark " R." (This 
reagent consists of picric acid, ten parts ; citric acid, twenty 
parts; and distilled water, one thousand parts.) 

The tube is closed with a rubber stopper and the contents 

mixed by inverting it several times. The number at the level 

of the precipitate, read after allowing the tube to stand for 

. ^' , ' , , , r - „ . FiQ. 80.— Ebbach'b 

tffonly-four hours, shows the number of grams of albumin Ai.BnuiNOMETKii. 

contained in one liter of urine. Each gram represents one 

tenth of one per cent by weight. When large quantities of albumin are 

present (over 0.7 per cent, the highest mark on the scale), the urine must 

■ Hastings, ffew York Medical Journal, July 7, 1906. 



78 THE URINE 

be diluted with equal parts of distilled water, and the results multiplied 
by two. 

This method is not absolutely accurate for the reason that picric acid also 
precipitates urates, peptone and vegetable alkaloids. 

Serum Globulin 

Serum globulin is nearly always present together with serum albumin, and 
usually it is not necessary to differentiate them. Excess of globulin, however, 
as compared to the amount of albumin, is noted in catarrhal cystitis, in acute 
nephritis, and particularly in amyloid degeneration of the kidney. In chronic 
nephritis, globulin is scant or even absent. 

Tests for Globulin. — The urine is accurately neutralized by adding alkali 
or acid, as the case may be; is filtered and is completely saturated with 
magnesium sulphate at ordinary temperature, a white precipitate immedi- 
ately forming with globulins. If this precipitate be filtered off, the same 
urine may be tested for serum albumin by heating w^itli a few drops of acetic 
acid. 

Fibrin 

Fibrin is an elastic, white, stringy albuminous substance, insoluble in water 
and alcohol. It is soluble in solutions of magnesium sulphate^ with the forma- 
tion of globulin, and by the addition of strong acid it is converted into acid 
albumin. When found in the urine, fibrin means the presence of blood. A 
urine containing fibrin may coagulate spontaneously on standing. It is im- 
portant to distinguish between fibrin and the gelatinous mass formed by pus. 
The nature of the clot can be determined chemically by Millon's reagent, but 
the point can be settled much quicker by a microscopical examination. 

Albumose 

Albumose is an intermediate product between the original proteid (albu- 
min) and the final products of digestion (peptone). Albumose is not coagu- 
lable by heat; is precipitated but not coagulated by alcohol. It is precipitated 
by nitric acid, the precipitate thus formed being temporarily dispelled by heat. 
It does not usually occur in ordinary albuminuria. It occurs in the urine in 
febrile diseases and in septic conditions, such as empyema, in intestinal ulcers, 
and ulcerating malignant growths. 

There is a very rare form of albuminuria which occurs only in myelo- 
sarcoma of the bones and is often spoken of as Bence-Jones albuminuria. 



CHEMICAL EXAMINATION OF THE URINE 79 

Mucus 

A small amount of mucus is present in normal urine. Under the microscope 
this mucus is seen to be composed of mucous threads — transparent, homogenous, 
stringy masses. Mucus is a normal product of epithelial cells and is, therefore, 
always found in the urine. An increase in the normal amount of mucus is one 
of the first evidences of irritation somewhere along the urinary tract. This 
may be due to highly acid or highly concentrated urine, or to the presence of 
irritating crystals. 

Mucin 

Mucin is the chemical basis of mucus and forms the great bulk of the so- 
called nubecula or mucous cloud occurring in normal urine. The amount of 
mucin is greatly increased in pathological urines, owing to the presence of irri- 
tation of the surface of some part of the genito-urinary tract. Mucin is pre- 
cipitated by acetic acid and is distinguished from nucleo-albumin in that it is 
soluble in a slight excess of the acid. The presence of mucin does not inter- 
fere with the ordinary albumin test, as it is dissolved in an excess of Esbach's 
and other reagents. 

Cabbohydrates 

Glucose 

The occurrence of sugar in the urine is especially of interest to the urolo- 
gist, on account of its association with polyuria and may, therefore, be a cause 
of frequency of urination. The polyuria may have escaped the patient's notice, 
because people voiding their urine in urinals and closets are not aware of how 
much they are passing each time. It is, therefore, important to include sugar 
tests as a matter of routine in every urine examination. 

Qualitative Tests for Sugar. — Fehling's Test. — The reagent consists of 
two parts which must be kept in separate bottles, in a dark place : 

I. Copper Solution (Tyson) 

Copper sulphate 34.652 gm. 

Distilled water 500 c.c. 

II. Alkaline Solution (Tyson) 

Sodium potassium tartrate (Rochelle salt) 175 gm. 

Sodium hydrate solution (specific gravity 1.120) .... 480 c.c. 
Distilled water, enough to make 500 c.c. 



80 TTTK TRINE 

(The sodinm hydrate solution contains 52.727 gm. of caustic soda nnd 
enough distilled water to make 500 c.c.) 

In testing for sugar, dilute 1 c.c. of each of these solutions in ahout foi;r 
times the amount of water anil hoil the mixture for a few seconds. If the solu- 
tion becomes clouded on boilin":, the reagents should he freshly prepared. If 
the solution remains clear, the suspected urine should be added drop by drop. 
If sugar is present in considerable amount, the first two drops will cause a 
yellow or red precipitate of copper suboxid. 

One should continue to add the urine until an amount has been added equal 
to the reagent, and tlien boil it. If no precipitate occurs within thirty minutes, 
allow the tube to stand for a day for possible traces of sugar. 



Fia. 81. — The Ladrbnt pENtriiBBA PouLBizma Saccoaroueter. (From Tyson.) 

An improved solution consists of thirty grains of copper sulphate, half an 
ounce of distilled water, half an ounce of pure glycerin, and five ounces of 
potassium-hydrate solution. Boil a dram of this solution in a test-tube, and 
add eight drops of the urine. Boil the mixture gently, and if sugar is present, 
a yellow or yellowish-red precipitate appears. 

Nylander's Test. — This test reveals sugar in amounts of 0.1 per cent or 
over and can be strongly recommended for the use of the practitioner. It is 
easily performed and the solution keeps perfectly for many months. The solu- 
tion is composed of bismuth subnitrate, 2 parts ; Rocbelle salts, 4 parts ; sodium 



CHEMICAL EXAMINATION OF THE URINE 81 

hydrate (sticks), 8 parts; water, 100 parts. One part of this solution is added 
to 9 parts by volume of the urine and the mixture boiled iji a test-tube for one 
or two minutes. The reaction begins as a grayish-black coloration which soon 
becomes deep black. 

PoLAKiMETBY is a Convenient and quick method for the quantitative deter- 
mination of glucose when it exceeds 0.5 per cent The urine must be clarified 
before testing. The test depends on the fact that glucose rotates polarized light 
to the right, and the proportion ©"f sugar in solution is determined by the de- 
gree of deviation noted. The polariscope of Laurent, made by Schmidt & 
llaench, of Berlin, is probably the most useful (Fig. 81). 

Phextl-IIydrazin Test {Williamson's Method). — Fill a test-tube of or- 
dinary size for about half an inch with powdered phenyl-hydrazin hydro- 
chlorate ; then add another half inch of powdered sodium acetate. Fill half the 
test-tube with urine, and boil it over a spirit lamp for about two minutes. The 
powders dissolve and the tube is allowed to stand to deposit a yellow sediment. 
This, under a microscope, is seen to consist of bright yellow needle-shaped crys- 
tals arranged in sunburst fashion (phenyl-glucosazone). They are almost in- 
soluble in water, but dissolve in boiling alcohol. 

Precautions in Testing foe Sugar. — In testing for sugar, all utensils 
must be perfectly clean, and albumin must be removed if present in any con- 
siderable quantities. In using the copper test, always add to the boiling solu- 
tion as few drops of the urine as possible, waiting a moment or two before 
adding a few more drops, and so on, until equal parts of the reagent and the 
urine are used. If the urine is boiled with a copper solution, there may be a 
greenish color, or a greenish opacity, or even a brownish color without the 
presence of sugar. An excess of copper sulphate or too strong a solution should 
not be used, because they give rise to these precipitates without any sugar. 

Quantitative Tests for Sugar. — Fermentation Test. — By fermenting 
urine with yeast, the sugar is decomposed into alcohol, carbon dioxid, etc., with 
a decrease in the specific gravity of the urine. Each degree lost is equivalent 
to one grain of sugar to the ounce of urine. 

Robert's Method. — Into a twelve-ounce flask, put four ounces of urine 
and a small lump of yeast; cork the bottle with a nicked cork to allow the 
carbon dioxid to escape ; set it aside in a warm place to ferment With it, put a 
tightly corked four-ounce flask of the same urine without yeast, for comparison. 
After eighteen to twenty-four hours, the fermented urine is decanted and the 
specific gravity noted. At the same time the specific gravity of the unfer- 
mented urine is taken. The former subtracted from the latter shows the de- 
gree of gravity lost, which may be read at once as grains of sugar per ounce. 
Or else, the number of the lost degrees may be multiplied by 0.23 to obtain 
the percentage. The chief objection to this method is that it requires too 
much time. 



82 THE URINE 

Lohnstein's SAccitABOMETEB (Fig. 82) is a very accurate fermentation 
apparatus devised for urines containing large quantities of sugar. It ia pro- 
vided with a scale graduated for 
sugar percentages at two different 
temperatures and is so constructed 
that the fermenting urine is separated 
from the outside air by a column of 
mercury. It thus avoids the errors 
made in the use of the Einhom sac- 
charometer at widely differing tem- 
peratures. 

ElNHOBs's SACCIIAKOMETEB (Fig. 

83) is used in sets of two, one being 



filled with normal urine for comparison, A small piece of fresh yeast is mixed 
thoroughly with a definite quantity of the suspected urine measured in a marked 
test-tube that comes witli the apparatus. The mixture is theu poured carefully 
into the graduated tiibc, care being taken to expel alt tlie air by slanting the 
tube so that bubbles escape. The tubes are allowed to stand at a temperature 
of about 86° F. until fermentation has ceased, i. e., for about twenty-four hours. 
The COa resulting from fermentation collects at the top of the tube, and the 
l>crcentage of sugar is read off at the level of the fluid. If the second tube also 
shows a small amount of gas, this is deducted. 



CHEMICAL EXAMINATION OF THE UKINE 83 

The above are the principal tests for sugar employed in clinical work. For 
the other methods, the reader is referred to the larger handbooks. * 

Other Carbohydrates 

Three other carbohydrates are sometimes found in the urine, but are of 
very sHght clinical importance. They are lactose or milk sugar, Icevulose or 
fruit sugar, and inosite, or muscle sugar. The isolation of these requires elabo- 
rate apparatus, and the use of the polariscope. Lactose, however, gives the 
phenvl-hydrazin test, forming yellow needles grouped in clusters. 

Urea and its Compounds 
Urea 

The most important element in the urine is urea, representing, as it does, 
the last term in the series of oxidized nitrogenous bodies. Its source is two- 
fold : from the tissue waste and from ingested food. The greater part of nitro- 
gen in food appears in the urine in the form of urea, which* ranges from three 
hundred to six hundred grains in twenty-four hours (20-40 grams or 1.5 to 2.5 
per cent). The average daily amount of urea for a healthy man on a mixed 
diet with moderate exercise may be estimated as 33.8 grams, which gives about 
0.015 to 0.035 grams per hour for each kilogram of body weight. Women and 
children excrete a less quantity of urea than men, but relatively more per pound 
of body weight. The normal standard urea excretion generally accepted in 
clinical work is two per cent, or twenty grams per liter, or ten grains to the 
ounce. 

The organs chiefly concerned in the production of urea are. the liver and 
the spleen, but lymph nodes probably assist to a slight extent. The maximum 
quantity of urea occurs with meat diet and the minimum with a vegetable diet. 
Changes in the daily amount of excreted urea correspond so closely to the de- 
struction of tissue and the assimilation of proteids that they form a valuable 
index of bodily health. In fevers and inflammations, in the waking state and 
under intense muscular or mental work, urea is markedly increased in the daily 
amount eliminated ; in liver and kidney disease, in several of the cachexias, it 
is diminished. 

Quantitative Estimation of Urea. — There are many elaborate methods for 
accurately ascertaining the amount of urea. The most available method in 
the clinical laboratorv is the one that is based on the fact that urea is decom- 
posed into carbon dioxid and nitrogen in the presence of sodium hypobromite. 

The reagents are most conveniently kept and applied in the form of Rice's 
solutions: (1) caustic soda 100 grams, distilled water 250 grams; (2) bromin 
30 grams, potassiimi bromid 30 grams, water 240 grams. 



84 



THE URINE 



The test is made in Doremus'a ureometer, or in one of the numerous modi- 
fications of it. 

DoREMus's L'rkometer (Figs. 84 and 85). — This apparatus consists 
o£ a bulb with an upright graduated tube and a small nipple pipette, hold- 
ing 1 e.c. of urine. The gradua- 
tions read in fractions of a gram 
of urea jwr c.c. of urine, or else 




Fia. 84. — DoREUDs Ubboiibteh. 

show the number of grains of urea per fluid ounce of urine. The bulb U 
filled with the hypobromite. solution (one of the formulii.' given above), and 
the tube is inclined so as to remove the last air bubble from its closed part. 
Oue c.c, of urine is then taken with the pi|>ette, and the point of the latter is 
introduced into the bend of the tube. The nipple is slowly and gently com- 
pressed, care being taken to ex]>el all the urine, but not to drive any air out 
of the nipple. The pipette should be dried before being introduced, and should 
be filled accurately. The sodium hypobromite in the solution comes into con- 
tact with the urea of the urine, which is decomjwsed into nitrogen, carbon 
dioxid and water. The amount of nitrogen disengaged is a measure of the 
urea, and 1 c.c. of nitrogen at standard temperature and pressure equals 0.0027 
grams of nrcn. The gas is, therefore, allowed to escape into the top of the tnlic 
and the level of the fluid to sink until no more bubbles escape. This takes Icn 
or fifteen minutes or sometimes hinger. The jtercentage of urea is then simply 
reail on the graduated tube. 



Uric Acid 

I'ric acid is a nitrogenous com])Ound occurring in the nrine in daily amounts 
from 0.4 to O.S grams. It is fornie<l in the body by the decomposition of the 
uucleins of the nuclei of the cells of both food and tissues. It is freely soluble 



CHEMICAL EXAMINATION OT THE TTRINE 85 

in vrator, especially with heat, and 13 still more soluble in solutions of urea. 
It Joes not occur often as free uric acid, but usiially is combined with sodium, 
potassium and ammonimn to form urates. When a strong acid ia added to a 
iirine containing the neutral salts of uric acid which are soluble, a deposit of 
itt-«hible acid urates occurs. Uric acid crystallizes in the urine in rectangular 
prisms, in wedges, whetstone shapes and rosettes of a yel- 
luirisii-red color. 

Qnalitative Tests for Uric Acid. — Qualitative tests for 
i:ric acid are of no clinical value. The following three 
Iwts may be used in recognizing the acid, 

Xo. 1. Put a drop of urine on a slide, add a drop of 
nitric acid, warm over a spirit lamp. After evaporation 
the characteristic crystals of urea nitrate will be discov- 
ered by the microscope. 

So. 2. Put a few drops of urine in a test-tube, add an 
qiial amount of solution of sodium hypobroiiiite. If urea 
is present there will be a rapid fonnation of bubbles. 

Xo. 3. Warm a few crystals of urea in a test-tube, add 
a trace of sodium hydrate, and then a drop of a dilute solu- 
tion of cupric sidphate, A violet or rose color will de- 
velop in the presence of urea: this is called the biuret 
n.'aetion. 

Qnantitative Estimation of Uric Acid. — There is no 
accurate method of estimating uric acid which is sufficient- 
ly convenient for clinical purposes. The following methods 
are (lcscril>ed because they are less troublesome than any 
iither devised : 

Hei.ntz's Method. — Add 10 c.c. hydrochloric acid to 
:J(Hl c.c. urine and let it stand twenty-four hours in a cool 
place. Weigh a filter and collect the deposited crystals 
iijion it, washing with cold distilled water. T>^y the filter 
thoroufrlily and weigh. ' Subtract the weight of the filter 
aWe and obtain the weight of the uric acid in !>00 c.c. of 
urine: from this may be determined the amount in the 
total daily urine. Always filter the urine before usiu^ 

this method. P,^ 86.-RuHB«Am,-a 

Rcuku.vjjn's URiqoMETER IS recommended for the Uhicoueter fob toe 
., . . . . ■ 1 , !-■- r.,,1 mi 1 Rapid Ebtiuatiok or 

rapid estimation of uric acid (rig, 80). ihe lowest UiucAcm. 

mark (S) shows the height to which the indicator (car- 
l»n disulphid) should reach. Then follows to the mark I, a space of 2 c.c, 
content into which iodin solution is poured. This -whition is composed of iodin, 
1-5 ; potassium iodid, 1.5 ; alcohol, 15.0 ; water, 185,0. Above the mark I, at 2,6, 



86 THE URINE 

begins an empiric scale which, at distances of 0.2 c.c, gives the uric acid value 
pro mille. After the carbon sulphid and iodin solution have been placed in the 
burette, the urine is slowly added and the mixture strongly shaken after each 
addition. The urine is added until the primary brown color gives place to a 
white one, at which moment the percentage of uric acid is read off at the top of 
the column of fluid. If the urine contains less uric acid than the apparatus 
will indicate, add the iodin only to the mark midway between I and S and read 
half values. Alkaline urines should be acidulated with acetic acid, and, if 
abundant sediment of sodium urate is present, the specimen should first be 
well shaken. Traces of sugar and albumin do not interfere, but if large 
amounts of pus or blood are present, these should be removed by heat and fil- 
tration. The procedure requires about from thirty to forty-five minutes. 

Urates 

Xearly all the uric acid in the urine exists in the form of urates, i. e., salts 
of potassiinu, sodium, ammonium, calcium and magnesium. These salts are 
soluble at body temperature, but a large part of them precipitate on cooling 
the urine. 

Two kinds of urates are found : the acid and neutral urates. The acid salts 
are less soluble and are more readily precipitated. When the neutral urates 
are in excess, they often remain dissolved for some time and precipitate only 
when the urine turns more intensely acid. (See Acid Fermentation.) The 
addition of acid to such urines also makes the urates insoluble and pre- 
cipitates them, as they are converted into acid urates. On heating, the 
precipitate of urates is dispelled. Urates usually precipitate in the form of 
amorphous granules, which may be mixed with uric-acid crystals if the urine 
has been allowed to stand. 

HipPURic Acid 

Hippuric acid exists normally in quantity from 0.5 to 1.0 gram and is in- 
creased by vegetable and fruit diets, by certain drugs like benzoic acid, and in 
some diseases, like chorea, diabetes, and acute fevers. 

DiACETic Acid 

Diacetic acid occurs in the urine in the advanced stages of diabetes. It is 
usually a grave symptom, giving warning of approaching coma and death. 

Acetone 

Acetone is a colorless, thin, watery fluid of a fruity odor, occurring in the 
urine and blood in dial^etes and malignant tiunors ; also at times in high fever, 



Fir,. I. Fm. 2. Fio, 3. 

NoRUAL ['rine. f^iHPLE Indicanuria. Potabsit'm Iodid Reaction. 



INDICAX COLOR REACTION' IN URINE. (After W. H. Porter.) 



CHEMICAL EXAMINATION OF THE UKINE 87 

smallpox, typhus fever, scarlet fever, measles and Bright's disease. In dia- 
betes, acetone very often precedes a dangerous diaceturia. 
Acetone can readily be detected by Lieben's iodoform test : 

Liebens Test 

1. Distil the urine. 

2. Add Gram's solution to the distillate and then some sodium hydrate. If 
acetone is present in any quantity, iodoform is immediately precipitated. 
If present in small quantities, then iodoform crystals should be looked for 
m i croscopically . 

Indican and other Ethereal Sulphates 

The ethereal sulphates in the urine constitute a group of substances, products 
of intestinal decomposition, which are sulphates of sodium and potassium, com- 
bined with an organic radical, such as iodoxol or a phenol. 

Indican is the most important of this group of sulphates. It is derived 
from indol, a product of intestinal putrefaction of proteids. Indol is absorbed 
from the intestine, is oxidized to indoxyl, and combines with potassium (and 
also partly with sodium) sulphate, forming indican, which is eliminated in the 
urine. 

Increased intestinal putrefaction increases the amount of indican eliminated 
by the kidneys, thus acting as a renal irritant and frequently giving rise to 
albumin and casts in the urine to such a degree that many cases of indicanuria 
have been diagnosticated as Bright's disease. 

Indicanuria is marked in all cases in which intestinal digestion is disturbed, 
such as: typhoid fever, cholera, acute and chronic enteritis, acute and chronic 
gastritis, dyspepsia, appendicitis, peritonitis, acute cancer of the peritoneum, 
diseases of the liver and pancreas, chronic constipation. 

Indican itself is a colorless or brown sirup, soluble in water and has a bitter 
taste. It can be turned into indigo blue by adding acids and heating. 

Test for Indican. — To equal parts, about 10 c.c. each, of concentrated hy- 
drochloric acid and fresh urine, add two or three drops of one-half-per-cent 
watery solution of potassium permanganate and then invert the tube several 
times. After one or two minutes, add enough chloroform to make a sediment 
about three quarters of an inch and shake well. If indican is present, the 
chloroform becomes blue. 

Phenol and skatol are also products of intestinal putrefaction, the latter 
forming low down in the tract. They are absorbed from the intestine into the 
blood and from there into the kidneys, the same as indican. 



88 THE URINE 



Bile Pigment 

The presence of biliary pigments, bilin, and biliverdin, indicates derange- 
ment of the liver or biliary tract. They are always formed in the urine in 
jaundice, due to obstruction of the common duct and after an attack of hepatic 
colic. Biliary pigments impart a greenish-yellow color to the urine and the 
foam produced by shaking the specimen vigorously has a yellow tint. 

Omelin's Test. — A modification of Heller's albumin test, known as Gmelin's 
test, is commonly used to demonstrate the presence of these pigments in the 
urine. 

In a test-tube the urine is carefully deposited on top of a small quantity of 
fuming nitric acid, to which has been added yellow nitrous acid. A greenish 
ring appears at the point of contact if the urine contains bilin or biliverdin. 
There are several modifications of this test. A drop of the same acid on the 
white filter paper, through which the specimen has been filtered, will give a 
similar reaction. 

lodin Test for Bile. — A solution of one part of tincture of iodin (or Lugol's 
solution) to nine parts of water, overlaid on the urine in a test-tube, produces 
a distinct green color at the point of contact of the urine and reagent if bile is 
present. 

Hemoglobinuria 

Hemoglobinuria, or the presence of hemoglobin, the coloring matter of blood 
in solution in the urine, is of rare occurrence. Upder normal circumstances, 
hemoglobin is a constituent part of the red blood corpuscles and is not found 
in the urine separate from them. 

Hemoglobinuria has been found with more or less frequency in severe types 
of infectious diseases, especially yellow fever, scarlet fever; also in purpura, 
scurvy and malaria. It occurs also in severe bums and in poisoning by coal-tar 
phenol derivatives, carbolic acid and naphthol. 

Heller's Test for Hematin. — By adding a little caustic-potash solution and 
gently heating the urine, the earthy phosphates are precipitated. The precipi- 
tate carries the blood-coloring matters w^ith it as it sinks and is stained red. If 
the urine is alkaline, the phosphates can be precipitated by adding a few drops 
of magnesium fluid and heating gently. (See page 91.) 

Test for Hemin Crystals. — The precipitated earthy phosphates are filtered 
and placed on an object glass and warmed imtil completely dry. Add a minute 
granule of common salt and mix thoroughly, cover with a thin cover glass and 
then allow a drop or two of glacial acetic acid to pass imderneath the cover glass. 
The slide is carefully warmed until bubbles make their appearance. After 
cooling, hemin crystals can be seen by the aid of the microscope. 



CHEMICAL EXAMINATION OF THE URINE 89 

Melanin 

Melanin is a pigment found in cases of melanotic cancer or sarcoma, and 
occurs either in solution in the urine, or is deposited in small black parti- 
cles. Melanin also occurs rarely in severe wasting conditions and in chronic 
malaria. 

To detect melanin, add bromin water to the urine, which causes a yellow 
precipitate that gradually blackens. On adding ferric chlorid, the urine turns 
gray; if enough be added, the phosphates will precipitate, carrying the coloring 
matter with them. The urine containing melanin is normal in appearance 
when freshly voided, but on exposure to the air becomes brown or black. 

Organic Constituents of Minor Importance 

I^ucin and tyrosin are found in the urine, chiefly in destructive diseases 
of the hver (acute yellow atrophy, phosphorous poisoning) and in acute infec- 
tions (smallpox, typhus). 

Leucin and tyrosin usually occur together; they may be deposited in the 
sediment when present in large amounts. Usually the urine contains an excess 
of bile and a deficiency of urea. 

The crystals may be obtained by evaporating the urine and, if the crystals 
are extracted with alcohol, leucin dissolves and tyrosin is left. 

Inorganic Constituents 

The principal inorganic constituents of the urine are the chlorids, phos- 
phates and sulphates occurring in combination with sodium, potassium, am- 
monium, calcium and magnesium. The total amount of inorganic substances 
excreted in twenty-four hours varies between nine and twenty-five grams. 

Chloride 

The chlorids rank next to urea in importance among the solid constituents 
of the urine. The greater part of the chlorids exist as sodium chlorid, while 
smaller amounts of potassium and ammonium chlorids are found. The chlorids 
HI the urine are derived from the food, and most of the salt ingested is elim- 
iJ^ted in the urine as such. 

The normal amount of chlorids excreted in twenty-four hours varies from 
^ to twenty grams, but if much salt is taken with the food, the amount may 
^ach fifty grams. Chlorids are diminished especially in all acute affections, 
^ which there is a serous exudation or transudation, vomiting, or diarrhea. 
Chlorids are diminished or absent also in cholera, septicemia, pyemia, puer- 
peral fever, and acute articular rheumatism. The chlorids may be absent in 



90 THE UKINE 

the urine in a chronic disease, if accompanied by dropsy (chronic nephritis, 
heart disease), and as the dropsy is absorbed, the chlorids gradually are in- 
creased. In pneumonia, the chlorids are low or absent in the acute stage, but 
as the exudate becomes absorbed, they increase, and may become normal. In 
meningitis (acute) the chlorids are also increased, so that by testing for them, 
we may differentiate between meningitis and typhoid. In nephritis, the amount 
of chlorids eliminated as compared to the amount of urea, is of considerable 
importance. 

Detection and Approximate Estimation. — Silver Nitilvte Test. — Be- 
fore applying this test, if more than a trace of albumin is present, it should be 
removed by heat, as albuminate of silver forms and interferes with the reac- 
tion. One half ounce of urine is laid upon an equal amount of pure nitric acid 
in the same manner as in the test for albumin. Then one drop of a 1:8 solu- 
tion of silver nitrate in water is added. . A precipitate of silver chlorid is 
formed, which, if normal or increased in amount, appears as a compact, solid 
mass which falls to the surface of the nitric acid. If the amount is diminished, 
the silver chlorid becomes more or less diffused through the layer of urine. 

Carbonates 

Minute quantities of carbonates and bicarbonates of sodium, ammonium, 
calcium, and magnesium, are found in fresh urine of alkaline reaction. Aui- 
monium carbonate may occur in large amounts, owing to alkaline decomposi- 
tion. The carbonates in urine are derived from the food, especially from vege- 
table acids, such as lactic, tartaric, malic, succinic, etc. They are, therefore, 
most abundant in the urine of herbivora. An excess of carbonates renders the 
urine turbid when passed or on standing and, as a rule, the sediment is mixed 
with phosphates. 

Detection. — On the addition of an acid, the presence of carbonates is de- 
tected by the evolution of gas bubbles, and this gas, when passed into baryta 
water, renders the latter turbid. The determination of the amount of carbonic 
acid will be found described in the larger text-books. 

PJiosphates 

Earthy Phosphates. — Render half a test-tubeful of filtered urine alkaline 
with ammonia and warm gently. Earthy phosphates, in the form of a whitish 
cloud, settle to the bottom of the tube. The precipitate is dissolved by the 
addition of acetic acid. 

Approximate Quantitative Estimation (Ultzmann), — A test-tube 2 cm. 
wide is filled with urine to the depth of 5§ cm., and a few drops of strong 
ammonia are added. The mixture is warmed over an alcohol lamp until the 
earthy phosphates separate. The depth of the sediment is measured after 



CHEMICAL EXAMINATION OF THE URINE 91 

standing for fifteen minutes. Kormally, the layer will be 1 cm. high: 
a greater depth indicates an increase, while a less abundant precipitate means 
diminution. 

Alkaline Phosphates. — After the earthy phosphates have been separated, 
as shown above, the mixture is filtered. To the filtrate is added one third of 
its volume of magnesium fluid (magnesium sulphate, ammonium hydrate, am- 
monium chlorid, of each one part; water eight parts). The white precipitate 
consists of alkaline phosphates. To make this test available for approximate 
estimation, according to TJltzmann, 10 c.c. of the urine are treated with 3 c.c. 
of the magnesium fluid. A precipitate of crystalline ammonio-magnesium 
phosphate is found, together with an amorphous mass of calcium phosphate. 
If a milky turbidity permeates the entire fluid, the alkaline phosphates are 
normal in amount. If an abundant precipitate gives the fluid the appearance 
of cream, they are greatly increased ; and if a slight turbidity follows, or if 
tlie fluid remains transparent, they are decreased. 

Sulphates 

The ethereal sulphates have already been considered. There are in addition 
in the urine the ordinary alkaline sulphate of sodium and potassium, the sodium 
salt being present in larger quantities. The amount of sulphates excreted by 
healthy adults ranges from 1.5 to 5.0 grams daily. About one tenth of this 
amount is represented by the ethereal sulphates, about nine tenths represented 
by the potassium and sodium salts. 

The sulphates in the urine are derived partly from food and partly from 
the decomposition of proteid substances in the tissues. The sulphur from the 
foodstuffs and from the tissue elements is oxidized to sulphuric acid, the lat- 
ter in turn combining with sodium and potassium to form a sulphate of these 
bases. The amount of sulphates in the urine is increased after taking sulphuric 
acid or sulphates ; after active exercise ; after the inhalation of oxygen ; in acute 
fever, in meningitis and in rheumatism. As a rule, the amount of sulphates is 
parallel to that of urea. Sulphates are decreased in most chronic diseases when 
metabolism and appetite are diminished ; also after carbolic-acid poisoning or 
after the use of large doses of salol, etc. In such cases the ethereal sulphates 
are increased. 

Detection. — For ordinary purposes, the following test is sufficient: To a 
test-tube one half full of filtered urine, add one or two inches of barium solu- 
tion (barium chlorid, 4 parts; concentrated hydrochloric acid, 1 part; distilled 
water, 16 parts). A white precipitate occurs which normally fills one half the 
concavity of the test-tube. A larger amount indicates an increase, a smaller 
amount a decrease. 



J 



THE URINE 



IV. MICROSCOPICAL EXAMINATION 

General Considerations 

To obtain the sediment of a specimen of urine for microscopical examina- 
tion, we can use either the old-fashioned gravitation method or the centrif\i{^. 
If the former is used, the specimen must Ic allowed to stand in a well-covered, 
conical glass, preferably in a cool, dark place, from six to twelve hours. Tins 
method has the obvious disadvantages of delay iii examination and more or less 
disintegration of the organic elements. 

Centrilu^ sedimentation permits the immediate examination of the urine 
microscopically and produces a concentrated sediment from freshly voided 
urine before cells and casts can be destroyed by the alkalinity of the stand- 
ing urine and before the development of bacteria. This is the only method 
by which crystals, formed in tbe 
urine Iwfore it is passed, can be dis- 
tinguished from those formed after- 
wards. By tiie old methods in urine 
of high specific gravity, the lighter 
forms of easts miglit float and thus he 
ovcrlookotl. This does not happen 
with the centrifuge. 



Fio. 88.— Water Centhitdgb. 



The Centrifuere. — Three types of centrifuge are on the market: the hand 
(Fig. 87), water motor (Fig. 88), and the electric centrifuge (Fig. 89). Of 
the three, the hand centrifuge is the least expensive and answers the purpose 



MICROSCOPICAL EXAMINATION 93 

where it is impossible or impracticable to use either a water or electric centri- 
fuge. The labor and time required in using it, owing to the limited speed ob- 
tainable, are obvious disadvantages. 

The trater motor is in many ways the 
most practical. It can be used wherever 
ihert' is a faucet of running water under 
onlinary city pressure and it is so simple 
that it never gets out of order. 

The electric centrifuge has some ad- 
vantages, and is preferred by laboratory 
workpr3 on account of the greater 8i>eed 
obtainable. It can be run with ordinary iu- 
caQ(le*ent lighting currents of 110 volts, 
(lifeot or allemating, or even by currents of 
less Toltage. 

Aluminum shields protect the tubes from 
»1I (lanjter of breaking, no matter what the 
^Kvi may be. The tubes have conical tips 
inffhioh the sediment collects, and it is not 

disiiirW hv sudden stopping of the instru- ^ „ „ „ .., 

• , . ^°- 89.— The Phrdt Elbctiuc Cbntbi- 

iDfnt or by decanting the urine. mm. 

Methods of Examinino the Sediment 

A pipette, consisting of a single glass tube, drawn to a moderate point, is 
nelii with its upper opening tightly closed with the inde.\ finger and dipped to 
tlie bottom of the sediment glass of the centrifuge tube. The finger is then 
released and tJie sediment is allowed to rush in from below upward. A speci- 
men should include portions of all strata of the sediment, mixed with a little 
UTine, eapecially if the sediment is very dense. 

Theswhmont is dropped upon a slide and covered with a large cover glass. 
The oscess of urine is taken up with filter pa[>er. When the low power (only 
I objective) is used, no cover glass is needed, but for the high-power lens a 
wer glaiB is essential to prevent soiling the lens, .the microscope and the ex- 
aminer's fingers. 

It is best to go over a slide with the low-power lens (Leitz Xo. 3, Zeiss AA, 
Bairsch & I^uib 3). With tliis, most of the larger elements can be made out. 
For the fine study of cpithelia, casts, etc., however, the higher power (T^itz 
Xii. 0, Zeiss D, Bausch & Lomb J) is necessary. For the routine examination 
"f .1 large number of specimens without a cover glass, the lower power with a 
iifMiifrer eyepiece (Zeiss Xo. 12, Achromatic or Leitz Xo. 3, Ocular ft) will 
be found sufiicient. In fact this combination offers a rapid, cleanly way of ex- 



94 THE URINE 

aiiiining urine, wliieli will appeal to tlie busy practitioner. For differentiating 
epithelia and tbe finer structures, however, it cannot serve in all instances. 

In searching for casta, especially of the hyaline variety, the diaphragm of 
tlie microscope should be closed so as to admit the least possible amount of light. 
The micrometer screw of the microscope should be freely used in looking for 
casts, as these structures are eyiindrie and often so trocated that one turn of 
the screw brings one part into view, while the rest remains hazy. The flat 
mirror should be used when looking for casts. The Abbe condenser should not 
be used when looking at urinary sediment. 

Unokoanized Sediment 

Urie>Acid Calculi — In uric-acid calculi in the kidneys or elsewhere in the 
urinary tract, considerable masses of uric-acid crystals, with jagged outlines, 
may be found in the urine. 

Detection. — Uric-acid crystals (Figs. 90, 91, 92) vary greatly in shape, 
but the typical forms are the rhombic, or six-sided plates, the whetstone shape 

• %' ^ 



,c| .*:" 









FiQ. 90, — Cbvstalb of Uric Acid. (Ftoi 



in stellate groups and crystals resembling a comb with teeth on both sides. All 
these are more or less yellow in color, though occasionally some of them appear 
colorless. They dissolve on adding a few drops of alkali and reappear on add- 
ing acetic acid. 



MICROSCOPICAL EXAMINATION 95 

Ontei. — The mixed sodium, potassium, ammonium, calcium and mag- 
De«ium urate deposit is a granular sediment of a reddish color, varying from 
pink to brick-red, and usually sinks quickly, though it may make the urine 
turbid. The precipitate rediasolvcs on gently heating the urine. 




Flo. 91. — Uncbcal FonuB of Uric Acre. F:i). 92.^UKcsnAL Fobub of Umo Acid, 



Sodium Urate. — This forms the greater bulk of the mixed urate deposit, 
and is usually amorphous. It is generally found in mosslike masses of mi- 
nute granules which easily adhere to larger masses of sediment. When crys- 
tsiJine, it is seen in the form of fan-shaped groups, pointed at the center, or 
arranged like sheaves of wheat. These crystals show characteristic striation. 

PoTASKiL'M Urate. — This occurs always 
as an amorphous sediment, forming a part of 
tW mised urate deposit. It is soluble in hot' -, .t^.^ 

water, inaoluble in cold water. ^ J^ 

Calcium Urate. — It is a rare deposit and 
is found as a part of the amorphous mixed ^fc' '*' 

orate sediment. "^^ 

Ammonium Urate, — It is said by some 
that this is in reality sodium urate in modi- 
fied form, marking a transition of an acid j 
sediment into an alkaline. Ammonium urate ^^^ 
is characteristic of alkaline fermentation, and iF^Bi^ft^ 
is usually associated with triple phosphate 1^^^^ ' J^ 
anJ calcium phosphate. It occurs in the ^^^J 
firm of yellowish-red or dark-brown spher- ^^r 
uW. studded with fine sharp thorns which )^t 
have given rise to the term " thorn-apple " 
crystals (Fig. 93). Ueatm. (Fn.m Wood.) 

These crystals may be massed in clumps 
or chains and are soluble in hot water or in acids; they emit the odor of aui- 
aonia on adding alkalies. It is the only urate found in alkaline urine. 



96 THE UEINE 

Calcium Oxalate. — Normally the greatest part of the oxalic acid taken in 
tlie food 13 converted hj oxidation into urea and carbonic acid. When for some 
reason (diseaae) this oxidation is inter- 
fered with, this change does not take 
place, then the oxalic acid is excreted as 
such in combination with calcium (from 
the blood, also derived from food and tis- 
sues). 

Detection. — The crystals of calcium 
oxalate may be found in acid urine when 
they may accompany crystals of uric acid, 
or in alkaline urine when they accompany 
triple phosphates. Two typical forma of 
calcium oxalate crystals are distinguished 
(fig. 94). 

The octahedral crystals consist of two 
four-sided pyramids placed base to base and appear like squares crossed like 
envelopes, or, if turned with their long axes toward the observer, like long- 



Fia. 95.— Crtstalb op AmroNicv Magnesiuu Pbosphatb. (From Wood.) 

pointed octahcdra. Sometimes these crystals coalesce with larger masses. Tlio 
dumb-bell crystals arc not so common and look like two crossed dumb-bells. 
They must be distinguished from the yellow or brown dumb-bells of uric acid. 



MICROS COPTCAL EXAMINATION 



97 



The dumb-bells of calcium oxalate are soluble in hydrochloric acid, those of 
uric acid in alkalies. 

Phosphates. — In the sediment the earthy phosphates are represented by cal- 
cium phosphate and by am monio-m agnosia phos- 
phate (triple phosphate, so called). The alkaline 
phosphates are not represented in the sediment. 
Calcium Phosphate. — Calcinni phosphate 
is either amorplious (the normal salt), or crys- 
talline (the acid salt), the latter consisting 
partly of magnesium phosphate. The amor- 
phous form occurs in feebly acid urines and is 
seen in small, highly refractive granules, in 
clumps or adhering to other parts of the sedi- 
ment. The crystalline form is found in urine 
about to undergo alkaline fermentation, but 
wbich is still weakly acid. They are prismatic — .«— "^"vv 
tod arranged in either single or in star-shaped, ^il^ 

often in fanlike, groups. Acetic acid rapidly ^"^ 

<lis3olves them, whereas it slowly affects sodium- 
nrate crystals similarly shaped. 

Triple Phosphate Crystals. — Ammonio-magnesium phosphate occurs 
either as the coffin-lid crystals or the feathery crystals. The former is more 
common and consists of a triangular prism with one of the three angles wanting. 
They are large in size and at times shortened into squares which may be 
mistaken for calcium oxalate. The stellate crystals are feathery stars or parts 
of stars. The phosphate crystals are soluble in acetic acid, while the oxalate 
crystals are insoluble in this acid. 

Carbonates and Stilphates. — (a) Calcidm Carbonate. — Calcium car- 
bonate is found rarely in the urine of man, but in large quantities in the urine 
of some lower animals. It occurs in the form 
of small squares. On adding acetic acid, an 
effervescence of carbon dioxid results. 

(b) Calcium Sulphate. — Calcium sul- 
phate is a very rare deposit ; it occurs in 
highly acid urine with high specific gravity, 
in the form of needlelike prisms which often 
are grouped in radiating fanlike arrange- 
ments (Fig, 07). 

Leucin and ^rosin. — (a) Leuci:t occurs 
in the fonn of yellowish, highly refractive 
!T)beres, looking like oil drops (Fig, 98), which show radiating or concen- 
tric stripes. They are often arranged in masses or groups of three or more 




Pw. 97.— Cbtbtai* o 



Calcicm Scl- 



98 THE URINE 

spheres. Unlike oil, leucin is not soluble in ether, but is soluble in alka- 
lies. They are larger than the spheres of araraonium urate and have no spikes. 




(b) Tyrosin occurs as very fine needles arranged In sheaves or rosettes 
(Fig. 99). Tliey are colorless, biit when arranged in masses, they appear quite 
dark. They are insoluble in ether, but soluble in alkalies. 

Blood and Bile Pigments; Fat; Cholesterin. — (a) Bilibubin. — In urine 
containing bile, bilirubin may be found as amorphous masses, or as needles in 
stellate formations, often adherent to cells, or in yellow or ruby-red rhombic 
plates. They show a green rim on adding nitric acid. 

(b) Hematoidin. — Crystals of hematoidin occur in urine containing blood, 
e. g., after an extensive hemorrhage, in pyonephrosis, renal stone, etc. The 
crystals are identical with those of bilirubin and probably hematoidin is iden- 
tical with the former. 

(c) Fat Globiii.es.— Fat globules may be seen in the urine as extraneous 
matter from unclean bottles, or from ointments in the genitals. When enough 
fat is present to be seen with the naked eye, the term " lipuria " is used. When 
the fat makes the urine milky, the tenn " chyluria " is used. The latter is 
usually due to the presence of a parasite, the Filaria sanguinis. 

Fat in small amounts may occur in healthy urine after a fatty diet, also in 
pregnancy and in phosphorous poisoning, ilany minute fat globules are found 
in the urine of chronic nephritis in whicli the fat granules are derived from 
disintegrated fatty epithclia. They are found also in other chronic inflamma- 
tions, such as cystitis, pyelitis, prostatitis, urethritis and vaginitis, in cystic 
kidney, and in abscesses opening into the ureter. 

{d) CiroLESTEKiN. — Cliolesterin is a monatoniic alcohol, normally present 
in the blood, the nerve tissues, the bile, etc. It occurs in gall-stones, in pus, tu- 
mors, etc., but is a rare deposit in the urine in extensive fatty changes in the 
kidney as a result of acute or subacute or chronic nephritis. Still more rarely 



MICROSCOPICAL EXAMINATION 99 

it occurs in cheesy degeneration of cystic kidneys. It crystallizes in large 
plates, is insohible in water, but soluble in alcohol, ether, chloroform, etc. If 
a misture of five parts of sulphuric acid is allowed to act on a cholesterin plate, 
a bright cannine-red color appears, which changes to violet. 

CyBtin. — Cystin is seldom found as a urinary sediment and probably never 
in normal conditions. Its origin in the econ- 
omy is not clearly understood, but the liver 
is r^riied as the seat of its formation. It is 
a crystalline compound and occurs in two 
forms; either as hexagonal tablets with an 
opalescent luster, or as four-sided prisms. It 
is soluble in caustic alkalies, oxalic and strong 
mineral acids, insoluble in boiling water, 
acetic acid, ether and alcohol. These crystals 
may be distinguished from uric acid by treat- 
ing them with strong acid — which dissolves 
them but not uric acid — and from triple 
phosphates by the solubility of the latter in 
acetic acid (Fig. 100). 

Clinical Significance. — But little is known as yet of the interpretation 
of cystin in the urine. It is found in typhoid fever, in renal degeneration, in 
chlorosis, and acute rheumatism. It occasionally forms calculi. 

Oroanized Sediments 

1. Blood CaUb. — As a iirinarj' sediment, blood cells are always pathological. 
Their form depends upon the source of the bleeding and the reaction of the 
nrine; when the typical biconcave disks are preserved, it is easy to recognize 

them by the microscope and in acid urine they retain their 

5 shape for a long time, gradually shriveling and becoming 

@® w® crenated (Fig. 101). They seldom form rolls as when drawn 

® <SJ from a blood vessel, except in cases of great hemorrhatje from 

© bladder or urethra. If the urine be concentrated, the biconca\e 

C^ ® form is exa^erated and the corpuscle'- shrink 

Fig. 101.— Blood and become Crenated ; when the urine is of 

CiLu IN TH* jQ^y specific gravity, they swell and may be 

come spherical. 

2. PtiB. — Pus cells may be derived from any part of the 
urinary tract The urine containing pus is usually turbid 
and gives the albumin reactions. Under the microscope, the 
pus cells appear as circular, pale, finely granular disks, 
about twice the size of the red blood cell; they contain distinct nuclei, often 
two or three (Fig. 102). Water swells the pus cell, renders it paler and oh- 




100 THE immE 

scures its outlines; acetic acid produces the same effect, more quickly, and, 
causing the granular condition to disappear, renders the nuclei very distinct. 
Pus cells resemble the white cells of the blood and lymph, and in the fresh state 
present the glistening appearance of living protoplasm and also ameboid move- 
ments ; seen in the urinary sediment, the cells are dead. 

The chief constituent of pus cells are albuminous bodies ; especially nucleo- 
albumin, which is insoluble in water, but expands into a tough slimy mass 
when treated by sodium-chlorid solution. Pus in the urine is usually accom- 
panied by tissue elements or bacteria, which aid materially in determining its 
anatomical and pathological source. 

3. Epithelia. — In normal urine, a few epithelial cells from the superficial 
layers of the urinary tract are always seen and have no special significance. 
When these cells are altered by disease and are found in considerable num- 
bers, accompanied by pus or red blood cells, a pathological process exists in 
some part of the genito-urinary tract. 

Theoretically, each separate portion of the urinary tract has a type of 
epithelium peculiarly its own, but in actual practice there are so many transi- 
tional forms in every portion of the tract, that it is not always possible to specify 
the origin of a given cell. Inasmuch, however, as the recognition of the differ- 
ent characteristic epithelia is absolutely essential to a localization of diseases 
of the tract by urinary examination, the problem of distinguishing the epi- 
thelia of each portion of the tract is of great importance. 

Most authorities maintain that, while histologic preparations of the dif- 
ferent urinary organs show that the epithelial lining of each has well-marked 
characteristics, the epithelia shed by these organs during life and appearing 
in the urine are radically altered in aspect, and their characteristics to a large 
extent obliterated. ]\[oreover, the same school of clinical pathologists holds that 
the cells of the deeper layers of the bladder, for example, are identical in ap- 
pearance with cells from other parts of the urinary tract. 

The chief characteristics of epithelia found in the urine are their form and 
size. By comparing the size of the different epithelia with that of the leucocyte 
or pus cell, we have, because the latter varies so little, a fair idea of the relative 
magnitude of the epithelial structures. 

Three chief types of epithelia occur in the urine, viz., the flat or squamous, 
the round or cuboidal, and the columnar or. caudate. All these epithelia have 
one or more distinct nuclei, and are more or less granular. When the epithelia 
in the urinary tract are stratified, the outer layers are usually flat, the middle 
layers cuboidal, the inner columnar. 

The tubules of the kidney, the prostatic acini and ducts, and the ejaculatory 
ducts are lined with a single layer of cuboidal or columnar epithelium. The 
pelvis of the kidney, the ureters, the bladder, the urethra and the vagina are 
lined with stratified epithelia. 



I 

HnntoveM ^i — 

f # • 
<' • I 

I- • • 
«' » t 



sr T 



^■9 



w 



Fio. 103.— Epithelial Ckllb tbou DiFFBBEin' Partb of thi Gbnito-ownart Tract. 
1. — The diflereut varietiee of these cells bb seen histologicaUy. 
H', «i(ivcilul*d tubulca. S". arched collecting tubules. Bd, deep layer of bladder cells. 

K". niiral tubules. IP. straiRht collectinR tubules. S. V. Kmiaal vesicle. 

B", (tscending and BBcendinB P. pelvic cells, P(^. prostatic urethra. 

limb of Henle. (.', ureteral celia. V.D, vas detcrenB. 

fi>. looji of Henle. Bi, auperficial layer of bladder (.'.ft, penile urethra. 

**, di«ij convtjuted. ccUb. f .A', fossa Davicularia. 

II.— The EToups of these cells rccogoiiod in the urine. 
fi.C, rpithdial odls from renal B, superficial bladder eetla. C, cells belonRing either to pd- 

lubulea. Ur, penile urethra. vis. deeper layers of bladder, 

f, nUa from renal peJvis. P.N, totta. navicularis. prostate or ureter. 

in.— Comparative siie of epithelium found in the urine. 
'■Mood cell. ^, renal pelvis, ureter, proslale fl, superficial layers of bladder. 

^cdblrom the renal parenchyma. dcr. 



102 THE UKINE 

The largest epithelia in the urine are the flat superficial cells from the male 
anterior urethra, the vagina, vulva and female urethra. Kext in size are the 
superficial squamous layers of the bladder. Next come the cells from the renal 
pelvis, the ureters, the prostate and the tubules of the kidney. The average size 
and the average shape should always be taken into consideration, not the many 
transitional sizes which are confusing. (See Fig. 103.) 

(a) Renal Epithelium. — These cells are the most difficult, yet the most 
important, to identify in the urine. They do not occur in normal urine, save in 
such small numbers that they may be disregarded. Their presence in any 
numbers is indicative, at least, of renal irritation ; when accompanied by or ad- 
hering to casts, they mean nephritis. 

The chief diagnostic characteristic of renal cells is that they are at least 
one third larger than the pus corpuscles. This relation is constant. If the 
renal epithelia are small in a given case, the pus corpuscles will also be small. 
The illustration shows the comparative sizes of pus corpuscles and renal epi- 
thelia. The smallest group is that of red corpuscles, which are the smallest 
cellular elements in the urine. The next group is composed of pus cells. Then 
follow the smallest epithelia, the renal, which are one third larger than the 
pus cell. The next group shows cuboidal cells twice the size of the pus cell. 
These may be either from the ureter or from the prostate. 

The epithelia from the straight collecting tubules are not frequently seen. 
They are about the same size as. the epithelia from the convoluted tubule, but 
narrower and columnar in shape. 

Renal epithelia, pus and pelvic epithelia, especially when accompanied by 
casts, are indicative of a pyelonephritis. It is important to look for epithelial 
casts and to compare the size and appearance of the epithelia on these casts 
with other renal epithelia found free in the urine. In this way we often con- 
firm our opinion that a given set of round cells are from the kidney. It is al- 
ways important, however, to compare the tubular epithelia with the pus cell. ^ 

(b) Epithelia from the Renal Pelvis. — These cells are of two types. 
The superficial layers shed a characteristic caudate, pear-shaped or lenticular 
cell. The deeper layers are represented by round or cuboidal cells, smaller than 
the bladder epithelia. 

The caudate cells of the pelvis are distinguished from those of the ureter 
and from the columnar cells of the bladder by various features. The pelvic 
cells are twice the size of a pus cell; they have more distinct nuclei; their 
granules are well marked and they often have jointed or bifurcated tails. They 
are smaller than those from the bladder and slightly larger than those from the 
ureters. The presence of these caudates is characteristic, when present in large 
numbers and accompanied by pus, of pyelitis. 

The round cells from the pelvis are not so characteristic, and fortunately 
are not so frequently seen, as they may be confused with renal cells. They 



MICKOSCOPICAL EXAMINATION 103 

often occur in clumps of considerable size, are always accompanied by pus, and 
indicate chronic pyelitis. 

(c) Epithelia from the Ureters. — These occur in the urine of uretero- 
pyelitis, stone in the ureter, etc. They are also found in normal specimens ob- 
tained bv the ureteral catheter. There are two forms of ureteral cells. The 
majority of epithelia from the ureters are round or cuboidal, smaller than those 
of the pelvis but of the same size as those of the prostate. They rarely occur 
without pelvic epithelia, and can be differentiated only when the renal and 
pelvic cells are present. The ureteral epithelia are twice the size of a pus cell 
and are comparatively rarely seen. They resemble a small narrow caudate 
spindle, having a small bright nucleus. These cells are rarely found in sedi- 
ments and are very similar to those of the deepest layers of the bladder, but 
are much smaller. 

(d) Epithelia from the Bladder. — The upper layers of the bladder 
strata are flat. They occur in moderate numbers in normal urines, but in cys- 
titis and other bladder diseases are greatly increased and modified. They occur 
either free or as fragments of cells irregular in size and shape. The largest of 
these flat cells are found near the neck of the bladder, and are apt to be confused 
with vaginal cells. The average superficial bladder cell, however, is smaller and 
has more rounded outlines than the vaginal cells. The latter also often contain 
bacteria. 

The middle layers are composed of cuboidal epithelia. These are present 
in moderate or in large numbers in acute cystitis, in conjunction with cells 
from the upper layers. When chronic cystitis is present, the middle layers 
are represented by a majority of the bladder cells found in the urine, as 
by this time the superficial layers have been to a marked extent destroyed. 
In addition, in chronic cystitis, the cells present are found filled with fatty 
granules of various sizes, and many of them are in a state of partial dis- 
mtegration. 

The deepest layers of the bladder are composed of columnar cells which are 
rarely found in the urine, save in ulcerative processes, in tumors, and in cases 
of intense inflammation. 

(e) Epithelia from the Ejaculatory Ducts and the Seminal Vesi- 
cles. — Epithelia from the ejaculatory ducts are elongated cylindrical and cili- 
ated, though the cilia may be broken off. These cells are easily recognized by 
their shape. 

Epithelia from the seminal vesicles are columnar, nonciliated, and some- 
times contain a yellow pigment. They are rather larger, broader and less 
regular than the epithelia from the ejaculatory ducts. 

Epithelia from the ejaculatory ducts and from the seminal vesicles occur 
in the urine in cases of seminal vesiculitis, and vesiculo-prostatitis. They are 
often associated with pus cells, urethral cells and prostatic cells. 



104 THE URINE 

(/) Prostatic Epithelia. — There are two types of epithelia from the 
prostate. The ducts of the gland are lined with columnar, the acini with cu- 
boidal cells. The cuboidal epithelia are twice the size of pus cells, and are 
identical with the epithelia from the ureter. Prostatic epithelia, however, do 
not occur in association with renal and pelvic cells. They are apt to be asso- 
ciated with pus, with spermatozoa and amyloid bodies from the prostate. 

(g) Epithelia from the Urethra. — The stratified lining of the urethra 
is represented in the urine by cells of a great variety of shapes. The super- 
ficial cells are present in the milder grades of inflammation and are squamous 
or cuboidal. They are always smaller than the bladder cells and larger than 
any other cells from the tract. The deeper layers of the urethra, with their 
smaller cylindrical cells, are less frequently represented, appearing in the 
deeper and more chronic processes. In such cases they show numerous fat 
granules and are often fragmented. 

(h) Epithelia from the Vagina. — The largest cells in the urine come 
from the vagina. Usually the superficial squamous cells are represented ; in 
fact, they are present in the urine of most women in health. In vaginitis, they 
are increased in number, accompanied by bacteria, mucus and pus. These cells 
may be found wrinkled or folded and show fine granules or fat globules. 

Thp cuboidal epithelia from the middle strata of the vagina are found in 
severe, especially in chronic, vaginitis ; and may contain fat granules. The col- 
umnar epithelia from the deepest layers are seen only in very extensive ulcera- 
tions. All vaginal cells are larger than those of the corresponding layers of the 
bladder. 

(i) Epithelia from the Uterus. — These do not often occur in the urine. 
They cannot he differentiated from urethral epithelia. The mucosa of the 
uterus itself sheds cylindrical ciliated epithelia, the presence of which indicates 
endometritis. 

4. Urinary Casts. — Three views are held as to the formation of casts: (1) 
That they are the result of the disintegration of the epithelium of the renal 
tubes, the resulting products being packed into molds by the pressure of the 
urine and at last forced out. (2) That they consist of a morbid secretion from 
the renal epithelium similarly caked into molds. (3) That they are formed 
from the coagulable elements of the blood (serum) albumin which gain access 
to the renal tubes through pathological lesions of the latter, and that any de- 
tached portions of the tubules become entangled in this coagulable product, 
assisting to form the mold which afterwards appears in the urine. This latter 
view is the one most generally accepted. 

Casts may be conveniently divided for purposes of study, into ten kinds, 
viz.: 

(a) Hyaline casts, whose origin and nature are still a matter of discussion, 
appearing as narrow hyaline, broad hyaline and comixjsite casts. 



MICROSCOPICAL EXAMINATION 



105 



(b) Granular casts, made up of a hyaline basis, containing granules of dis- 
inte^ated leucocytes, and red and epithelial cells. 

(c) Epithelial casts, made of unchanged anatomical elements, including 
red blood corpuscles, leucocytes, epithelial cells, or bacteria. 

(d) Blood casts. (h) Amyloid casts. 

(e) Pus casts. (i) Mixed casts. 

(f) Fatty casts. (;) Cylindroids. 
{g) Waxy casts. 

(a) Hyaline Casts (Fig. 104). — These are the pale structures of variable 
but usually considerable length, sometimes very difficult to detect in the sedi- 
ment. Sometimes they are transparent and free from granules; more fre- 
quently they present fine granulations of a very light color. They may also 
have a few dropi of fat or fragments of epithelium adhering to the surface. 
The origin of the hyaline cast has been variously explained as a result of secre- 
tion from the epithelia of the kidney, or as a coagulation of the albumin or its 
derivatives excreted with the urine. In support of the latter view it is stated 
that they are found only when the urine is albuminous, or has lately been so. 
The occurrence of albumin and casts may not be simultaneous. 

It is a mistake to regard the presence of very small narrow hyaline casts as 
of no great importance, as is sometimes done, for they are often the chief 
urinary sign of the existence of a very grave disease of the kidneys, namely, 
chronic interstitial nephritis in which the albuminuria may be slight or absent. 




Fio. 104. — Htaxinb Casts. 




Fia. 105. — Granular Casts. (Ogden.) 



a, granular cast. c, coarsely granular cast. 

6, finely granular cast. d, brown granular cast. 

e, granular cast with normal and abnormal blood adherent. 
/, granular cast with renal ceUs adherent. 
0, granular cast with fat and a fatty renal cell adherent. 



(6) Graxitlak Cast8 (Fig. 
105). — This form of casts, 
resulting from the metamor- 
phosis of anatomical elements, such as epithelium, pus, or blood, is found in 
the urine in great variety. The casts vary much in shape and appearance 
and are most often seen in fragments. They are irregular, in both fine 
and coarse outline, with ragged ends, the granules varying from those which 



106 



THE URINE 



require the higbest powers to discover to a relatively coarse size which gives its 
name to the cast. They are of various colors — ^yellow, gray, or brown — and 
may have scattered over their surfaces epithelium, leucocytes, fat globules, or 
fatty crystals. Granular casts have generally been regarded as evidence of 
pathological changes in the kidney of a chronic d^enerative nature. 

(c) Epithelial Casts (Fig, 106). — This form is due to pathological con- 
ditions which cause the exfoliation of the renal epithelium. At times this is 
thrown off intact for short distances, resulting in cylinders with lumens ; or 
the cast may be solid, the body being hyaline and the epithelia adherent to it. 
The cells when seen under the microscope appear more or less swollen and gran- 
ular, with ill-defined margins. Sometimes the epithelial cells appear as rows 
or patches scattered over the surface of the cast. In other cases the epithelia 
have undergone degeneration and present dots of fat, significant of chronic 
inflammation of the kidney and consequent fatty change. Finally, some casts 
consist of epithelial cells alone, glued together. Casts of epithelial variety are 
usually of medium size and length, refracting light to a marked degree and 
therefore easy to find with the microscope. They resist the action of chemical 
reagents more than most varieties. Epithelial casts always signify inflamma- 
tion of the kidney and are therefore of great diagnostic worth. 




TB, CouPOBBD Wholly of 
K CoHpnscij;s on Htaune Sdb- 
BID WITH Blood Cobfubclbb. 



Pio. 106. — Epithelial Castb. 

- (d) Blood Casts (Fig. 107).— 
Blood casts appear in the urine under 
conditions which cause hemorrhage 
in the renal tubules. The corpuscles 
may be well preserved and glued to- 

getlier to form perfect molds of the renal tubes, usually short and of uniform 
diameter with rounded ends. 

These casts are found in nephritis, especially acute, in hemorrhages, acute 
renal congestion and hemorrhagic infarction of the kidney. They do not in 
themselves furnish positive proof of organic renal disease, but, on the other 
hand, blood casts are positive evidence of renal hemorrhage. These casts are 
among the rarer kinds and are usually hard to find, since a large sediment of 
blood corpuscles is apt to accompany them and obscure the microscopic field. 



MICROSCOPICAL EXAMINATION 



(e) Pus Casts (Fig. 108). — Casts composed altogether of p»s are very 
rare. Compound easts, however, may present a few corpuscles here and there 



Flo, 108. — Pes Cabtw. 




Fia. 109.— Fattt and Other Casts, (Ogden.) 
1. epithelial cast. 3, pua cast. 

t, blood cast. 4. fatty cast. 

5, fatty cast with compound granules and fatty 

renal cells adherent (cryatalfl of the fatty acid 

protruding). 



on their surface. They signify puni- 
leiii inflammation in the kidney itself 
— i. e,, pyonephritis or pyonephrosis. 
Sacteria are present in pus casts. 

(/) Fatty Casts {Fig. 109). — Oil globules are often found adherent to 
many varieties of easts, whereas others are frequently seen which seem wholly 
made up of fatty material, 
including crystals of the fat- 
ty acids. These fatty acids 
indicate fatty changes in the 
feidneys and are found in 
ttieir most typical form in 
the large white kidney. 
They suggest pathological 
slates of the kidney whose 
chief feature is chronicity, 
since they are the result of 
complete destruction of the 
<*1I protoplasm, which is re- 
placed by fatty elements. 

(s) Waxy Casts (Fig. 
110), — Waxy casta reseiii- 
hle somewhat hyaline easts. 
Tliey are more refraetive, 
Md are yellow or grayish- 
yellow in color and differ 

f"ftIiermore in presenting a Fio. no. — Ttpeb of Cabts with * Waxt Matrix from a 
.[„„] TT i-i Case or Subacute PAREficHruATOus Nephhitis. (Wood) 

cioudv appearance. Lnlike , , , , .,. , 

, ■ ■^' Some Qf the casts are quite transparent, others are granular 

I'.^snne easts, they are not at one end and clear at the other. Some are composed partly 
attacked by acetic acid. ■>( ajamil" ■°f"=- ""d P"tly "' ""y ■»^t'^ri«'- The casts 

_ ' varv Ereativ in sue. but are all drawn to the same scale. 

inter is of the hyaline variety. 




108 



THE UKINE 



loid casts in appearance, yet their presence does not indicate amyloid disease 
of the kidney. It is possible that they were originally hyaline casts which have 
remained in the uriniferoiis tubules for a long time and have there undergone 
certain chemical changes analogous to " amyloid metamorphosis." 

(h) Amyloid Casts. — Amyloid casts resemble in appearance waxy casts. 
They can be differentiated, however, by the addition of dilute iodopotassic 
iodid solution (LugoPs solution), when they assume a mahogany color which 
changes to a dirty violet upon the addition of dilute sulphuric acid. Waxy 
casts do not give this reaction. The presence of amyloid casts is indicative of 
amyloid degeneration of the kidney. 

(t) Mixed Casts (Fig. 110). — The various kinds of casts are sometimes 
found in the same specimen, depending on the stage of pathological process in 
the kidney. 

(;) Cylindroids (Fig. 111). — In addition to the varieties of casts men- 
tioned, the urine may contain what are called cylindroids. These are long, 

wavy, ribbonlike .structures, 
which often divide and sub- 
divide at their ends. The ends 
may be folded or twisted. 
They are pale, colorless and 
of greater length than casts, 
and seldom have cells adher- 
ent to them. They appear 
flat and do not give the im- 
pression of being solid struc- 
tures like the true renal casts. 
It seems probable, however, 
that these cylindroids come 
from the renal tubules. Thev 
occur in nephritis, cystitis and 
in renal congestion, and may 
be present in urine which 

Fio.iii.-<>rLiNDRoiD8 OR FAL8B Casts. (After Peyer.) contains no albumin. They 

are not characteristic of kid- 
ney disease, but ratlier of irritations of the lower urinary tract, which have 
extended to the kidney. 




Note. — To find casts with the least delav, the urine should be voided 
freshly, immediately centrifuged for three minutes, and four to six drops of 
the sediment taken up with the pipette and placed on a perfectly clean slide, 
a cover glass laid on, the excess urine removed by blotting paper, and the speci- 
men examined with a quarter-inch objective in not too bright a light. Hyaline 



MICKOSCOPICAL EXAMINATION 109 

casts may be overlooked, but when the focus has been carefully adjusted, if 
the field be darkened gradually till perhaps one third of the illumination is 
cut off, and the slide be moved slowly about, the contents of the field are viewed 
in different lights and the outlines or shadows of the hyaline casts may be de- 
tected. If doubt exists as to the nature of a cast, slight pressure on the cover 
glass will cause currents under it and cause the cast to turn. 

5. Shreds. — Under the Microscopical Examination of Sediment, something 
should be said of shreds voided with the urine in an acute or chronic process 
of the genito-urinary tract If they are derived from destructive processes in 
the bladder, prostate, or the kidney, they contain connective tissue. Shreds 
not due to destructive lesions are the result of subacute or chronic urethritis, 
prostatitis, pyelitis, or cystitis. 

Several varieties of shreds may be distinguished: (1) Pus shreds, (2) 
mucous shreds, (3) muco-pus, and (4) epithelial shreds. The characteristics 
of these four varieties are sufficiently well marked to be readily recognized by 
the microscope. 

Examination of Shreds. — They are carefully "removed from the urine 
with a platinum loop and spread upon a slide with a few drops of water, teased 
apart with a needle if they are thick, and a cover glass placed over the speci- 
men, after which their composition can be determined. For a bacteriological 
examination, the shreds can be stained like tissue sections. For this purpose 
the following method can be employed. 

1. Fix with alcohol and ether for ten minutes. 

2. Stain for one or two minutes with Unna's polychrome methylene blue. 

3. Wash in distilled water. Dry. 

4. Dehydrate for a few seconds in ninety-five-per-cent alcohol. Dr^' with 
filter paper. 

5. Clear in xylol or in clove-thyme mixture. 

6. Mount in balsam. 

Massage Products in the Urine. — After massage of the prostate and 
vesicles, certain products may be voided with the urine and these should, there- 
fore, be mentioned under Examination of Sediment. 

In chronic inflammations and infections of the prostate and vesicles, the 
urine contains many pus cells and red blood cells, together with shreds. In 
seminal vesiculitis after massage, large masses of the secretion of the seminal 
vesicles, together with inflammatory detritus, are thrown off, looking like meal 
in the water, and sometimes like a thick white lump. These are often so large 
and thick as to block the urethra for an instant. In addition to these elements, 
the urine, after massage of the prostate and vesicles, very frequently contains 
other products, the significance and pathology of which are not quite so clear. 
1 call them tapioca, sugar granules, skin flakes, and snowflakes. 



110 THE URINE 

Sago Bodies, — Sago bodies consist of round or ovoid masses, of a semi- 
opaque, yellowish-white, colloid material, varying in size from a barley com 
to a lentil. Under the microscope they are found to consist of homogenous col- 
loid matrix, in which are imbedded motionless spermatozoa. 

Tissue Shreds. — Tissue shreds are never found in the urine under normal 
conditions. They are always evidence of tissue destruction or deep-seated in- 
flammation, and are found in ulcerative conditions, in tuberculosis, trauma, 
tumors, and abscess of the prostate. 

Sugar Granules, — These bodies resemble granules of melting sugar; they 
are much smaller than sago bodies, of the same transparency and light-yellow 
color. They are often present in large quantity, falling rapidly to the bottom 
and dissolving in a few minutes. Microscopically they are homogenous, struc- 
tureless bodies, consisting of a highly refractive matrix, in which there are few 
or no spermatozoa and cellular elements. 

Skins. — These are delicate, opaque, white, skin or membranelike fragments. 
They are composed of thickened inspissated vesicular secretion which has lain 
for a considerable time in the organ. They represent a deposit of secretion 
that has been formed in some of the recesses of the seminal vesicles and has 
been loosened and pushed through the ejaculatory ducts by massage. Skins 
are found especially abundant in men who have abstained from sexual inter- 
course for a long time, especially if a chronic catarrhal condition is present. 
Snowflakes represent a similar accumulation that has lasted but a short time 
and are much lighter and more flaky. 

V. BACTERIOLOGY OF THE URINE 

Although germs have been found in the urine of healthy persons, the ma- 
jority of investigators state that the urine in health is sterile, provided it be 
obtained by sterile instruments and under proper precautions. The blood and 
the various tissues and organs of the body also are said to be free from bacteria 
in health. During and after infectious diseases, such as typhoid fever, grip, 
pneumonia, and septic infection, germs are often found in the urine. 

Inasmuch as the urethra is always inhabited by saprophytic bacteria, the 
urine flowing from the meatus can hardly be expected to be absolutely sterile, 
all the more so because it is often mixed wdth bacteria from the surface of the 
glans and prepuce in men and from the vulva in women. Therefore, an or- 
dinary specimen of urine freshly passed even in health will certainly contain 
some bacteria. 

Experiments have proved that the urine possesses bactericidal properties 
in health and shown that the absence of bacteria from normal persons may mean 
that the germs have been destroyed by virtue of this property. It has also 
been shown that fresh urine has the property of destroying the anthrax, cholera 



PLATE II 




Fig. 1. — Staphylococcus pyoqenes 

AUREUS. 





Fig. 2. — Streptococcus pyogenes. 



Fig. 3. — Bacillus coli. 



BACTERIA FOUND IN THE URINE. 



BACTERIOLOGY OF THE URINE HI 

and less constantly the typhoid bacilli, by virtue of the presence of the acid- 
potassiiim phosphate. If the urine is neutralized by addition of alkalies, its 
bactericidal property tends to disappear. Possibly the chlorids or some other 
constituents may also act as antagonists of the bacteria. 

In disease, the bacteria which may occur in the urine are many. A few 
of them, however, are of importance, as they play a prominent role in the causa- 
tion of urinary affections. These important special germs are the gonococcus, 
the tubercle bacillus, the colon bacillus, the Streptococcus pyogenes, and the 
Staphylococcus pyogenes aureus and albus, the Bacillus proteus of Hauser, the 
typhoid bacillus, which occurs in the urine in typhoid fever, and rarely the 
Bacillus pyocyaneus. Still more rarely the pneumobacillus of Fraenkel is 
found. In certain infectious diseases, such as anthrax, plague, etc., the cor- 
responding germs have been found in the urine. With the exception of the 
last-mentioned germs, which are rarely found in the urine, all the above-men- 
tioned germs have been known to produce cystitis. The following is a list of 
germs concerned in the causation of suppurative inflammations of the kidney, 
ureter, and bladder in the order of frequency : 



These may be saprophytes in the 
urethra, especially in the female. 



1. The colon bacillus, 

2. The Bacillus proteus vulgaris, 

3. The Staphylococcus pyogenes, 

4. The Streptococcus pyogenes, 
6. The tubercle bacillus, 

6. The gonococcus. 

7. The typhoid bacillus. 

8. The Bacillus pyocyaneus (rare). 

The gonococcus is found in the urine in gonorrheal infections of the 
nrinary tract and the tubercle bacillus in tuberculous infections. The germs 
of suppuration, such as the streptococcus and staphylococcus, and the colon 
and proteus bacillus are found in suppurative conditions of the kidneys, pelvis, 
ureters, etc. 

Bacteria in the Urine 

Hode of Entrance. — Grerms may be introduced from the urethra or from 
the outside into the bladder either by unclean instruments or simply by pushing 
germs present in the urethra into the bladder with sterile instruments. A 
urethral infection also may be transmitted by continuity to the bladder, where 
the germs will then appear in the urine. If the bladder is sterile and the 
urine therein free from germs and if the urethra is infected, the urine, of 
course, may wash numerous germs from the urethra into the vessel in which the 
sample is collected. These modes of infection of the urine are practically self- 



112 THE URINE 

evident. Infection of the urine in the bladder by germs transmitted from the 
normal urethra does not occur in man, owing to the fact that the vesical sphinc- 
ter shuts off the bladder from the urethra. On the other hand, in women, blad- 
der infection may occur through the healthy urethra. 

In addition to an infection from the urethra upward, the urine may become 
contaminated also by the entrance of bacteria into the kidney through the cir- 
culation (especially of the tubercle bacillus), and by the passage of bacteria 
into the bladder through the intestinal wall. 

The question of a descending infection has been demonstrated both experi- 
mentally and clinically. It is difficult to understand at first how bacteria can 
infect the kidney from the bladder when the stream of urine apparently tends 
to prevent this by opposing the ascent of the germs. Animal experiments, 
however, have shown that under certain conditions, the contents of the bladder 
regurgitate into the pelvis of the kidney. When the germs reach the pelvis, 
they may enter through the lymphatics of the kidney, less frequently through 
the urinary tubules, and more rarely through the capillaries of the kidney. 
The entrance of germs from the blood through the kidneys into the urine has 
been repeatedly demonstrated. Germs may enter the bladder directly from the 
intestine in cases in which the bladder is damaged, or from the intestine into 
the blood and thence into the kidney. 

The Oonococcus in the Urine. — To avoid repetition, we have grouped all 
data on the gonococcus in the chapter on the Examination of Urethral Dis- 
charges. 

The gonococcus is usually found in the urine in urethritis, sometimes 
in prostatitis and vesiculitis after massage, and occasionally in cystitis, pyelitis 
and pyelo-nephritis in ascending infections of gonorrheal origin. The germ is 
much more difficult to detect in the urine than in smears of discharge. In the 
urine, it is always accompanied by pus and is to be looked for within the cyto- 
plasm of the pus cells, or upon the epithelia of the sediment. The methods of 
obtaining and precipitating the sediment for such examination has been given 
in the preceding pages. 

The Tubercle Bacillus. — The tubercle bacillus occurs in the form of a small 
rod, one quarter to one half as long as the diameter of a red blood corpuscle. 
The rods are delicate, straight, slightly bent or curv^ed, and somewhat beaded; 
They occur either singly or in groups, especially in the form of tufts which 
are commonly found in the urine. At times they are found also within the 
body of the pus cell. In some specimens, the ends of the rods are somewhat 
clubbed or branched, or present swellings at different points. In stained 
preparations, the bacilli show alternation of stained and colorless portions. 

Method of Staining. — The detection of the tubercle bacillus depends 
upon its characteristic behavior toward anilin dyes and decolorizing agents. 
The penetrating power of the dye used must be increased by the addition of 



PLATE III 




^ !/ 





Fig. 1. 



Fig. 2. 



BACTERIA, SHOWING THE OPSONIC ACTION INCREASED BY THE PROPER 

ADMINISTRATION OF BACTERIAL VACCINES. 



Fig. 1 . — Tubercle Bacilli in Sputum. The 
tubercle bacilli are stained red with carbol- 
fuchsin. At A the bacilli are inside the 
leukocytes, showing phagoc3rtosis, or that 
the bacteria have been prepared for inges- 
tion by the opsonins. B shows the bacilli 
outside the leukocjrtes not prepared for in- 
gestion by the opsonins. 



Fig. 2. — Gonococci in Urethral Pus. The 
gonococci are stained with methylene blue. 
At A the cocci are inside the leukocytes, 
showing phagocytosis, or that the bacteria 
have been prepared for ingestion by the 
opsonins. B shows cocci outside the 
leukocytes not prepared for ingestion by the 
opsonins. C shows the cocci having prob- 
ably been ingested by the white blood- 
corpuscles, but the toxins of the gonococci 
have destroyed the leukocytes. 



BACTERIOLOGY OF THE URINE 113 

either carbolic acid or anilin oil and by the application of heat. Oncis stained 
in this way, the bacilli resist acids, and upon this depends the differentiation 
from other bacteria in the same specimen. 

ZiehUNeelsen Method. — This is the method in common use for staining tu- 
bercle bacilli in the urine. 

The sediment is obtained in as concentrated a form as possible, and spread 
in a thin layer upon a slide or cover glass and allowed to dry in the air. The 
preparation is then fixed in the usual way in the flame of a Bunsen burner. 
The specimen is then covered with some filtered Ziehl-lN^eelsen carbol-fuchsin 
solution (five-per-cent aqueous solution carbolic acid, ninety parts; saturated 
alcoholic solution of fuchsin, ten parts) and held over the flame of a Bunsen 
burner, allowing the solution to steam for one or two minutes without bringing 
it to the boiling point The specimen is then washed in a stream of running 
water and immersed in five-per-cent sulphuric or thirty-per-cent nitric acid. 
The film turns yellow or brown, but, on washing again in water, the red color 
reappears. The operation is then repeated until only a very faint tinge is left 
and no more of the stain is given off. The specimen is now washed for from 
ten to fifteen minutes in strong (ninety-five per cent) alcohol, followed by rins- 
ing in water. In staining a urine specimen, the use of alcohol is an important 
step as a means for excluding the smegma bacillus, which is decolorized by 
alcohol. The specimen is now covered with a weak, watery solution of methy- 
lene blue, which is allowed to remain for from one to two minutes. After wash- 
ing and drying, the specimen is ready for examination with an immersion lens. 

Differentiation. — The tubercle bacillus may be confounded morphologic- 
ally with two different germs: the smegma bacillus and the leprosy bacillus. 

The smegma bacillus is most often confounded with the tubercle bacillus. 
It occurs in the decomposing secretion around the genitals. In obtaining speci- 
mens of urine for examination for tubercle bacilli, care must be taken, first, to 
wash the external genitals with soap and hot water, so as to remove any smegma 
germs, and then to draw off the urine with a sterilized catheter. If, in addi- 
tion to these precautions, the specimens are washed in alcohol after decolorizing, 
as previously mentioned, there is very little danger of error in the microscopical 
diagnosis. 

The lepra bacilltis resembles the tubercle bacillus both in shape and stain- 
ing properties, but is somewhat shorter, thicker, and stains unevenly. It oc- 
curs, however, so rarely, that its differentiation from the tubercle bacillus need 
not be discussed here. 

Animal Inoculation, — In case of doubt as to the nature of the bacillus and 
in instances in which repeated examinations of urinary sediments do not show 
any tubercle bacilli, although clinically tuberculosis is suspected, recourse may 
be had to inoculation of animals and to cultures on artificial media. The ma- 
terial should be introduced subcutaneously or into the peritoneum, the former 



114 THE URINE 

method taking from four to ten weeks, the latter from ten to twenty days for 
tubercular lesions to develop when tubercle bacilli are present If smegma 
bacilli only are present, no lesions develop. At the end of the time stated, an 
autopsy is performed upon the animal, and the site of puncture, the peritoneum, 
the lungs, and other organs are examined for tubercles. 

The Colon Bacillus. — The colon bacillus occurs normally in the intestine 
of man, bovines, dogs, and other domestic animals. Its close resemblance to 
the typhoid bacillus makes it an object of interest. Certain features, however, 
distinguish it from the typhoid bacillus, and it is regarded as a distinct species 
of germ. The colon bacillus may under favorable conditions produce serious 
disease. It is the cause of local suppuration in a great variety of organs, and 
also produces at times general septic infection. The colon bacillus plays an 
important role in urinary affections, as it is one of the chief germs concerned 
in the causation of cystitis, and is found also in the urine and the purulent 
sediment in cases of infection of the kidney, the pelvis, and ureter. 

Morphology. — The colon bacillus occurs in the form of rods, with rounded 
ends, which may vary in two directions : they may be either so short as to ap- 
pear almost like cocci or so long as to resemble threads. No spores have been 
demonstrated, but flagella may be shown by LoefHer's method. It is motile in 
most cases, but often its movements are very slow. 

Staining Properties. — It stains with ordinary anilin dyes and is decolor- 
ized by Gram's method. 

Streptococcus Pyogenes. — The Streptococcus pyogenes is the cause of local 
inflammatory and suppurative processes and of general infections such as sep- 
ticemia. In the urinary tract it is found in inflammatory conditions of the 
urethra, bladder, kidney, pelvis, and ureter, either alone or more generally in 
company with other germs of suppuration, as the tubercle bacillus, with which 
it is very frequently associated. 

The Streptococcus pyogenes occurs in the form of chains of minute round 
or oval cocci resembling strands of beads. Sometimes two or more cells in the 
chains coalesce to form a somewhat longer segment. The chains may be short, 
consisting of a few cells, or very long. Sometimes the cocci composing a chain 
divide simultaneously, so that a chain of diplococci may be seen. The strepto- 
coccus stains easily with anilin dyes and usually stains with Gram's method. 

Staphylococcus Pyogenes Aureus. — The Staphylococcus aureus is the most 
common of the germs of suppuration. It occurs in abundance everywhere, and 
is the usual cause of wound infection. It is present in the normal as well as 
the diseased urethra, is frequently found in the bladder in cystitis, and plays 
a prominent part in infections of the kidney, either alone or accompanying 
other germs, as the colon bacillus, the streptococcus, etc. In tuberculosis of the 
urinary tract, it is often present as a complicatory organism, along with other 
germs of suppuration. 



BACTERIOLOGY OF THE URINE 115 

It occurs in the form of round or oval cocci arranged typically in clusters, 
but often in pairs. In preparations from pus, they are found outside the pus 
cells, rarely within these bodies. It stains readily with the basic anilin dyes and 
is not decolorized by Gram's method. 

Staphylococcus Pyogenes Albus. — Microscopically, this variety cannot be 
differentiated from the Staphylococcus pyogenes aureus. The difference be- 
tween the two lies in the appearance of the cultures. The occurrence and sig- 
nificance of the two varieties are very similar. 

Bacillus Proteus Vulgaris. — The Bacillus proteus frequently occurs in cys- 
titis. It occurs as short and long bacilli, and also in the form of threads. It 
is markedly motile and shows numerous flagella. It stains well with basic 
anilin dyes and is not decolorized by Gram's method. It forms grayish-white, 
minute colonies upon agar, which later coalesce into a dirty-gray translucent 
film. On gelatin it grow^ in the form of grayish-white colonies and liquefies 
the medium rapidly. 

The proteus is frequently found in suppurative conditions in the urinary 
tract, especially in cystitis. Experimental cystitis has been produced by in- 
jecting cultures into the bladder in animals. 

Bacillus Pyocyaneus. — The Bacillus pyocyaneus, or bacillus of green pus, 
is mentioned here as a germ occasionally found in cystitis. It is found in 
fetid pus from wounds. It is a delicate rod with rounded or pointed ends, 
actively motile and does not form spores. It occurs in irregular masses or 
singly ; grows on all the ordinary media, giving a characteristic green color to 
the same, which becomes blackish in old cultures. The bacillus stains with 
the ordinary anilin dyes. 

Other Microorganisms of Minor Importance. — The rays or granules of 
Actinomyces may be found in the urine when this infection affects the genito- 
urinary tract or when this fungus is present in the system and finds its way 
into the urine. 

The Micrococcus ureos is the germ which occurs in long chains consisting of 
large cocci. It occurs in urines undergoing ammoniacal fermentation and de- 
composes urea into ammonia. 

Yeast cells and molds of various kinds are very often found in the urine, 
entering either from the air or as a result of contamination from the vessels 
in which the urine is collected. 

Methods of Examining the Urine for Bacteria 

Sp)ecimens of urine which are to be examined bacteriologically should be 
obtained from the bladder by means of a sterile catheter (introduced after copi- 
ous washing of the urethra with boric-acid solution), collected in a sterilized 
bottle, and handled thereafter only with sterile apparatus. Before introducing 



116 THE URINE 

the catheter, the external genitals in either sex should be thoroughly cleansed 
with soap and hot water and the smegma removed from the neighborhood of 
the orifice of the urethra. The urine should be examined, as a rule, as soon as 
obtained, especially w4ien looking for tubercle bacilli, so as to prevent decompo- 
sition and multiplication of extraneous germs. 

Centrifugation is a rapid and most satisfactory method of obtaining bac- 
terial sediments. The centrifuge sediment is drawn up by a slender pipette, 
and spread on slides and allowed to dry. The spread preparations are then 
fixed by immersing in alcohol and ether, equal parts, or by passing slowly 
through the Bunsen flame. Care must be taken always to spread the film very 
thinly. The successful fixation of the sediment depends upon the presence of 
a certain amount of pus containing coagulable proteid substances. When these 
are absent in the urinary sediment, as sometimes is the case, fixation on the 
slide is not easily accomplished without the addition of egg-albumen. The 
sediment is taken up with a platinum loop and spread upon a slide, upon which 
a drop of a mixture of egg-albumen and glycerin has previously been placed, 
and then fixed as alreadv described. 

Shreds from the urethra, clumps of fibrin, masses of epithelium and other 
tissue elements which may be found in the urine, may be examined for bacteria 
after being fished out with a platinum loop and spread on the slide and stained. 
They are fixed and stained in the same manner as the other smears from the 
urinary sediment, but especial care should be taken to spread them very thinly 
by means of a platinum needle. It is difficult to detect germs in these shreds 
of tissue under the best conditions. 

When the bacteria looked for are absent from the sediment on microscopical 
examination of stained preparations, cultures and inoculations into animals 
may be resorted to — methods to be employed when the importance of the diag- 
nosis requires them. The details of cultivation and animal inoculation are 
given under the headings of the respective germs. 



CIIAPTEK IV 



DISCHARGES 



Under this heading we sliall consider tlie character of all discharges from 
tbe genitourinary tracts of men and women, whether they be normal or ab- 
normal. In the list of discharges are included urethral, prostatic and seminal 
elements, which are best considered under the headings of : 

Urethrorrheaj Chancroidal Urethritis, 

Prostatorrhea, Acute Gonorrheal Urethritis, anterior 

Spermatorrhea, and posterior, 

Xonspecific Urethritis, Chronic Gonorrheal Urethritis, 

Tubercular Urethritis, Chronic Prostatitis, 

Syphilitic Urethritis, Chronic Vesiculitis. 

Discharge for examination is taken in the following manner: 
Taking' of the Specimen. — In men, take a slide between the thumb and fore- 
finger of the right hand (Fig. 112), and the glans in the same way with the left 




Fig. 112. — Manker of Holding the Slide in Taking a 
SpBcnacN OF Urethral Discharge in the Male. 



117 



118 



DISCHARGES 



hand, and apply the surface of the slide to the meatus (Fig. 113). The dis- 
charge on the glass should then be smoothed out on the slide. If none is ax)par- 

ent, draw the finger along the urethra 
and express its contents from the 
meatus. If nothing appears, insert a 
platinum loop (Fig. 114) into the 
fossa navicular! s and even farther 
down the canal to see if some can be 
obtained. If so, the secretion adhering 
to the platinum loop can be smoothed 
out on the surface of the slide for 
examination. When the discharge is 
abundant,' a sufficient amount can be 
taken on a platinum loop for exam- 
ination and it is not necessary to 
apply the slide to the meatus. 

In women, the patient should be 
placed on the table with the feet in 
the stirrups. If there is a discharge 
about the vulva, a slide can be pressed 
against it and smear Ko. 1 can be 
taken. 
The vulva should then be sponged until cleansed. This exposes the open- 
ings of the vulvo-vaginal glands on the inside of the labia majora, so tliat the 
contents can be expressed by the finger placed upon the gland and drawn along 




Fio. 113. — The Urethra Squeezed Between the 
Thumb and Forefinger and Pua Appearing at 
the Meatus. 




Fig. 114. — Platinum Wire to be Passed Down the Urethra, to Take Some Discharge from 

its w^alls. 



its duct. If discharge appears, it should be taken on a slide smear Xo. 2. The 
labia should then be separated by the thumb and forefinger of one hand, when 
discharge may be seen at the meatus. If none is seen, the forefinger of the 
other hand should be inserted into the vagina as far as the bladder and then 
drawn along the urethra (Fig. 115), by which means a drop of moisture may 



URETHROKEHEA 



119 



appear at the meatus. The smear is then obtained by placing the slide against 
the mouth of the urethra, or else by taking it with a platinum wire (Smear 
Xo, 3). A speculum should then be introduced into the vagina and its wall 
and the cervix uteri examined. If discharge is seen at the orifice of the cervical 
canal, it can be taken by means of a forceps, a swab or a platinum loop and 
then placed upon a slide (Smear No. 4). Figs. 116 and 117 show slides 
with i 



Flo. 115. FOBCINQ THE DlSCHAROK 

Oct or the Feuaue Ufusrafu 
BT Pbibbuks Aoainst thb Ca.- 




Fio. 117. — The Slides Tooethek. 
e wrapped up, the iiAme macribod, and scDt U 



Urethrorrhea ex libidine consists of a scant, mucoid discharge which occurs ■ 
as an oozing in conditions of sexual excitement. It is in all probability due to 
an exa^ierated activity of the muciparous glands of the urethra and is inter- 
esting because its appearance, when noted by the patient, is apt to frighten 
one into the belief that he has some urethral disease, or that he is losing 
semen. 

Under the microscope it shows the presence of urethral epithelia, mucus, 
a few leucocytes and a variety of bacteria normally present in the urethra. 
It represents merely an excess of the normal secretion, from which it differs in 
no way when examined microscopically. 



120 DISCHARGES 

The discharge is to be distinguished from prostatorrhea and from sper- 
matorrhea by the absence of the Bottcher's crystals, in the first instance, and of 
spermatozoa in the second. It is differentiated from the discharge of chronic 
urethritis by containing fewer epithelia, and the absence of pus cells and of 
pathogenic germs. 

ProBtatorrhea. — Prostatorrhea consists in a leakage of prostatic fluid from 
the ducts of the prostate. It is characterized by a discharge of a wliite, viscid 
substance from the meatus during defecation, after urination, at times of sexual 
excitement and sometimes on arising after a morning erection. The fluid is 
free from mucin, but rich in proteid substances. 

Microscopic examination shows cylindrical epithelia, leucocytes, lecithin 
globules, amyloid bodies and " Bottcher's " sperm crystals. A few spermatozoa 
also may be found. Bottcher's crystals are rendered more distinct if a drop 

of one-per-ccnt solution of 
ammonium phosphate is added 
to the discharge (Fig, 118), 
They are rhombic prisms end- 
ing in fine points or rhombic 
margins. If one of these 
prisms lies upon the other a 
cross is formed and if several 
are placed across each other a 
rosette is produced. 

Spermatorrhea. — Sper- 
matorrhea ia an atonic condi- 
tion, due to passive congestion 
and leakage from the urethra 
and all contributing genital 
channels. It is characterized 
by oozing out of the semen, 
with or without erection or 
pleasurable sensation, <hie to 
erotic tlioughts, or light me- 
chanical stimuli. It may, however, occur after urination and defecation, as in 
prostatorrhea. It is thick and viscid and under the microscope shows large 
numbers of spermatozoa, by which it is differentiated from prostatorrhea. 
Amyloid bodies may or may not be present. Besides spermatozoa, the discharge 
contains testicular cells, cylindrical epithelial cells from the seminal vesicles 
and the prostate, flattened epithelial cells from the urethra, large round cells 
from Cowper's glands and pigment granules. 

Nonspecific Urethritis. — Nonspecific urethritis is an inflammation of the 
urethra caused by infection with other germs than the gonococcus, or by ren- 



SYPHILITIC URETHKITIS 121 

dering active the saprophytic germs that may be present in a normal urethra 
in a quiescent state. Any irritant may render the quiescent germs active. If 
an irritant is injected into the urethra, such as strong solution of silver nitrate, 
there develops within a few hours a fairly abundant purulent discharge, a non- 
specific urethritis which to the naked eye appears very much like the beginning 
discharge of true gonorrhea. It varies in amount and from white to yellow in 
color. On microscopical examination, this discharge presents a large number 
of fairly normal epithelia from the superficial layers of the urethra, including 
the cuboidal and the columnar varieties, as well as the flat cells from the fossa 
navicularis. The epithelia are mixed with a more or less abundant amount 
of pus, and among and within the pus cells may be noted numerous microor- 
ganisms belonging to the normal urethral flora ; also Staphylococcus albus, colon 
bacillus or streptococcus. 

Tubercular Urethritis. — Tubercular urethritis is nearly always situated in 
the prostatic urethra and secondary to tuberculosis of the prostate. The dis- 
charge is scanty, mucoid, muco-purulent or purulent in character, the amount 
of pus depending upon the presence or absence of mixed infection. The micro- 
scope shows the presence of such bacteria as are found in nonspecific urethritis, 
mucus, urethral epithelia, pus, tubercle bacilli, other microojganisms of sec- 
ondary infection and connective-tissue shreds. When the prostatic urethra is 
involved in cases of tuberculosis of the prostate, prostatic tissue may also be 
found. The specimen is placed on a slide in the way already outlined 
and it is stained and examined in the manner already described in the chapter 
on The Urme. 

Syphilitic Urethritis. — Syphilis may involve the urethra in two ways: 
^ irst, as the initial lesion or hard chancre just within the meatus, and, second, 
as an ulcerating gumma of the glans in the later stages which extends into 
the urethra. 

When the initial lesion is in the form of an erosion, the discharge is usually 
scanty in amount and ranges from a thin mucoid to a sero-sanguinolent or puro- 
sanguinolent consistency. It is sometimes quite profuse when due to an ulcer- 
ating chancre. Microscopical examination shows few red blood cells, pus cells, 
muciis, urethral epithelium and many bacteria. The active organism of syph- 
ilis is the Spirocheta pallida. 

The Spirocheta pallida (Schaudinn) (Fig. 119), or more correctly, Tre- 
ponema pallidum, is a slender spiral-shaped, very motile organism with pointed 
ends, 4 to 14 micromillimeters in length, \ micromillimeter in width. The 
number of its corkscrew-like spirals is extremely variable, and typical forms 
Aare been noted with as few as two to four, or as many as twenty and more, 
t^^X:^, In the other treponema of this group, for example, the Spirocheta re- 
/fingens, the individual twists are fewer, larger and more wavelike. The Spiro- 
cheta pallida is present in practically all acquired syphilitic lesions, including 



122 DISCHARGES 

genital and extra-genttal chaocres, moiat papules, indurated lymph glands, and 

mucous patches, on the surface as well as in the interior of the tissues and in 

the blood. All the organs of 
the body, notably the supra- 
renal glands, the spleen aad 
the liver, have been found to 
contain it in congenital syph- 
ilis. This microorganism has 
never been encountered in 
any disease except syphilis. 
Negative findings in an 
initial lesion do not prove 
that the lesion is not a 
chancre, as In typical initial 
lesions we have failed to 
find it in repeated examina- 
tions. 

The Spirocheta pallida 

may be demonstrated in the 

r,«. 119.-Sp,«,<.«A P.Li,.A. .ecretions from initial lesions 

of syphilis in two ways: (1) 

Direct examination of the living organism by a reflecting condenser under 

dark ground illumination; (2) by the staining methods of Goldhom and 

Giemaa. 

The specimen is obtained 

as follows: The part is 

washed clean from discharge 

with boric-acid solution. 

The syphilitic lesion is then 

lightly curetted with a small 

sterilized curette until blood 

begins to ooze; the blood la 

carefully sponged off with 

sterile gauze and usually 

stops in a few minutes, after 

which serum will be seen 

to ooze from the lesion. A 

sterile glass slide is lightly 

touched to this serum and 

the specimen is fixed and 

dried like ordinary blood 

smears. Fia. uga. — Spirocbbta as Seen bx Golpbobh Stain. 



SYPHILITIC UKETIIRITIS 123 

METHODS OF STAISINO THE SPIROCIIETA PALLIDA 

I, Goldhorn's Method: 

Goldhorn's Spirocheta Stain is used. 

1. Cover unfixed preparation with dye. (Tlie Goldhom Spirocheta 

Stain.) 

2. Pour off excess of dye in three or four seconds and immediately 

plunge the whole slide gently face downward into water to pre- 
vent precipitation of the stain, 

3. Hold in water for three to four seconds and wash. 

4. Dry, (Do not let the slide lie flat while drying, but stand it op or 

shake in the air.) 

5. The si)eciinen is then mounted by dropping on a drop of Canada bal- 

sam and placing a cover glass over it. It is examined microscopic- 
ally with a iV oil -immersion lens, 

II, Giemsa's Method: 

1. Clean a test-tube by boiling in soda solution, after which wash thor- 

oughly and dry. 

2. Put thirteen drops of Giemsa's Solution II in the test-tube and add 

10 c.c. of a 0.5-per-ccut solution of chemically pure glycerin in 
distilled water. 

3. Warm this solution in flame. 

4. Cover fixed preparation with stain, and after five minutes pour off 

and cover again with fresh solution; after five minutes wash, dry 
and mount, and examine with Vi oil-innuersion lens. 

The reflecting eoudenscr under dark-ground illumination offers a rapid 
and accurate method for the observation of the living spirocheta. This ap- 
paratus (Fig. 120) can be 
attached to the stage of 
any microscope and held 
in position by the ordinary 
clips. 

The condenser is pro- 
vided with two reflecting 

Burfaces, as shown in Fig, 

121 on next page. The 

j:arallel rays of light com- p,^, i2o._RBFLBcnNo Condensbh. 

ing from below (that is, 

from the plane mirror of the microscope), are almost completely united in 

one point " P." An intense illumination of the spirocheta and other organ- 



124 DISCHARGES 

isms is thus obtained. The light diffused hy the hacteria, aa represented by 
dotted lines, enters the objective and thus produces an image o£ the bacteria. 
The best source of-light for dark-ground illumination is furnished by a small 
arc jight (Fig. 122). But where this is not available, a Nemst lamp or an in- 
candescent gas lamp may be used, in which case, it is necessary to employ a 
bull's-eye lens on a stand, so placed that it is between the source of light and 
the reflecting mirror of the microscope; the distance between the light and the 
lens should be 17 cm. and between the lens and mirror reflector of the micro- 
scope 40 cm. 



Fig. 121. — Reclechno Condbnsbb. 

Q. glass slide with cover glass. 

a. b, reflected raya meeting at P. 

C, condenser apparatus. Fia. 122. — ElectmcaL Arc LaUP witb Hand Feed 

O. objective. for a Ccbrbht or 4 Auperes and an Illuhi- 

P, point of concentrHtion of the rays. natinq Lenb Mounted on a Stand. 

The Specimen to be examined is taken on a slide, but the serum is not al- 
lowed to dry; a drop of distilled water is added to it and a cover glass placed 
over it, and the si^eciinen is examined in the wet state. The slide is now placed 
on the condenser and, the source of light having been adjusted, it is then ex- 
amined either with a dry or an oil-immersion lens. The object slide and cover 
glass must be thoroughly clean, as dust particles interfere with the observation; 
the preparation itself should be very thin and the sjrecimens must not contain 
any air bubbles. 

Chancroidal Urethritis. — This is the result of infection of the meatus by 
chancroidal virus and an extension of a few millimeters down the canal. The 
discharge is moderately profuse in amount and muco-jnirulent or muco-san- 
gninolent or puro-sanguinolent in character, ilicroscopically, mucus, epi- 
tlielium, pus cells, pus-producing organisms. Bacillus of Ducrey and sometimes 
blood are found. The infective agent in chancroid is the Bacillus of Ducrey. 

The Bacillus of Ducrey is a short, thick bacillus with rounded ends, some- 
what like a dumb-bell. It is about 1^ micromillimeters in length. It is found 
both within the cells and between them. 



CHRONIC GONOCOCCAL URETHRITIS 125 

The specimen is taken on a slide and prepared in the usual way, and then 
stained for one half hour in the following solution : 

Sol. acid boric five per cent oSS ; 

Sat. sol. methylene-blue aqueous ov ; 

Distilled water 3vj. 

It is sometimes very difficult to demonstrate the bacillus in stained speci- 
mens, owing to the extremely small number compared to the enormous numbers 
of other bacteria present. 

Acute Gonococcal or Specific Urethritis. — This condition is the most fre- 
quent cause of urethral discharge. The constituents of the discharge are mucus, 
epithelial cells, pus cells and diplococci, which are the infective agents called 
gonococci. Other germs existing normally in the urethra or complicating the 
original infection may be present. 

At the onset of the disease, the discharge is mucoid or muco-purulent, ap- 
pearing as a slight moisture or a drop at the meatus when the gonococcal in- 
vasion has as yet not penetrated farther than the fossa navicularis. , If Very 
acute or moderately acute, the discharge becomes more abundant, purulent or 
miico-sanguinolent, and the gonococcus is found in the discharge. The char- 
acteristic discharge of acute urethritis contains but very few epithelia as com- 
pared to the enormous number of pus cells present. As the acute infection 
begins to subside and as a proliferation of epithelia goes on in the process of 
healing, the number of epithelial cells in the discharge grows larger, while the 
relative number of pus cells is less. Thus we are able to gauge with fair ac- 
curacy by the microscopical examinations, the acuteness of the urethritis, by 
the number of epithelia as compared with the number of pus cells. An excep- 
tion must be noted, however, during the first few hours of an acute attack 
when the discharge is mucoid and when there are more epithelia than pus cells, 
the epithelia coming largely from the anterior region of the canal, that is, of 
the large, flat type, irregular or polygonal in shape. Gonococci are present until 
tlie discharge has ceased or is a simple moisture. 

Chronic Gonococcal Urethritis. — The discharge of chronic urethritis differs 
from that of the acute conditions in that it is scanty, mucoid or muco-purulent, 
sometimes absent during the day, but present in the morning. It contains mu- 
cus, urethral epithelia, especially many squamous cells and usually but a small 
amount of pus. Gonococci are usually, but not always, found. 

Gonococci are coffee-bean-shaped micrococci, grouped in pairs, the flattened 
surfaces facing each other. For this reason the gonococcus is generally spoken 
of as diplococcus. It is usually found in the pus cells, that is, intra-cellular, 
occupying the protoplasm, but never penetrating the nuclei. It stains deeply 
with anilin dyes and can readily be distinguished upon the paler background 



126 DISCHARGES 

of the pus cells or epithelia. Examined under high magnifications, the longi- 
tudinal slit between the two cocci constituting the pair, can be very distinctly 
made out. 

The gonococcus varies somewhat in size, the average being 1.25 microns in 
length and from 0.6 to 0.8 microns in diameter. The well-developed and full- 
sized germ is found in acute conditions, while in some chronic cases, the 
smaller form may sometimes be seen, showing possibly an attenuated state. A 
variety of sizes may be noted in some pure cultures. 

The pairs of cocci are grouped usually in small masses; occasionally, how- 
ever, a cell will contain but a few pairs. In acute urethritis, on the other hand, 
when the process is virulent, numerous pus cells will be found so closely packed 
with gonococci, that tlie cell protoplasm is entirely masked. Often, also, the 
gonococci are found grouped about the nuclei of a cell, but the cell body seems 
to be absent, because it is either very faintly stained or has been obliterated 
in the course of the inflammatory process. When epithelial cells occur in the 
urethral discharge, the gonococci are often grouped about them or seem to lie 
upon the cells or within them. The intra-cellular position of the gonococcus in 
the pus cells, however, is so characteristic, that its recognition is made a condi- 
tion for the morphological diagnosis of this germ. 

The important part of the examination of the discharge in gonococcal in- 
fection is naturally for the gonococcus. The number of gonococci found in a 
specimen of gonorrheal pus varies greatly, according to the stage of the disease 
and the virulence of the infection. There is also a variation in the number of 
gonococci found within the pus cells in different stages of the inflammation. 
They are most numerous in the creamy discharge. 

A large number of other cocci and bacilli are also found in some cases of 
gonorrheal urethritis (secondary infection). It is said that when these are 
present, complications are more apt to occur. 

In chronic cases accompanied by very little mucoid discharge and by some 
shreds in the urine, it is difficult and sometimes impossible to detect gonococci 
either in the discharge emitted in the morning (morning drop), in the shreds 
or in the urine. 

In cases of relapse or of exacerbations of a chronic gonorrhea, the gonococci 
reappear, although occasionally they are not found. 

Methods of Staining and Examination. — The first step in this exam- 
ination is the fixation of the smear upon the slide by means of heat. This is 
done by taking the slide between the thumb and forefinger and passing it slowly, 
smear side up, three times through the flames of an alcohol lamp. The next 
step is to stain the smear with one of the anilin dyes, which suffices in routine 
work. In case of doubt as to the identity of the germ, it can be determined by 
Gram's stain. It is advisable, in important cases, to take several smears, so 
as to have material for confirmatory examinations. 



CHKONIC PROSTATITIS 127 

The gonococcus stains readily with the basic anilin dyes, but loses its color 
when treated with Gram's method — in other words, it is Gram-negative. 

1. Methylene Blue. — A great variety of staining methods have been used 
for staining the gonococcus. The simplest method, which at the same time is 
perfectly satisfactory for ordinary clinical work, is with a dilute solution of 
methylene blue, which is dropped upon the smear by a medicine dropper in 
sufficient quantity to cover the slide and allowed to remain for five minutes; 
it is then washed thoroughly with distilled water. Such is the differentiating 
action of this basic dye, that the nuclei of the cells are stained a pale blue, while 
the cell bodies are stained a still paler tint, forming a background against which 
the gonococci appear distinctly. If the preparation has been carefully and 
thinly spread, if the light and the optical conditions are perfect, the morphology 
of the germ appears sharply defined with this method of staining. (The for- 
mula for the methylene-blue solution is a matter of individual choice.) 

2- Grams Differential Method. — The most important method of differen- 
tiating the gonococcus from other germs which resemble it, and which may 
occur in urethral discharges, is the method of Gram, to which reference has al- 
ready been made above. This method consists in treating the smears with a 
staining solution known as " anilin water gentian violet." 

The anilin water is dropped on the fixed smear in the same way as the 
methylene blue and allowed to remain five minutes. It is then transferred to 
Gram's solution (composed of 1 gram of iodin, 2 grams of potassium iodid, and 
800 c.c. distilled water), in which it remains for about two minutes. It is 
next rinsed thoroughly in absolute alcohol until no trace of violet can be seen. 
If there is still some violet color, the iodin solution is again used, followed by 
rinsing in alcohol, and this is repeated until no trace of violet is visible. The 
specimen is next washed in water, and then counterstained for about two min- 
utes in a solution of 1 part of Bismarck brown, 10 parts of alcohol and 100 
parts of distilled water. The specimens are then dried and examined with tlie 
oil-inunersion lens. 

The characteristic feature of the gonococcus in specimens thus stained is 
that it loses its color when treated with the decolorizing solution of Gram, and 
takes the brown counter stain. 

The other bacteria in the preparation, including other diplococci, which 
may resemble the gonococcus, retain the purple color of the gentian violet. 
Gram's method is, therefore, useful in the diagnosis of the gonococcus in 
smears. It should be employed whenever there is any doubt as to the identity 
of a diplococcus found in urethral discharges, especially in medico-legal in- 
vestigation. 

Chronic Prostatitis. — Chronic prostatitis is an inflammation of the pros- 
tate usually following gonorrhea or some other urethral infection. The dis- 
charge is generally seen in the morning, having passed the cut-off muscle dur- 



128 



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130 DISCHAKGES 

ing morning erections, as in prostatorrhea. The discharge is similar to that 
of prostatorrhea, plus pus and infection. It is scanty and viscid, and con- 
tains prostatic and urethral epithelia, leucocytes (pus), mucus, few or no 
spermatozoa, amyloid bodies and Bottcher's crystals, gonococci or other 
bacteria. 

Chronic Vesiculitis. — Chronic vesiculitis is an inflammation of the seminal 
vesicles, due to gonorrheal or other infection. The discharge is scanty and 
viscid, and resembles that of spermatorrhea. It contains urethral, vesicular and 
frequently prostatic epithelia, pus corpuscles, mucous and colloid material, gono- 
cocci or other microorganisms, usually many spermatozoa, well developed and 
in different stages of disintegration. The condition is characterized by the dis- 
charge oozing out in nocturnal erections, the same as in prostatitis. 

DISCHARGES IN THE FEMALE 

In men the discharges come from the meatus, as the urogenital canal com- 
mences in the prostatic urethra, where the secretions of the prostate and those 
coming from the ejaculatory ducts first meet the urinary flow. From here 
to the external meatus, the genital and urinary tract are in common. In women, 
the urinary and genital tracts first meet at the vulva and therefore the dis- 
charges from the urinary and genital tracts would reach this point in case they 
are suflSciently profuse. 

A discharge found on the vulva may come from the vulva itself, the urethra, 
Skene's glands, the glands of Bartholin, the vagina, the cervical or uterine 
canals or the Fallopian tubes, under the following conditions : Nonspecific ure- 
thritis, acute gonococcal urethritis, chronic gonococcal urethritis, gonorrhea of 
Skene's glands. Bartholinitis, nongonococcal, gonococcal, tubercular, syphilitic 
and malignant disease of the vagina, chancroids, in endocervicitis or endome- 
tritis due to nongonococcal or gonococcal infection or to tumors, benign or ma- 
lignant, tuberculosis or salpingitis. 

A smear should be taken from the vulva by touching it with a glass slide. 
This smear may, therefore, contain a combination of discharges from various 
points, consisting of mucus, pus and blood cells, epithelia from the mucous 
membrane of the vulva, urethra, vagina, glands of Bartholin, uterus and the 
Fallopian tubes; also gonococci and various other cocci and bacilli. 

The vulva should then be wiped with a piece of moist gauze and the dis- 
charges from the various other contributing parts should be taken in the man- 
ner previously described. 

Urethral discharges occur in gonococcal and nongonococcal inflammations, 
just as in the male. The appearance varies from a thin, scanty, transparent or 
turbid drop to a thick yellow or greenish-yellow discharge. In nonsj^ecific in- 
flammations, microscopic examination shows mucus, pus cells, urethral epi- 



DISCHARGES IN THE FEMALE 131 

theliiim and the various kinds of cocci and bacilli normally present in the 
urethra. Blood cells may also be present, but no gonococci. 

The gonorrheal discharge from the urethra differs only on account of the 
relatively greater number of pus cells, plus gonococci, both intra- and extra- 
cc»llular. In chronic gonococcal urethritis, the discharge is often very scanty 
or absent, in which case a specimen should be obtained by introducing a plati- 
num wire into the urethra. Skene's glands should then be pressed upon and 
ajiy discharge coming from them should be taken. Very often in latent cases 
these glands harbor gonococci. 

Discharges due to chancre or chancroid are the same as in the male, and 
have to be determined by the presence of the Spirocheta or the Bacillus of 
Ducrey. Bartholin's glands should next be gently squeezed, and the discharge 
from their ducts examined. Bartholinitis is due in nearly all cases to gonor- 
rheal inflammation, and the microscopic examination of the discharge shows 
mucus, pus cells, columnar epithelium from the gland's duct and gonococci, 
both intra- and extra-cellular. 

The discharge coming from the vagina is then examined. This may come 
from the vagina itself or from the cervix, uterine canal or the Fallopian tubes. 
This discharge is known as leucorrhea, although the gynecologist in whose field 
it belongs, seems to use the name less than formerly. A speculum is inserted 
into the vagina and the sides of its walls explored. The vaginal discharge is 
usually thin and creamy, although in chronic cases, it may be thick and ad- 
herent The examination may also show a chancre, chancroid, tuberculosis, 
cancer or an inflammation due to gonococcal or other infection. Smears or 
scrapings are taken and the microscopical examination is made as already de- 
scribed in the first part of the chapter. 

The cervix is then examined for lacerations or malignancy. If there are 
no evidences of either of these conditions, but a thick opaque discharge, white 
or yellow in character, is seen coming from the cervical canal, the patient has 
an endocervicitis due to a gonococcal or other infection; whereas, if it is very 
purulent, it probably comes from the tubes. In case it is due to a gonorrheal 
process, gonococci are present. If they are not present, it is due to some other 
infection, and has as a predisposing cause uterine displacement, or subinvolu- 
tion or new growth. Besides mucus, pus and the germs of infection, the dis- 
charge from the uterus occasionally contains ciliated epithelia. 



CHAPTER V 

THE BLOOD IN RELATION TO UROLOGY 

Blood examinations are especially useful in differentiating septic or sup- 
purative conditions from other fevers, as, for example, typhoid or malarial 
fever. They also give a clew as to the degree of resistance to be expected from 
an anemic patient before operation ; while blood counts, periodically made after 
operations, show us the progress of our patients on the road to recovery. The 
degree of coagulability of the blood, determined before operation, gives us con- 
fidence to operate in certain cases, while it warns us not to in certain grave 
conditions of the kidneys or the prostate. 

In this brief chapter I shall confine myself to those clinical facts which 
should be known in order to interpret properly the blood examinations fur- 
nished by the laboratory. 

Blood comprises a fluid, liquor sanguinis or plasma, in which float certain 
specialized cellular bodies known as corpuscles. The plasma is a solution of 
various salts and of proteid materials (fibrinogen, serum albumin, serum globu- 
lin), and is the fluid medium which acts as a recipient and carrier of metabolic, 
eliminative and nutritive substances. 

The Percentage of Hemoglobin. — In healthy men, the percentage of hemo- 
globin is from eighty-five to ninety-five per cent. In robust persons, it may, 
however, reach above one hundred per cent A percentage below eighty-five per 
cent indicates anemia. The determination of the hemoglobin percentage is a 
most important feature in blood examinations in both general and urological 
surgery. All chronic surgical conditions generally produce some secondary 
anemia, which grows more profound as the case progresses. This is especially 
so in septic conditions and in malignant growths. In this secondary anemia, 
the decrease in the hemoglobin percentage is the first change noted in the blood, 
except in septic conditions, and frequently the hemoglobin is diminished in 
disproportion to the comparatively slow or moderate decrease in the blood 
cells. 

Corpuscles. — The corpuscular elements of the blood are divided into three 
classes: (1) The red blood cells, or erythrocytes; (2) the white cells, or leuco- 
cytes and (3) the blood platelets. Other minute particles of irregular-shaped 
bodies, known as blood dust or hemokonia, will not be considered. 

132 



LEUCOCTTOSIS I33 

Blood Count. — The blood count means determining by count the num- 
ber of red and white blood cells contained in a cubic millimeter of blood. 

The Red Cells, — The normal number of red cells is 5,000,000 to the cubic 
millimeter of blood in men and 4,500,000 in women. They contain about 
ninety per cent of oxyhemoglobin and a small amount of nucleo-proteid. Their 
function is to carry oxygen from the lungs to the tissues in loose combination 
with hemoglobin. 

Leucocytes. — The white cells or leucocytes in fresh blood appear as color- 
less, highly refractive bodies, containing one or more nuclei, and sometimes 
granular matter in their cell bodies. They number from 5,000 to 10,000 to 
the cubic millimeter, an average being 7,500. A differential blood count means 
an estimation of the percentage of the different white cells, which is of great 
importance in urological diagnosis. The four varieties of leucocytes found 
(Ehrlich) are: 

(1) Small mononuclear leucocytes — lymphocytes, twenty-two to twenty-five 
per cent. 

(2) Large mononuclear and transitional leucocytes, two to four per cent 

(3) Polynuclear (neutrophile) leucocytes, seventy to seventy-two per cent. 

(4) Eosinophile (polynuclear or bilobed nuclei) leucocytes, two to four 
per cent 

Blood plaques and blood dust need no mention here, as they are not of in- 
terest in surgical conditions. 

Leucocytcsis. — When the number of leucocytes is markedly increased, we 
have a leucocytosis. Simple leucocytosis affects chiefly the polynuclear leuco- 
cytes and is sometimes styled " polynuclear leucocytosis." When the lympho- 
cytes (small mononuclear) are increased, the term " lymphocytosis " is used. 
When the eosinophile cells are increased we speak of " eosinophilia," and when 
several varieties of leucocytes are increased, we have a " mixed leucocytosis.'' 
A physiological leucocytosis may occur in pregnancy, during digestion, after 
exercise, hot or cold baths, massage or electric treatment. 

A moderate leucocytosis means from 10,000 to 15,000; a marked leucocy- 
tosis from 20,000 to 25,000 ; and a very marked one may reach 85,000 or even 
90,000. 

Leucocytosis in disease may be temporary in acute and permanent in chronic 
conditions. 

Inflammatory leucocytosis is the infective type. The theory of this is, that, 
when infectious agents (bacteria, etc.) enter the system, they generate chemical 
substances which have the property of attracting leucocytes into the blood out 
of their hiding places in the spleen, the marrow, etc. In addition, however, the 
influence of germs seems to favor the formation of new leucocytes in the mar- 
row, spleen and lymphatic glands, and it is from these sources that we have 
leucocytosis in the blood — emigrated and newly formed leucocytes. 



134 THE BLOOD IN RELATION TO UROLOGY 

Leucocytosis and Infectious Diseases. — The importance of leucocytosis 
in an infectious process can be realized when we consider that the leucocytes 
attack bacteria and engulf them within their protoplasm, where the germs are 
digested by a special ferment or killed by a bactericidal substance which exists 
in the white cells. The leucocytes are, therefore, the body's army of defense, 
sent out to annihilate the enemy, which is the germ', and this process is called 
phagocytosis. Blood serum and lymph also contain bactericidal substances 
which take part in the fight against the germs and their poisons. 

A person with strong resistance to infection will develop a marked leucocy- 
tosis when a virulent germ enters the system. A person with poor resistance, 
on the other hand, will have a slight or no leucocytosis when the same germ 
enters. In a person with good resistance, even a mild infection will produce 
moderate leucocytosis. We see at once how leucocytosis may be employed 
to gauge the constitution of the patient in a septic case before a serious 
operation. 

The importance of blood examination is shown in the following diseases, 
occurring in or with diseases of the urinary tract : 

Septicemia, Malaria, ) ^t- i . - 

rjy \_ ^ ' o i_-T > A o leucocytosis, 

iubercuiosis, Ibypnilis, ) 

Gonorrheal Infection, Hemorrhage, 

Peritonitis, Malignant Growths. 

(a) Septicemia, — In septicemia, patients with a slight resistance to infec- 
tion have no leucocytosis. The prognosis of those cases is, as a rule, unfavor- 
able. In most patients, however, there is a distinct polynuclear leucocytosis. 
The prevalence of polynuclear cells in septicemia, in fact in any septic condi- 
tion, serves to differentiate these affections from typhoid fever, where the whole 
number of polynuclear leucocytes is diminished, but the lymphocytes are mark- 
edly increased. When typhoid is complicated by suppurative conditions, this 
rule does not hold good and a leucocytosis is present. In such cases, one 
must rely upon the Widal test. 

(6) Tuberculosis, — In tuberculosis, no inflammatory leucocytosis results 
unless a mixed infection is present, when a polynuclear leucocytosis occurs. 

(c) Gonorrheal Infection, — In gonorrheal infection, a moderate leucocy- 
tosis of the polynuclear type is found, especially in acute gonorrhea when ac- 
companied by fever and complicated by epididymitis, orchitis, etc. The gono- 
coccus can be isolated from the blood in gonorrheal endocarditis and other 
gonorrheal metastases. 

{d) Peritonitis, — All forms of peritonitis, except the tuberculous, produce 
a leucocytosis, unless the patient is very weak. A sudden rise in the number 
of leucocytes indicates a spread of the process. Chronic cases are associated 
with increasing anemia. 



BACTERIA IN THE BLOOD 135 

(e) Cachectic Leucocytosis. — In malignant tumors there is leucocytosis 
which becomes more marked as the disease advances, and which is due to the 
local inflammation (that is, ulceration and necrosis) and the chronic toxemia. 
The blood is usually normal in the early stages. A profound anemia with a dis- 
tinct leucocytosis follows later, due to toxemia. Usually the ratio of the poly- 
nuclear cells is increased, but occasionally there is an increase in the mononu- 
clears, or myelocytes may be present The anemia becomes profound as the 
cachexia advances. In some cases of sarcoma, there is a marked lymphocytosis, 
the blood looking like that of lymphatic leukemia. 

(f) Posthemorrhagic Leucocytosis, — Great loss of blood is followed by a 
marked increase in the white cells. This leucocytosis rapidly disappears before 
the red cells reach their normal level and is due to the pouring in of the lymph 
to take the place of the lost blood. 

The Degree of Coagulability. — The degree of coagulability of the blood ia 
of great interest to the surgeon. In urology, it is of special importance in cases 
of tumor of the bladder and kidney, and also when such operations as prosta- 
tectomy and nephrectomy are contemplated, where much bleeding and oozing 
may be expected. Roughly stated, the blood normally clots within five minutes. 
If the clotting is delayed to ten or fifteen minutes, one may look for a danger- 
ous oozing or hemorrhage in the patient. A number of conditions, chief among 
them hemophilia, purpura and jaundice (cholemia), produce a deficient coagu- 
lability. Wright's coagulometer is an instrument used to measure this physical 
property of the blood. If the coagulability is found deficient, the usual treat- 
ment with calcium chlorid, gelatin, etc., may be employed. 

Bacteria in the Blood. — The discovery of specific bacteria in the blood is 
not an easy matter, and requires the most rigid aseptic technique and the utmost 
watchfulness and skill in the preparation and use of the various media. But 
few germs occur in the blood in such numbers that they can be detected in 
ordinary smears. The principal microorganisms which are found in the 
blood are : 

(1) Streptococcus and Staphylococcus. — In septic conditions, malignant en- 
docarditis, etc., their presence in the blood always means a bad prognosis, but 
care must be taken to exclude accidental contamination by the Staphylococcus 
albus always present in the skin. 

(2) Tubercle Bacilli. — This has been found in the blood in acute miliary 
tuberculosis and is difficult to detect, but it exists probably oftener than is 
supposed. 

(3) Gonococcus. — The gonococcus has been isolated from the blood in a 
number of cases, principally in malignant endocarditis due to gonorrheal in- 
fection. 

(4) Bacillus Coli. — The bacillus coli can be often detected in the blood in 
some form of septicemia in urological cases. 



136 THE BLOOD IN RELATION TO UROLOGY 

(5) Typhoid Bacillus, — Typhoid bacillus is always present in the blood in 
typhoid fever and is not difficult to detect 

An important point to remember is that the absence of a germ from the 
blood is not to be regarded as a negative diagnostic factor. 

(6) Protozoa in the Blood, — Among these are the Plasmodia malarise and 
the embryos of Filaria sanguinis and the spirilla of European and African re- 
current fever. 



CHAPTER VI 

UROLOGICAL EQUIPMENT 

In considering urological equipment, we will discuss the space that the 
physician uses for his office work, his office furniture, apparatus, instruments 
and dressings. In case he has a clinic or hospital service, it should also be 
taken into consideration. The methods of conducting his private and institu- 
tional work should also be spoken of. 

Space Eeqnired for Office Work. — In order to do good work in urology, it 
is not necessary to have an elaborate plant ; efficient urological work can be done 
and is done in a very limited space. 

This usually consists of one room in which the patients wait, called a re- 
ception room, and another in which to attend them, called the office, situated 



I 




u 






□ 



o 



Q 

no 



D 



u 



6 



D 



m 



Fig. 123. 



D 



D 



V 




on the same floor. The office proper, in case it consists of but one room, is a 
combined consultation and treatment room. Such was my office for many years. 

(See Fig. 123.) 

137 



138 



UROLOGICAL EQUIPMENT 



Here it will be seen that the waiting room faced the patient on entering, 
while the office opened into the hall on the left. The office was a large one, hav- 
ing two windows facing the street, on the opposite side to which were two 
doors, one opening into the hall, the other into the waiting room. The two re- 
maining sides of the room with their comers were used for my library and 
equipment. 

On the side of the room extending from the hall door to the front, was an 
open bookcase with hanging curtains on the shelves. In the comer of this, 
near the adjacent window, was placed my microscope with its accessories. 

On the opposite side of the room, was the fireplace in the center and a cabi- 
net with shelves, resembling a bookcase, extending from it to the wall on either 
side. The space between the fireplace and the window contained everything 
required in the office for urological work — the examining table, the instrument 
table and an open cabinet on the shelves of which were all the apparatus, instru- 
ments and dressings used for the examination and treatment of patients. In 
a corner corresponding to the space between the fireplace and the reception- 
room door, was kept my sterilizing and throat apparatus. The fourtli corner 
was unavailable on account of the presence of the hall door. 

In my one-room office, everything that was used for my microscopical 
and throat examinations was kept on the shelves of the bookcase or cabinet 
and just before office hours was placed on the tables in the corners, ready for 
use; and they were put away again after office hours. The comer where the 
examining and instrument tables and the urological apparatus and instruments 




u 



Q 



ft 



O 



O 



Jl 



Fia. 124. 



<?- -Q 








i 




J 



were kept, was hidden by a screen. Within a few minutes, this room was trans- 
formed from a library into an office and vice versa twice a day. Everything 
pertaining to my work w^as kept in this one room and there was no running 
about, no looking for things that were in some other room. The only disad- 



APPARATUS AND INSTRUMENTS FOR OFFICE 



139 



vantage of this limited space was that I could only do a certain amount of work 
in the time allotted to office hours. 

In the course of time it became necessary to add more space. The first step 
was to convert the adjoining reception room into a treatment room and to place 
in it a similar equipment to that which I already had in my single office be- 
hind the screen. I took an adjoining room for my patients to wait in, thus 
making a consultation, treatment and reception room. (See Fig. 124.) This 
enabled me to have a patient in the consultation room and another in the treat- 
ment room at the same time. It also permitted me to have an assistant to 
handle the old cases while I was examining the new ones. 

As my practice increased, I added another room as a laboratory, thus mak- 
ing a complete suite of offices. (See Fig. 125.) 



I 



1 



c 



Q 



<? 











D 



u — U 



Q 



D 



X 









(y 



o 



c 



C^^TH 



^ i 



^ 



Fig. 125. 



OflSce Furniture. — The consultation room in a urological office can be fur- 
nished in any way that the practitioner desires, but it is desirable to have 
strong, heavy furniture, preferably of a dark color, covered with leather. It 
should consist of a table-desk, a number of chairs and a couch; also a book- 
case, if it contains the library. Besides this, if the patients are to be treated 
in the same room, it should have additional office furniture indicated for a 
one-room office, such as an examining table for the examination and treatment 
of patients ; an instrument table ; a small table for microscope, or for whatever 
other purpose the practitioner might desire; a cabinet for apparatus and in- 
struments and a lamp — electric or gas (probably both). Small stools and 
tables are always convenient and take up but little space. 

Apparatus and Instruments Recommended for OflSce. — Tables. — For ex- 
amination and treatment of patients; for instruments; for microscope and ac- 
cessories. 

Lamp. — With a reflector — electric, gas or oil. 

Sterilizer. — Steam, formalin, a pan for boiling instruments. 

RuBBEB Goods. — Rubber tubing for irrigating jars ; hard-rubber irrigating 
tips, shields and cut-offs; finger cots. 



140 UKGLOGICAL EQUIPMENT 

Glasswabe. — Irrigating jars; jars for dressings; jars for solutions; glass 
graduates ; urine tubes ; medicine droppers. 

Graniteware. — Basins for solutions ; douche pan ; pus basin. 

Piston Syringes. — Large and small urethral; bladder; hypodermic 

Dressings. — Assorted bandages; T-bandages; cotton balls; tampons; sani- 
tary pads ; gauze compresses — 3 by 5 ; 5 by 6 ; 8 by 10 ; gauze compresses with 
cotton-combined dressings — 5 by 6 ; 8 by 10 ; adhesive plaster. 

Miscellaneous. — Instrument tray; galvanic and faradic battery; small 
water barrel (for hot water) ; tub for bichlorid solution in which to sterilize 
utensils requiring chemical disinfection; stirrups and lithotomy uprights for 
examination and treatment tables. 

Cocain tablets; bichlorid tablets; peroxid; Holzien solution; silver solu- 
tion; boric acid; alcohol; lubricants (glycerin, gommenol) ; green soap; brushes. 

Instruments. — Special, — Catheters — soft rubber, straight or elbowed ; 
woven, straight with olivary tip and elbowed ; metal. 

Filiform bougies; bougies a boule. Cystoscope. 

Sounds. Prostatic douche tubes. 

Stone searcher. Instillating syringe. 

Dilators — Kollmann and Oberlander. Applicators. 

Urethroscope. Tunneled sound and catheters. 

Perineal grooved probe, director, cannula and gorget; perineal drainage tube. 

Rectal bag. 

Prostatic forceps and depressor. 

General. — Retractors, dull with rounded edge, large and small; sharp with 
short teeth. 

Probe, grooved director. 

Scissors, dull curved, sharp curved ; dull straight. 

Knives, straight scalpels, large and small ; straight and curved bistouries. 

Needles, large and small Hagedorn's, short round, surgical and straight. 

Needle holder. 

Forceps, thumb ; artery, curved with long slender blades ; bullet. 

Sponge forceps. 

Vaginal speculum, depressor, dressing forceps. 

Throat mirror and tongue depressor. 

Sutures, ligature material, catgut plain and chromic, Nos. 1, 2 and 3 ; braided 
silk. 

Ligature carrier. 

Kelly pad. 

Paquelin cautery. 

Extra Equipment for Outside Work. — Besides the office equipment, little 
is needed for outside visits. The following list will show what is generally used 
for operations and cystoscopy outside of the office. 



EXTRA EQUIPMENT FOR OUTSIDE WORK 



141 



Syringes 



BAGS FOB 

For Cystoscopy 

Rheostat. 

Two cystoscopes and cords. 
Bougies a boule ; sounds. 
Assorted catheters. 

Bladder. 

Urethral. 

Fountain. 
Glvcerin. 
Test glass. 
Cocain solution. 
Bichlorid tablets. 
Silver solution. 
Medicine dropper. 
Rubber tubing. 

Suppositories of morphin and quinin 
Kelly pad. 
Rubber sheeting. 
Table and lithotomy leg rest 
Sterilized towels. 
Cotton balls. 
Gauze pads. 
Battery, if no electric light. 



Forceps 



OUTSIDE WOBK 

For Operation 

Portable metal table. 

Rubber sheeting and Kelly pad. 

Basins. 

Sterilized towels. 

Green-soap tincture. 

Brushes and nail file. 

Alcohol. 

Bichlorid tablets. 

r. . r Fountain and piston. 

Syrmges \ ^y . . 
(^ Hypodermic. 

Assorted catheters, knives, scissors. 

Lubricant. 

Cocain. 

Peroxid. 

Thumb. 

Artery. 

Sponge. 

Bullet 

Prostatic. 
Assorted retractors. 
Assorted needles. 
Needle holder. 
Sutures 

and 
Ligatures . 
Sounds. 

Bougies a boule. 

Gouley tunneled sound and catheter. 
Filiforms. 

Otis. 

Maisonneuve. 
Grooved probe. 
Grooved director. 
Grooved cannula. 

. Gorget 
Bandages, assorted dressings. 
Large catheter drain tubes. 
Portable sterilizer. 
Pedicle clamp. 
Infusion jars. 



^ Catgut 



{ 



Plain. 
Chromic. 



Braided Silk. 



Urethrotomes 



Perineal 



142 UROLOGICAL EQUIPMENT 

OflSce Dressing Equipment. — Towels. — A large supply of oflSce towels, 
18 by 36 in size, must be kept on hand. The variety known as " glass '' towels 
are the best for general use. They are kept wrapped in an outer towel, or 
preferably in a piece of muslin, in packages of ten for office work and six for 
outside operating. The packages of towels should be kept in a tin box as stock. 

Cotton Balls. — These are convenient in office work for sponging the 
meatus and glans in men, and the vulva, meatus and vagina in women, before 
instrumentation. They are kept in glass jars on a treatment table. Before us- 
ing, they should be dipped into a bichlorid solution, which should always be 
kept in a jar close at hand. The solution should be changed daily. 

Gauze. — This is a most useful surgical dressing, and much care should 
be given to its preparation and sterilization. The following varieties of gauze 
dressings are useful. They should be kept in separate jars and a supply should 
be in each room, while a sufficient supply should be kept in tin boxes for office 
and outside work. 

Gauze sponges, 3 by 6 inches, for absorbing blood, etc., during an operation 
and for use with probangs or sponge holders, are folded from pieces of gauze 
9 by 16 inches. They are also useful unfolded to wrap about the forefinger in 
making a rectal examination. 

Sponges or compresses, 5 by 6 inches, are made of pieces of gauze, 15 by 18 
inches, folded three times each way, with the cut edges inside. They can be 
stitched at their free borders or left free as the surgeon prefers. They are 
packed in tiers in jars, or are tied up in packages containing four pads each, 
wrapped and pinned in pieces of muslin. Some of these packages may contain 
in addition a number of cotton balls, as these are better adapted for use in a 
minor operation. 

Large gauze compresses for abdominal pads are gauze pieces, 18 by 24 
inches, folded to make pads, 6 by 8 inches. For abdominal sponges these gauze 
pads should have their edges sewed and provided with tapes. 

Oauze packing strips should be an inch wide and three yards long. A thread 
is pulled from a piece of gauze of this length and the strip is cut along the line 
indicated. These strips are kept in eight-inch tubes plugged with cotton, the 
tubes being in turn kept in jars. When the dressing is needed, it is pulled out 
with sterile forceps and cut with sterile scissors. 

Strips of gauze, an inch wide and a yard long, saturated with five- or ten- 
per-cent iodoform and others of the same size, saturated with Balsam of Peru, 
are also kept in stock for packing wounds. 

Other Dressings. — Bandages, both gauze and muslin, from 1 to 4 inches 
wide, are used for office work and outside operating. They can be wrapped in 
sets of from two to four in pieces of muslin. 

KuBBER TISSUE in assorted sizes is scrubbed with green soap and is kept in 
1 : 500 solution of bichlorid. 



OFFICE DKESSmO EQUIPMENT 



143 



SuRGiCAi. PLASTER (diachyloii or zinc oxid) is kept in convenient rolls. 
For small dressings, pieces of diachylon plaster, 1 inch wide by 4 to 6 inches 
long, are kept in readiness in a small jar and are known as dressing holders. 
They are heated for a moment over an alcohol lamp before being applied. 
Ordinary adhesive plaster is used for strapping on dressings of large size. 

Forceps for taking dressings and gauze out of jars and tubes are sterilized 
by dipping into pure carbolic and alcohol, or are kept, during office hours, in a 
glass jar containing five-per-cent carbolic. 

Glass hand syringes, irrigator tips and shields, couplings of glass 
OR HARD RUBBER are kept on the treatment table in alcohol or bichlorid solution. 
Infusion jars are rarely used in office work, but they are an important part of 
the outfit for an outside operation and should be provided with a thermometer. 

Needles, threaded with silk or unthreaded, are put through pads of gauze 
in assorted sizes and varieties. The pads with their needles are wrapped in 
small pieces of muslin and sterilized by dry heat or formaldehyd. The packages 
are thus ready for operations. Ordinarily, needles of assorted sizes are kept 
in covered glass dishes containing a mixed powder of boracic acid and lyco- 
podium. The suture material is all kept in tubes ready for use. 




Fig. 126. — Table in the Examining Room. 

On the top are kept in jars, gauze cotton balls, lubricants, syringes in alcohol, applicators, catheters, 
urethral speculum, sterile water, magnifying glass. On the lower shelf, urine cylinders, finger cots, 
Tsaeline, material for quick urinary tests, two dishes, and cases for instruments. 



144 UKOLOGICAL EQUIPMENT 

Hypodebmic syringes are kept with their needles, etc., in a small glass 
tray. The needles should always have wires in them when not in use. 

Arrangement of Author's Present OflSces. — In arranging my rooms for 
office work, it was necessary for me to convert the basement, situated imme- 
diately under my consultation room, into a reception room. This was easily 
done and it was connected with the offices and treatment rooms above by a 
private staircase. The arrangement of the office floor still remains as it was 
then planned. 

Room No, 1 is the consultation room, containing bookcases for the largei* 
part of the library, a table, a desk, a letter file, two easy chairs, two arm- 
chairs, two ordinary chairs and a couch. It opens into the examining room 
(No. 2) by one door and into the hall by another. 

Room No. 2, the first examining and treatment room, is painted and fur- 
nished entirely in white. It contains an examining table, an instrument table 
(Fig. 126), a tray table, two stools, a chair, a commode, a screen and a cabinet 
for apparatus and instruments. 

The examining table is of the counterbalance variety, with a drain pan 
below (Fig. 127). The seat section of this table, on which the buttocks of the 




FlO. 127. — AUTHOR*8 COUNTBRBALANCB TaBLB IN THK POSITION POR EXAMINATION OP 

Male Patients. 

patient rest, is made of two pieces of glass with a slit between them, which 
allows the fluids used in treatment to drain into the pan. The head or back 
section can be raised to any position (Fig. 128) for facilitating the examina- 
tion of the abdomen, or increasing the comfort of the patient; while the leg 
part of the table, for supporting the lower extremities, can be removed and the 
hip portion elevated for cystoscopy. With the leg section removed, this table 
makes an ideal table for treating women, as the solutions run into the pan below. 
Care must be taken, however, to see that the patient, when lying on the table, 



AERANGEMENT OF AUTHOR'S PRESENT OFFICES 



146 



aits on the middle part first, as seating oneself on either of the end pieces might 
result in falling to the floor. The patient must also be instructed in moving 
about on the table to take hold of the side bars, as, if the top of the table is 





Fio. 128. — Different Positions in Which the Patient Can be Placed in Examining the Abdominal 
Organs, espbciallt in Kidnet Cases, bt Raising and Lowering the Shoulder Piece of the 
Table. 

grasped when the shoulder part is elevated, the fingers might be crushed in 
case that part of the table were to slip from the cog in which it is caught. 

Over the. examining table is placed a large tray table on an adjustable 
stand, which is exceedingly convenient for holding close at hand the various 
instruments used in the examination of the patients while on the table. 




Fig. 129. — Counterbalance Table with a Douche-pan on It. 

This counterbalance table is probably the best antiseptic metal table that 
has ever been placed on the market. The slit in the seat part, however, does 



146 UROLOGICAL EQUIPMENT 

not prevent the solutions from wetting the patient during urethra and bladder 
washings, when it is covered by the leather pad, and the glass or metal is too 
cold for the bare buttocks. I have personally found an ordinary wood table 
of my own designing more convenient for treatment than these more modem 
ones and they are more pleasing to the patient. I have consequently gone back 
to first principles, in that I do not depend on the slit in the modem tables for 
draining away solutions during medication, but prefer to place a douche pan 
under the patient's buttocks, finding that in this way the buttocks and clothing 
are kept dry (Fig. 129). 

In the instrument closet are kept all the instruments and supplies necessary 
for a thorough examination and treatment of a patient in the office and outside, 
as well as for an operation. On the top of the closet is a row of glass jars for 
dressings. Behind the screen, near the washstand, the commode is placed, for 
the use of the female patients when they void urine for specimens. 

Room No. S is the next room and has conmaunicating doors with Room No. 2 
as well as with the corridor. In the little passage between Rooms 'Ko. 2 and No. 
3, on shelves, are bottles containing sterile water and solutions, also irrigators 
and other appliances kept in reserve. 

Room No. 3, also finished in white entirely, with an impermeable floor, 
contains a coimterbalance table of the same pattern as that in No. 1. It is also 
surmoimted by an instrument tray with a stand (adjustable). One or more 
irrigators are hoisted on pulleys over the table from the ceiling, in a manner 
described farther on. A glass table in this room serves for dressings and solu- 
tions, while in the comer is an instrument closet. On the top of this closet is 
the massage vibrator, properly connected with the electric current ; the flexible 
shaft of this instrument is sufficiently long to reach the treatment table. 

In a recess of this room is an electric outfit for high-frequency current, 
for X-ray work and for cautery and for other electrical appliances. A closet 
over the washstand holds the stock for the solutions and medicines that are used 
in the daily work in the treatment of cases. The scales, on which patients are 
weighed from time to time, are also included in the furnishings of this room. 

Besides the examining table and tray stand for the instruments, there is an- 
other glass-top table for the apparatus and instruments used in the examination 
and treatment of patients. This stands just beside the examining table. 

Boom No. Jf, the next in order, is of the same size as No. 3 and com- 
municates with the latter as well as with the corridor. It connects also with 
the room behind it by means of folding doors. It serves as the second examin- 
ing and cystoscopic room and is used principally for treating women and for 
urethroscopy, cystoscopy and ureteral catheterization in both sexes. The gen- 
eral arrangement is the same as Room No. 2, in that it contains an instrument 
cabinet, washstand, examination and instrument tables. The table for examining 
and treating patients is known as the Allison (Fig. 130), which I find unequaled 



AKRANGEMENT OF AUTHOR'S PRESENT OFFICES 



147 



for cystoscopic work. It seems to afford a better position for this purpose than 
any other, as the seat part of it is shorter than that of other tables. The illustra- 
tion shows the position of the hips when this table is used in cystoscopic work. 
Each of the examining tables is provided with a detachable and adjustable 
pair of leg and knee rests^ as seen in the illustrations. The choice of these is 
a matter of individual preference, the knee rests having the advantage that the 
patient can be more quickly placed in position than with the straps attached 
to the leg holders. 




Fio. 130. — Allison Table in the Ctstoscopic Position, with Shoxtlder and Buttock 

Pieces Elevated. 

Knee rests or lithotomy uprights are used when cystoscopy is performed. 

In the comer of Room No. 4 is a washstand over which is a closet for solu- 
tions, etc., the entire corner being screened by a white, washable curtain swing- 
ing upon a hinged rod. An instrument case with glass shelves contains all the 
instruments used in this room. A glass table with a shelf underneath contains 
all the necessary articles for conducting cystoscopy and other examinations the 
same as in Room No. 2. 

The next room, No. 5, separated from No. 4 by folding doors, is known 
as the back office, and is the assistant's room, in which correspondence is looked 
out for and office work attended to which is not accomi)lished in the main office. 
The files for histories and records are kept in this room. Doctors who call 
with their patients often wait here. It is used as a second consultation room 
in which to take histories and interview patients when the front office is in use. 
A part of the library is here and easy chairs, and a couch for patients who may 
want to rest. It forms with Room Xo. 4 a second consultation and treatment 
room corresponding to Rooms Xos. 1 and 2. 



148 



UROLOGICAL EQUIPMENT 



The last room of the series is the laboratory, No. 6. In this room the urines 
are examined. All the equipment needed for the examination is found here. 
The room contains washstand, draining boards, closets for chemicals and re- 
agents, the microscopes and laboratory accessories. A desk serves for keeping 
the records and filing the laboratory cards. Some of the interesting operation 
specimens are also kept here. 



APPOINTMENT 


NO 








NAMR 










ADDBESS 


DIAGNOSIS . 












FIIE 








R1?NT BY - 


WIUL COMB ON . 


AT - ■ 


APPOINTMENT 


WITH 








DR. RAMON GUITERAS 










80 Madison Avb. 










Nbw Yobk 








M 










DATB „ „... 


.-„„„„..... — . — _....„.. 





— 





HOUR 


..A. M., 








NO 


• 








N. B. — Office visits 


are not expected to last more 
an hour 


than 


a quarter 


of 


No special appointme 

in 


>nts are given in the afternoon, 
the order in which they arrive. 


Patients are seen 


TBLKPBOKK 


OFFICE HOURS: 


8-lS A. 


M. 


IffADiaOlf maVAMM, 07»« 


• 









Fia. 131. — Appointment Form. 



Office Management. — A patient, calling for the first time, on entering the 
reception room is handed a card bearing the date of his or her visit and is in- 
structed to write the name and address. All old patients write their names on 
a similar card at each visit Whenever a patient arrives, the attendant at the 
door telephones upstairs announcing the arrival, which is immediately regis- 



OFFICE MANAGEMENT 



149 



tered by the nurse in attendance on the office floor on a list that I have always 
before me. The card which has been received in the reception room is then 
brought up and placed on a table in the hall. New patients are shown up to 
the consultation room and their histories are taken by one of the assistants, 
who also makes arrangements regarding the fees. The patient is then brought 
to me for examination, and any specimens requiring examination are sent to 
the laboratory. When the examination is finished, the diagnosis made, the treat- 
ment outlined and an opinion given, if the patient is in need of further treat- 
ment in the office, an appointment is given for the next visit- (See Fig. 131.) 

The old patients, on arriving, are called up and assigned to one of the as- 
sistants with whom treatment is continued until they are discharged. All pa- 
tients are seen by me personally at each visit or as often as necessary. At the 
expiration of office hours, the cards of new patients are placed in the file index 
of patients. A card with the name of the physician recommending the case 
is put in another file, and cards with the name of the disease written on them 
are placed in the third file. The history is put in an envelope and placed in a 
large vertical file. This gives a very thorough record of the case. Very often 
histories used to lie about in 
the office pending the writing 
of the urine analysis or other 
data and consequently no 
diagnosis of the case was 
wTntten, no treatment out- 
lined and no diet prescribed. The 
following rules were therefore for- 
mulated and posted over the mi- 
croscope tables in the laboratory. 

Arrangement of the Rules 
FOR the History of Patients. 
— (1) The history of each patient 
should be taken by an assistant. 

(2) The patient should be ex- 
amined physically and the find- 
ings written down. The one who 
makes any part of the examina- 
tion should write it down with his 
initial after it. 

(3) The urine goes to the 
laboratory and is examined by the 
laboratory man who writes the urine report on the examination card. It is then 
sent to me for the diagnosis and should not be filed until the diagnosis is written 
upon it 




Fio. 132. — Three Vertical Fiusa in Which the En- 
velopes Containing the Patients' Histories and 
Correspondence are Kept. 



150 



UROLOGICAL EQUIPMENT 



If there is an opinion to be given, it should be written out by me and 
under no circumstances should the history be filed without this having been 

done. 

When these letters of 
opinion and diet are writ- 
ten, a carbon copy should 
be made and they should 
be submitted to me before 
they are sent out. 

All correspondence is 
kept in the history en- 
velope. 

The management of 
the office is entirely in the 
hands of the nurse who 
is also secretary. She has 
care of the correspondence, 
the appointments for vis- 
its and operation, the pa- 
tients' accounts, the laun- 
dry, the purchase of office 
supplies, the making of 
the dressings, the steriliz- 
ing of the instruments 
and dressings and the lists 
of instruments and ap- 
paratus that leave the 
office for outside opera- 
tions. 

Equipment for Clinic 
and Hospital. — The work 
in the clinic corresponds to 
that in the office on a largo 
scale, although the equip- 
ment and records are not 
kept so carefully. There 
are generally plenty of as- 
sistants, most of whom are 
there to learn the routine 
of the work of the clinic and who are generally not so well trained as are office 
assistants. 

The clinic records are, therefore, but about a quarter as valuable, except 




FlQ. 



133. — Plan of the Clinic at the New York Post- 
graduate Medioal School. 



7, waiting room for old patients. 
g, waiting room for new patients. 
3, passage to Rooms 4, 5, 6, and 7. 

In the corner of Room 3 is seen a table and chair where the 
history file is kept by the historian. The room to the left of 
Room 4 is for the acute cases. Room 5 is the room for chronic 
cases. Room 6 is the cystoscopic room. Room 7 is the amphi- 
theater. Each of these rooms has two treatment tables, an in- 
strument table and a sterilizer. 



EQUIPMENT FOR CLINIC AND HOSPITAL 151 

so far as a record for the number treated is concerned. The greatest difficulty 
is found in obtaining assistants with the true scientific spirit who are willing 
to give their time to tabulating statistics, to investigating new methods and to 
doing research work outside of the clinic. 

The plan of the clinic (Fig. 133) is that of a semicircle and is arranged as 
follows : 

No. 1 is the general waiting room. No. 2 is the waiting room for new pa- 
tients. No. 3 is the passage in which the records are kept. No. 4 is the first- 
treatment room. Ko. 6 is the second-treatment room. No. 6 is the cystoscopic 
room and No. 7 is the amphitheater or lecture room. The old patients enter in 
the basement Room 1 — the new ones are brought into Room 2 where they wait 
for the lecture. 

Room 3 is the passage and here is the table at which the card index is kept. 
The clinic filer, who sits at this point, directs the new patients to enter from 
Room 2 for the lectures and the old patients come in from Room 1 to be treated 
in the other rooms. The card filer hands the cards to the patients as they come 
in and replaces them when they pass out. The first assistant investigates the 
new patients before they go to the lecture room, writing down their names and 
principal symptoms, and brings the list into the lecture room (No. 7). The lec- 
turer reads over the list and has the cases sent in as chosen. The patient, on 
entering, is placed on the table, his history is taken aloud by the lecturer, and 
recorded by the historian. The local examination is then made by inspection 
and palpation. 

If the patient is an acute case, there is usually but little difficulty in making 
a diagnosis. If the case is chronic, however, the patient is instructed to leave 
the table and pass his urine in two glasses. The first and second specimens are 
inspected and the appearance noted, after which the patient leans over the table 
and the prostate gland and seminal vesicles are examined. The patient then 
passes the remainder of his urine, containing any debris that has been expressed 
from the internal genitals during examination. The three specimens are then 
handed to the microscopist, seated at the table, for examination. While be is 
attending to this, the patient is again placed on the table and the lecturer pro- 
ceeds to examine the urethra with the instruments at hand. As the instruments 
are used, they are handed to an assistant, who attends to the sterilization. 

After the patients have been examined and the diagnoses made, they are 
each referred to a certain clinical assistant outside, whose patients they then 
become and who are treated by him until cured, unless some complication oc- 
curs or the assistant in charge of the case desires him to come again before the 
lecturer. All the acute cases are sent to the first-treatment room (No. 4) and 
are placed in the care of the two assistants in charge of this room. All chronic 
cases are sent to the second-treatment room (No. 5), in which there are also 
two assistants working. When an acute case becomes chronic, the physician iu 



152 UKOLOGICAL EQUIPMENT 

charge can either continue treating him or else refer him to the room for the 
chronic cases. In both these rooms, there are two treatment tables, an instru- 
ment and a sterilizing table and some chairs. The instruments are of the same 
variety as those used in the office. 

Room 6 is the cystoscopic and bladder room. In this are two tables, on one 
of which the patients are prepared for cystoscopy, while on the other they are 
examined by the cystoscopist. As the preparation for cystoscopy takes some 
time, the case lectured on is not prepared in the amphitheater, but outside, after 
which the patient is wheeled into the lecture room with the cystoscope in the 
bladder, ready for examination. This is the usual routine, but in cases in 
which the fluid medium becomes rapidly turbid, as in marked pyuria and hema- 
turia, the last washing is given in the lecture room and the cystoscope is then 
introduced. 

The clinic is managed by a chief of clinic, who goes about from room to 
room and gives help and advice to the clinical assistants. Clinic patients 
are in charge of the first assistant. One man is at the head of the cys- 
toscopic room, and two in each of the treatment rooms, the man who has 
had the longest duty outranking the other in each of the rooms. The rec- 
ords are in charge of two men, one in the lecture room who takes all the his- 
tories, the other on the outside who niakes notes, at each lecture, of the inter- 
esting cases that are kept under observation, such as the kidney, bladder and 
stricture cases, as well as those who are to be operated or have already been 
operated upon. 

The new men coming to assist the clinic go through a regular circle of serv- 
ices before they are permanently appointed clinical assistants, serving in each 
for at least three months. The rotation is as follows : Historian in the amphi- 
theater; first-treatment room, treating the acute cases; second-treatment room, 
treating the chronic cases ; third-treatment room, working in cystoscopy. When 
they have finished cystoscopy, if fitted for it, they go on the microscope, other- 
wise they go on the book and around the circle again, as the head man of the 
different departments. 

The development of the clinic and of the clinical assistant has been very 
satisfactory of late, owing principally to the formation of an Alumni Society, 
that meets once a month, at each of which meetings one of the assistants reads 
a thesis on some subject that has been assigned as a special work. 

The hospital is connected with the clinic, inasmuch as the patients requiring 
operation are referred to the hospital for the operation clinic, which takes place 
once a week. After they recover, they are again sent to the clinic for observa- 
tion and treatment. Patients are also referred to the hospital for treatment, 
although it is principally for an operative service. The same instruments and 
apparatus are used at the hospital and for outside work, as have already been 
indicated under Equipment for the Office. 



CHAPTEE VII 

8TERIUZATI0N OF INSTRUMENTS AND APPARATUS 

The methods of destroying germs applicable to urological instruments are : 
Disinfection by means of chemicals, by boiling, by steam, and by the vapors of 
bactericidal substances. It is important to know the particular method which 
is suitable for each special class of instruments, as some appliances are injured 
by subjecting them to the wrong process. Probably the most efficient method 
of disinfecting an instrument that can be sterilized by any method is by boiling 
or steam. The least effective of the methods at our disposal is disinfection in 
chemical solutions, a method which is used chiefly in emergencies. Disinfection 
with chemical vapors is more thorough and more trustworthy than with solutions, 
and the vapors of formalin have now been adopted very generally in the dis- 
infection of urological instruments which do not bear the application of heat. 

Chemical Solutions. — Formerly it was considered sufficient, for all practical 
purposes, to disinfect certain urological instruments, such as catheters, by im- 
mersing them in solutions of carbolic acid or bichlorid of mercury. It has been 
shown, however, that these methods are untrustworthy, and that even when 
catheters are immersed for half an hour in a 1 : 1,000 solution of bichlorid, 
living microorganisms have been found within their lumen. 

Of the solutions which are employed with more or less safety in the steril- 
izations of urological instruments, we may mention formalin and mercuric 
oxycyanid, the latter 1 : 1,000 to 1 : 500. Formalin is probably the better of 
the two, and can be used in a strength of from two to five per cent The most 
convenient solution of formalin is that recommended by Holtzein, which serves 
for the disinfection of cystoscopes, urethroscopes, woven catheters, etc. The 
stock solution consists of sixty parts of formalin and forty parts of alcohol. 
Two drachms of this solution are added to each pint of distilled water for im- 
mediate use. 

Mercuric oxycyanid is employed in the strength of 1 : 200 for the dis- 
infection of delicate instruments, such as cystoscopes, etc. The value of this 
substance is rather questionable. 

Boiling. — Boiling is one of the best ways of attaining absolute asepsis. The 
material to be boiled, however, must be carefully selected. Metallic instru- 
ments^ cou^isting entirely of metal or of glass or the two combined, may be 

153 



154 STERILIZATION OF INSTRUMENTS AND APPARATUS 

boiled with impunity. It is always best to add some soda to the water, so as 
to prevent rusting and to preserve the nickel plating. Soft-rubber catheters 
may also be boiled, but plain water 
should be used. The time required 
ior boiling any of these classes of 
instruments is five minutes. Any 
instrument boiler, fish boiler, or 
common agate or enameled pan, 
can be used. Special long and nar- 
row pans with covers are useful for 
boiling soft rubber, glass or metal 
instruments in the office or the 
treatment room. 

Steam. — When employed 
correctly, steam under pres- 
sure disinfects with the same 
efficiency as boiling. The 
steam must penetrate through 
every part of the material to 
be disinfected, and the time 
of exposure must be sufficient 
1 1 to kill the most resistant 
I germ ; that is, about twenty- 
five minutes. Disinfection 
with steam requires special 
apparatus, although in an 
emergency an ordinary fish 
kettle, with a perforated pan hanging over the boiling water, can be employed. 
One of the best all-round steam sterilizers 
is that known as the "Willy Meyer" (Fig. 

134). This can be used for both dressings I 

and instruments, and is very convenient 
for carrying to an operation at the patient's 
house. Another of about the same size, 
though a more complicated sterilizer, is 
the type known as " Rochester Combina- 
tion" (Fig. 135). In this sterilizer, we 
can use alternately steam and dry heat, so 
that the steamed articles can be dried by 

heat without removing them from the ^°- 13=— Ro^^'TeH Stihilizrb. 

trays. Both these sterilizers have an arrangement for boiling instruments in 
the water ■which produces the steam^ 



FORMALIN VAPOEti 165 

Formalin Vapors. — Formalin vapors offer a very convenient, and at the 
same time very efficient, way of disinfecting all kinds of urological instruments, 
especially cystoseopes, woven catheters, etc. The most convenient apparatus 
for this purpose is Scliering-Glatz'a formaldehyd sterilizer (Fig. 136). 

This apparatus consists of a box of japanned tin, measuring 18x11^x8 
inches. It has two shelves upon which the instruments may be placed, and a 
small compartment for the formaldehyd lamp. One side of this box swings 
OQ hinges, forming a door of sufficient size for the introduction of the longest 



instruments that the box will hold. The lamp is about eight inches high, con- 
sisting of a body for the alcohol and a chimney, ia the top of which is a 
cup or receptacle for formalin pastilles, white tablets which by heat are com- 
pletely converted into formaldehyd gas. The strength of each pastille is five 
grains. Two of these tablets are sufficient for ordinary disinfection in this 
apparatus. 

The instruments are placed on the wire shelves. Two five-grain paraform 
pastilles are put into the cup or receptacle. The lamp is now lit and the door 
closed. A small glass window in the door permits us to watch the flame of the 
lamp. An outlet at the top of the box allows the escajie of gas when steriliza- 
tion is complete. The lamp will burn for twenty minutes in the air of the box, 
wlien empty. About ten minutes are needed to bum a five-grain pastille of 
paraform in the sterilizer. Ten minutes' exposure to the amoimt of gas obtained 
by vaporizing two five-grain pastilles will kill anthrax, diphtheria, tubercle and 
typhoid germs, aa well as those of suppuration. At my suggestion, Prof. H. T. 
Brooks, of the Post-Graduate Hospital, made a series of experiments with this 



156 STERILIZATION OF INSTRUMENTS AND APPARATUS 

sterilizer to determine its efficiency. The following is an extract from his 
report, which was sent to me in December 17, 1899. 

Woven catheters were injected with dilutions of live cultures of the typhoid, 
colon and prodigiosus bacilli, and the Staphylococcus aureus. The catheters 
were then drained, dried, and placed in the Schering formalin sterilizer. Two 
pastilles were burned for ten minutes, after which the lamp flame was spon- 
taneously extinguished. The door of the sterilizer was then opened, two new 
pastilles placed in the cup above the lamp chimney, the lamp relighted, and the 
door closed. The lamp was then allowed to bum for an additional ten minutes. 
The door was not opened until a third ten minutes had elapsed — i. e., thirty 
minutes from the beginning of the exposure. The catheters were then removed 
from the chamber with sterile forceps, cut with sterilized scissors, and portions 
placed on gelatin plates, in tubes of alkaline bouillon, and also in surface and 
submerged agar tube cultures. Xo growth of any of the above-mentioned organ- 
isms occurred after three days in the incubator at 98° F. Control cultures 
were made from the original dilutions used for injecting the catheters, and all 
grew. 

Subsequent experiments showed that the tubercle bacillus and the strepto- 
coccus also were killed by exposure to the formalin fumes for half an hour. 

Detailed Methods of Sterilization and Disinfection: 

1. Water. 

2. Surgeon's hands. 

3. Rubber gloves. 

4. Packages of dressings and tubes of gauze. 

5. General care of instruments. 

6. Catheters. 

7. Cystoscopes, urethroscopes, etc. 

8. Piston syringes. 

9. Glass hand syringes. 

10. Instillation syringes. 

11. Hypodermic syringes and needles. 

12. Glass and agate ware, etc.; infusion jars; irrigator jars and tips; 

pans, pus basins, pitchers, dishes, trays and glass jars. 

13. Catheter lubricants. 

Snell's formaldehyd sterilizer is recommended for catheters (Fig. 137). 

1. Water. — The quality of the water used in the office for making our 
solutions was found unsatisfactory. It was ordinary boiled city water and 
at times was discolored and often formed some chemical combination with silver 
or other salts used for solutions. Besides this, the enamel was burned off the 
bottom of the kettle, giving rise to a certain amount of mineral deposit in the 
water. When thi^ occurred in the instrument sterilizer, which was of the same 



METHODS OF STEEILIZATION AND DISINFECTION 157 

construction as the kettle, a grittj substance clung to the mstniments, while a 
scum floated on the water, !For a long time we used filtered water, which had 
been boiled, but even filtered water formed a chemical combination or gave 
rise to precipitates. We then began to use distilled water, which has proved 
most satisfactory. 

In the smaller towns, this can be made in the ofiico with the aid of a still, 
such as are now used for its rapid manufacture. In the large cities we simply 
buy distilled water in five-gallon bottles. The water is heated in a large tea 
kettle, which should be changed for another as soon as it is burned in the least 
degree. 

After the distilled water has been heated, it is poured into an aseptic pitcher 
and thence into an earthenware jar with a faucet in the lower part The 



Fig. 137. — 3neli.'8 Forhaun Sterilizer for Steriuzino all Cathbtebs, 

BUT BSPBCtALLT UEKTEHAL. 

The catheters are pushed over hollow posts leadiuK to the formalin chamber. 

sterilized water is drawn, as needed, from this jar. The kettle is always kept 
full of hot water in order to replenish the treatment-room jar whenever neces- 
sary. The cooled water is drawn ofE into a second jar, which is kept beside the 
one for hot water in order to mix the two for solutions at a proper temperature. 
An extra supply of cold sterilized water is kept in sterile flasks, stoppered with 
cotton or gauze, 

2. Sceoeon's Hands. — The care of the hands is one of the moat important 
details in a urological ofiico. It is a problem how to keep the hands clean, as 
they are constantly touching septic matter. Each treatment room should be 
provided with soap, brushes, nail cleaners and jars of bichlorid for the hands. 

3. RuBBEB Gloves, — At intervals I have worn rubber gloves, but have 
never become accustomed to them in office work. There is so much changing 



158 



STERILIZATION OF INSTRUMENTS AND APPARATUS 



of clothes, telephoning, handshaking, prescription writing and other matters 
of a business and social nature transacted during office hours, that the changing 
of gloves becomes a difficulty and involves a great loss of time. The surgeon 
should, however, wear rubber gloves in the treatment of all cases which threaten 
infection. In the office, they are washed with soap and water, wrapped in a 
towel, and boiled for ten minutes after using them, then dried, powdered and 
wrapped in gauze and put away until next needed. 

4. Packages of towels, gauze compresses, sponges or pads, gauze band- 
ages, cotton balls, sanitary pads, muslin table covers and sheets should be 
sterilized by steam. Strips of plain gauze, for packing, should be sterilized 
in the tubes in which they are kept. 

5. General Care of the Instruments After Using. — After use, all 
instruments should be washed in hot water and green soap with a soft brush 

or piece of gauze, thoroughly dried and 
put away. Special care should be taken, 
in the case of cystoscopes, not to sub- 
merge the entire instrument in cleaning 
or other solutions. Metal instruments 
should be cleaned in the same manner as 
house silver, when they begin to tarnish. 
All instruments should be kept free from 
dust in closed cabinets, or between towels 
if on open shelves. 

6. Catheters. — It is very difficult to 
clean catheters and other hollow instru- 
ments, as the remnants of pus, mucus 
and blood are apt to remain adherent to 
their interior. This is especially true 
when greasy lubricants have been used. 
A catheter must be flushed out, after 
using it, with soapsuds, by means of a 
piston syringe, or by attaching to a sink 
faucet a small nozzle which will fit into 
the lumen of the catheter. In this wav, 
a strong jet of water can be made to flow 
through it (Fig. 138). This is most 
important especially in woven catheters, 
which are usually sterilized by means of 
gas or chemical solutions that do not 

penetrate a coat of dried albuminous matter containing infection that adheres to 

their inner walls. 

Soft-rubber catheters are best sterilized by boiling for ten minutes in 





Fio. 138. — Method op Flushing out Cathb- 
TEBs Emploted IN Author's OmcE. 



METHODS OF STERILIZATION AND DISIKFECTION 



159 



plain water after a thorough cleansing. They should be wrapped in gauze or 
a towel and put into the boiler so that they do not come in contact with the wall 
of the boiler and become burned. In the office, we boil our catheters in bags 



:iMi 



la. 139. — Cathitbb a 



> Catrbtkb Tubs. 



and then put the bags into glass tubes. In this way fliey are handled more 
easily than in the wet bags alone {Fig. 139). 

Woven urethral and ureteral catheters cannot be boiled or placed in carbolic 
acid. They may be sterilized either by immersing tlieui for thirty minutes in 
a solution of silver nitrate or of mercuric oxycyanid (1 : 1,000), or else by 
exposing them to the vapors of fornialdehyd in the 
formalin sterilizer. The last-named method is the 
best and is the one used in the office. 

Another way of sterilizing woven catheters by 
formaldehyd, consists in placing them in a glass 
tube, in the stopper of which is a rubber receptacle 
containing formalin tablets (Fig. 140). The 
lower part of the stopper is perforated and 
through these perforations the vapors of formalin 
are constantly passing into the tube. They can 
also be placed in boxes in the center of which is a 
piece of gauze containing tablets or a powder of 
formalin. The formaldehyd gas is spontaneously 
generated and sterilizes the catheters in twenty- 
four hours. Special boxes are constructed for this 
purpose, although any ordinary fiat air-tight tin 
box will do as well. 

7. Cystoscopes, urethroscopes and other 
delicate instruments of this type are sterilized in 
the formalin sterilizer. After being used, the 
outer surface of the shaft is washed with tincture 
of green soap and water by means of a piece of 
gauze, then with alcohol, after which they are laid 
away in their cases, or, better still, wrapped in gauze, ready to be sterilized at 
any moment. 

8. PiSTOM 8YBINOES of large size, that is, holding from four to six ounces, 



1. 140. — ^TnBEfl WITH Hollow 

itCBBBH STOPFEBS CoNTAlNINQ 
POBHAUN. 



160 STERILIZATION OF INSTRUMENTS AND APPARATUS 

such as are used for washing out the bladder, are usually made of hard rubber, 
metal or glass and metal. They are best sterilized with formalin gas in the 
Schering sterilizer. The metal syringes and those of glass and metal can 
also be boiled. They may be sterilized in chemical solutions the same way 
as the woven catheters, but they are better sterilized in the chemical vapor 
(formalin). 

9. Glass hand syringes are usually kept in jars with cotton in the bottom, 
partly filled with five-per-cent carbolic or a 1 : 500 biehlorid solution and placed 
nozzle down. I keep mine in alcohol and rinse them with sterile water, as then 
no deposits form on the instruments that will make chemical combinations with 
the salts in the solutions used. Another good. way is to keep them in water 
and boil before using them. 

10. Instillation Syringes, Aspirators, etc. — These are sterilized in 
the same way as the large piston syringes. The instillation metallic catheters 
are boiled before being used. 

11. Hypodermic Syringes and IN^eedles. — Hypodermic needles should 
be boiled before using. The needles are kept in a small glass box con- 
taining a powder made of equal parts of boric acid and lycopodium, always 
with their wires passed through their lumen. Two small glasses, one for a 
five-per-cent carbolic solution, the other for sterile water, are kept on a tray 
on a shelf, called the emergency shelf, during the office hours; also one- 
ounce bottles of atropin solution (10 drops equal to -rh of a grain); of 
camphor in oil (10 drops equal to 2 grains); of str^^hnin sulphate (10 
drops equal to -5*0^ of a grain) ; and pearls of amyl nitrate, each containing 
3 grains, in a cotton-lined box. These should also be kept at hand on a 
table in hospitals and outside operations in case of emergency. A little 
glass receptacle with a cover contains cotton balls in ninety-five-per-cent 
alcohol. 

For local anesthesia, special solutions, which are prescribed in the appro- 
priate chapter, are kept on a tray with special syringes and needles, arranged 
in a similar manner to the hypodermic tray just described. (See chapter on 
Anesthesia.) 

12. Miscellaneous Articles of Hard Rubber, Glass, Porcelain and 
Agate Ware. — Irrigator tips and couplings of glass or hard rubber, to be used 
with rubber tubes and catheters, are kept in glass jars containing biehlorid 
solution. 

Irrigator jars should be washed out daily and flushed out with 1: 1,000 bi- 
ehlorid solution. 

Infusion jars are an important part of the operative outfit and should 
hold two quarts; a thermometer is provided for each. They are kept filled 
with biehlorid solution and are cleansed with sterile water before using. The 
tubes, cannulas, etc., are kept w^rapped in a towel, sterile and ready for instant 



METHODS OF STERILIZATION AND DISINFECTION 161 

use. Two bottles of sterile salt solution, one drachm to the pint, are kept at 
hand for use with this apparatus. 

Pans, pitchers, pus pans, dishes, basins, trays and glass jars should be 
divided into classes, those for aseptic cases and those for septic. Pitchers, 
basins for solutions or sterile water, instrument pans,. trays, glasses for solutions, 
etc., should be thoroughly washed and cleaned with soap and water, rinsed out 
and put into a tank, or an unpainted washtub, where they are kept submerged 
in 1 : 500 bichlorid solution. If they are not to be used immediately, they are 
kept bottom up on glass shelves or wrapped in sterile towels. Glass jars in 
which dressings are kept are cleaned in the same way and should be kept in the 
bichlorid solution, with their covers on, for an hour, and then dried with a 
sterile towel. 

Pans for the reception of dressings which have been removed, pus pans or 
basins, urine tubes and all other soiled articles of this order should be scrubbed 
with soap and water, rinsed with bichlorid and kept in their customary places 
without further attention. 

13. Lubricants fob Instruments. — The lubricants generally employed 
for urinary instruments include petroleum bases (vaselin), oils, glycerin and 
vegetable bases. Vaselin should never be used, except for rectal examinations. 
Olive oil should be used only after sterilizing it thoroughly by allowing the un- 
corked bottle to stand in boiling water until the oil itself boils. The only cases 
in which olive oil is useful is in examination for a supposedly impassable stric- 
ture. Certain oils are prepared with an antiseptic, as gommenol, which is a 
preparation of olive oil and eucalyptol. 

The usual lubricant employed in both hospital and office work is glycerin. 
This is kept in tall jars, into which sterilized instruments can be easily dipped. 
Glycerin is easily kept sterile, as germs do not thrive in it. Some surgeons use 
boro-glycerid, which is a compound of boric acid and glycerin, containing thirty 
per cent of the former. Personally, I do not care for it, as it sometimes 
irritates. 

The vegetable bases, which have of late years been employed for lubricants, 
are composed chiefly of tragacanth, or of Irish moss (chondrus, carragheen). 
These bases have the advantage of being soluble in water and sufficiently slip- 
pery to be an efficient lubricant. 

They are easily washed off from the instruments or washed out of the canal. 
Most of the lubricants now on the market contain such a base, and have added 
to them either boric acid, eucalyptol, thymol, formalin, etc., as antiseptics. 
They are usually put up in collapsible tubes with a nipple-shaped nozzle which 
can be used to introduce the lubricant into the urethra before passing sounds. 
The nozzle can be sterilized by boiling, or each patient should have his owti 
tube of lubricant. The lubricant that I use in the office is made according to 
the following formula: 



162 STERILIZATION OF INSTRUMENTS AND APPARATUS 

^ Tragacanth Sss ; 

Glycerin 3vijss ; 

Ilydrarg. Oxycyanid grs. ij ; 

Aquffi 5iij. 

The objection to oil and vaselin in urethral work is that they leave a coating 
over the mucous membrane of the urethra and thus prevent the thorough medi- 
cation of the canal afterwards. 



CHAPTER Vni 



TECHNIQUE OF INSTRUMENTATION 



CATHETERS 

A CATHETEB 18 a hoUow tube with an opening at one end the size of its 
lumen, while at the other end the opening is smaller and called the " eye." This 
is either in the tip or near it. 

Shape of Catheters. — The shape of the catheter is either straight (Fig. 
141), or elbowed (Fig. 142) or curved (Fig. 143). The straight has the same 
caliber throughout, or else it tapers into the neck and then widens out at the 

end forming a small olive-shaped 
dilatation (olivary tip) (Fig. 144). 




FiQ. 141. — Straight Cath- 
ETEB WITH Single Etb, 

USUALLY OF THE SOPT- 
BUBBBB VaBIETT. 



Fig. 142.— Elbowbd.Coudb 
OB Mercier Catheter 

WITH THE Emu ON THE 

Side, usually of the 
Woven Variety. 



Fig. 143. — Curved Catheter op the 
Woven Variety. 

Not much used. 



The neck is the narrowest part of the instrument, while the olive-shaped 
end, though larger than the neck, is smaller than tlie shaft. 

Elbowed catheters have a curved beak, somewhat similar to that of a sound, 
but shorter and more angular. They are also called coude or Mercier catheters. 
\Vhen the beak has a double curve, it 
is called bi-coude (Fig. 145). Curv^ed 
catheters are shaped like sounds. 





Fig. 144. — Straight Olivb-tippbd Woven 

Catheter. 



Fig. 145. — Bi-coud^ Woven Catheter. 



163 



164 TECHNIQUE OF INSTRUMENTATION 

Catheters are made of soft rubber, of a woven material with a varnish fin- 
ish, or of metal. Those made of other material are not recommended. 

The Eye of the Catheter. — The eye of the catheter is the opening through 
which the water escapes into the urethra or bladder. It is more frequently on 

the side, the end opening be- 
ing confined principally to 
instillating and large peri- 
neal drainage catheters. 

Openings on the side 
may be either single or mul- 
tiple. The single opening is 
most common, usually oval in 
shape and, especially in the 
soft-rubber variety, situated 
about a quarter of an inch 
from the tip (Fig. 140). 
The edges are rounded, so 
they may not give rise to 
traumatism of the canal. 
Such a finish is frequently 
spoken of as tlie " velvet 
eye." Straight catheters, 
whether they arc soft 
rubber or woven, usually 



Fia. 146. Pio. 147. 

have but one eye. In the olivary type of woven catheter, the eye is 
situated in tlie body of the catheter, and may be one inch or more from 
the tip. 

In the elbowed catheter, when made of soft rubber, the o])cning is usually 
made in the concavity of tlie elbow, although, when the catheter is of a 



■#-■ 



large size, it may be on the side, between the convexity and the concavity 
(Fig, li7). Side openings are generally found in tlic woven catheters, in 
which case two or more may be present. In the single-elbow catheter, there 



CATHETERS 165 

are rarely more than two, one on each side. Metal catheters are also better 
when they have the openings on the side (Fig. 148). 

Catheters for giving a general irrigation of the urethra may have multiple 
eyes — a dozen or more small round openings, through which the water spurts 
against the urethral walls (Fig. 149). They are generally of soft rubber 
in texture. Perineal drainage 

catheters, to be used after opera- i "'-^i- ^u.-m.^ ^ n^i 

tion, usually have an opening in i/uWi'iYiirMfi.tiihiyiUft\WhiitiVaHii^^^^^ 

one end and on the side to allow Fiq. 149. — NAlaton Cathbteb. 

better irrigation. 

The Passing of the Catheter. — A soft-rubber catheter is dipped into a lu- 
bricant in such a way that about one half of it is covered. It is then held in 
one hand, with the fingers a few inches from the tip. The meatus is opened 
by the thumb and forefinger of the other hand, the organ being at right angles 
to the body. The end of the catheter is then brought into the opening while 
dangling from the fingers. After the tip has entered the urethral meatus, a 
few doAvnward impulses are made and the instrument glides down the canal. 
When the catheter has passed down the canal to the point at which the fingers 
are holding it, they are moved farther up on the instrument and the downward 
impulses continued, by means of which it glides through the deeper portion of 
the canal and into the bladder. When eight and a half inches of the catheter 
has passed down the urethra, urine will usually escape from its eye. As the 
catheter passes down the canal, it may catch at the compressor urethrae, or neck 
of the bladder, this being due to spasm. Such is usually the case when there 
is inflammation of the prostatic urethra, or of the neck of the bladder. Such 
a spasm will usually yield to gentle pressure, or it may be overcome by substi- 
tuting a woven for a soft-rubber catheter, or an olivary-tipped instrument for 
one with a larger end. A metal catheter will sometimes enter when others will 
not. Urine will not escape until the catlieter has reached the bladder. 

Straight catheters are used for washing out the anterior and posterior ure- 
thra and bladder, and for drawing urine from the bladder that cannot be 
passed spontaneously. 

Elbowed catheters are also used in bladder work in drawing off urine in re- 
tention and washing out the bladder where inflammation is present. They are 
especially valuable in cases of enlargement or deformity of the prostate gland. 
The best coude to use is the soft rubber, but it is usually not as easily passed 
as the Avoven variety. 

The object of bends, angles or elbows in the ends of the catheters is to allow 
them to pass over prostatic enlargements, bulging into the urethra. It is easy 
to imderstand how the end of a straight catheter would come up against a pro- 
trusion in the prostatic urethra and might not pass it, while the elbowed catheter 
meeting such an obstruction would have its convexity at the end parallel to the 



166 TECHNIQUE OF INSTRUMENTATION 

side of the protrusion. Its tip would be against the roof of tlie prostatic urethra 
and a slight push would thus send it along the upper wall and past the prostatic 
enlargement into the bladder. 

The metal catheters are passed the same as soimds. They are not in common 
use, but will sometimes pass in cases in which soft-rubber and woven instru- 
ments will not. At present I use the metal variety almost entirely in washing 
out or filling the bladder after a perineal section, as with this instrument I can 
hug the upper wall of the urethra better, and, consequently, am not so liable 
to pass the catheter through the incision in the floor of the perineal urethra as 
might be the case with a straight instrument. 

The catheter with a mandrin, a wire in its lumen, such as is used in the 
urethra to overcome prostatic impediments, is not, in my opinion, a good in- 
strument. In using this instrument, it is passed as far as the obstruction in the 
prostate and the mandrin is then withdrawn, thus giving a slant to the tip of the 
catheter, so that it will glide up and forward through the prostatic urethra and 
enter the bladder. It seems to me that the improved models of elbowed catheters 
have sufficiently good curves, cause less traumatism and can at present be used 
in all cases in which the mandrin types were formerly employed. 

Retained Catheters. — A retained catheter, or a catheter d demeure, is one 
which, having been passed through the urethra, is fastened in such a way that 
it will not slip out. Retained catheters are useful whenever it is desirable to 
establish continuous drainage from the bladder, or to protect the walls of the 
urethra from contact with urine. Usually this necessity arises when the blad- 
der is infected, when an operation or traumatism has been done in the urethra, 
when it is necessary to cure a suprapubic vesical fistula, and also when spasms 
prevent repeated catheterization in cases of a complete retention. 

Unless the retained catheter is properly introduced and properly main- 
tained, it may give rise to complications, as an ulceration of the bladder, when 
the instrument is inserted too far, so that its end presses constantly upon some 
point of the wall. At other times, there is an ulceration of the upper part of 
the deep urethra, just beyond the pendulous portion, at which point the catheter 
is bent Avhen the urethra hangs dov^ni, thus compressing the above-mentioned 
portion of the wall. These accidents are rare in my own practice, as I gener- 
ally use a soft-rubber catheter, and only employ woven catheters d demeure im- 
mediately after an operation when there are blood clots in the bladder. I 
believe that the soft-rubber catheters made in this country are superior in qual- 
ity to the European product and that, consequently, we do not meet as much 
trouble with retained catheters as do some of the foreign surgeons. 

Catheters may be retained for several days or several weeks. They should 
be so introduced that the eye and the tip alone are in the bladder. This means 
that the catheter should be pulled forward after having entered the bladder 
until the flow just ceases and then pushed back a trifle until the flow is reestab- 



CATHETERS 



167 



lished. The bladder is emptied and the flow continues in dribbles corresponding 
to the flow of urine from the ureters. 

The next problem is to maintain the catheter in place. My own method 
is simply to tie two pieces of thread about the instrument close to the meatus, 




Fia. 150. — Retained Catheter. 
P, adhesive plaster. G^ gauze. 7, retaining threads. 

then to reflect the threads back on the upper, lower and lateral surfaces of the 
organ and to hold them in position by a piece of gauze or adhesive plaster 
wrapped around the penis (Fig. 
150). The point at which the 




FiQ. 150a. — ^A More Secure Method of 
Holding a Retained Catheter. 

C, catheter. 

G, a piece of gause surrounding the organ 
and tied to the instrument. 

P, a strip of plaster passed around the 
gauie-covered organ just behind the corona. 

G/, gians penis. 




Fig. 151. 

Fig. 151.- 

FiG. 152.- 

FiG. 153.- 

FiG. 154.- 



Fio. 152. Fig. 153. Fig. 154. 

-Malecot's Catheter. 

-Another Type of Malecot's Catheter. 

-Pezzer's Catheter. 

-Another Type op Pezzer's Catheter. 



thread should be tied around the catheter is, of course, determined by the 
maneuver already spoked of, whereby the exact position of the instrument is 
secured for efficient drainage. The catheter can now be inserted into the mouth 
of the urinal placed between the legs. 

Special catheters have also been devised which are self -retaining (Malecot's or 



168 



TECHNIQUE OF INSTRUMENTATION 



Pezzer's, Figs. 151, 152, 153 and 154). Their bladder ends are wider than the 
rest of the instrument and they are introduced after stretching them upon a 
metallic mandrin. Personally, I never use these catheters, as 1 always fear that 
I may cause traumatism in inserting or withdrawing them, especially if the man- 
drin should happen to slip out at the perforated sides and thus injure the tissues. 
They often enter with difficulty and pain, and sometimes cause hemorrhage. 

If the penis with the retained catheter is allowed to remain too long in 
one position, it is said that periurethral abscess or ulceration followed by a 
fistula may result It is advisable, therefore, to change the position of the 
penis occasionally by placing the or- 
gan on the side of the abdomen and 
draining by siphonage into a bottle at- 
tached to the side of the bed, or into 
a urinal in the bed by the side of 
the patient. I often allow patients to 
walk about with a urinal between the 
legs. (See Fig. 156.) 

When it is unnecessary to have 
continuous drainage and yet it is con- 
sidered desirable to retain the cathe- 
ter in the bladder, the instrument can 
be plugged and the plug withdrawn as 
often as necessary. With a plugged 
catheter, the patient is much more com- 
fortable, as he can move about in bed and 
in many cases walk about. The plugged 
catheter may also be resorted to in cases 
of complete retention in which a large amount of urine has accumulated in the 
bladder and is being gradually withdrawn every two or three hours. In certain 
spasmodic cases, it may bo desirable to keep the sphincter stretched until the 
spasm that is present has worn off, especially when the catheter has been in- 
troduced after a long series of trials. 



Fio. 155. — Glass Urinai 




INJECTIONS 

Urethral injections are best given by means of a glass syringe with a 
conical nozzle holding two drachms, an amount which usually can be con- 
tained in the anterior urethra. In making an injection, tlie end of the glans 
should be held by the left forefinger in such a way that the meatus occupies 
the middle of the finger (Fig. 156). The end of the nozzle of the syringe is 
then inserted into the moatiis ; the forefinger is now contracted around the 
tip of the penis, thus pressing the end of the urethra containing the syringe 



IKRIGATIONS 



169 



tip so firmly against it that the injection does not leak around the sides of 
the syringe and is contained in the urethra (Fig. 157). As the syringe tip is 
withdrawn from the meatus, the 
forefinger maintains its pressure 
on the end of the urethra, thus 
keeping the solution in the canal 
as long as desired (Fig. 158). 
Injections are usually retained 
for five minutes and are then al- 
lowed to escape. 




Fig. 157. — Manner of Holding the Nozzle of the Fig. 158. — How the Solution is Held in 
Stringe in the Uhethra. the Urethra. 

The meatus is seen in the bend of forefinger. 

IRRIGATIONS 

These include irrigations of the antero-posterior urethra and bladder or of 
the anterior urethra alone. 

(a) With the Piston Syringe Alone. — The syringe is held in the right hand 
of the surgeon, while the meatus is compressed by the forefinger of the left 



170 



TECHNIQUE OF INSTRUMENTATION 




Pia. 169. — A Larob Piston Stiuhod (Biaddeb SraraaE) 
Ubbd fob Usethho-vehccal Ihhioations and Wabhino 

oar THE BlADDEB THBOUOB A CATaETEB. 



hand. The piaton is pressed M]mn until the urethra is filled and inflated. 
The fluid can then either be held in or allowed to escape, and the canal 
then filled again. The fluid may be introduced into the posterior urethra 

and bladder by gradually 
increasing the pressure on 
the piston, thus overcoming 
the compressor tirethree and 
the vesical sphincter mus- 
cles. I am not in favor of 
this procedure and never 
use it. 

(b) With a Piston Syringe and Catheter. — If this is simply for the pur- 
pose of washing out the anterior urethra, the catheter is passed down to the 
bulb and the tip of the syringe is introduced into the end of the catheter. The 
solution is injected slowly and ia allowed to escape along the side of the catheter. 
If the catheter is now pushed into the membranous portion, the fluid will still 
escape from the urethra, or will flow both into the anterior and posterior urethra. 
If the end is pushed into the prostatic portion of the canal, the membranous 
sphincter will prevent the fluid from escaping and after filling the prostatic 
urethra, the solution will pass into the bladder. The catheter, however, is com- 
monly used in filling 

and washing out the 
bladder, in which case 
it is at once passed 
into the bladder and 
the organ ia filled by 
the piaton syringe. 
The fluid can then 
either escape through 
the catheter after the 
syringe is removed, or 
the catheter is with- 
drawn and the patient 
allowed to void the 
contents of the blad- 
der, thus medicating 
the urethra. 

(c) With an Irri- 
gator Working by 
Hydrostatic Preasnre 
without a Catheter. — The irrigation of the urethra without a catheter by hydro- 
static pressure is very effective in treating urethral inflammation. Tor this 



Fig. 160. — Cct-oft, Noiei.b and Shield t 
I DoncaB Jab. fok GivtNa Uretqbal a 

T BtDBOSTATIC PRBsaDBG. 



IRRIGATIONS 



171 



method it is necessary to have a reservoir containing the solution to he used. 
With this is connected a piece of rubber tubing to which is attached a nozzle, the 
tip of which is inserted into the meatus. The reservoir is then raised to a suf- 
ficient height to force the fluid to run into the urethra and as far as the back of 
the bulb. Pressure is then made on the tip of the penis, thus pressing the meatus 
against the nozzle. The fluid then passes into the urethra as far as the com- 
pressor urethne muscle and escapes when pressure is removed. 

The Janet Method. — In case it is necessary to introduce the fluid into the 
prostatic urethra and the bladder, the reservoir is raised so that its lowest part 
is about a yard and a half above the pubes. The pressure on the meatus is 




Fio. 161. — Author's Method of Suspending Douche Jars for Irrigations in Office, 

Hospital and Clinic. 



maintained and the patient is instructed to breathe deeply and try to relax all 
the muscles, or else to try to pass out the fluid that is in the canal. The effort 
to urinate relaxes the cut-off muscle and alloAvs the solution to enter the bladder, 
after which the patient passes it out. 

The douche jars vary in shape, but are usually conical. They are made of 
glass with a metal collar about the neck, to which is attached a metal bucket 
handle. This handle can be used to suspend the jar from a hook, or a cord can 



172 



TECHNIQUE OF INSTRUMENTATION 



be attached to it that is passed through a pulley by means of which it can be 
raised or lowered as desired. Other reservoirs are flat on one side and these 
fit better to the wall. Some of the jars are graduated. Rubber foimtain 
syringes are used, but are not so easily sterilized and do not allow one to see 
the level of the fluid. 

Various ways of suspending these jars have been tried by us in oflSce and 
clinic practice. They are illustrated in Fig. 161. 

A represents a board nailed to the wall, the door or a window frame. B 
is a hook to which is hung a pulley. C is the irrigator, i? is a piece of cord, 
one end of which is attached to the handle of the irrigator. The other end runs 
through the pulley and is fastened to a cleat, E, on the wall. 




A 




U^" 



A 



1 



Fig. 162. — ^Author's Apparatus for Irriqatino Urethra and Bladder by Hydrostatic Pressure. 



P shows a gas pipe stretching across the ceiling of the room to which a pul- 
ley is attached at B by means of a wire. The cord runs from the irrigator 
handle through this pulley to the cleat, as has just been described. This second 
method has many advantages, inasmuch as a series of irrigators can be strung 
from one pipe. " 

F shows an upright fastened to the table which supports an irrigator. (? 
shows a fountain syringe hung on a nail on the wall. 



IKRIGATIONS 173 

The object of the pulleys is to regulate the pressure of the fluid by raising 
or lowering the reservoir. If the jars are stationary, the force of the stream 
can be regulated by means of the cut-off to be described below. 

The irrigator is connected by means of a rubber tube about three yards long 
with cut-off, shield and nozzle. The first figure (Fig. 162) shows (A) the rub- 
ber tube leading from the irrigator ; (B) the hard-rubber coupling in which the 
nozzles (D) fit, and which is provided with a cut-off valve at C. This valve can 
be so regulated by pushing upon its lever that one can either shut off the solu- 
tion or allow it to flow at different velocities. Over the body of the coupling, 
fits shield E, which is a cup-shaped guard intended to prevent the water from 
splashing or spilling. Into the coupling, B, fit the various nozzles provided for 
the apparatus, D-1, i?-2, Z>-3 and DA. D-l has a blunt end suitable for irrigat- 
ing the urethra by hydrostatic pressure. Z>-2 is elongated into a tip that can 
easily be inserted into a catheter. D-S is a short nozzle, with an olivary tip, 
made for irrigating the fossa navicularis and DA is the same shape but long 
enough to extend to the bulb, for irrigating the bulbous portion of the urethra. 
It has also an olivary tip. 

The shield, which is pictured in the figure (E), is the one I prefer in 
my own work. A number of shapes have been tried at my clinic at the Post- 
graduate Hospital. At first we irrigated without any shield, using simply hard- 
rubber nozzles at the end of the rubber tubing. We next tried round, soft-rub- 
ber shields with an opening through which the nozzle could be pushed. 
I have for many years used the copper detachable hemispherical shield, modeled 
after half of a hollow rubber ball, which I have found to be most satisfactory. 




Fig. 163. — Irrigatino Kollmann Dilator. 

(d) With Irrigating Dilators. — Irrigating dilators are used for the purpose 
of irrigating the canal when it is dilated. They are of the Kollmann pattern, 
the dilating portion of which is composed of four blades. They can be used 
without sheaths or covers, such as are placed upon other dilators. Tliey are 
straight or curv^ed with a Benique curve. They are introduced into the urethra, 
their blades are separated by turning the wheel in the handle of the instrument. 
This smooths out the mucous membrane and oi)ens the mouths of its follicles. 
The attachment is then made and tlie solution is allowed to run tlirough, which 
thoroughly washes the urethra, while it enters the ducts, emptying into the canal 
as much as possible. 



174 



TECHNIQUE OF INSTRUMENTATION 



INSTILLATIONS 

Instillation is the injection of a solution by drops into the urethra or blad- 
der. This is done either with or without a catheter. The object of an instilla- 
tion is to apply a strong solution to a definitely circumscribed portion of the 





Fia. 164. — Guton's InstilIiAtino Strinqb. 

canal and allow it to remain there, in contra- 
distinction to an injection, which acts upon the 
entire anterior urethra and is allowed to escape 
after holding it for a few minutes. 

The Guyon instrument (Fig. 164) is a 
piston syringe, the barrel of which is gradu- 
ated and which holds 4 grams (1 drachm). 

The tip of the syringe 
is attached either to 
an olive-ended, hollow 
bougie or to a catheter 
with a perforation at 
the extremity. 

The Ultzman in- 
strument is a piston 
syringe holding twen- 
ty drops attached to a 
curved, hollow sound 
(Fig. 166). 

The solution used 
in instillations consists 
of silver nitrate, in the 
strength of from one 
to five per cent for 
the stronger effects or of 1 : 500 or 1 : 250 for milder action. Exceptionally, 
a caustic effect is obtained by the use of ten-per-cent solutions of silver nitrate. 
The amount of the latter is limited to three or four drops, while the weaker 
solutions are injected in quantities of from five to thirty drops. Other silver 
salts are used and will be considered in the chapter on Urethritis. Some sur- 
geons use strong solutions of bichlorid of mercury and sulphate of copper for 
instillations, but I do not recommend them. 



Fio. 165. — Manner of Giving an Instillation of the Urethra 

WITH THE Guyon Instillator. 



INSTILLATIONS 



175 



Instillations can either be given in the anterior -or tbe posterior urethra. 
The method of procedure is aa follows: The patient ia allowed to pass hia 
nrine and the external parts are cleaned in the usual manner. For instil- 
lations in the anterior urethra Guyon's perforated, olive-tipped catheter is 
used and is introduced as far as the point of localized inHanimation (Fig. 
I(i5). The tip of the piston syringe 13 then introduced into the outer end 
of the catheter and the fluid is slowly injected, from ten to fifteen drops being 



In instillation of the posterior urethra, as practiced with the aid of 

the Guyon apparatus, the end of the catheter is passed into the posterior 

urethra and the solution de[K>sited there in the same 




way. 



M 



J 



Fia. 166. — UlTZUAn's iNSTIU.ATlNa SlBINOB. 

The ITltzman syringe is, however, generally 
used for the posterior uretlira. The hollow sound 
and the piston ayringe are connected and the syringe 
filled with the solution. It is then passed into 
the posterior urethra 
like a sound and the 
solution instilled into 
it^usuallj ten to 
twenty drops. If the 
tip has reached the 
bladder, by rotating 
the instrument it can 
be felt to move freely 
about and it should 
then be withdrawn 
until it rests in the 
— comparatively narrow 
confines of the pros- 
tatic urethra. In giv- 
ing bladder instilla- 
tions, either apparatus can be used, the end of the instrument being introduced 
into the urethra and the entire amount contained in the syringe instilled. Usu- 
ally from thirty to sixty drops are instilled and left to act locally (Fig. 
167). 




Fio. 167.— Mannkh o 



TECHNIQUE OF INSTRUMENTATION 



A sound is a metal instrument consisting of a shaft and a handle. The shaft 
is round, 8J to 10 inches l«ng, and tapers toward its distal entl, which is curved 




Fio. 168. — Cdbveb o 



and well rounded at its tip. The handle is a piece of flattened metal, alwut 2^ 
inches long, wider in its transverse diameter and not so thick as the remainder 
of the instrument. The curve of the sound varies in its length and degree. 



Fio. 160. — Frbhcb (CharriIre) Sound Scale, Compared with Enolish Meahdhement. 

There is tlie long curve, the short, the acute and the less marked. Straight 

sounds are also made, but are very rarely used. 



SOUNDS 177 

The sounds principally used in this country are the Van Buren, the 
Benique and the Otis. The following diagrams illustrate these curves and 
ai^iments have been made in favor of each (Fig. 168). The short curve FBE 
is the one that I generally use in ihy urethral work, although, for the dilatation 
of hard strictures difficult of dilation, CBD is preferable, not on account of 
its shape, but because the difference between the sizes of the Benique sounds 
is only half what it is between the sizes of the other sounds of the ordinary 
French scale, the Charriere (Fig. 169). I ajso prefer the short cnrve 
because I believe that I can pass it Oy 

more easily and feel the urethra X!;;;; - ^^^^~-^~^ 

better than I can with any other ^^ ^o.-Sotmi. Cubv. Pb.f»b™» bt a^ob. 
sound (Fig. 170). 

Technique at PaBsing Sotmds. — This depends on the teaching in different 
countries and in different schools. In this country, the physicians pass sounds 
from the left side of the patient, whereas in Europe, they are passed from his 
right The patient is placed in a reclining position, his body making an 



FiQ. 171.— First Step of Passinq a Sodnd. 

angle of about 22J° with the table. (1) The physician stands on the left side 
of the patient and grasps the handle of the sound between the tliumb and fore- 
finger of the right hand, while he grasps the penis with the left hand and holds 
it perpendicular to the body. He passes the sound over the thigh at right 
angles to its side and inserts its tip into the urethra (Fig. 171). (2) If the 
sound is of the proper size and is not held back by the operator, it should slide 



178 TECHNIQUE OF INSTHTTMENTATION 

down the urethra by its own weight as far as the bulb. The handle is then some- 
what elevated and when the instrument ceases to glide, it sliould be swung 



Fio. 173.— TaiBti Step of PASaiNo a Soond. 



SOUNDS 



179 



around gently toward the pubcs imtil it is over the symphysis and the median 
line of the body, corresponding to the linpa alba (Fig, 172). (3) The organ 
is then extended and steadied by the fingera of the left hand, while the right 




Fio. 174. — BbNiQU^ Sound, With 



hand gently moves the soimd in the arc of a circle from the abdomen to be- 
tween the thighs (Fig. 173), In passing the sound, the right hand simply 



, 175.— First Step o 



PAsaiHa A Beniqd^ Sound. 



guides the soimd, while the left hand keeps the organ fairly well on the stretch, 

so that the tip of the instrument, in passing the perineal part of the urethra, 

will hug the middle line of tlie roof of the canal and not catch along its course. 

If Uie meatus is tight, the physician should pull the glans ]K;nis up toward 



180 TECHNIQUE OF INSTRUMENTATION 

the handle of the sound from time to time, which will allow the part of the 
soimd beyond the meatua to glide down farther into the canal. In this way, the 
hugging of the sound by the meatus can be overcome. A meatna smaller than 
the remainder of the canal ahonld be cnt. 

In case the end of the sound catches in the perinea] urethra and does not 
pass through its curve, this can often be aidetl by taking the instrument in the 
left hand and simply pressing over the pubes and suspensory ligament with the 
palmar surface of the fingers of the right hand. If this does not suffice, the fin- 



Fio. 17B. — Second Stbp or PAsaiMa a Bbnique Soitnd. 

gers of the left hand can be placed in the perineum to steady and lift the end of 
the sound out of any pocket that it may happen to be in, up against the anterior 
wall of the urethra and in contact with the opening of the membranous urethra. 

In France, the Benique sound, which has a long and pronoimced curve like 
that of the perineal urethra, is principally used. These instruments are well 
adapted for stretching strictures, because they increase in size more gradually, 
by one sixth of a millimeter, instead of one third of a millimeter. They are used 
with a guide like a filiform bougie, fixed into a metal socket with a screw at the 
end (Fig, 174), which is screwed into a corresponding ojiening in the end of the 
sound {Fig. 174). The guide is passed through the urethra into the bladder, 
and the sound screwed on, after which the instrument is also introduced. 

The French method of passing metal sounds is as follows: 



(1) The operator stan«lfl on the right side of the patient, holding the penis 
with hie left hand and the eound with his right, so that its concavity points to 



FiQ. 177. — Third Step ot Pasbino a Benique Sodhq. 

tlie right thigh (Fig. 175). He guides it down the urethra to the perineal 
portion, at the same time drawing the organ over the instrument around toward 



Wia. 178. — FoOBTa Step or PiMtna a Bbhiqcb Soi;in>. 



182 



TECHNIQUE OF INSTRUMENTATION 



the median line (Fig. 176). (2) The left hand then draws the organ up in 
front of the abdomen (Fig. 177). (3) When the end of the sound engages in 
the membranous portion, the left hand drops the organ and presses supra- 
pubically over its suspensory ligament, while the right hand guides the instru- 
ment into the bladder (Fig. 178). 




DILATORS 

Urethral dilators are instruments shaped like sounds that can be enlarged 
by turning a wheel at the distal end, so as to stretch different portions of the 

canal. The shaft of the in- 
strument, where the dilata- 
tion takes place, is com- 
posed of blades, bands of 
steel, that separate from 
one another either antero- 
posteriorly, or both antero- 
posterior ly and laterally, 
when the w^heel is turned. 
A dial near the wheel regis- 
ters the amount of dilata- 
tion. 

The instruments in 
which the bands separate 
antero-posteriorly are called 
the Oberlander, and the 
others in w^hich they sepa- 
rate both antero-posteriorly 
and laterally, are called the 
Kollmann dilators. 

The Oberlander dilator 
is of three forms, two with 
a flat curve for the anterior 
urethra (Fig. 179, Nos. 1 
and 2), another with a curve 
like a sound for the antero- 
posterior urethra (No. 3) 
and the third with a more pronounced curve, Benique, for the posterior portion 
of the canal (No. 4). 

Of these four Oborliindor dilators, No. 3 is the best, as it can be used for 
the deep anterior urethra and the membranous and posterior portions by intro- 
ducing it until the beak is in the bladder and then dilating. Or it can be used 





No. 1. 



No. 2. No. 3. No. 4. 

FiQ. 179. — Oberlander Dilators. 



DILATORS 



183 



simply for the dilatation of the anterior urethra, by inserting it and dilating 
when the instrument is at right angles to the table. All these instruments, when 
they are closed, show no space between the two blades of the dilator. 




No. 5. 



No. 6. 



No. 10. No. 11. 



curved 
11 



No. 7. No. 8. No. 9. 

Fig. 180. — Kollmann'b Dilators. 

5. KoUmaon's straight articulated 4-bladed dilator for the anterior part of the urethra, with short 

branches. 
" anterior parts of the urethra, with long 

branches. 
'* posterior part of the urethra. 

and part of the anterior urethra, 
part of the urethra, with Guyon's 

curve, 
and part of the anterior urethra, 
with Guyon's curve. 
•* " anterior part of the urethra, with irrigating 

attachment. 
" " posterior and part of the anterior urethra, 
with irrigating attachment. (Shown 
in Fig. 184.) 



6. 

7. 
8. 
9. 

10. 

11. 

12. 



II 



•• double-curved 
straight 
curved 



II 



It 



II 
11 
<< 

It 

<i 

II 



II 

II 
II 

II 

II 
II 
« 



11 
II 
II 

II 



II 

II II 

II 11 

II II 



II 
II 



« 



The dilator of Oberlander (Fig. 179, No. 3) is composed of a shaft; of two 
pieces of steel, with three small levers between them; a handlepiece, composed 
of the body where the two pieces of steel come together ; a screw connected with 
the wheel, at the end of the handle for separating the two pieces, of which the 



184 



TECHNIQUE OF INSTRUMENTATION 



instruuient is composed; a metal loop for holding the instrument and a dial, 
which records the number of millimeters of dilatation. When the Oberlander 
is inserted, it is of the size Xo. 16 French, and when fully opened, No. 40 
French. 

The Kollmann dilators (Fig. 180) are worked on the same principle as the 
Oberlander, but, as they have four blades, they dilate on four sides and thus 
make more even distention. They dilate from 24 to 50 French. The posterior 
dilator, like the posterior Oberlander, has the Benique curve. 

The blades of the Kollmann dilators are arranged in such a way that two 
blades lie at right angles to the other two, so that the cross section of the instru- 
ment at its widest point is shaped like a cross (Fig. 181). 









B 



Fio. 181. — Blades of a Kollmann Dilatob. 
A, cross section of blades closed. B, cross section of blades open. 

These four-bladed dilators of Kollmann are made in three different types: 
Two straight Kollmann dilators, which are used only in the anterior urethra 
(Fig. 180, Nos. 5 and 6), two curved posterior dilators, which are used for 
the posterior urethra, as the blades separate only at the distal end (Fig. 
180, Xos. 7 and 9) and finally, the dilators which dilate both the anterior and 
posterior parts of the canal (Nos. 8 and 10). 

Of the Kollmann dilators without an irrigating attachment, if but one is 
to be used, the instrument with the curve like a sound for dilating both the an- 
terior and posterior part of the urethra. No. 8, is the most useful. 

The posterior Kollmann, No. 9, is also of great value, as in many cases 
of chronic prostatitis it is necessary to dilate the posterior urethra, and, as it is 
so much larger than the remainder of the canal, the necessary dilatation would 
not be obtained by means of an antero-posterior dilatation without danger of 
rupturing the anterior or membranous portion. 

The varieties of instruments just described, both Oberlander and Kollmann, 
are all used with a rubber cover or sheath to prevent their blades from pinch- 



DILATORS 



185 



ing the urethral mucous membrane when closing them and thus causing trau- 
matism (Figs. 182, 183). The Oberlander with a curve like a sound (No. 3) 
is the best of the Oberlander group, while the antero-posterior Kollmann (No. 




Fig. 183. 
Figs. 182 and 183. — Rubber Sheaths Drawn Over the Dilators. 

8) is the best of this group. Kollmann dilators are better than the Oberlander. 
The posterior Kollmann (No. 9) is the best instrument for stretching the pros- 
tatic portion of the urethra alone. 

There are two other varieties of Kollmann dilators — one straight irrigating 
instrument (Fig. 180, No. 11), and another curved dilating instrument with 
an irrigating attachment (Fig. 184). These two instruments are naturally 
made to use without a cover and do not pinch the mucous membrane of the 




Fig. 184. — Kollmann Irrioatino Dilator. 



urethra, as when they are closed the blades touch only at their inner angle. The 
irrigating Kollmann has, in addition to the ordinary dilating instrument, a 
hollow shaft for irrigating purposes, and a bell or guard to catch the irrigating 
fluid as it escapes from the urethra. 

Technique of Instrumentation. — The cover is drawn over the dilator. The 
instrument is then dipped into glycerin or some other sterile lubricant that 
mixes with water, such as lubrichondrin, and is passed into the urethra the same 
as a sound. The straight instrument is only passed into the anterior urethra 
until it is in a position perpendicular to the table (that is, at an angle of 90°), 
when the dilatation is made. 

The antero-posterior and the posterior Kollmann are passed into the bladder 



186 TECHNIQUE OF INSTRUMENTATION 

in the same manner as a sound and are allowed to remain in the position that 
they naturally assume, which is at an angle of about 45° with the table. The 
dilatation is made in this position. 

The dilator is steadied by its handle with the fingers of the left hand, 
while those of the right hand grasp the wheel controlling the distention of 
the blades, and slowly turn it to the right until the degree of dilatation desired 
is indicated on the dial. But it must be remembered that if the patient 
complains of pain, or if any undue resistance is felt, the dilatation should not 
be pushed any farther. The dilator is left in place for a few minutes. It is 
then closed by turning the wheel in the reverse direction, after which it is gently 
withdrawn. 

When the urethra is narrowed by a stricture, the No. 16 French Oberlander 
may be the only dilator that will pass it, and the first dilatation, therefore, will 
be up to No. 17 French. The average dilatation at the first treatment with the 
Kollmann dilator can be said to be about No. 25 French. 

The rule is to increase at subsequent treatments by one or two numbers of 
the French scale each time. It must be remembered also that the two-bladed 
dilator of Oberlander causes more tension than the four-bladed one of Koll- 
mann, and that, consequently lower degrees of dilatation must be begun with it. 
After a size of No. 32 or 35 French has been reached, the dilatation should be 
increased very slowly, indeed, a fraction of a degree at a time. 

The duration of the dilatation at each treatment should be about ten min- 
utes up to No. 32 French; about fifteen minutes from No. 32 to 36 French, 
and even longer with higher degrees of dilatation. 

After dilating the urethra by means of dilators, the canal should be irri 
gated with some antiseptic solution, unless the irrigating Kollmann is used. 

In using the irrigating Kollmann dilator (Fig. 184), it is passed in the same 
way as the other dilators until its curve corresponds with that of the urethra. 
The outflow tubing from the reservoir or douche bag is then connected with 
the nozzle on the handle portion of the instrument, and the solution runs 
through a central hollow shaft and escapes from slits in its sides, thus irrigat- 
ing the urethra and running out along the sides of the instrument against the 
bell and then into a receptacle, such as a douche pan, placed beneath the patient's 
buttocks, or some other pan placed between the legs. It is a most satisfactory 
instrument. 

The irrigating Kollmann dilator is of a rather complicated construction. It 
can be boiled, or at least its lower portions can be, and the mechanism at the 
handle is open so that it can be frequently cleaned and oiled. 

The care of dilators is important, as the surgeon will find that, unless they 
are well cared for, they rust and get out of order. They should always be 
opened to their fullest extent after using, should be thoroughly cleansed and 
dried, especially at the joints and cross pieces, and should be wiped with a very 



DILATORS 187 

thin coat of vaselin and kept free from dust. Some prefer to clean the dilators, 
after they have been used, with liquid soap, and to wipe them with alcohol. 
The covers should be kept in a cool place, free from moisture and covered with 
talcum. Talcum can also be dusted into the covers before applying them to the 
dilators, but this is not a good plan, inasmuch as the powder clogs the joints. 
The dilators with their covers can be sterilized in a formalin sterilizer. With 
care a cover lasts about a dozen treatments. 



CHAPTER IX 
URETHROSCOPY 

The visual examination of the urethra through a metal tube by means of an 
artificial light reflected into it, or by means of a lamp in the distal part of 
the tube near its end, has been one of the greatest advances in modem urology. 

Desormeux, in 1853, was the first to devise a urethroscope of any value. 
He used a tube illuminated by a lamp, the rays from which were thrown into 
the urethra by means of mirrors. Various other modifications were then made, 
using reflected light, until Nitze, in 1878, constructed an instrument which 
later became known as the Nitze-Ober] Under, in which the urethral field was 
illuminated by means of a lamp in tlie tube. Since then, many modifications 
have been brought oitt, siich as the Antal, Casper, Chetwood, Fenwick, Gorel, 
Klotz, Mark, Otis, Powell and Valentine, the most practical of which were 
those that had the lamp in the tube. 

Urethroscopy was revolutionized and made simple by the introduction of 
the Mignon lamp by Drs. Koch and Preston of Rochester. This lamp \yas prac- 
tically cold and was inserted into the tube on a carrier. Chetwood, Valentine 
and myself were among the first to use this variety of illumination in the ure- 
throscope. 

The urethroscope which bears my name consists of a tube six inches long 
and rounded at the distal end ; but the remaining part of the tube, extending 



-^ 



from this point to the disk at its proximal end, has its lower arc transformed 
into a glitter which is not separated from the remainder of the tube. 

The illuminating apparatus consists of a thin rod or wire carrier, at the 



rRETHROSCOPT 189 

distal end of which ia the Mignon lamp. At the proximal end of the carrier is 
the handle which has a switch for the light and two posts to which a cable ia at- 
tached, the other end of which cable is connected with an electric current derived 



either from a portable storage battery or from the street. The turning of the 
switch lights the lamp at the end of the carrier. Along the gutter of the tube, 
the electric lamp, at the distal extremity of its carrier, is passed almost to 



Fio. 187. — PoETABLE Battery for the Gditekab Urethroscope. 

the end of the instrument. In this position it does not interfere with the view 
and yet it gives a perfect illumination of the urethral field. There are several 



190 



URETHROSCOPY 



a UaGTHHoacopy a 



tubes, varying in size from 22 to 28 French. A tube of 28 French, or even 
larger, is preferable in- uretliroscopy. 

The tubes of this urethroscope can be introduced into the deep and the pos- 
terior urethra with greater ease than those of any other straight instrument, 

on account of the round- 
ing of the lower part 
of the tube when it curves 
over the bottom of the in- 
strument. 

The battery providing 
electricity for illuminating 
tlie urethroscope is one 
of from four to nine dry cells, provided with a rheostat controlling the current. 
Such batteries may bo obtained in cases which liave space for the carrying of 
urethroscopie tubes, light carriers and lamps and cables. Fig. 187 shows the 
battery made for the author's urethroscope. When the street current is available, 
a controller which regulates the current must bo employed (Fig. 188). Care 
should always be taken to test the controller before making the connection with 
the lamp, as the rheostat at times burns out and when the little lamp is connected 
it is instantly destroyed by an excess of current Another precaution in using 
the controller is always to turn off the current in the socket of the fixture to 
which the controller is attached as soon as the use of the apparatus is discon- 
tinued. This prevents overheating ia the controller and prolongs the life of 
this appliance. 

The battery or controller is connected with the light carrier by means of an 
insulated cord, the end of which fits into the hard-rubber handle of the car- 
rier. A milled screw in the handle of the carrier shuts off or connects the lamp 
of the urethroscope. 

In addition to the instruments, the source of light and the controller, the 
surgeon should provide himself with glycerin in a wide-mouthed vessel for 
lubrication and with a number of applicators about nine inches long. Metallic 
applicators are the best for both swabbing out tlic canal and making ai>- 
plications. The advantage of the metal applicators is that they have a 
special end which prevents the cotton from coming off in the tube and also 
because some of tJieni are so fine near the end that, with a thin layer of cot- 
ton about them, they can be introduced into small areas for the a])pIication of 
solution. 

A number of very useful instruments, for intranrethral treatment through 
the endoscopic tube, have also been devised by Kollmann and others. These 
include a pipetle with a rubber bulb at its end for removing drops of secretion 
from the urethral glands ; probes ; silver cannulas which acn^w to a small syringe 
by means of which local injection of nitrate of silver can be made; a set of 



URETHROSCOPY 



191 



minute knives for dividing strictures or urethral bands; and a urethral snare 
(Fig. 189). 

Physicians who wish a special instrument for the posterior urethra will find 
one in the urethroscope of Dr. G. K. Swinburne of New York, constructed on 



lo. 189.— Cask o 



INTBADRITBRAI. iNBTRUMBim. 



c^ 



_^ 



Fio. I89ft.— Cannula 
UaBD fOB Injectcnu 
Glands and Fqlli- 



^ 



Flo. 189c. UaKTHRAL Khites. 




POLTPDH SNA BE. 



192 UEETHEOSCOPT 

very much the eame pattern and by the same company. It is 16 cm, long and 
has a beak 2 cm. in length. The size used is No. 28 as a rule (Fig. 190). 



■^s?^ 



%t> 



Fio. 190. — SwiNBnBKE'a PoansaiOB Urbthrobcopb. 



t 



The Buerger cysto-uretliroscope gives a fine view of the prostatic urethra 
on all sides aud is constructed on entirely different lines from the cylindrical 



Fta. 191. — Tqb Boaun-Bubbobb Cibto-ubethroscopb. 

urothroacopcB (Fig. 191). The ejaculatory and prostatic ducts, veru mon- 
tanimi and all portions of the prostatic urethra can be seen. 



TECHNIQUE OF DRETHROSCOPY 

The patient is placed either in the dorsal position, with his shoulders ele- 
vated, or, if preferred, in a sitting posture with his body at an angle of 67^° 
with the table. His feet rest in inverted stirrups below the surface of the table 
on either side. If the urethroscopy is to be followed by cystoscopy, as it some- 
times is, he can be placed at once in the cystoscopic position. 

The examiner then sits in front of the patient between his legs. He takes 
the urethroscope with his right hand, in such a way that his thumb is on the 
obturator and bis fore- and middle finger on either side of the tube behind the 
disk. He dips it into glycerin, opens the meatus with the thumb and forefinger 
of his left hand and inserts the tube into and down tlie urethra as far as the 
bulb, while he steadies and slightly stretches the penis with his left band (fig. 



URETHROSCOPIC CONDITIONS. 
Fio. 1, — Appearance of the urethra after a rourse FiG. 7. — Longjluilinal section of the normal iire- 

of treatment by electrolysis. thra. showinft the tosaa naviculariH above; two 

Fio. 2. — .\ngioma ot the urethra occupying only a lar^ urethral follicles (crypta of MorgaRni) 

segment of the canal. lower down. Numerous orifices of smaller fol- 

Fia. 3. — Pedunculated polyp of the urethra. lielca are also seen, showing the difficulty of 



Flo. 4. — Normal veru montanum, anterior portion. thoroughly treating all these small openings 

FiQ. 5. — Normal view of the urethral bulb. when involved in chronic urethritis. 

Flo. a.^Normal view of the largest portion of the Fia. 8. — Congbmeratp polypoid (p'tmulations. 



1©4 URETHROSCOPY 

obscuring the field. The swabs are made by winding sufficient cotton around 
the end of an applicator to have a wad one sixth to one quarter of an inch in 
diameter. Several of these should be always ready to use in doing urethroscopy. 
The canal is swabbed until dry (Fig. 193). The lamp and its carrier, with the 
cable attaclied, is then introduced into the tube and fastened to the pins on the 
disk. The current is then turned on, and tlie examiner puts his eye to the ocular 
end of the tube and proceeds to inspect the urethral field, holding the urethro- 
scope with the right hand and the organ with the left. Fig. 194 shows the 
position for examining the anterior urethra, whereas Fig, 195 shows the posi- 
tion for examining the posterior part of the canal. 



Flo. 194, — PoBrnoN in Ekamininq the Atrnimoii Ubbtbiu. (After Luya.) 

The Normal Urethra. — In onler to make a correct diagnosis of urethral 
lesions with the aid of the urethroscope, one must be tlioroughly familiar with 
the normal urethra. An imjiortaiit fact to bear in mind is tliat the urethra 
varies normally in appearance, both according to the degree of anemia and 
hyperemia, and according to the particular part which is under observation. 
It may be pale red, moderately red or deep red. Tlie paler tints have some- 
times a grayish or a yellowish tinge. The pressure of the urethroscopie tube, 
especially when it is too large for the canal, and when it presses against one 



URETHROSCOPIC CONDITIONS. 



FlQ- l- 

Mc „_ -. - - 

inRamcd gliuids of Littr^. 

Fio. 2.— Chronically inflamed crypt o( MorRagni 
which can be cured only by appliciitions of 
eiectrolyaia. 

Fig, 3, — Appearance of Litlr^'a glands during a 
chronic suppurative prooees. 

Fia. 4. — Combined cystic and suppurative con- 
dition of the glands 6f Littr^. This sbowa 
the necessity of dilatations in such a con- 

FiQ, 5.— The same condition as in Fig. 4. 



Fia. 6. — .4 very lai^ cyat of Littr^'a gland which 
gave way under dilatation. 

Fig. 7.- — Normal appearance of a large crypt of 
Morgaftni of a "V" ahape. 

Fjo. 8. — Strieture of the urethra. Mucous mem- 
brane is seen to be darker with rigid walb 
invaded by fibroua tissue. Very inelastic. ■ 

FiQ. 9. — Soft infiltrate of the bulbous urethra, a ' 
typical case. There is a pufliness resembling- 
hemorrhoids. 

Fig. 10. — Sessile poiyp in the bulbar region. 

Fig. 11. — Small polyp situated on the edge o{ a 
large crypt of Morgagni. 



TECHNIQUE OF URETHROSCOPY 195 

side of the urethra, produces a local anemia which the beginner must learn to 
recognize. 

Various regions of the urethra present certain important features which 
must be remembered. Near tlie glans, that ia, in the region of the fossa navicu- 



laris, the lining of the canal is very pale and smooth. Beginning with the re- 
gion behind the fossa and extending throughout the anterior urethra, the mucosa 
is thrown into longitudinal folds which are necessary for allowing the canal 
to be distended when filled with urine. The size of these folds varies in dif- 
ferent individuals, as does the size of the j>enis and the urethra. The longi- 
tudinal folds ap])ear in the urethroscope between radiating lines from the cen- 
tral depression which represents the lumen of the canal. Frequently the 
pressure of the tube so distends these folds that they are more or less obliterated. 
Aa the urethra, when undisturbe<I, is in a collapsed state, the introduction of 
the tube widens the part immediately behind the end, that is, the part we are 
looking at in the form of a funnel whose narrow portion is constituted by the 
lumen of the undisturbed part of the canal. If we look into the tube, there- 
fore, and if we hold it so that the lumen is central, we are looking into the 
funnel whose walls are formed by the radiating folds of the spreading mucosa. 
The latter are, naturally, most marked toward the bottom of the funnel and are 
obliterated where the edges of the tube touch the mucosa. The central depres- 
sion at the bottom of the funnel should always he carefully noted, as it varies 
considerably. Thus, in the bulb wliere we begin the examination, the inferior 
wall of the funnel bulges upward so that there ia a central depression shaped 
like a Y whose angles are roimded. Aa we advance into the cavernous part of 
the urethra, the central depression becomes smaller and forms either a horizon-' 



196 URETHKOSCOPY 

tal slit or a small circular figure. Finally, in the region of the glans the lumen 
assumes the shape of a vertical slit which sometimes appears as an oval figure. 

In addition to the folds, we have in the normal urethra certain radiating 
striations which are specially noticeable in the cavernous portion when there is 
a good blood supply and when the urethroscopic tube is sufficiently large. These 
striations are of a pale or yellowish red. In persons with robust constitutions 
and plentiful blood supply, one also sees minute branched vessels coursing 
through the mucous membrane. 

In the normal urethra, the surgeon should learn to distinguish three kinds 
of glandular openings: (1) The mouths of the ducts of Cowper's glands. These 
are not always visible, but should be looked for in the lower wall of the bul- 
bous portion, at the bottom of the folds of the mucosa. (2) The urethral fol- 
licles are widely scattered over the anterior wall (upper wall) of the urethra 
and should be looked for in the cavernous or bulbous portions by gently press- 
ing the mouth of the tube against the anterior wall and carefully going over the 
canal. They look like minute depressions of the size of the head of a pin or 
smaller, sometimes of the same color as the mucosa around them, but oftener 
of a dark red with a still darker center or depression. We shall see that, in 
chronic urethritis, they may be materially altered. (3) Littre's glands, which 
are very numerous and scattered throughout the canal, are only visible when 
diseased, but they remain in evidence a long time after the urethritis is cured. 

All these different characteristics of the normal urethra are far less evident 
in anemic and debilitated individuals than in persons with robust constitutions. 

It must be remembered that, when it is desirable to examine the posterior 
urethra, this should be done before examining the anterior portion of the canal 
by inserting the instrument at once through the membranous into the prostatic 
portion. The urethroscope is then slowly withdrawn, examining from behind 
forward, as has been described. 

Pathological Conditions. — Other important factors in urethroscopy include 
the localization of lesions along the canal in urethras of large size in which no 
strictures are present. One of the important lesions which should be detected 
with the urethroscope, if present, is a polyp of the mucosa for which urethras 
are frequently dilated for a long time, under the impression that it is a nar- 
rowing of the canal. Simple and tubercular ulcers, erosiohs, granular patches 
and the dilated glandular ducts can also be seen. 

Tubercular ulcers occur in the urethra, although rarely. Soft and hard 
chancres are always situated near the meatus and can be easily seen without the 
urethroscope. 

In strictures, urethroscopy serves to show the narrowing and the presence 
near by of chronic congestion or inflammation. Unfortunately, the tube which 
has to be used in most cases of stricture is so small that it does not allow us to 
examine the field very minutely. 



TECHNIQUE OF URETHROSCOPY 197 

Uretiiroscopic Treatment of Pathological Conditions. — Foreign 
bodies in the urethra can be detected through the urethroscope and occasionally 
removed by introducing alligator forceps, grasping them and pulling them out 
through the tube. Polyps can be removed from the urethra by means of a snare ; 
ulcerated surfaces and granular patches can be curetted and cauterized; the 
dilated ducts of urethral glands can be cauterized and destroyed by electrolysis 
or slit up with minute knives. 

Urethroscopy is of great value' in the diagnosis of the lesions of chronic 
urethritis, showing as it does the stage of the disease and the type of the lesions 
present. This subject, however, is discussed in the chapter on Chronic Ure- 
thritis, to which the reader is referred for further particulars. 

There is a certain amount of difficulty in learning to do urethroscopy and 
in interpreting wliat is found. The procedure requires much patience, practice 
and precision. In order to become skilled in it, one must examine a large num- 
ber of cases, remembering always that the introduction of the urethroscope is 
contraindicated in all acute conditions. It is a question whether urethroscopy 
is of such great practical importance as has been stated by some authors. In 
the majority of cases, I have gained nothing from my examinations with the 
urethroscope and have often felt that the work has been a loss of time. In most 
instances, nothing is seen but a slightly granular condition of the urethra in 
certain localities, or else areas of chronic inflammation which can only be 
treated by dilatation and irrigation. Occasionally we see something of im- 
portance like a polyp of the urethra and then we feel how important it is to 
urethroscope all patients with chronic urethral trouble as a matter of routine. 



CHAPTER X 



CYSTOSCOPY 



Cystoscopy is at the present day a practical procedure. During the last 
twenty-five years of the nineteenth century, many investigators who were in- 
terested in urinary diseases were bending their energies to discover some instru- 
ment that would reveal to them the character of the interior of the bladder and 
the ureters leading to the kidneys. When such instruments were finally made 
practical, the advance became very rapid, so that to-day the bladder can be ex- 
plored by every conceivable visual apparatus; and, although w^e can see what 
we consider necessary for us in urinary work, the probabilities are that in a few 
years this procedure wull be looked upon as crude and behind the times. It 
is well to consider what cystoscopy is ; the diflferent instruments that were used 
in the past and are used at present, as well as the details of performing cysto- 
scopic examinations. 

The cystoscope (from cystis, bladder and skopein, to view) is a tube fitted 
with lenses, or lenses and prisms, for viewing the interior of the bladder when 
illuminated with an electric lamp. 

While cystoscopy is essentially a method of examining the bladder, it also 
shows the vesical aspect of the prostate and, through the inspection of the ure- 
teral orifices and the urine coming from the ureters, it aids in diagnosing dis- 
eases of the kidneys. 

It must always be borne in mind that the object of cystoscopy is to examine 
the bladder, and that it is not done for the purpose of catheterizing the ureters, 
unless clinical and urinary evidence point to ureteral or renal involvement. 

fflSTORY OF CYSTOSCOPY 

The early attempts at cystoscopy were combined with those to illuminate 
the urethra. The first of these dates from 1805, when Bozzini, of Frankfort, 
invented an apparatus which was meant to illuminate the urethra and bladder. 
A number of attempts of similar character were made Avith little success until 
Desormeux, Furstenheim and Cruise (1853-65) constructed the first endo- 
scopes that made an examination of the bladder possible. In 1867, Briick, a 
dentist in Breslau, devised an instrument for examining the mouth, called 

198 



HISTORY OF CYSTOSCOPY I99 

a stomatoscope, which was illuminated by means of an incandescent platinum 
loop, heated to white heat by means of a galvanic current, and later constructed 
another for examining the bladder, called a diaphanoscope. Although it was 
found to be unpractical, it is interesting, because the Nitze instruments, which 
are now in use, are constructed on the same principles. 

In 1876, Xitze devised an electric cystoscope and urethroscope, and demon- 
strated the instrument in 1877. This cystoscope was later improved and sim- 
plified by Leiter of Vienna, so that the first electric cystoscope bears the name 
of Nitze-Leiter and the date of 1879. The lighting device of this cystoscope 
was also an incandescent platinum loop which was surrounded by a stream of 
water so as to keep the end of the instrument cool. A flow of water was neces- 
sary to keep the temperature of the beak of the instrument below the danger 
line. The original Xitze-Leiter cystoscope was complicated, cumbersome and 
imsatisfactory in many respects. 

In 1879, Edison first patented his incandescent lamp, which revolutionized 
the methods of constructing illuminating instnmients in general and cystoscopes 
in particular. Since then, the incandescent lamp system has been used in 
cystoscopy. 

In 1887, came the introduction of the cystoscopes of Nitze and loiter, both 
constructed on similar principles, and also the direct cystoscope of Brenner, 
which have served as models for all the cystoscopes since devised. These cys- 
toscopes had shafts shaped like a coude catheter and were of the observation type 
for viewing the interior of the bladder through a water medium. 

Catheterization of the Ureters. — The steps leading up to the catheterization 
of the ureters began at about the time that Xitze, Leiter and Brenner had per- 
fected their observ^ation cystoscopes in 1887 and were not associated with 
cystoscopy. 

Iverson, in 1888, began to catheterize the ureters by opening the bladder 
suprapubically and thus reaching their mouths, while Bozeman reached them 
through a vesico-vaginal opening; these procedures were in the line of major 
operations and consequently dangerous in character. 

At about the same time, in the development of ureteral catheterism, Pawlick 
(Wiener Med. Pressc, 1886) found that, by placing a woman in the genu- 
pectoral position, he could lift up the posterior vaginal wall with a speculum 
and expose to view the anterior wall; then, having introduced a catheter into 
the bladder, he could guide the point of the instrument by his finger in the 
vagina until it reached the ureteral orifice, when he could push it into the 
ureter. This procedure was exceedingly difficult of execution, rather dangerous 
on accoimt of the blind manner in which it was performed, and, of course, only 
applicable in women. 

Later, Kelly, of Baltimore, modified the method that had been employed 
without much success by Pawlick and devised a method of catheterizing the 



200 



. CYSTOSCOPY 



ureters, familiar to us all, which consisted in passing a tube through the urethra 
into the bladder, illuminating its interior by reflected light from a head mirror, 
and searching for the ureters with the aid of a long stilet which served to unfold 
the bladder. When the ureteral orifices had been found, the stilet was re- 
placed by a catheter. 

It was not, however, until 1892 that catheterization was performed through 
a cystoscope and then by means of the direct instrument. The first of these 
was that of Brenner in 1892; then that of Nitze in 1895, of Casper in 1896 
and finally the Nitze- Albarran in 1897. 



A COMPARATIVE CONSIDERATION OF MODERN CYSTOSCOPES 

Having gone over our historical review and found that the principal men 
to whom we are indebted for early knowledge of the examination of the bladder 
were Nitze, Brenner, Feilwick, Pawlick, Kelly, Casper and Albarran, let us con- 
sider the later work along these lines. 

We will put first on our list Brenner and Nitze, as the two leaders in the 
respective lines of direct and indirect cystoscopy. 

Brenner's direct instrument (Fig. 196) was perfected in 1887 and was the 
first direct-observation cystoscope of practical value for examining the bladder 

^ 




Fig. 196. — Brenner s Observation and Catheterizino Ctstoscopb. 

through a water medium. The instrument had an optical apparatus consisting 
of a telescope, which looked straight into the bladder without requiring any 
prisms to reflect the image. 

The First Direct-Observation, Irrigating and Gatheterizing Cystoscope. — 
In 1892, Brenner added a small separate compartment on the convex side of 
his instrument which contained a mandrel. The mandrel could be withdrawn 
and the bladder washed out through this channel, or a catheter could be intro- 
duced through it into a ureter. The instrument could also be slipped out over 
this catheter, leaving it in the ureter. It was for a long time considered the 
best instrument for ureteral and kidney work in women. The Brenner instru- 
ment was thus transformed from an observation cystoscope to an irrigating, and 
a single catheterizing cystoscope, which marked the greatest achievement up to 
that time in cystoscopy. 

The Indirect Cystoscope. — The steady improvement of the indirect instru- 
ment in the hands of Nitze, Casper, Leiter, Fenwick and others, made the 



CONSIDERATION OF MODERN CYSTOSCOPES 



201 



indirect cystoscope of the Nitze type more useful than the direct. The advan- 
tage of the indirect instrument was that a better view of the whole bladder 
interior could be obtained, especially of the anterior wall. 

The Construction of the Nitze Cystoscope. — The Nitze cystoscope 
(Fig. 197) consists of an elbowed tube, having at its vesical end, in the elbow, 




Fio. 197. — Nitze's Observation Cystoscope. 

an electric lamp, contained in a metal sheath which is fenestrated upon its an- 
terior surface. Close to the elbow, upon the upper surface of the straight por- 
tion of the tube, is a prism, which lies so that the hypothenuse, which is silvered, 
forms a mirror and reflects the rays of light entering the prism from the blad- 
der into the lumen of the cystoscopic tube. In this, Jby means of an arrange- 
ment of lenses similar to those of a telescope, the rays are transmitted to the 
eye applied at the ocular end of the cystoscope. Owing to the fact that a prism 
is employed as a mirror, we obtain an inverted image. This, at first, may lead 
to some confusion; but, after a little practice, it will be found that one grows 
sufficiently accustomed to this change to be able to disregard it entirely. To over- 
come the difficulty of dealing with the inverted image, the use of the straight- 
tube telescopic cystoscope, minus the prism, has been advocated by Brenner and 
others. All the instruments of the Brenner type, while giving us an image in 
its proper relative position, have the disadvantage that there are parts of the 
bladder wall which cannot be brought into the field of vision. The indirect 
cystoscopes made by the Wappler Company now have a correcting appliance 
in their telescopes by means of which the image is seen as it naturally exists, 
that is, not inverted. 

The Observation, Irrigating, Catheterizing Indirect Cystoscope. — Nitze 
added an irrigating apparatus to his cystoscope, making an irrigating instru- 




Fio. 198. — Nitze's Irrigating Cystoscope, Showing the Nozzles for the Entrance and Exit 

OP the Solutions. 

ment (Fig. 198). Later he made further improvements, enabling him to treat 
and operate on bladder lesions and crush stones and remove foreign bodies. He 
also added a channel to his instrument through which a catheter could be passed 
into a ureter. Nitze, then, advanced a step beyond Brenner, in that he had 



202 



CYSTOSCOPY 



combined (1) observation cystoscope, (2) irrigating cystoscope, (3) single- 
catheterizing cystoscope, (4) operating cystoscope and (5) photographing 
cystoscope. 

Nitze Operating and Photographic Cystoscope (Fig. 199). — The cautery 
snare is used to cauterize the base of groM^ths in the bladder. 




FiQ. 199. — Nitze's Operatinq Cystoscope, Showing the Snare and Lithotrite. 



The lithotrite can be used for crushing small stones, while the evacuator 
washes out the fragments. 

The photographic cystoscope requires much care and rarely produces photo- 
graphs which will repay one for the time expended upon them. 

Mechanism for Influencing the Direction of the Ureteral Catheter. — The 
Nitze cystoscope was a better one for catheterizing the ureters, as it could not 
only show the ureters in women as well as the direct instrument, but in men it 
could turn its beak over the base of an enlarged prostate and catheterize the 
ureter when it could not be done with a direct instrument. It was, however, 
exceedingly difficult to introduce a catheter into the ureter by means of Nitze's 
indirect cystoscope. Cas^x^r modified Nitze's instrument and constructed a slot 
along the concave shaft of the instrument, which helped to give a turn or bend 
to the catheter, thus facilitating its entrance into the ureter. 

Albarran modified Nitze's catheterizing instnnuent by constructing a lever 
upon the concave surface of the shaft at the point where the catheter comes out, 
which can change its direction by the turning of a screw on the side of the cysto- 
scope. This lever in Albarran's instrument is a little tongue of metal which is 
controlled by the screw near the handle, by means of which the end of the cathe- 
ter can be pushed away from the prism or lamp and straighten out at any angle 
to the cystoscope the operator desires. Albarran's instrument, in addition, had 



CONSIDERATION OF MODERN CYSTOSCOPES 203 

an irrigating attachment somewhat similar in construction to that seen in the 
newer types of Nitze's catheter izing cystoscope (Fig. 200). 




Fig. 200. — Nitze-Albarran Catheterizino Cystoscope, Showing the Lever for Moving thb 

Ends of the Catheters toward the Ureteral Openings. 



The Air Direct-Observation and Single-Catheterizing Cystoscope. — At 

about the time that the Nitze-Albarran cystoscope was considered the highest 
development of the combined observation and catheterizing instruments, the 
catheterizing of the ureters was still considered a mysterious, sleight-of-hand 
trick, and was not believed possible by many practitioners, who were inclined to 
put in the fakir class anyone who professed to be able to do it. Indeed, so won- 
derful was it considered, that the announcement that a lecture on catheteriza- 
tion of the ureters was to be given with a demonstration of the same was suffi- 
cient to pack an amphitheater. 

How strange it must have seemed to the unbelievers of the profession to see 
a direct cystoscope put upon the market (by an instrument company in Roches- 
ter, X. Y.), which was not only capable of showing the ureters in a bladder 
dilated with air, but by means of which the ureters could be catheterized even 
by the lay salesman who sold it! It seemed then that cystoscopy had been 
brought to such a simple form that any practitioner could examine the interior 
of the bladder and perform a ureteral catheterization. It was found, however, 
on trying the instrument, that such was not the case and that a knowledge of 
the subject on the part of the best physician or surgeon did not avail as much 
as practice in the hands of a lay agent of the company. Many of these so-called 
direct-air cystoscopes could be used by means of a water medium as well as by 
air. Since then air cystoscopes have been used in France, and much improved 
by Luys and Cathelin. 

The air cystoscope consists of a tube which has in its upper wall a smaller 
passage for the conduction of a wire that connects with the electric lamp and on 
its lower or convex wall another tube for the introduction of the urethral cathe- 
ter. The light from the lamp emerges through a glass window, in the convexity 
of the main tube near its end. The lamp, when burned out, is removable by 
imscrewing the tip and pulling it out. To facilitate the introduction of the 
cystoscope, an obturator is furnished, which closes the distal orifice and pre- 
vents scraping of the membrane against the edges of the opening. A glass- 
covered cap may be placed over the ocular end to enable the operator to dis- 
tend the bladder forcibly with air, when that condition is not effected by 
posture. The inflation is made by a rubber bulb attached to a stop cock. 



204 CYSTOSCOPY 

The instrument resembles somewhat the megalescope of Boisseau du Kochet 
(Fig. 201). 

The Cold Lamp. — The use of cystoscopy by air dilatation was first made 
possible by the production of a diminutive incandescent lamp, practically heat- 





<Z~P 



Fig. 201. — A Direct Air Ctstoscope op American Make. 

less, by E. C. Preston of Rochester. lie first began to manufacture it for 
throwing light into the nostrils, by using it on a long holder for illuminating 
the mouth and throat, and also attached it to a tongue depressor. Later, working 
with Dr. Koch of liochester, they applied it to urethroscopes and cystoscopes, 
calling it the Mignon lamp. 

As soon as the cold lamps were introduced, I had them placed in all of my 
imported cystoscopes — the Xitze, Albarran, Leiter and Fenwick — and have 
been using them as cold-lamp cystoscopes since that time. The cold lamps do 
not give as powerful a light, however, as the hot lamps, and at times superficial 
ulcerations might be overlooked. The cold lamps have been very much im- 
proved since they were first introduced and are now much more powerful and 
durable. 

It is claimed that it radiates so little heat that it may be held within a quar- 
ter inch of live tissues for an indefinite period without any discomfort, to say 
nothing of pain. It is really this property of the electric lamp that made the 
air instrument feasible. A hot lamp requires the protection of fluid before it 
can be safely introduced into the bladder. Thus, the use of fluid is eliminated, 
together with its several disadvantages, such as rapid clouding by inflowing pus 
or blood, etc. 

From the brief description given, it is evident that the air instrument is ex- 
tremely simple, which, I believe, is one of its chief advantages. Its freedom 
from complexity relieves it from many of the sources of difficulties encountered 
in the use of the older forms. Many of them have no lenses between the eye 
and the subject of investigation. Lenses must be perfect in order to be of any 
service whatever, and perfection in them is both expensive and difficult of attain- 
ment ; also, after perfection has been attained, the usefulness of the instrument 
may be destroyed in an instant by their displacement in the slightest degree. 

The Combined Observation and Double-Catheterizing Cystoscope. — The 
advance in cystoscopy next turned to perfecting the double-catheterization appa- 



CONSIDERATION OF MODERN CYSTOSCOPES 



205 



ratus which had been devised by Boisseau du Kochet some time before this. The 
catheterizing apparatus consisted of a double tube, or else a single tube divided 
in two parts by a partition. In either case, two ureteral catheters could be 
placed in the cystoscope at the same time. Such an arrangement for the carry- 
ing of two catheters was incorporated in both the direct and indirect instruments. 

Direct-catheterizing cystoscopes through a water medium were brought out 
in this country by Ayres, Brown, Cabot, Kolisher, Schmidt, myself and others, 
while that of the indirect type was first brought out by Bierhoff. The addition 
of the double-catheter channel, however, did not interfere with the observation 
purpose of the instruments any more than when the single-catheterizing tube 
was used. 

The first direct-observation and double-catheferizing cystoscope of American 
make was brought out by Brown of Xew York. It was manufactured by 
Wappler of the Wappler Electric Controller Company, of this city. The shaft 




Fio. 202. — The Brown Cy8TO»cope. Below is the shaft with its obturator, and above it is the direct 

telescope showing the catheters in their grooves. 

of this instrument was constructed on the same plan as that of the direct-ob- 
servation type and the light showed through a window in the convex side of the 
beak. The instrument, like that of the observation type, was introduced into 
the bladder with a mandrel in place. After the end of the instrument was in 
the bladder, the mandrel was withdrawn and the telescope carrying the catheter 
was introduced. It now has a double passage in order to carry two catheters 
(Fig. 202). 

Indirect-Observation and Double-Catheterizing Cystoscope. — Bierhoif was 
the first in this country to construct a double-catheterizing cystoscoim of the in- 




FiQ. 203. — BiERHOPy's Indirect Catheterizinq Cystoscope.' 



direct type. (Med. News, March 8, 1902.) The size of the instrument is 23 
French. It is arranged for double-current irrigating. 

It is a modification of the improved Nitze-Albarran catheterizing cystoscope 
and consists of a cystoscope U|)on which is the movable catheterizing portion. 



206 



CYSTOSCOPY 



(See Fig. 203.) The latter contains two separate tubes in which the catheters 
pass and which terminate at the outer end in two separate cannulae capped by 
the usual screw caps. At the inner end they terminate in two small, movable 
tongue, finger or knee mechanisms, which are controlled and moved by the 
large screw, as in the single-catheterizing instrument. There are also two stop- 
cocks to replace the screw caps upon the cannulse, when the double-current irri- 
gation is to be employed. The catheterizing portion, being movable, can be 
sterilized by boiling. The cystoscope itself must be sterilized by formalin vapor 
or by immersion in an antiseptic solution (Holstein solution). 




FiQ. 204. — BiujfSFOBD Lewis Cystoscope. 



1, The shaft. 

f . The direct observation part. 

5. Direct catheterixing. 



4. Retrograde vision. 
6. Indirect observation. 
6, Indirect catheterizing. 



CONSIDERATION OF MODERN CYSTOSCOPES 207 

The first direct-observation and double-catheterizing air cystoseope in this 
country, was that of Bransford Lewis, made by one of the Rochester companies 
(Fig. 204). This was shortly afterwards made into a water cystoseope and is 
manufactured by Kny-Scheerer. It is a very complete instrument and is to-day 
probably the cystoseope that has more additional contrivances for bladder work 
than any other. 

The Combined Direct and Indirect Teaching Cystoseope. — Five years ago 
I had a combined direct and indirect observation cystoseope constructed for 
examining the interior of the bladder. The need of such an instrument was 
shown to me by the difficulty that practitioners encounter in making a thorough 
and systematic examination of the bladder which is so important for bladder 
diagnosis, and for familiarizing oneself with the position and appearance of the 
mouths of the ureters before using the catheterizing cystoseope. 

For a long time cystoscopy was not taken up in the United States, although 
it was quite extensively practiced in Europe. The two principal reasons for the 
neglect of this important step in diagnosis were the price of the imported in- 
strument and the lack of teachers in cystoscopy, such as could be found in Berlin 
and Paris. 

Eventually genito-urinary surgeons visited Berlin and Paris to acquire the 
knowledge and art in which they found they were lacking. Finally the instru- 
ment-makers and electricians in the United States, principally Wappler in New 
York and Preston in Rochester, through the suggestions of surgeons interested 
in cystoscopy, started to manufacture cystoscopes and they have placed very 
satisfactory and creditable instruments on the market. 

At the time, however, when the American manufacturers began to intro- 
duce their instruments, the cystoscopists in Europe had passed through the 
period of observation cystoscopy and were interested in the catheterizing in- 
struments. The result of this was that the catheterizing cystoscopes were prin- 
cipally brought out in this country, and were bought by practitioners without 
training in cystoscopy, who soon found themselves unfitted for the work. The 
instruments then became toys which they could not use, and when trials were 
made, it was generally for the purpose of endeavoring to pass catheters into the 
ureter, in which undertaking they were usually unsuccessful, in consequence 
of which most of them gave up cystoscopy as hopeless. 

WTien I first started the cystoscopic room in my clinic nine years ago, I used 
the Leiter and Nitze indirect-observation instruments. The assistants follow- 
ing used a direct-observation and catheterizing instrument of American make, 
with the result that they found numerous cases of papillomas of the bladder. 
These proved to be from traumatism due to the rough manipulation of the tel- 
escopic end of the direct cystoseope. Accordingly, I made a rule that no one 
should do cystoscopic work until he had served a certain time as an assistant 
in the cystoscopic room, washing out the bladder and preparing the cases 



208 



CYSTOSCOPY 



for cystoscopy. After this no more vesical papillomas of this nature were 
seen. 

I also found that, with the development of the direct-catheterizing cystoscope, 
the object of cystoscopy, that is, the examination of the interior of the bladder, 
was lost sight of, and the men working in cystoscopy simply looked for the 
ureters in order that they might catheterize them as a matter of practice. 

Therefore I had this observation cystoscope made in order that the assistants 
might learn to examine the bladder before taking up the catheterization of the 
ureters and each man could spend six months on cystoscopy, three with the ob- 
servation and three with the catheterizing instrument. 

Description of the Cystoscope. — The teaching cystoscope is a com- 
bination of Nitze, Brenner and Boisseau du Rochet instruments, or, more prop- 
erly speaking, of F. Tilden Brown, Bransford Lewis and William K. Otis, with 
modifications that have seemed to me practical, the principal one being the 
elimination of the obturator as an unnecessary attachment. 

My cystoscope consists of four parts (Fig. 205) : (1) A hollow shaft with a 
lamp in its beak; (2) a combined obturator and indirect-observation telescope; 





^^rr 



£ 




<EI 



3 





4 

Fia. 206. — GuiTBRAS Teaching Ctstoscopb. 
1. Straight, hollow shaft for reception of the S. Direct telescopic tube. 

telescopic tube. 4. Direct telescope with grooves for the 

S. Indirect telescopic tube. catheters. 




(3) a direct-observation telescope; and (4) a direct-observation telescope with 
catheterizing attachment. 

To go into the separate parts more in detail: (1) The first is a straight tube 
with curved beak, in which there is an electric light that throws its rays both 
from the convexity and concavity. It has an oi)en space on the straight part of 



CONSIDERATION OF MODERN CYSTOSCOPES 209 

the shaft near the concavity, serving as a window through which one can look 
from the indirect visual part of the telescope that fits directly behind it. 

(2) The second is a combined telescope and obturator with a visual ap- 
paratus, the window of which is about one third of an inch from its end. The 
end is solid, cut obliquely and of an angle that exactly fits in the distal ex- 
tremity of the hollow tube which it fills, thus serving both as an obturator and 
for indirect examinations. 

(3) The third is a telescope similar to those in all the direct Wappler cys- 
toscopes for the direct examination of the bladder, which, when pushed through 
the hollow shaft, protrudes through the opening in its convexity. 

(4) The catheterizing part closely resembles the direct telescopic portion, 
excepting that it has on its surface a fin with a groove on either side of it. These 
two grooves connect with the nozzles on the proximal end, through which the 
catheters are inserted. The catheters then pass along the grooves to the end 
of the instrument, being held in place by the inner wall of the hollow shaft as 
far as its distal end, from which point they are pushed out into the ureters 
when the instrument is in the bladder. 

This instrument is very practical, as, with the indirect visual apparatus in- 
serted, it answers the same purpose as a Nitze observation cystoscope. After 
the bladder has been thoroughly examined by the indirect method, the indirect 
apparatus is removed and the direct telescope of the instrument is introduced 
for the corresponding examination. The cystoscope stands for my teachings in 
cystoscopy during the last ten years : First, that a bladder should always be ex- 
amined with the indirect cystoscope before the ureters are catheterized ; second, 
the ureters are more easily catheterized by the direct cystoscope. 

This instrument combines these two important principles. The straight, 
hollow shaft with a curved beak can hold either the indirect or direct telescopes 
(Xo. 1). When the indirect telescope is introduced, the solid beveled end 
of the telescope fills the opening in the end or convexity of the shaft and they 
enter in the same way as the former shafts did with the solid ends. At the 
same time, the mirror near the end of the indirect telescope fits into the window 
near the convexity, on the straight part of the shaft, in such a w^ay that a most 
satisfactory indirect examination can be made. 

Having thoroughly examined the bladder, the indirect telescope (No. 2) 
is withdrawn and the direct telescope (No. 4) containing the catheters is in- 
troduced into the shaft (No. 1) and its end protrudes from the opening in the 
end of the shaft. The ureters are then catheterized. No. 3, the direct- 
observation telescope, is only used in teaching the student to find the ureters. 

There is an irrigating apparatus connected with the shaft (No. 1), into 
which the direct telescope has been introduced. The bladder can consequently 
be washed clean, examined thoroughly and the ureters catheterized without 
removing the outer part of the instrument. 



210 CYSTOSCOPY 

The bladder can be washed out through the shaft of the instrument by al- 
lowing the solution to run through the opening in one of the posts when neither 
the direct nor indirect telescope is inserted, or through the same opening when 
the direct telescope is in place. 

TECHNIQXIE OF CYSTOSCOPY 

The following practical part of this chapter has been the result of experience 
gained in twenty years of cystoscopy. The work was principally done in the 
Post-Graduate, Columbus and City hospitals. In my clinic at the Post-Gradu- 
ate, we have done over 3,000 cystoscopies and ureteral catheterizations. 

The following instruments and apparatus are required in cystoscopy : 

(1) Cystoscopy 

(2) Table with knee or leg rests. 

(3) Battery; or, if street current is used, a controller. 

(4) Soft-rubber and woven coude catheters, Nos. 12 to 16 French scale. 

(5) Piston syringe, holding six ounces; or a fountain syringe. 

(6) Ultzmann syringe for injecting cocain. 

(7) Antiseptics: Bichlorid solution, 1:2^000; silver solution, 1:4,000; 
boric-acid solution, 1 : 30. 

(8) Cocain solution, 1 : 100. 

(9) Glycerin as a lubricant. 

(10) Test glass. 

(11) Douche pan or Kelly pad to catch fluid. 

(12) Slop jar at foot of table. 

For sterilization of the cystoscope, catheters and above apparatus, see the 
chapter on Asepsis and Antisepsis. The cystoscope should never be boiled 
or placed in hot water. It may be sterilized in an emergency by placing 
it for fifteen minutes in a two-per-cent solution of formalin. This solution we 
prepare by adding two drachms of our stock office solution, called Holzien's 
solution, to one pint of water. (Holzien's solution is composed of formalin, 
sixty parts, and alcohol, forty parts.) Cystoscopes in the office are always kept 
sterilized and ready for use. After using them, they are cleaned on the outside 
with soap and water and then alcohol, wrapped in gauze and placed in Schering- 
Glatz formalin sterilizer for ten minutes and allowed to remain in the gauze 
until the next examination. 

The catheters used for washing out the bladder should have been previously 
sterilized. This is done by boiling the rubber ones, while the woven ones are 
sterilized in the same manner as the cystoscopes. The author keeps the rubber 
catheters in a muslin bag, in which they have been boiled, while the woven cathe- 
ters are kept wrapped in the gauze in which they have been sterilized. 



TECHNIQUE OF CYSTOSCOPY 211 

Just prior to the examination, all instruments shoiikl be laid out on a sterile 
towel, where they will be within easy reach of the examiner. Before doing a 
cystoscopy, the instrument and the light should always be tested to see if they 
work properly and to determine how much light will be necessary; the op- 
tical part should be wiped with alcohol and dried with gauze. The urethra 
should also be examined to see i£ it will admit the cystoscope. Nothing 
is so exasperating as to prepare a patient for cystoscopy and find that 
the lamp is burned out or that the cystoscope cannot pass through the 
urethra. 

It is well to have everything in readiness before the patient is brought into 
the room. The table generally used in this country is one which will admit 
of a certain position, that is, the body part at an angle of 135° with that part 
which supports the thighs. There should bo 
supports on each side, either upright lithot- 
omy bars or knee rests. 

If cystoscopy is to be performed in a 
private house, it is advisable to send a port- 
able metal table, which can be adjusted to 
the position already referred to; tlie appa- 
ratus referred to should also be sent. 

The patient, if a male, is placed upon 
the table in a reclining position, with his Fiq. 206.— Portable Table Uhed fob 
head and shoulders sliurhtly elevated and Ctstoscopt in the Cuhic anb at 

. PaiVATB HOVSEB. 

feet extended. The clothing is removed 

from the lower limbs, which are covered with clean towels, a sheet or flannel 

stockings. The external genitals are thoroughly washed with soap and water, 

followed by bichlorid solution 1 : 2,000 as for an ordinary surgical operation. 

The operator prepares his hands by s<Tubbing and iuuuersing them in bichlorid 

solution. 

In the ease of a female patient, she is immediately placed in the gimecolog- 
ical position, with her feet on the sides of the upright lithotomy bars, or else her 
legs are supported by knee rests. 

Waahing the Bladder. — The first step is to determine the bladder capacity 
by the amount of urine voided, plus the amount of residual present; or else by 
measuring the entire amount of fluid that can be tolerated when injected into 
the empty bladder. A solution of boric acid, in the strength of one part of boric 
acid to thirty of water, is used for washing out the bladder. In cystoscopic 
work I usually have small packages consisting of half an ounce of boric acid 
wrapped in a piece of sterile gauze, and in making my solution I put one of 
these into a pint of hot water, or two into a quart. The solution is injected 
through the outer cylinder of the cystoscope from a fountain syringe, after 
removing the indirect telescope, or through a catheter from a six-ounce piston 



212 CYSTOSCOPY 

syringe, until the patient's bladder begins to feel full. This marks the subjec- 
tive capacity of the bladder in a given case, and the amount so injected should 
be noted for future reference. The more fluid a bladder holds, the more easily 
it can be examined. 

When the bladder feels full, the fluid is allowed to escape into the test 
glass, its clearness or turbidity is noted and a fresh quantity is injected into 
the bladder until the viscus is filled. This is repeated until the boric-acid 
solution flows into the test glass perfectly clear. At times, this is not possible 
when there is much pus in the bladder ; in such cases, we wash until we get as 
clear a washing as possible, and then hasten the examination for fear the blad- 
der fluid will become clouded again before we see its interior. I have fre- 
quently washed out a bladder for an hour and a half without obtaining a fluid 
medium sufficiently clear for an examination. This usually occurs in cases of 
I)us kidney or sacculated bladder. 

The test glass is a small glass such as is used for mineral water, or else an 
ordinary tumbler. 

Filling the Bladder. — ^When the washing of the bladder results in the dis- 
charge of a clear fluid through the catheter, the organ is tilled with as much 
fluid as can be introduced without causing hematuria. The desired amount of 
distention for cystoscopy is 150 to 200 c.c. (5 to 6 oz.) of fluid in male cases, 
and 200 to 300 c.c. (6 to 10 oz.) in female. 

Introducing the Cystoscope. — The instrument, having been well lubricated 
with glycerin, is then passed into the bladder, practically the same tecli- 
nique being used as in introducing metallic sounds. Very often the in- 
strument glides into the urethra dowTi to the cut-off muscle, w^here it meets 
resistance, due to a certain amount of spasm whicli takes place if the posterior 
urethra is involved and tender. The cystoscopist must not attempt to push the 
cystoscope through this muscle, for if he does it may be attended by a certain 
amount of hemorrhage which would blur tlie vision ; therefore, he should hold 
the instrument against the muscle, exerting gentle pressure, and soon it w411 
be felt to relax and the instrument will glide through into the posterior urethra 
and then through the sphincter into the bladder. Sometimes, however, it is not 
the cut-off which resists, but the vesical sphincter, in w^hich case the same tac- 
tics are pursued and the cystoscope passes the rebellious sphincter and enters 
the viscus. A small amount of two-per-cent cocain, injected by means of an 
Ultzmann syringe or through a very fine catheter into the posterior urethra and 
the neck of the bladder just before the final filling, will prevent the spasm. This 
is usually caused by an inflammatory condition beyond the cut-off muscle or the 
bladder sphincter, which sensitive areas these muscles try to protect through 
their contraction. 

Changing the Patient's Position.— The foot board of the table is then low- 
ered to the full extent, and the patient, if a male, has his legs supported in 



TECHNIQUE OF CYSTOSCOPY 



213 



lithotomy uprights, or knee rests (Fig. 207), after which his buttocks are 
brought to within six inches of the edge of the table, the surgeon meanwhile 
keeping the cystoscope in place by a gentle grasp upon the handle of the in- 




Fio. 207. — The Patient's Legs Supported by Knee Rests, and the Seat Portion op the Table 
SLIGHTLY Elevated, the Position usually Employed in the Office. The table is the Alli- 
son model. 



strument. In the case of a female patient, she is already in such a position 
from the first, and, therefore, does not require to have it changed. The patient's 
hips may be slightly elevated, as this helps the cystoscopist to examine the 
bladder more easilv. 

Should the bladder contents become too cloudy before the examination is 
completed, the cystoscope, in case it is a simple observation cystoscope, should 
be withdrawn, the bladder once more washed, filled with clear fluid and the 
instrument reintroduced. 

The irrigating cystoscope has an arrangement for washing the bladder while 
the instrument is in place. In order to do this, there must be a small piece of 
rubber tubing on the nozale of the irrigating opening, and water should be 
forced into this through a piston syringe. This not only cleanses the bladder 
wall, but also the window of the instrument and thus washes away any deposits 
of blood, mucus or pus, that may have collected there. The fluid escapes from 
a nozzle on the other side of the instrument. Thus a thorough lavage of the 
bladder can be made. In my own cystoscope, the lavage can be made through 
an irrigating apparatus by connecting the tube from a fountain syringe with 
the nozzle and allowing the solution to run into the bladder and out of the hoi- 



214 



CTSTOSCOPT 



low shaft (FigB, 208, 209). The quickest way to cleanse the bladder is through 
the shaft of the instrument, as a larger quantity of solution 
can quickly run in and out again. 

The Light. — The power for the light is taken either from 
the street current by means of a Wappler electric controller, 
or else from a storage battery on the 
left side of the patient. One end of 
the cable is then connected with the 
cyatoscope and the other with the 
electric controller or the storage bat- 
tery, after which the operator turns 
on the current by means of a switch 
or screw in the handle of the cysto- 
Bco|)e. And here the technique dif- 
fers according to whether a direct 
or indirect instrument is being 
used. 

If the instrument is indirect, as 
in the observation part of my own 
cystoscope, turning on the current is 
sufficient to allow the cjstoacopist to 
examine the bladder ; whereas, in di- 
rect cystoscoi>ea of American make, 
it is necessary to withdraw the ob- 
turator, place the thumb quickly 

through a tube attached to the irrigating noiile "^^r the Opening of the shaft of 

rftheinBtrameDtithethumbisbeidovi'rtheend the instrument to prevent the es- 

of the hollow shaft. Thetorceof the fluid can be a . i i i 

chaogetl by raising or loweriDg the irrigating jar. cape of the nuid and then intro 





Flo. 209. — Washing Ottt ths Bladdbb. The bladder has been dilated to its point of tolcraoce (sei 
dotted lines), the thumb has been removed from the end of the shaft and the Quid rushes ou 
through its lumen, the bladder quickly emptying. 



TEOHjfrenE or ctstoscopt 



216 CYSTOSCOPY 

duce the telescope before the interior of the bladder can be examined by the 
cystoscopist. 

In either case, after the instrument has been introduced and everything is 
in readiness for examination and the cable connection is made, the examiner sits 
between the .legs of the patient and turns on the power until the light is suffi- 
ciently bright for him to see plainly the interior of the bladder, before pro- 
ceeding to examine it (Fig. 210). The storage battery, freshly recharged at 
regular intervals, is generally used for outside work in private houses and in the 
office or in hospitals, unless electric illimiination is present, in which case a 
controller is preferable. 

The position of the patient wdth air cystoscopy is different as, in this case, 
the patient is in a partial Trendelenburg position which allow^s the bladder to 
balloon out to better advantage and the urine coming from the ureter to gravi- 
tate toward the apex of the bladder and away from the instrument (Fig. 211). 

DIFFICULTIES IN CYSTOSCOPY 

Stricture of the Urethra. — The first difficulty encountered in cystoscopy is 
organic stricture of the urethra. Very few cystoscopes that give a good view of 
the bladder are less than No. 24 of the French scale in size. Therefore, the 
urethra should be a": least 25 French in caliber, in order to allow free admission 
of the cystoscope without causing traumatism or hemorrhage. If the meatus 
is smaller than this number, it should be cut up to 28 or 30 French and should 
be treated as any other case of meatotomy for a few days, until it has healed 
to a larger size, sufficient to admit the instrument easily. 

If there are strictures along the canal, they should be dilated, if soft and 
dilatable ; if not, they should be cut to a sufficient size to admit the instrument 
before cystoscopy is performed. 

Spasmodic strictures are also common, but they usually yield to instilla- 
tions of a two-per-cent solution of cocain, given through a small catheter, or by 
means of an Ultzmann syringe. In case, however, that local cocain anesthesia is 
not sufficient, a general anesthetic should be administered, preferably nitrous- 
oxid gas alone or followed by ether. 

An enlarged prostate that bleeds easily should be treated by a deep urethral 
instillation composed of equal parts of a two-per-cent solution of- cocain and a 
1: 1,000 solution of adrenalin. 

Pelvic exudates, uterine displacement and pelvic tumors, of sufficient size 
to interfere wuth the function of the bladder and to make cystoscopy difficult, 
are of enough importance to call for a vaginal operation in the first instance and 
an abdominal operation for the other two conditions. 

Small, Intolerant and Sensitive Bladders. — Sometimes a few irrigations 
of the bladder will dilate it sufficiently to allow of a satisfactory cystoscopy, for 



DIFFICULTIES IN CYSTOSCOPY 217 

which 150 to 200 c.c. (5 to 6 oz.) is usually necessary. Examinations can, how- 
ever, be made with two ounces of fluid in the bladder, and I have made them with 
but one ounce and a half, by means of an indirect instrument. In case a bladder 
is very sensitive, cocain or a general anesthetic should be used, as many blad- 
ders that will hold but from one to two ounces under other circumstances 
will, when anesthetized locally or generally, retain four ounces or more. 
Twenty grains of antipyrin and ten minims of laudanum in an ounce of water, 
injected into the rectum forty-five minutes before cystoscopy, will often relieve 
the patient sufficiently to permit a cystoscopic examination. 

If the bladder is found intolerant and will not hold enough fluid, it should 
be emptied and half an ounce of a one-per-cent solution of cocain, or a two-per- 
cent solution of eucain, should be injected into the bladder through a catheter, 
(^hismore, of San Francisco, in doing lithotomy in old men, used to inject two 
or three ounces of a three-per-cent solution of cocain into the bladder as a mat- 
ter of routine, with no ill effects. Surgeons differ so much as to the strength of 
cocain used, that it is really a matter of individual experience. In the ordinary 
case, ten one-half-grain cocain tablets in two ounces of water, making a one-half- 
per-cent solution, is sufliciently strong for cystoscopic use. In cases of severe 
tubercular cystitis, a solution of the maximum strength cannot be relied on. 

If cocain does not produce sufiicient anesthesia, nitrous-oxid gas should be 
used during the introduction of the instrument; and if anesthesia has to be 
continued, ether should be administered. 

Distention Hematuria. — Under ether, patients are supposed to hold more 
fluid in the bladder than when examined without anesthetics. If, under anes- 
thesia, the bladder holds two ounces and you try to insert three for cystoscopy, 
you may have a pinkish discoloration of the fluid, due to the bladder wall being 
stretched and some capillary leakage resulting, or else bleeding from ulcera- 
tions, tumors or erosions. Such bladders can often be dilated, under anesthetics, 
better by means of the fountain syringe than by the piston variety. In this 
way, after a quarter of an hour of washing, during which time the hematuria 
may increase somewhat, perhaps five ounces can be introduced into the bladder. 
In these cases, the time that it takes for this amount of fluid to enter should 
be noted, and at the next filling a certain number of seconds under this time 
should be allowed the fluid to run in, to see if hematuria is caused. If hema- 
turia is caused, then, the next time the bladder is filled, allow still less time for 
its filling; and so on until a point is reached where, in a certain time, the 
amount of water entering the bladder is not sufficient to cause a pink discolora- 
tion of the fluid. On the following injection of the bladder, if five seconds less 
are allowed, you will be sure to have a clear fluid for cystoscopy. 

To make this clear, I will cite one or two cases. A patient with a cystitis 
dependent upon a hypertrophied prostate had a maximum bladder capacity of 
two ounces of urine. Under an anesthetic, his bladder held three ounces. The 



218 CYSTOSCOPY 

three ounces ran in through the catheter in forty-five seconds. The next time, 
fluid was allowed to run in for one minute ; four ounces were then introduced, 
which in escaping was found to be tinged with blood, being slightly pink in 
color. At the next filling of the bladder^ a minute and a quarter was allowed 
and five ounces entered. The escaping fluid was then of a more reddish color. 
The next time it was allowed to run in for about a minute and a half, and six 
ounces entered. This on escaping was no more bloody than when the five ounces 
had been injected. The next time four ounces were put in in one minute and 
the fluid was clear. Five ounces were again put in, which showed on escaping 
a pinkish tinge, but not as marked as before. It was then felt that a little undet 
four ounces would be the sure capacity of the bladder for cystoscopy without 
hematuria while under an anesthetic. This was accordingly carried out by 
allowing the fluid to run in for fifty-five seconds. 

Another patient with tuberculosis of the bladder could hold but an ounce 
and a half of fluid when his bladder was washed out. Under an anesthetic two 
ounces entered in half a minute, producing no hematuria. Three ounces entered 
in forty-five seconds, producing hematuria. On introducing two ounces again, 
there was no hematuria. Several trials were made with three ounces both 
through fountain and piston syringe, and each produced hematuria. It was 
foimd that two and one half ounces could be put in the bladder in thirty-eight 
seconds without making the urine bloody. The cystoscopic examination was 
then made with this amount in the bladder. It must always be remembered that 
a very sensitive bladder, particularly in tuberculosis, will not dilate to its full 
capacity, even under general anesthesia, unless it is pushed to a point at which 
it is dangerous to life. Ether is the best general anesthetic to use. 

NORMAL AND PATHOLOGICAL FINDINGS WITH THE CYSTOSCOPE 

After the cystoscope has been introduced and the light has been turned on, 
it is always advisable to pursue a certain routine in the order of examination, 
so that one may not miss any part of the bladder in the survey and yet may per- 
form the examination with as few movements of the instrument as possible. 

We will now speak of the indirect cystoscopes used for observation which are 
the best for diagnostic purposes. As the field of the cystoscope is limited, we 
must form a picture of the entire interior of the bladder by means of a series 
of partial pictures which should so follow each other as the instrument moves 
that we gain a very accurate knowledge of the entire organ. The rules that 
Nitze gave for this purpose may be set down here for reference, although each 
observer will necessarily vary his method somewhat, according to his own prac- 
tical experience. 

Nitze advised that the anterior and upper portions of the bladder be in- 
spected first and the fundus and trigone last. After the cystoscope has been in- 



FINDINGS WITH THE CYSTOSCOPE 



trodiiced, with the mirror poioting upward and tlie instrument parallel with 



tlie table, its beak is turned at an 
patient and the instrument is now 
passed slowly backward until the 
beak touches the posterior wall. 
The field o£ the eyatoscope thus 
sweeps over a section of the an- 
terior and upper vault of the 
bladder, and covers part of the 
posterior wait. The strip of the 
illuminated bladder corresponds 
in width to the angle of the prism 
which defines the width of the 
field. As soon as the beak touches 
the posterior wall, it is 
turned still farther to the 
right (i. e., at an angle of 
45" from the median 
line), and is swept for- 



^le of 22.5° toward the right side of the 





Pro. 212a. — InapBCnoN of the Bi.ai>deii with thb 
Indirect Ctbtobcopk. The cicuraion made on the 
right aide of the bladder at an angle of 22.5° from 
the median line of tbe bladder. aA, and the eicuraioD 
iiiadeHtsaangleof45°, Dd. AS and Ccahow similar 
excurtdoDa on the left side of the bladder. The cyato- 
■oope turned down in a similar pomtioD would easjly 
Bhow the trigone. (Prom Morrow, after Nit«e.) 



ward, illuminating a strip paral- 
lel to the first, but lying to the 
right of the latter, sweeping the 
beak from behind forward and 
thus covering the right lateral 
portion of the bladder. Next the 
left half of the bladder is in- 
spected. This is done by placing 
the instrument again in the me- 
dian line with the beak at the 
internal opening and turning it 
22.5° to the patient's left, sweep- 
ing it slowly from before back- 
ward in this position until it 
touches the posterior wall ; then 
turning it to 45°, i. e., still more 
to the patient's left, and sweep- 
ing it from behind forward, thus 
covering the two zones lying to 



220 



CYSTOSCOPY 



the left of the median line. With these four motions, two to the left and two 
to the right, practically the entire upper and lateral portions of the bladder are 
inspected (Fig. 212a). 

There remains to be seen now the fundus and the neighborhood of the in- 
ternal meatus. For this purpose the instrument is turned so that the beak points 
directly downward and is swept from side to side from behind forward, or from 
before backward, until every portion of the posterior wall of the bladder and tlio 

trigone has been covered. 
It is needless to say that all 
these manipulations must 
be gentle to avoid injuring 
the bladder wall. Burning 
the bladder would not be 
liable to occur with the cold 
lamp now generally used 
in this country, although it 
was common when the hot 
lamp was in use. 

The direct cystoscope is 
not so good for observation 
purposes. It is introduced 
with its obturator, which 
is then withdrawn and the 
direct telescope inserted. 
It is then pushed well back 
into the bladder and its 
beak is tilted up and 
swept from side to side, in 
this way showing some of 
the roof of the bladder 
with the adjoining part of 
the anterior wall; the lat- 
eral and posterior walls 
are then examined and the 
instrument is drawn for- 
ward imtil the interure- 
teral band and the trigone 
are seen. This applies to direct-air or water cystoscopes, while another telescope, 
made by Wappler, with an opening in the side near the end, allows us to look 
back at an acute angle at the neck of the bladder and the prostatic base. 

Normal Cystoscopic Pictures. — It is necessary for the practitioner to be 
familiar with the appearance of the normal bladder before he can understand 




Fia. 2126. — Inspection op the Bladder with the Direct 
Cystoscope. The beak of the direct cystoscope is moved 
from right to left and vice versa in examining the floor and roof 
of the bladder, and from above downward in examining its 
sides. 



FINDINGS WITH THE CYRTOSCOPE 221 

the conditions seen in a pathological organ. The interior of the bladder as illu- 
minated by the cystoscope has a pale-yellow, orange or a pink tinge, depending 
for its exact color upon the lamp and prism used. A number of branching blood 
vessels are seen outlined upon it in darker red, which in healthy bladders are 
clear-cut and finely drawn. The upper hemisphere of the healthy bladder wall 
is smooth, but as the cystoscope is drawn over the posterior wall toward the neck 
of the bladder at its base, a thickened, slightly redder portion is brought into 
view, triangular in shape and tapering toward the vesical neck, where it ends 
in a dark-red color. This triangular space, with sides an inch and a quarter to 
an inch and a half long, is called the trigone. Its apex corresponds to the in- 
ternal meatus, and its base to the interureteral band. The apex is on the base 
of the prostate in men, which is a dull red, or crimson, color. The female blad- 
der differs from the male principally in not showing so much thickening about 
the internal meatus, nor such a well-marked trigone. The base of the trigone 
sweeps from one ureteral opening to the other and disappears in the w^all of the 
bladder beyond these openings, where the color changes to an orange shade. 
On either side of the trigone is the paratrigonal fossa. 

The Finding of the Ureteral Orifices. — The next step is the most 
important of the whole procedure, namely, the finding of the ureteral mouths. 
With the direct instrument, it is more difficult to inspect the bladder walls and 
consequently the position of the instrument must be changed considerably to 
accomplish this. The instruinent in the bladder, with the direct telescope in- 
serted, should be pushed back slowly, in the median line, illuminating the 
trigone until the interureteral fold is brought into view. The end of the cys- 
toscope is then turned from the right to the left, following the interureteral 
band, until an angle from 30° to 40° from the perpendicular is reached, 
when the ureteral orifice will usually be brought into view. This is the theo- 
retical procedure, but practically the exact modus operandi must be varied to 
a marked extent, according to the condition of the ureters, which varies normally 
to a considerable degree according to various peculiarities of the bladder of the 
individual examined. 

The Appearance of the Ureteral Orifices. — The ureteral openings are 
at the two posterior angles of the trigone and present in most bladders the sha})e 
of a slightly oblique, dark-red slit, or a more rounded depression, and are situ- 
ated ui)on a more or less marked papilla or prominence. With the indirect 
cystoscope and the patient in the cystoscopic position, if the beak is turned 
downward, the part of the bladder before us will be the base, the interureteral 
band and the ureters. 

Difficulty in finding the ureter in a healthy bladder depends usually on an 
insufficient amount of fluid and the consequent folding in of the mucous mem- 
brane in places. The introduction of an additional amount of water through 
the irrigating apparatus, by dilating the entire wall, will stretch out these folds 



222 CYSTOSCOPY 

and bring the ureters into view. This is best accomplished as follows : The irri- 
gating nozzle of the cystoscope is connected with the tube of a fountain syringe, 
or the tip of a large piston syringe is inserted into a small piece of tubing at- 
tached to the irrigating nozzle, and the fluid slowly injected, while at the same 
time the base of the trigone is carefully watched. This portion of the bladder is 
sometimes out of position ; in men, usually due to prostatic involvement, and 
in women, due to cystocele. In such cases, the finger, a rectal bag or a vaginal 
depressor inserted into the rectum will serve to push it to a better position. 

Having found the ureters, it is well to examine them carefully, not only for 
the sake of learning their shape and locality, but also to note any abnormalities 
connected with them or the urine they emit. 

The ureteral mouths are sometimes so dilated as to resemble diverticulse, 
and I have at times been able in this condition, after a perineal urethrotomy, 
to insert the tip of my forefinger into the mouth of each ureter. 

If a ureteral mouth is prolapsed, it reminds us that there may be some in- 
flammation of it, or, more probable, that a calculus is present in the ureter near 
the opening into the bladder, not perhaps of the correct shape to absolutely 
occlude the ureter, but sufficient to give rise to ureteral strain and a consequent 
protrusion of its walls. Sometimes a stone can be seen protruding into the 
bladder, as a dark spot in a gaping ureter. 

If the ureteral openings be watched for a time every thirty to sixty seconds, 
the slit may be seen to dilate suddenly, to take On a transparent pink-orange 
hue and a whirl of fluid of an oily appearance is seen streaming from it as the 
result of the expulsion of the urine from the ureters. These spurts are not 
synchronous. 

In disease, the ureteral opening is often markedly altered and blood and 
pus may be seen coming from it. Blood coming from the ureters is almost al- 
ways renal, although it may be ureteral. It usually comes down mixed with 
the urine and is often squirted out like a thin stream of red ink, although clots, 
of a wormlike appearance, may descend. Pus comes down in flakes and is car- 
ried away in the swirl and then seen to scatter and fall in the bladder, or else a 
flake may catch in the ureteral mouth and be thrown out with the next swirl ; 
or it may come down from a ureter as a thick mass and remain hanging in the 
bladder at the ureteral mouth, or mixed with urine giving it a milklike color, or 
as a mealy mixture which is shot out in a urinary swirl. 

Pathological Findings in the Bladder. — Cystoscopy tells us whether the 
ureteral orifices are both present, their location, shape and condition, whether 
they are both secreting urine normally, and whether this urine is clear, purulent 
or bloody. It also enables us to determine whether the sphincteral margin is 
normal or the seat of disease, such as inflammation, ulceration, papillomatous 
formation, etc. ; whether the trigone is normal or the seat of inflammations or 
new growths; or whether foreign bodies or calculi, which occur in a majority 



FINDINGS WITH THE CYSTOSCOPE 223 

of cases in this region, are present. It shows us the presence and probable char- 
acter of new growths ; the presence and position of foreign bodies and calculi ; 
the presence of prostatic hypertrophy, of cystocele, the condition of the wall 
of the bladder and whether it is the seat of trabecular bands or the scarlike con- 
tractions of pericystitis; whether it is normal or the seat of inflammations, 
points of hemorrhage, ulcerations, nodules, new growths, vesicles or diverticula? ; 
whether the cavity of the bladder is encroached upon by other organs, as an 
enlarged or displaced uterus or by pelvic tumor-masses or exudates. 

Trabecule, Bands and Pouches. — When the bladder is subjected for a 
long time to an increased strain, the muscular wall may become more or less 
hypertrophied, the result being that muscular bands develop in certain parts of 
the bladder, while other muscular fibers remain unchanged. When we look into 
such a bladder, we notice prominent bands or trabeculse crisscrossing in various 
directions and forming an irregular network. As the hypertrophy goes on, the 
bands become more and more markedly developed, resembling the intertwining 
of the roots of trees in the woods or swamps, and the spaces between them be- 
come dark depressions. W^hen large enough, these depressions are called diver- 
ticula. With an increase of pressure and with an atonic condition of the de- 
pressed portions, the latter become veritable pouches, which sometimes have 
such small mouths that their interior cannot be inspected. In fact, in many 
bladders removed at autopsy the pouches have such small mouths that they look 
like distended ureteral orifices. 

Trabeculation is easily recognized even by the beginner and may be inter- 
preted as a sign of hypertrophy of the walls due to some jcondition which in- 
terferes wdth the emptying of the bladder. The conditions may be a small 
meatus, a stricture or enlarged prostate in men, and displacement of the bladder, 
adhesions or pressure on the outside of the bladder in women. 

Inflammations of the Bladder. — It is difficult to cystoscope a patient 
with an acute cystitis on account of the very sensitive condition of the bladder. 
Inflammation is most frequently about the vesical neck, although it may extend 
throughout the viscus. Less frequently there is a generalized reddening and in- 
tense congestion of the entire bladder. The characteristic changes of an acute 
inflammation consist in the presence of reddened areas with many enlarged 
blood vessels, with the presence of pus and mucus — both upon the walls and in 
the fluid which becomes rapidly turbid — and at times blood oozing from the 
walls which quickly renders the field obscure. When we make a closer exam- 
ination of the mucosa in such cases, small erosions, which have a dull surface 
instead of the normal shiny lining of the wall, and localized hemorrhagic areas, 
which appear as dark-red patches, may be noted. 

In chronic cystitis, the bladder is usually pale in its interior, except over the 
trigone, where it is generally thickened and reddened. Reddened patches may 
also be noted in other portions of the wall, however. In cases of long standing, 



224 CYSTOSCOPY 

with hypertrophy of the walls, there are also trabeculse and pouches. Accumu- 
lations of pus may be noted adhering to the walls, or hanging or waving in the 
fluid in the form of shreds. The blood vessels are turgid in places and circum- 
scribed ulcerating areas may also be seen in this condition. 

In the early stages of chronic cystitis, there is no perceptible change in the 
volume of the bladder, but later on there may be hypertrophy, or an interstitial 
inflammatory process with a contraction of the viscus; while in the advanced 
stage of chronic obstructive cystitis, there may be a dilatation of the organ due 
to the retention of urine. When this takes place, the mouths of the ureters will 
appear to be enlarged and distorted. 

Simple Ulcees of the Bladder. — Simple ulcers may be either single or 
multiple. If single, they are usually large and accompanied by thickened and 
elevated edges and irregular base which may be covered by a collection of phos- 
phate-of-lime salts or an accumulation of pus. Multiple ulcers are usually 
smaller and less marked. They are sometimes mistaken for epithelioma, espe- 
cially when they are large and have a coarse, granular base covered with pus. 
They are generally due to traumatism and heal, leaving scar tissue. 

Tuberculosis of the Bladder. — Tuberculosis of the bladder is one of the 
most frequent pathological conditions. In its early stages, all that can be seen 
are the minute lesions, white, yellow or gray, surrounded by a pink aureola. 
These are seen scattered about the bladder, often in clusters. Later they break 
down as tubercular ulcers which are of different varieties. There may be a clus- 
ter of small ulcers resembling a cold sore, but more infiltrated, usually seen 
about the mouth of a ureter ; or a local thickening with fine ulcerations on its 
surface ; or a superficial ulcer resembling an erosion with the epithelia removed, 
and a pink, pulpy surface with the edges but slightly marked and with almost 
no infiltration. In other cases the bladder, especially the trigone, may be cov- 
ered with small ulcers, the wall intensely inflamed, oozing blood and contracted : 
this is spoken of as hemorrhagic cystitis. In this last class of cases, which are 
tubercular, it is diflScult to obtain a good view of the bladder, even under an 
anesthetic. 

When ulcers are seen around the ureteral mouths, we must suspect a tuber- 
cular renal affection on that side, especially when such ulcers have some sur- 
rounding hyperemia and a base so uneven as to make it difficult to know which 
of its various recesses is the opening into the ureter. In advanced cases of 
tuberculosis of the bladder, the organ is so contracted and sensitive that cystos- 
copy cannot be satisfactorily performed. 

Stone in the Bladder. — Stone in the bladder can usually be recognized 
quite readily with the cystoscope. The appearance of a stone in the bladder, 
next to a tumor, is the most beautiful sight in cystoscopy. The detection and 
recognition of stones, however, is not so simple as might be supposed. The 
position of stones varies quite markedly with the position of the patient. When 



FINDINGS WITH THE CYSTOSCOPE 225 

the patient is standing, the stone tends to fall down into the depression at the 
neck of the bladder. When the patient is lying down, the stone tends to fall 
back upon the posterior wall of the bladder. When reclining, with the body 
elevated at a moderate angle (145^ or less), the stone tends to rest on the 
trigone. It is in these two latter positions that the calculus is best seen 
through cystoscopy. 

The appearance of stones through the cystoscope is somewhat deceptive, as 
they look much larger than they really are, especially if the cystoscope is brought 
close to them. The shape of the stones cannot always be accurately determined 
with the cystoscope and some stones which seem fairly well rounded, appear like 
lozenges when they are removed. 

One of the difficulties often mentioned in the diagnosis of stones, is the 
tendency which they have to lodge in pockets. This is not so common as was 
formerly believed before the cystoscope was in use. The principal pocket for 
stones is in a posterior prostatic pouch in men, and in a cystocele pouch in 
women. Cystoscopy can do more to show the presence of pocketed stones than 
the stone-searcher or any other method save exploratory incision. A cystoscopic 
examination should be made in every case in which stone is suspected, and, in 
fact, in every case of chronic cystitis before we exclude the presence of stone. 
Vesical calculi are sometimes not detected by cystoscopy, and I have seen well- 
known genito-urinary surgeons fail to see them when situated in the postpros- 
tatic pouch. 

Tumors of the Bladder. — These can be properly diagnosticated only with 
the cystoscope. They vary greatly in size from that of a split pea to that of an 
orange and are either infiltrating, sessile or pedunculated, the sessile form being 
more common. If malignant, the surface may appear granular and red or 
whitish and covered with pus or salts like ulcers of the bladder. Sessile growths 
sometimes appear like a luminous cone in the crater of a volcano, while at other 
times they have a cauliflower appearance or a warty surface. Pedunculated 
tumors are usually more vascular, and the growth is not so dense. The small, 
pedunculated growths have numerous tendrils that wave about as they are 
struck by columns of urine shot from the ureters. 

Tumors of the bladder frequently bleed so that it is impossible to use the 
cystoscope satisfactorily. In such cases, it is best to wash out first with hot 
boric acid and then to use a solution of adrenalin. This often stops the hemor- 
rhage, but sometimes defeats the purpose of the examination, as the adrenalin 
shrivels up the tumors to such a degree that, when small, they cannot be seen. 
In one case of most persistent hemorrhage, no tumor could be found upon cys- 
toscopic examination; I saw simply a dark area on the anterior wall of 
the bladder which could be barely made out on account of the rapid discolora- 
tion of the fluid. The tumor, which was afterwards discovered at the opera- 
tion, was no larger than a very small French pea and was directly in the 



226 CYSTOSCOPY 

line of the incision so that it showed only when the retractors were taken 
away. 

The posterior wall of a hypertrophied prostate at times simulates a tumor, 
in that it resembles a new growth with a granular surface which projects into 
the bladder; at other times a bladder tumor develops on the base of the en- 
larged prostate, showing itself as a papilloma. 

Malignant tumors, especially those situated about the trigone, which is the 
favorite location, are often red and indurated, their color sometimes resembling 
the coral of a boiled lobster. These tumors usually have an irregular surface 
which may be granular or lenticulo-papular. 

Rugae sometimes resemble papilloma, especially if they have suffered 
from traumatism. When we first began to use the direct cystoscope in 
the clinic, numerous papilloma were diagnosticated, but these usually disap- 
peared with rest and bladder washing. Multiple sessile villous tumors of the 
bladder are sometimes seen, but slightly elevated and covering a large part of 
the bladder area. 

In prostatic hypertrophy, the base of the gland often projects into the blad- 
der. A dark space may be seen behind it, which is a favorite seat for calculi. 
These can usually be seen with the cystoscope and resemble eggs in a nest, al- 
though they are occasionally overlooked. 

Edema Bullosum Yehicje, — Of the forms of edema which affect the 
human bladder, that which Kolischer describes as " edema bullosum " is per- 
haps the most characteristic, and certainly the most interesting. Circumscribed 
areas of the vesical mucous membrane appear to be covered by vesicles varying 
in size from a small seed to a pea, often closely packed together, between which 
white, floating particles are seen adherent at one end to the bladder wall, the 
probable remains of ruptured vesicles. They are situated near some inflam- 
matory tissue pressing against the bladder wall, as carcinoma of uterus, tumors 
of the prostate, pelvic tumors and in connection with cystoscopic bums, pyosal- 
pinx, parametritic exudates and abscesses. 

Intravesical Evidence of Perivesical Processes in the Female. — In 
women with bladder symptoms, a condition resembling trabeculated bladder is 
often seen. Bierhoff noticed that the changes were confined to limited por- 
tions of the bladder wall and occurred in people without obstruction or diflBculty 
in urination, but who were suffering, or had formerly suffered, from parame- 
tritis or similar trouble. He examined 443 cases. In 214, there was a history 
of parametritis or perimetritis. In 264, there were symptoms referring to the 
urinary organs present. In 136, pericystitic strands were seen. 

In cases of perivesical inflammation, the cystoscopic picture varies accord- 
ing to whether it has extended to and involved the bladder wall, or only the 
adjacent tissues. If the process is recent, the exudate encroaches to a greater 
or less extent upon the bladder, the distensibility of which is, to a corresponding 



CATHETERIZATION OF THE URETERS 227 

degree, impaired. If the exudate is unilateral, the excursions of the cystoscope 
are limited on the affected side, while normally free on the unaffected one. 
Similarly, if it occupies Douglas's cul-de-sac, the uterus tends to be somewhat 
displaced forward and the excursions are limited toward the posterior wall of 
the bladder. In all these cases, if any amount of exudation is marked, the blad- 
der wall will be seen to bulge inward over the site of the exudate. When an 
inflammatory process in the tissues adjacent to the bladder extends to and in- 
volves the wall of this viscus, as in cases of salpingitis and perisalpingitis, 
" edema bullosum " is often present. 

When the process is an old one and the exudate has gone on to organization, 
the cystoscopic picture is an entirely different one. In the same way that dis- 
placements of the uterus and ^dnexa may be caused by the traction of the 
fibrous strands, resulting from the contraction and organization of an inflam- 
matory exudate, we may have the bladder affected by these strands pulling upon 
parts of its wall. The most characteristic appearance, however, in these cases, 
is the presence, over parts of the bladder wall, of sharp, scarlike formations, 
which rise, to a greater or less extent, above the surrounding wall, have a yellow- 
ish-white color and tend to fimbriate at the ends. The parts usually affected 
are the lower lateral and the upper posterior, and the postero-lateral portions of 
the bladder. 

The pericystitic strands are limited to certain circumscribed portions of the 
bladder wall, and are less marked above the surface than regular trabeculae. They 
tend to have fimbriated extremities and are of sharp contour. These conditions 
of the female bladder, described by Bierhoff, were frequently noticed by me in 
my gynecological ward at the City Hospital, and the operations confirmed the 
cystoscopic and gynecological examination made. Ilis admirable description 
of these conditions from the view point of a cystoscopist, cleared for me many 
an uncertainty which I did not understand prior to reading his work. 

CATHETERIZATION OF THE URETERS 

Catheterization of the ureters has always been a difficult procedure and for- 
merly surgeons went abroad to learn it, when they could as well have mastered 
it at home if they had had the necessary amount of patience. Ordinarily in 
the past, the practitioner bought a cystoscope and looked for a case to work 
upon. He at last found one and, not being familiar with the details of the 
examination, he hurt his. patient and did not accomplish the catheterization. 
After a few more trials, he usually gave it up and put his cystoscope away on 
the shelf, where it soon became an unused instrument. 

How to Acquire the Knowledge. — It is advisable for the practitioner to 
buy a phantom (artificial) bladder (Fig. 213) and to practice upon it for a 
while ; or to use for this purpose half of a rubber ball with openings correspond- 



228 



CYSTOSCOPY 



ing to the uretlira and the ureters. The eystoscope can then be inserted through 
the urethral opening in the phantom or in the ball and he can practice catheter- 
izing the other two openings. 

He should then obtain a position in 
some clinic with the necessary clinical 
material, and every day he should keep 
certain of the patients after the others 
have gone and practice washing out their 
bladders, examining them and searching 
for the ureters. After he hag found 
them in the way I have spoken of, he can 
catheteri^e them, although it might re- 
quire three months to find them easily 
in norma) cases (Fig. 214). 

In everything that one undertakes in 
, the line of professional work, there are 
difficulties to be encountered. It is diflfi- 
ciilt to palpate the pelvic and abdominal 
organs ; to detect the abnormal sounds in 
the lungs and heart with the stethoscope ; 
to examine intelligentlj' the eye with the 
ophthalmoscope; to make a diagnosis of 
the condition of the larynx; to see the 




CATHETERIZATION OF THE URETERS 229 

posterior nares, or to catheterize the Eiistacliian tubes. It is also difficult to 
cystoacope a patient and catheterize the ureters, and one must not be discour- 
aged because he fails and hears those who have acquired the art speak of it as 
easy. It must be remembered that no one is bom a cystoseopist and that every- 
one who learns cystoscopy causes more or less harm to patients' bladders before 
he becomes proficient. 

I have seen the most expert surgeons fail to catheterize the ureters after 
trying for an hour and a half. I have seen them at times fail in two cases out 
of three even after they have had long experience. 

In order to acquire tlie cystoscopic eye and the cystoscopie fingers, one must 
look many times into the bladder and into many bladders. He must cultivate 
persistence, patience and precision. It is easy for a man in a large city to learn, 




Fw. 21fi,— The Savb PoamoN a 

if he is willing to take the time, for, after trying a number of times without 
success, he can go to one of his friends interested in that branch who will show 
him the way; but in smaller comuiuntties it is more difficult, and one is more 
easily discouraged if he is not persistent A well-known surgeon in a city of 
150,000 inhabitants in which there was no one who could do cystoscopy or cathe- 
terize the ureters, cut both ureters in doing a hysterectomy. He concluded that 
if the patient had had catheters in the ureters, the accident would not have 
happened and he accordingly bought an air-catheterizing cystoseope. He exam- 
ined bladders religiously for one year before he could see the ureters. He was 
then able to find them and he catheterized fifty successive cases before doing 
hysterectomy. lie accomplished his purpose and for a long time was the only 
thorough cystoseopist in bis city. 



230 



CrSTOSCOPT 



The Instruineilts. — At present all the models of catheterizing cystoscopea 
made in tliis country have the double canal and can be used for observation as 
well ; therefore, in considering the subject of catheterizing the ureters, only the 
double-cat lie teri zing instruments will be mentioned. The ureteral catheters 
should be Nos. 6 to 8 French scale, the latter being the better size to prevent the 
leakage of urine along the sides. A catheter with a tip No. 6 French gradually 
increasing in size toward the proximal end ia most desirable. 

The Dieect Inbtkument. — The iiretera having been seen as outlined 
under cystoscopy, a catheter is first passed up the ureteral opening on one 
side and then tlie instrument is moved along the interureteral band to the 

other ureter, and the remain- 
ing catheter is pushed up in 
the same way ( Figs. 215, 
216). 

The same method applies 
to the air cystoscope, which ia 
also direct. When the ure- 
teral orifice cannot be seen, 
more water should be added 
by the piston syringe, in the 
case of water cystoscopy; or 
more air by means of a 
pump, if the air cystoscope is 
used. 

The Indieect Instru- 
ment. — The Bierboff instru- 
ment is the one used in this 
description, and presents 
more difficulties in ureteral 
catheterization than docs the 
direct instrument, as it is 
necessary to move the cathe- 
ter toward the ureter in an 
angle instead of in a straight 
line. In other words, one 
must di]> the end of the cathe- 
ter into the opening instead 
of pushing it straight in. It 
must he remembered that, as the image is inverted, the movement is liable at 
first to ajipear ata.\ic, and the examiner must consequently learn to turn the 
wheel on the side of tlie shaft in wliat aeems to he the wrong way, in order to 
make the point of the catheter move in the right direction. The ureters are 



Flo, 216. — CaTHETBHIIation or the Ureterh. The riRht 
ureter has been catbctcriied by the direct method and the 
bpftk of the instniment moved across the inteniret«ral hand 
with the catheter in the left ureter. 



CATHETERIZATION OF THE UEETEES 



231 



at the extremities of the hypothenuae of a triangle represented by the inter- 
ureteral band, the apex of which is the internal urinary meatus. In looking 
for the ureters, the floor of the bladder must be compared to the dial of n watch, 
the central point of which should be that from which the catheter protrudes from 
the instrument, in which case the 
opening of the right ureter should 
correspond to twentj-five minutes 
before the hour and the left ureter 
twenty-five minutes after. 

When the catheter is in place 
and the examiner, looking at the 

ureteral mouth, endeavors to in- I 

sert the tip of the catheter, he ' 

finds that it tends to catch on the 
side of the trigone, or reach over 
it. The wheel on the side of the 
shaft of the instrument is then 
turned, which projects a knee or 
finger on the concave surface of 
the instrument near its base in 
such a way that it moves the end 
of the catheter in front of the 
ureter mouth. When the catheter 
tip has reached this position, the 
fingers are removed from the 
wheel and grasp the catheter and 
gently push it into the ureter. 
The finger is then turned down 
again and the other ureter is lo- 
cated. During this latter pro- 
cedure, the first catheter moves 
entirely out of the field of vision, 
and may be entirely disregarded 
by the operator. The second ureter 
is now catheterized (Fig. 217), 
the knee again turned down and 
the instrument turned so that the operator may assure himself, before with- 
drawing it, that both catheters are in situ (Figs. 218 and 219). The cystoscope 
is then turned within the catheterizing portion, so that the beak points toward 
the median line of the abdominal wall, the catheterizing portion meanwhile 
being held, and continuing to point downward. The instrument is then slowly 
withdrawn, its removal being compensated for by a gradual insertion of more 



Flo. 217. — Cathbtbweation op thb Urcterb. The 
catheter id the left ureter, and OD the other aide, la 
dotted linea. the movement of the catheter before 
enterins the right ureter in cathcteriiation by the 
indirect method. 



232 CYSTOSCOPY 

of the catheters into the eannulsp. When the kneea of the inatniment, with the 
catheters, appear at the meatus, the catheters are fixed at the urethral orifice 
with one hand, and the cystoscope steadily withdrawn with the other. In 
performing cystoscopy, the catheters should be of different colors, so that they 



FlOS. 2I8-2Ifl. CATRBTEtUZATION < 

the ureteral catheter poiuta to ' 

" twenty-five miDutca after." ^ 

can be easily distinguished from one another, as a black and a brown, or a black 
and a striped catheter. The collecting bottles should also be marked right and 
left. It is thus an easy matter to distinguiali and collect the separated urines. 
With the present system of lenses in the Wappler cystoscopes the image is not 
inverted and the catheters can easily be introduced without resorting to the 
maneuvers just described. 

Should the urine become turbid during the cotirse of the e.iamination, the 
catheters should be withdrawn and rubber tubes attached to the irrigating noz- 
zles connected with the cannula?, after which the solution should be forced 
through one of the tubes from a fountain or piston syringe. The streams 
then, flowing through separate tubes, are kept distinct, and the one tube may 
be used for the inflow, the other for the outflow. In refilling, after irrigation, 
one stopcock is closed, and the bladder filled through the other tube. 

The lUiTthm of Ureteral Secretion— How to Remedy It When Interfered 
with.— After the catheters are inserted, the plugs, if used, are removed from 
the ends and the urine is collected in different test-tubes or bottles. Normally 
the urine will be seen to come in dribbles, interrupted periodically, each dribble 
consisting of about ten or twelve drops. If the urine does not flow from one 
side, it is probable that the catheter is blocked with pus or mucus, and should 
be aspirated. If this is not successful in reestablishing the flow, a small hut 
measured amount of boric-acid solution should be injected to clear the catlie- 



CATHETERIZATION OF THE URETERS 233 

ter, by means of a hand syringe inserted into the end of the catheter. It 
must be noted whether this all comes away or not and its appearance after it 
comes away as compared with the solution before injection. A clear fluid in- 
jected and a turbid one coming away would indicate pus ; a bloody one coming 
away, hemorrhage ; a less amount of turbid fluid coming away would show that 
some debris has plugged the catheter. If the fluid comes away clear, it shows 
that the pelvis is normal. If no fluid enters, it shows that the catheter was 
plugged before using it and it should be withdrawn and cleaned, or else an- 
other one used. This shows the importance of testing the catheters always 
before using them and washing them out immediately afterwards. If but one 
ureter can be catheterized, a soft-rubber catheter should be left in the emptied 
bladder to collect the urine from the other kidney. 

The catheterization of both ureters at the same time is very important, as it 
shows us the comparative secreting activity of the kidneys. We know that the kid- 
neys secrete normally about forty-eight ounces of urine in twenty-four hours ; or 
that each organ will average an ounce an hour. This gives a certain standard for 
us to compare the urines with, although we know that there are certain conditions 
depending upon ureteral catheterizations which influence in a way the secre- 
tion of urine. Changes in the rapidity of secretion of the two specimens, of 
the color and the clearness are also noted, as well as the appearance of the 
coloring matter in case it is given for testing the function of the respective 
kidneys. 

If, on inserting a ureteral catheter into the pelvis of the kidney, a few 
drachms of urine of normal appearance pours down from that side, it is 
a case of renal retention ; whereas, if it be of a whitish, turbid flow, pyonephrosis 
is probably present in that kidney. 

The primary purpose of ureteral catheterization is the determination of the 
presence of both kidneys, their function and a comparative examination of 
the urine from each. After the urines from each side have been collected, they 
should be examined separately, and the examination recorded on blanks marked 
right and left kidney. 

Diagnostic Value of Ureteral Catheterization in Ureteral Diseases. — Ure- 
teral catheterization, furthermore, is useful to recognize the presence of and to 
locate obstruction in the ureter due to strictures, bends or kinks (movable kid- 
ney), valvular formation, stones and the pressure of bands of adhesions or 
adjacent tumors. Furthermore, this procedure may be employed for the 
diagnosis of inflammation, distention or suppuration in the pelvis of the 
kidney. 

Ureteral Catheterization as a Therapeutic Procedure. — As a therapeutic 
procedure, catheterization may be resorted to for the purpose of increasing kid- 
ney drainage by dilating the narrowest parts of the ureter ; for the purpose of 
irrigating and treating the ureters and the pelvis when they are inflamed. A 



234 CYSTOSCOPY 

catheter in the ureter can also be employed as a guide in some abdominal and 
pelvic operations, and as a means of permanent drainage. By introducing a 
catheter, provided with a silver or lead mandrel, and then exposing the abdomen 
to X-rays, the course of the ureter can be accurately mapped out and strictures, 
calculi or displacements of the renal pelvis can be detected. 

The Importance of Ureteral Catheterization in Pelvic Operations. — ^Ure- 
teral catheterization is also an important step, prior to hysterectomy, in cases of 
malignant growths of the uterus, as the independent tumors in the abdomen, not 
connected with the kidneys or ureters, can thus be made out. 

Dangers and Complicatons of Ureteral Catheterizations. — These are gen- 
erally slight, provided two conditions are fulfilled. The first is not to work too 
long on any one occasion, but, if unsuccessful after working a short time, to 
have the patient call again and to repeat the calls until the catheterization is 
successful. The second important point is to be careful not to use undue vio- 
lence in the introduction of the instrument. It is needless to mention the im- 
portance of as perfect asepsis and antisepsis as possible, both in the preparation 
of the bladder for the eucain or cocain, and in every manipulation connected 
with the procedure. 

It is remarkable how rarely infections of the pelvis and ureters occur if 
proper precautions are taken in catheterizing the ureters. At the Post-Gradu- 
ate Clinic, where several hundred cystoscopies and ureteral catheterizations 
have been performed in the past few years, no distinct cases of renal or pelvic 
infection following ureteral catheterization have been noticed, although numer- 
ous attacks of urinary fever have followed in patients whose urethra, bladder 
or kidneys were already infected. The prophylactic injection of solutions of 
silver nitrate, 1 : 2,000, with a syringe through the ureteral catheter and into 
the pelvis of the kidney, and the washing of the bladder with the same solution 
after every ureteral catheterization, has been carried out in these cases as a mat- 
ter of routine. This has proved to be a useful precaution against the exten- 
sion of existing infections and the prevention of a new infection. 

It must be remembered that a certain amount of blood and a certain number 
of ureteral epithelia are often found in the catheterized specimens of urine, sim- 
ply as a result of the mechanical effect of the catheters upon the mucous mem- 
branes. This should be borne in mind in judging the results of the urinary 
examinations of the separate urines. 

Ureteral catheterization has now become so universally recognized as a 
method of diagnosis and treatment, that it is no longer necessary to plead in 
its favor or to refute the attacks which have been made upon it by surgeons 
who were so conservative that they did not care to employ this procedure. The 
technique is difficidt to acquire, but with practice, patience and perseverance, 
there is no reason why anyone possessed of moderate dexterity, cannot become 
expert. 



CYSTOSCOPY IN AUTHOR'S CLINIC 235 

EVOLUTION OF CYSTOSCOPY IN THE AUTHOR'S CLINIC 

For a long time, although there were assistants in the clinic who had 
studied cystoscopy and ureteral catheterization abroad, the cystoscopy was 
performed by me alone and none of them could catheterize the ureters. 
To remedy this state of affairs, I accordingly established a cystoscopic room, 
which was probably the first one in this coimtry, connected with a clinic 
for routine cystoscopy. Now every assistant coming to the clinic has to 
go through a certain course of service — three months in each department 
of the clinic — so that it requires from one to two years for him to reach the 
cystoscopic room. Here he is on duty for three months, washing out bladders 
and preparing patients for cystoscopy, and then for three months more in per- 
forming cystoscopy and in catheterizing the ureters, at the end of which time 
he has become very proficient. 

The result has been that we have developed a cystoscopic school and some 
of the most expert cystoscopists in this country have served terms in our clinic. 

It requires about six weeks for each man to become acquainted with the 
bladder, and six weeks more for him to be able to catheterize the ureters. For- 
merly, physicians returning from Europe were constantly telling us about the 
dexterity with .which certain surgeons abroad, who taught them, could cathe- 
terize the ureters. When they attempted to show their technique, however, they 
usually failed. At present, they find that our methods of catheterization are 
the simplest and that our cystoscopists have more speed than those in Europe. 
On one occasion when the question of quickness was being discussed by a body 
of men visiting the clinic, I requested the cystoscopist in charge of the room 
to illustrate the speed of our American method. He filled the patient's bladder 
with solution, inserted the cystoscopie and catheterized both ureters in twenty- 
nine seconds. 

I do not approve of these trials of speed and it was the only time in our 
work of ureteral catheterization in the clinic that it has been indulged in, as I 
feel that, while showing the dexterity of the operator, it detracts from the care- 
ful and conservative methods which it is our endeavor always to carry out in 
bladder work. 

After the cystoscopic examination, either for observation or ureteral cathe- 
terization, is finished, the patient is again placed in the horizontal position, a 
catheter is introduced and the bladder is emptied, after which it is washed out 
with a 1 : 4,000 solution of nitrate of silver, as is also the urethra. 

Fifteen grains of urotropin in a glass of water is given by mouth, and a 
suppository is inserted containing ten grains of quinin and one quarter of 
a grain of morphin to prevent an attack of urethral fever. 

Fig. 220 is a chart showing bladder laid open, used by me in depicting blad- 
der lesions seen by cystoscopy. 



236 CYSTOSCOPY 

Eeaction after cystoscopy ia due to the patient's spasmodic resistance to the 
passage of the instrument through the urethra, which causes a traumatism and 
consequently a urethral fever in case the urine or the canal is infected. This 
is intensified in a damaged condition of the kidneys. A alight reaction may 



occur even though asepsis and antisepsis is perfect, and the bladder and urethra 
are washed out after it by silver solution, and uiorphin and quinin solution is 
given, 

QUESTIONS REGARDING CYSTOSCOPY 

In concluding this chapter, I will consider the questions that have been so 
frequently asked uie regarding cystoscopy: 

(1) Which is the bettor instrument, the direct or the indirect? 

(2) Which is the better instrument, the air or water cystoscope ? 

(3) Which is the easier to eatheterize, a man or a woman? 

(1) As to the question, which is the better instrument, the direct or in- 
direct, I will say that the indirect is the better. This is especially true in 
the hands of the eystoscopist who is an expert in the use of both instruments, 
as with an indirect you can examine the interior of the bladder better, which is 
the object of cystoscopy. You can also see and pass the catheter into any ureter 
that can he catheterized by the direct instrument, besides introducing it into 
many ureters that cannot be catheterized by the direct cystoscope on account 
of an enlarged prostate, a displaced or deformed bladder, or a cystocele. 



QUESTIONS REGARDING CYSTOSCOPY 237 

With the direct instrument, it is much easier to catheterize the ureters of 
ninety-five per cent of the patients, if this percentage can be catheterized ; I 
feel quite certain that they cannot be, the first time, in pathological cases. Once 
the ureters are seen, the catheters can easily be introduced, as they are simply 
pushed straight into the openings. The direct cystoscope, however, does not 
give the examiner as good a view of the entire bladder and, therefore, is not 
such a good instrument for observation. This led me to bring out the cystoscope 
that I have described, as it stands for the teaching in the clinic — namely, ex- 
amine the bladder with the indirect telescope ; withdraw it, introduce the direct- 
catheterizing apparatus and catheterize the ureters. 

(2) Which is the better instrument, the air or the water cystoscope? The 
*w^ater cystoscope is certainly better, as the indirect instrument, which is the 
best general cystoscope, can only be used successfully in a water medium. 

There is, consequently, remaining for discussion, only that part of the ques- 
tion as to the relative merits of direct-air and water cystoscopes, and here again I 
believe that, in the great majority of cases, the direct-water cystoscope is prefer- 
able. A bladder dilated with water is more tolerant than when dilated with 
air, and it is less liable to traumatism, as the maneuvers are made in a field 
full of an antiseptic solution. 

Formerly the air cystoscope could not be used, as the cystoscopic lamps 
were too hot and would burn the bladder, and cystoscopy had to be performed 
in a water medium. The advent of the Mignon cold lamp, brought out by Pres- 
ton of the Electro-Surgical Company of Rochester, and introduced into the 
instruments devised by Dr. Koch and Dr. Lewis, made air cystoscopy practical, 
on account of the bladder being able to tolerate the cold lamp. 

There are advantages that an air cystoscope has in certain cases, as, for in- 
stance, when a large amount of pus is coming dowoi the ureter from a kidney 
and clouding the fluid in the bladder or when blood coming from the kidney 
renders the fluid medium diflicult to see through, in either of which cases the 
diseased kidney would be determined and the ureters easily catheterized by the 
air instrument. It is also valuable in certain cases of cystitis with bladder sac- 
culation. In the treatment of certain conditions, it should be more suitable 
than the water instrument, as in curetting or cauterizing ulcers of the bladder. 

It is, however, a more difficult instrument to use than the water cystoscope, 
as the patient complains of pain, and is kept in position with difficulty ; while 
the leaking of air, and the bubbling up of air and urine disturbs the composure 
of the examiner. These causes have been sufficient to make the majority of 
the practitioners who have purchased the instrument put it away, and its use 
is limited to the specialist with an abundance of material. There is, however, 
a great field for the air cystoscope if alterations can be made by which the patho- 
logical field in the bladder can be kept sufficiently smoothed out by air dilatation 
to allow operative work to be done through the instrument. A cystoscopist 



238 CYSTOSCOPY 

should, therefore, be able to use the direct and indirect water, air and catheter- 
izing cystoscope equally well, in order to be proficient in his specialty. 

(3) Which are the easier to catheterize, men or women? This may be an- 
swered by stating that it is easier to introduce the instrument into the female 
bladder than into the male, but once introduced it is more difficult to make the 
examination in the female. This is because, in the female bladder, the land- 
marks are not so clearly defined, and also because, in women, the pelvic con- 
tents are not always normal, especially the internal genitals. Uterine displace- 
ments change the shape of the bladder and its relations, as do fibroid tumors, 
the adhesions of exudates about the tubes, the presence of ovarian tumors and 
the prolapse of the posterior wall in cystocele. 



CHAPTER XI 

« 

SPECIAL URINARY SYMPTOMS 

I. DISTXJRBAWCES OF MICTURITION 

Frequency of Urination 
(PollaJciuria) 

Frequency of urination is perhaps the most common form of urinary dis- 
turbance. The normal frequency of urination varies somewhat in different 
individuals and at different times. A healthy person, with a normal urinary 
tract not pressed upon or interfered with by anything outside of its walls, passes 
urine five times a day without any difficulty or pain, and with a stream of good 
size which can be started or stopped at will. At the end of the act, the bladder 
is empty and no sense of discomfort will be felt in any part of the tract. Urina- 
tion usually takes place on arising ; at the time of the stool ; before the midday 
meal; before the evening meal and on retiring. 

The temperature plays an important role in the frequency of urination. 
During the hot weather when the skin is active, much fluid is taken from the 
body in the perspiration and the amount of urine and the frequency tend to 
diminish, excepting when the individual is in bathing, when the desire is much 
increased. In the autumn, the skin becomes less active, additional work is 
thrown upon the kidneys and the frequency is increased. Wetting the feet in 
the fall of the year or chilling of the legs increases the amount of fluid voided 
by producing a congestion of the internal urogenital tract and, therefore, an 
irritability of the urinary organs bringing on the desire. Autumn frequency 
is often caused by sitting or standing quietly watching some game or other 
object of interest, when the circulation is active and the extremities, on account 
of not being well covered, are chilled. This tendency disappears during the 
winter when the extremities are better protected by heavier clothing and over- 
coats. The frequency, perhaps, returns in the spring from a different cause — 
the sudden beginning of active perspiration which takes a certain amount of 
fluid from the urine and renders it more concentrated and irritating. 

The amount of exercise has the same effect as heat, in that it increases the 
activity of the circulation and consequently perspiration, when the quantity of 
urine is temporarily diminished. 

230 



240 SPECIAL URINARY SYMPTOMS 

Mental emotions give rise to many varieties of frequency, which may nhow 
themselves in an unexpected desire to urinate, as in the case of sudden fright. 
At other times frequency is increased when waiting to take part in some event, 
competition or game, in which the participant is especially interested ; in which 
case, before beginning, it may be necessary to urinate three times in an hour, 
whereas perhaps a few minutes after the affair is over, the desire is gone and 
will not occur again for several hours. 

Mental association or continuous thought centered upon the urinary organs 
may have the same effect, as students working on the subject either in a literary 
or clinical way, but especially the former. 

Pathological frequency of urination or bladder irritability is a condition 
in which the urine is not only voided more frequently than normal, but in which 
the desire to urinate is present again soon or immediately after voiding it. The 
frequency of micturition observed in disease is variable, ranging from six urina- 
tions in the daytime and one at night, to an almost continuous desire, or a mic- 
turition every few minutes. 

Etiology. — Frequency of urination is due to troubles independent of the 
urinary tract; to diseases of the urinary tract; to affections outside of the 
urinary tract that interfere with its (the urinary tract's) function. 

(1) Diseases Independent of the Urinary Tract. — The diseases inde- 
pendent of the urinary tract causing frequency of urination are those of me- 
tabolism, as diabetes mellitus and insipidus, giving rise to overproduction of 
urine; nervous disorders, as hysteria, neurasthenia and hypochondriasis pro- 
ducing an increased amount of urine ; or the character of the urine itself, as a 
highly acid urine or one containing an increased amount of uric acid, oxalate 
of lime or indican, the results of faulty metabolism through irritation of the 
kidney and the consequent polyuria. 

Frequency may also follow certain articles of diet, as pepper and other con- 
diments; an abundance of spring water; mineral diuretics, alcoholic drinks, 
especially gin and beer; certain foods giving rise to intestinal fermentations, as 
sweets, fried food, onions, radishes, cabbage, tomatoes; also a diet too rich in 
meat which may give rise to intestinal putrefaction. These articles of food, 
if not properly digested, give rise to the products of faulty metabolism already 
mentioned: indican, uric acid, diabetes, oxaluria, etc. 

(2) Diseases of the Urinary Tract Giving Kise to Frequency of 
Urination. — The diseases of the urinary tract causing this trouble are situated 
above and below the middle zone of the bladder, principally in the latter. Above 
this zone, we have the kidney, which causes pollakiuria, owing to a polyuria. 
The polyuria is generally due to an interstitial nephritis, to a tubercular nephri- 
tis in its early stages and sometimes to the irritation of a renal calculus. An 
intermittent pollakiuria is sometimes present in the case of a movable kidney 
that has become displaced, where there is an intermittent hydronephrosis, which 



DISTURBANCES OF MICTURITION 241 

on its return to position ponrs out a suflScient amount of urine to give rise to 
frequency for a brief period. 

The bladder is, however, usually responsible for frequency of urination, due 
to a congestion or inflammation of its wall as a result of the irritation from a 
foreign body, as a calculus in its cavity, from tubercular deposits or ulcers in its 
wall, from tumor, or indirectly from the back pressure owing to some obstruc- 
tion in the tract below^, as the prostate or the urethra ; or from an extension of 
an inflammation from the urethra. 

Most of the troubles in the bladder giving rise to frequency, are those situ- 
ated in the part below what would correspond to the middle zone of an organ 
in health when full of fluid. This would include the base or fundus from the 
internal meatus to a line above the interureteral band, thus including the 
trigone. 

A calculus in this position when the patient is standing, sitting or moving 
about, would give rise to irritation and consequent congestion of the bladder 
nearest the internal meatus; while at night, when he is sleeping, it would fall 
away from the posterior wall of the bladder and the patient would be compara- 
tively comfortable. The shape and surface of the calculus influences frequency, 
as calculus with a smooth surface that does not come in close contact with the 
internal meatus produces a less degree of frequency. 

Vesical tuberculosis resembles closely vesical calculus in the day frequency, 
excepting that the stream is not interrupted, as it often is when stone is present ; 
but at night the frequency continues in about the same degree. The frequency 
in this disease is very great when there is an ulcer near the internal meatus and 
consequently over the vesical sphincter ; whereas, when ulcers are farther away 
from it, the urgency is much less marked. In vesical tuberculosis, before ulcers 
have formed, the frequency is not so great. 

Vesical tumor does not usually cause such marked frequency as either cal- 
culus or tuberculosis, as it is not generally situated near the vesical outlet. 

In all three of these conditions, there is congestion, in the first due to the 
irritation of the stone, in the second about the tubercular deposits and in the 
third in and about the tumor. In all these conditions, the closer the contact 
of the pathogenesis with the internal meatus, the more marked the frequency. 
The symptoms are also more severe after a cystitis has developed. 

Impediments to urination also give rise to frequency in different ways and 
in different degrees. 

When a bladder has to force urine through a canal in which there is a nar- 
rowing in some locality, or w^here its shape has become changed through pres- 
sure, an extra strain is brought upon it and consequently an extra amount of 
blood is brought to its walls, resulting in congestion. If this impediment is 
temporary, the bladder quickly regains its normal condition, after it has sub- 
sidedy and the frequency is consequently of short duration and of a varied de- 



242 SPECIAL URINARY SYMPTOMS 

* 
gree. If the impediment is slight at the start and increases slowly, then the 
bladder becomes accustomed to it and slowly hypertrophies; the congestion is 
then not marked and the frequency develops slowly and insidiously. If the 
impediment interferes with the urination to such a degree, owing to a mechan- 
ical obstacle or a weakened state of the bladder wall, that the bladder cannot 
completely empty itself and a certain amount of residual urine is always pres- 
ent, occupying a part of the bladder space, then the remainder of the space 
for the transient urine is consequently lessened and the patient must urinate 
more • frequently on account of this diminished space being filled more fre- 
quently. 

Temporary impediments to urination are due, first, to an acute prostatitis, 
principally of the parenchymatous form; next, to that of the follicular type, 
or to an abscess resulting from either of these forms, or to a chronic prostatitis. 
In an acute parenchymatous prostatitis, when one or both lobes are involved, 
the inflamed gland grows up into the prostatic urethra, toward the bladder, the 
same as in prostatic hypertrophy. This gives rise to frequency of urination on 
account of the inflammation near the bladder neck, and also on account of the 
residual urine resulting from the impediment itself and the consequent dimin- 
ished transient capacity of the bladder. If the prostatitis is follicular, then 
there is simply a bulging into the urethra of a sufficient degree to give fre- 
quency, due to an increased strain being brought upon the bladder to pass the 
urine through the narrowed canal. In either of these conditions, an abscess 
may form, giving rise to an increased eifort of the bladder to force urine by 
the imi)ediment, to residual urine or even to complete retention. When the 
inflammation subsides or the abscess breaks or is evacuated, the frequency dis- 
appears or subsides. If it disappears, the disease is probably cured; but if it 
subsides and the urine is not clear or shreds are present or prostatic leakage, 
then the disease is not ciired and the slight frequency remaining is the result 
of a chronic prostatitis. 

In tuberculosis of the prostate, there is frequency in a varied degree due 
to the associated prostatitis and urethritis. This is more marked if it extends 
to the bladder. When confined to the prostate alone, in time it usually subsides. 

In prostatic calculus, the frequency also varies in degree and is often very 
marked, due to an associated prostatitis and sometimes to incomplete retention. 
This subsides slowly after the stone has been removed. 

Exudates about the urethra in any part which may or may not result in a 
'periurethral abscess, often give rise to temporary frequency of urination, due 
to the narrowing from the outside pressure, which disappears when the abscess 
has been incised or broken. If there is great pressure in the urethra in these 
cases, there may be complete retention of urine. 

Posterior urethritis occurring during an attack of acute urethritis will also 
give rise to frequency, often in a very marked degree. 



DISTURBANCES OF MICTURITION 243 

It is easy to understand the mechanism of frequency of urination in acute 
posterior urethritis. Normally, the pressure of a few drops of urine in the 
posterior urethra, as the result of a slight leakage through the sphincter when 
the bladder is sufficiently distended, is said to be the real cause of the desire to 
urinate. The desire to urinate is a physiological phenomena, initiated by a cen- 
tripetal irritation of the posterior urethra and the neck of the bladder, by a 
small quantity of urine. When the posterior urethra is inflamed, the irritability 
of its mucous membrane is increased to a high potential and thus the patient 
is obliged to pass water frequently. 

Trequency of urination slowly increasing is caused by a chronic impediment 
to urination, as in the case of stricture or prostatic hypertrophy. 

A stricture may be congenital, acquired or traumatic, and the nearer to the 
bladder it is situated the more marked will be the frequency. Congenital 
strictures are usually linear and situated at the meatus or just in front of the 
fossa navicularis. The frequency of urination in children is principally due 
to this condition and there is generally a history of nocturnal incontinence. 
If these patients develop a urethral inflammation, the frequency becomes more 
marked. 

Acquired strictures, resulting from a urethral infection, are the most fre- 
quent. The frequency in these cases until the stage when residual urine begins, 
is due to vesical congestion or cystitis, usually the latter. The frequency is more 
marked, in proportion, during the day than during the night, and increases 
after dissipation or exposure. 

Traumatic stricture is due to a fall and the pressure of the urethra between 
the triangular ligament of the pubis and the impinging body. This is often 
severe, giving rise to retention and later, perhaj)s, to overflow incontinence, 
or to extravasation of urine. In cases of moderate degree with no com- 
plications, however, a mild but steadily increasing frequency will probably 
result 

Impediment, with residual urine, causes frequency of urination by the 
vesical congestion resulting from the impediment, and also on account of the 
lessened bladder space for the transient urine, due to so much of the bladder 
cavity being taken up by the residual. The frequency will continue to increase 
in proportion to the amount of bladder space that becomes occupied by the 
residual urine, and often until complete retention or overflow incontinence 
results. 

In prostatic hypertrophy, the frequency occurs in the same way as it does 
in cases of acquired stricture and is at first due to congestion from the extra 
amount of work thrown upon the bladder in its effort to overcome the obstruc- 
tion. As the prostate increases in size and the venous return flow from the 
bladder is interfered with, a passive congestion takes place. This is more 
marked at night ; for then the circulation is less active than during the day when 



244 SPECIAL UKINARY SYMPTOMS 

the patient is up and about. The more marked frequency at night thus differs 
from the frequency of stricture. Later, as the prostate continues to increase in 
size and pushes up into the bladder, the residual urine increases, and, as the 
bladder is more encroached upon by it, the space for the transient urine, there- 
fore, is consequently diminished and frequency increases. This increased fre- 
quency increases as in stricture, until complete retention or overflow incon- 
tinence takes place. 

In prolapse of the uterus, cystocele and vaginal hernia, there is also a pouch 
of the posterior wall of the bladder, giving rise to residual urine and conse- 
quently less room for the transient urine; the patient, therefore, passes urine 
more frequently, just as he would in case of prostatic hypertrophy. 

(3) Frequency of Urination Due to Disease Outside of the Urinary 
Tract Interfering with its Function. — First among these, are the injuries 
and diseases of the spinal cord and brain (usually the latter), as the sclerosis 
or tumors press upon them, increasing pressure slowly and causing an inter- 
ference with their circulation. 

Here the innervation of the bladder is interfered with, there is loss of 
power in its wall, the desire is not so imperative, but the patient feels the neces- 
sity of passing urine more frequently in order to avoid dribbling of urine. This 
increased frequency, the result of mental calculation, increases until there is a 
larger amount of residual urine and a consequent overflow retention. 

Interference from without, when there is no disturbance of the innervation 
of the bladder, is due to the pressure or pulling of some perivesical tissue with 
which it is in close relation or to which adhesions have formed. 

Seminal vesiculitis causes frequency when the vesicles are enlarged, tense, 
acutely inflamed or adherent to the bladder. The seminal vesicles are at times 
very large, the size of the finger, which gives rise to a sense of fullness of the 
bladder when a small amount of urine has accumulated in it. At other times, 
the tense feeling of the seminal vesicles is transmitted to the bladder, which 
lies in front and above them. Adhesions to the bladder, if the walls of the 
vesicles are thick and inelastic, give rise to a sense of discomfort when the 
bladder is stretched a little. In these cases, the feeling of discomfort or fullness 
is transmitted to the suprapubic region. The frequency in seminal vesiculitis, 
as in stricture and stone, is more marked in the day than in the night. 

The uterus, w-hen misplaced, causes frequency of urination. This is espe- 
cially annoying w^hen it is displaced forward in such a way as to rest on the 
bladder, and by its position causes a feeling of discomfort to such a degree, when 
a small amount of urine has accumulated in it, that, in order to be relieved, 
the patient must empty the bladder. 

Again, when the uterus has fallen back and pulls the bladder with it, there 
is a feeling of discomfort from pressure on the pelvic plexus of nerves, from 
interference with the function of the bladder, and perhaps from residual 



DISTURBANCES OF MICTURITION 245 

urine that accumulates in the back of the bladder, resulting in a desire to 
urinate. 

An inflammation of the tubes also interferes with the function of the blad- 
der, through holding it to one side by adhesions and interfering with its dilata- 
tion and contraction, and consequently causing frequency. 

An exudate, infiltration or abscess, due to a pus tube or to a torn or septic 
uterus, may press upon the bladder from without so as to prevent it from dilat- 
ing, except to a limited degree, and thus, by diminishing its capacity, neces- 
sitate voiding when but a small quantity is present. 

Tumors in the pelvis pressing upon the bladder, on account of their weight, 
shape or size thus interfering with its dilatation, may give rise to frequency. 
This condition creates a sensation of fullness before the bladder is actually full, 
or it may be that pressure only allows the bladder to fill partially. Instances 
of this are fibroids of the uterus, hydatid in the recto-vesical space and appen- 
diceal abscess in the pelvis. 

Cancer of the uterus, involving the bladder wall, may also give rise to fre- 
quency of urination, through the congestion it causes ; through interfering with 
the vesical contract ibility; through the infiltration of its wall; or through the 
irritation of an ulcerating area. 

Malignant tumors of the rectum produce much the same result. 

A loop of atonic dilated sigmoid, in case of fecal retention or a sigmoiditis, 
may press upon the bladder sufficiently to give rise to frequency or even to re- 
tention. This is a much more frequent cause than is generally realized. In 
women, this loop is often caught down and held by adhesions resulting from 
salpingitis. 

The omentum, when adherent to the bladder, may pull it in any direction, 
thus interfering with its function. This is generally due to pelvic inflammation 
starting as a salpingitis. It may also pull other tissues or organs against the 
bladder. 

TABLE OF FREQUENCY OF URINATION 

A. Causes Independent of Diseases of the Urinary Tract 

In hot weather, due to prolonged bathing in cold water. 

In autumn, due to diminished perspiration and extra work 

thrown on the kidneys. 
In winter, due to wetting of the feet, chilling of the extremities. 
In spring, when the sudden active perspiration begins, it is due 

to concentrated urine charged with irritant properties. 
Fear, anxiety, excitement, or thoughts regarding urinary 

troubles or brought about by clinical or literary work on the 

subject. 



Temperature 



Mental 
emotions 



246 



SPECIAL URINARY SYMPTOMS 



Diet 



^ Condiments, mineral waters, alcoholic drinks. 
Certain vegetables giving rise to intestinal fermentation. 
Too much meat giving rise to intestinal putrefaction. 
The faulty metabolism from this diet giving rise, through in- 
dicanuria, uricacidemia, oxaluria and diabetes, to renal irri- 
tation. 

Diseases of Metabolism : — Diabetes insipidus and mellitus. 
Nervous Disorders: — Hysteria, neurasthenia and hypochondriasis. 



B. 



Polyuria 



Vesical 
congestion or -* 
cystitis 



Interference — 
temporary 



Urethral 



Interference- 
slowly 
increasing 



Interference 
Avith residual ^ 
urine 



Dependent on Diseases of the Urinary Tract 

Interstitial nephritis. 

Tubercular nephritis. 

Calculous nephritis. 

provable kidney (temporary polyuria). 

Vesical calculus. 

Vesical tuberculosis. 

Vesical tumor. 

Prostatic impediment. 

Urethral impediment. 

Parenchymatous prostatitis. 

Follicular prostatitis. 

Suppurative (abscess) prostatitis. 

Chronic prostatitis. 

Tubercular prostatitis. 

Calculous prostatitis. 

Acute posterior urethritis. 

Exudates about the urethra. 

Urethral calculi. 

Periurethral abscess. 

Stricture, frequency due to vesical congestion or inflammation 
until residual urine begins. 

Prostatic hypertrophy, due to vesical congestion or inflamma- 
tion until residual urine begins. 

Stricture and prostatic hypertrophy, due to lessened bladder 
space to hold the transient urine after residual urine has 
begun to be present. 

Prolapse of uterus, due to lessened bladder space to hold the 
transient urine. 

Vaginal hernia, due to lessened bladder space to hold the tran- 
sient urine. 

Cystocele, due to lessened bladder space to hold the transient 
urine. 



DISTURBANCES OF MICTURITION 



247 



C. Dependent on Diseases Outside of the Urinary Tract Interfering with its 

Function 



Interference — 
temporary 



Interference — 

slowly 

increasing 



" Seminal vesiculitis. 

Salpingitis. 

Abscess, exudates, infiltrates. 
.Appendiceal abscess. 
" Hydatid cyst of pelvis. 

Tumor of rectum. 

Sigmoiditis or sigmoid retention. 

Displaced uterus. 

Uterine fibroids. 

Sclerosis of the cord 



Interference 

with residual 

urine 






Tabes dorsalis. 
Lateral sclerosis. 
Tabes dorsalis. 
Lateral sclerosis. 
Injuries and diseases of the brain. 



Sclerosis of the cord 



Consecutive Cases of Frequency of Urination. — In 240 cases coming 
to my clinic during the winter of 1907, frequency was found to be due to a 
single cause in 127 cases. Mixed causes, namely, two or more pathological con- 
ditions tending by their combined action to cause this, occurred in 113 cases. 



List 1 

Cases of frequency in which a single condition 
ivas found as a cause at the time of the visit. 

Urethritis 46 

Stricture 25 

Prostatitis (including 1 case of tuberculosis) 23 
Seminal vesiculitis (including 1 case of tuber- 
culosis) 10 

Cystitis (including 3 tubercular) 7 

Prostatic hypertrophy 5 

Movable kidney 2 

Tumor of bladder 2 

Stone in bladder 2 

Contracted bladder (frequency from dimin- 
ished capacity) ....'. 1 

Dilated bladder (transient capacity or di- 
minished space left for urine over the 
amount of residuum) 1 



List 2 

Cases of frequency in which a number of 
pathological conditions were found as contributing 
causes at the time of the visit. 

Urethritis 43 

Stricture 38 

Prostatitis (including 2 cases of edema and 

2 cases of tuberculosis) 80 

Vesiculitis (including 2 cases of perivesic- 

ulitis) 73 

Cystitis 46 

Prostatic hypertrophy 6 

Prostatic abscess 5 

Tiunor of bladder 3 

Nephritis 5 

Pyelitis 4 

Pyelonephritis 3 

Renal calculus 3 

Ulcer of bladder 1 

Sarcoma of prostate 1 



Note. — ^In looking at this table, we will see that urethritis was present in 89 cases of frequency, 
stricture in 63 cases, cystitis in 53 cases, prostatic hypertrophy in but 11 cases, while prostatitis 
was present in 103 cases and vesiculitis in 93 cases. This can be explained by saying that ure- 
thritis, stricture, cystitis, and prostatic hypertrophy are the principal active causes of frequency; 
whereas, prostatitis and vesiciilitis, excepting in the real acute attacks or in tubercular cases, are 
usually contributory causes. This list was compiled by Dr. Nelson of Cincinnati. 



248 SPECIAL URINARY SYMPTOMS 

In the list of cases in which we could ascribe the frequency to one cause, the 
largest number occurred in the following order: Urethritis, stricture, prostatitis, 
seminal vesiculitis, cystitis and prostatic hypertrophy ; whereas, in the remain- 
ing cases, there was no marked number under any one disease. Of the com- 
bined causes, we will also see that these six conditions were more or less present 
in the majority of the cases. This list embraces 240 consecutive cases of fre- 
quency coming to the clinic during the winter session. 

In my hospital work, tlie causes are different singly and combined ; stricture 
is the most common cause, next acute prostatitis, posterior urethritis, vesical 
tuberculosis, vesical calculus and prostatic hypertrophy. 

Of these, stricture, prostatic hypertrophy, vesical tuberculosis and vesical 
calculus are generally accompanied by cystitis, while acute prostatitis and pos- 
terior urethritis are usually complications of acute anterior urethritis. 

Treatment of Frequency of Urination. — Treatment of frequency of urina- 
tion varies largely according to the cause, and is considered in the various chap- 
ters dealing with each of the conditions involved. This leaves but few words to 
be said regarding the general treatment of functional frequency of micturition. 

It is important to keep the feet warm and dry during the fall and winter, 
to increase the clothing in accordance with the temperature of the air. All 
excitement which would tend to cause local irritation should be avoided. The 
diet should be simple mixed animal and vegetable, taking a small amount of a 
variety of food rather than a large amount of any one kind. Fried foods and 
sweets should be partaken of sparingly. Condiments, salted and pickled food, 
should be avoided. Alcoholics should be avoided or restricted. Spirits, ale, 
beers and champagne, are the worst drinks, whereas red wines are the least 
harmful. About three pints of water should be taken in twenty-four hours. 

In the therapeutic line, hot Turkish baths should be taken twice a week, hot 
sitz baths before retiring. , If there is any fecal retention or trouble with the pros- 
tate gland or seminal vesicles, hot rectal douches are better than hot sitz baths. 

Massage of the prostate and vesicles is of value in diseases of these organs, 
unless they are tubercular. 

If the urine is very acid, alkalines should be given, preferably acetate or 
citrate of potash. Of the mineral waters, the most satisfactory in my judg- 
ment is Celestine vichy. If much pus is present, urotropin, salol, benzoic acid 
and benzoate of soda, are the best urinary antiseptics. If there is acute inflam- 
mation, santal oil is the best. 

For relieving the frequency, especially if spasm is present, the antispas- 
modics, as belladonna and hyoscyamus, codein, morphin and the bromids are 
the best. 

For bladder irrigation, solutions of boric acid, nitrate of silver or protargol 
are the best. For bladder injections, small quantities of argyrol, ten to twenty- 
five per cent, gommenol or iodoform emulsion, are the most efficacious. 



DISTURBANCES OF MICTURITION 249 

The bowels should be kept open bj caseara sagrada, salines, such as phos- 
phate of soda, Apenta or some mild mineral laxative waters, and should be as- 
sisted if necessary by glycerin suppositories or rectal enemas. 

Moderate exercise should be taken. 

Dysuria or Ischuria 

Dysuria, or ischuria, is a term which, when correctly used, applies to dif- 
ficulty in voiding urine and may be accompanied by pain and a spasmodic condi- 
tion of the bladder at its neck, known as tenesmus. Dysuria does not mean 
painful micturition, pure and simple. Just as dyspepsia stands for an inabil- 
ity to digest food, so dysuria stands for a difficulty to pass the water. 

Dysuria may occur suddenly as an unforeseen event; for example, when a 
stone becomes jammed in the neck of the bladder or when a papilloma of the 
bladder suddenly twists in such a w^ay as to block the orifice. In other condi- 
tions, as, for example, in hypertrophied prostate, in tumors of the prostate 
and in strictures of the urethra, dysuria often comes on gradually, the difficulty 
in passing water becoming more and more pronounced. 

In the milder forms of dysuria, the act of urination is merely accompanied 
by a slight amount of exertion in which the accessory muscles, the abdominal 
and the perineal, are brought into action. In severe forms, the individual may 
be unable to pass w^ater, except in certain positions, as squatting or leaning over 
and bracing against stationary objects. In these severe cases, the face may be- 
come agonized, red with swollen veins ; perspiration appears in beady drops on the 
forehead, the breath is held and the lips are compressed in the effort at expulsion, 
which is repeated periodically with intervals of rest and is accompanied often 
by an involuntary discharge of gas and feces. When the patient is in the squat- 
ting position, a prolapse of the rectum of two inches or more may take place. 

This is the clinical description of the symptom dysuria as such. Of course, 
a number of other disturbances of micturition and of allied clinical signs are 
very frequently associated with this particular manifestation. 

Among these, frequency of micturition, retention and overflow incontinence, 
pain during, before and after the act of urination may be grouped in a syn- 
drome, each element of which can be analyzed and set down by itself as having 
its own significance. 

Dysuria being present, the question arises to what cause it should be at- 
tributed ? Our, first thought, of course, will be the presence of some obstruc- 
tion which prevents a free and normal outlet of the stream. The chief causes 
of such an obstruction have already been mentioned. They are stricture of the 
urethra; prostatic hypertrophy; stones in the bladden or the urethra; tumors 
of the bladder or the prostate; or acute infiammatory swelling of the mucous 
membrane of the neck of the bladder or the prostatic urethra. 

A form of ^dysuria depending only upon a spasmodic contraction of the 



•• ^ • •• ^ # •« 



<<ri 



250 SPECIAL URINARY SYMPTOMS . . ' sjH J*r^ 



sphincter may be styled a nervous dysuria. It may be followed later by in- 
continence and is characterized by an absence of all local fevidenc^Bs*' of disfiBs^y^ij'Y 
of the urinary organs. Whenever such a dysuria is present, a suspicion arises 
as to the presence of a spinal disease. f^r'^* •• •-, *'^ 

Dysuria of inflammatory origin is simple in its mechanism, oependmg upon 
the congestion and swelling of the parts, and is usually fairly easy to recognize 
by the history and symptoms. In the presence of an acute urethritis, the onset 
of dysuria with painful and frequent micturition is the signal of the involve- 
ment of the posterior urethra. It occurs in an intense degree, especially if ac- 
companied by fever, when an acute involvement of the prostate should be feared, 
unless excluded by rectal examination. When dysuria and other disturbances 
of micturition occur in tlie course of a chronic urethritis, we are led to suspect 
stricture. If the patient is advanced in age, and if the dysuria has been coming 
on gradually, increasing apace with frequency of urination, we naturally look 
for hypertrophy of the prostate. A characteristic of the dysuria of prostatics is 
that the symptom is aggravated at night. Rest in bed, a horizontal position of 
the pelvis, a sedentary life and the presence of constipation, are all factors 
which increase the dysuria of prostatics. 

One of the most interesting forms of dysuria is that due to stone in the 
bladder. In this form, patients, instead of being aggravated when lying in bed, 
are relieved by the horizontal position, while the upright position and any jars 
or jolts, as in walking or running, in which the stone has a chance to become 
lodged in the vesical orifice, increases the discomfort. 

A temporary dysuria frequently occurs after urethro-vesical instrumenta- 
tion — as after the passage of a cystoscope, sounds, or other dilating instruments 
— and after irrigations by the Janet method, or deep instillation of strong solu- 
tions of silver nitrate. This should be termed a false dysuria, as it is simply 
due to irritation and not to a pathological condition, and is usually of very 
brief duration. 

All varieties of dysuria are frequently accompanied by more or less pain, 
or at least by a sensation of pressure and burning which is quite distinct from 
that of an exaggerated desire to urinate. The latter is a sensation of pressure 
or burning, which cannot exactly be called a pain, in fact, can scarcely be anal- 
yzed, yet it forms part and parcel of the mixed sensations experienced by 
patients afflicted with dysuria. In certain conditions, the contraction of the 
bladder walls in trying to overcome the obstacle, whatever that may be, gives 
rise to a colicky pain. This vesical colic may be an accompaniment of dysuria. 
It is characterized usually by a gradual onset^ a rapid rise to a climax, followed 
by a remission. Usually it is located in the body of the bladder, accompanied 
by intense desire to urinate, and may radiate to the perineum, the rectum or 
the urethra, or into the hypogastrium, the groin, or even the loin. 

Vesical colic is an accompaniment also of retention, especially of the acute 



DISTURBANCES OF MICTURITION 



251 



form. It is due to troubles accompanied by residual urine, to lesions seated in 
the upper zone of the bladder or to that covered by peritoneum ; to deep-seated 
lesions and to perivesical troubles. 



CONDITIONS GIVING RISE TO DYSURIA 



Bladder 



Extra- 

A'esical 

causes 



Prostate 



rxy 



X'^esieal tiunors -. 



Inflammation outside 
of the bladder 






Vesical calculus, especially if it obstructs the neck of the bladder. 

^ Papillomas, if they ob^ruct the vesical neck. 
Infiltrated or malignant, if they interfere with 
dilatation and contraction of the bladder. 
Vcute inflammation of the bladder neck, the congestion of the 
mucous membrane imparting the sensation that the bladder is 
not entirely emptied. 

Vesiculitis. 

Appendicitis with bladder adhesions. 

Salpingitis. 

Uterine displacement. 

Uterine. 

Ovarian. 

Rectal. 

Hydatids. 

Inflammatory exudates. 

Pressure of sigmoid. 

. , f In Retzius' space. 

Abscess J ^ , . ^ 

Pelvic. 

"Adhesions of omentum. 
Adhesions of tubes. 
Adhesions of large intestines. 



Extra vesical 
pressure 



Pelvic tumors 



Extravesical 
traction 

'Calculus in prostate. 
Tumors of prostate. 

Acute prostatitis 



Parenchymatous. 

Follicular. 

Abscess. 



Urethra 



, Hypertrophy. 

" Calculus in any part of the urethra, but most marked in the pros- 
tatic portion. 

Acute posterior urethritis, the sensation of obstruction being due 
to intense congestion. 

Stricture accompanying chronic urethritis. 

" Periurethral exudates. 
< Periurethral abscess. 
Urinary extravasation. 

Nervous diflSculty due to lesions of the spinal cord. 



Extra- 
urethral 



252 SPECIAL URINARY SYMPTOMS 

Painful Micturition 

Under this heading, we shall discuss pain which either precedes, accompanies, 
or follows the act of micturition. This symptom is of the greatest importance 
in urological diagnosis, as it often enables us to localize and to define the char- 
acter of urinary diseases. 

Micturition is made painful in the presence of congestion, inflammation, 
ulceration, new growths, calculi, foreign bodies or traumatism, either in the 
bladder, the prostate or the urethra. 

There is, however, a group of conditions of the kidneys and the ureter 
which indirectly give rise to painful micturition. Of these, perhaps, the most 
prominent is due to stone in which small calculi pass down the ureter and stick 
just above or at the opening into the bladder, giving rise to a sensation akin to 
those in the bladder, the prostate, or the urethra. 

Painful micturition is a prominent accompaniment of cystitis. In the 
milder degree, especially of the chronic type, it is not very pronounced. In the 
acute form, the pain is very distressing and the same may be said of the tuber- 
cular form, especially w^hen accompanied by ulceration. In tumors of the 
bladder, painful micturition is also one of the important symptoms, becoming 
marked when the new growth involves a large portion of the organ and when it 
ulcerates. 

Stones or foreign bodies in the bladder, especially if they be rough or 
pointed, may cause intense pain during the act of micturition. 

The rule is, so far as the time of occurrence of the pain is concerned, that, 
in bladder conditions, the acme of intensity is reached at the end of the act of 
expulsion — that is, when the greatest amount of vesical contraction takes place. 

The character and the position of the pain during micturition, when due to 
bladder conditions, is not distinctive. It may present itself as a tenesmus or 
burning sensation at the neck of the bladder, or it may be located in the hypo- 
gastrium, radiating to the end of the penis, the groin or even the loin. The 
pain of stone in the bladder is characteristically located at the end of the urethra. 

In posterior urethritis and in inflammations of the prostate, painful urina- 
tion, accompanied by dysuria, and frequency, constitute a very frequent and 
important set of symptoms. Usually the pain is felt at the beginning of urina- 
tion, when the posterior urethra is distended by a rush of urine. The contrac- 
tion of the posterior urethra at the end of micturition causes an exacerbation 
of the pain at that time. 

Painful micturition may also be present without any organic affections of 
the urinary organs, when the character of the urine is such as to irritate the 
lower passages. Among these conditions may be mentioned phosphaturia, 
oxaluria, uricacidemia and other conditions in which there is an excess of crys- 
talline elements in the urine. 



DISTURBANCES OF MICTURITION 



253 



(2) Congestion or inflammation 
of the bladder (cystitis) 
due to 



PAINFUL MICTURITION 

(1) Ureter: — Calculus near or at the opening into the bladder. 

Vesical calculus, especially if rough 
or pointed. 

Vesical tuberculosis with ulcer near 
the urethral opening. 

Vesical tumor, especially when ma- 
lignant or ulcerating, or if it comes 
in contact with the urethral open- 
ing. 

Vesical ulcer. 

Impediment from below, pressure 
from without, displacement or an 
interference with its functions. 

Gonorrhea, giving rise to an acute 

prostatitis. 
Tuberculosis. 
Calculus. 
Tumors (especially malignant). 

Gonorrhea 



(3) Congestion or inflammation 
of the prostate (prostati- 
tis) due to 



(4) Congestion or inflammation 
of the urethra (urethritis) 



Stone 
Crystals 



Especially in the 
posterior portion. 



For treatment, see the treatment of the trouble under the special chapters. 



Changes in the Urinary Stream 

Changes in the urinary stream include alteration in the shape, caliber, force 
and rhythm of the stream. 

The form and direction of the stream is altered in epispadias, hypospadias, 
fistula, abnormalities of the meatus and other anomalies. There are certain 
changes in form that are transient and depend upon the gluing of the meatal 
lips by discharge. In such cases, the stream may be twisted, flattened or split 
for a few seconds, but when the meatus has been washed by it, the stream again 
becomes normal. 

Persistent changes in the form of the stream indicate the presence . of 
strictures. They may consist of a special twisting, a flattening, or a splitting 
of the stream into several smaller jets, depending on the distribution, size, or 
amount of thickening forming the stricture. In stricture, these changes may 
be accompanied by difficulty in passing water. 

The caliber of the stream varies greatly according to the size of the meatus, 



254 SPECIAL URINARY SYMPTOMS 

i. e., the nozzle through which the stream must pass. If the meatus is narrow, 
the stream is fine, but when the meatus is normal and the stream is very small, 
the presumption is that there is a stricture farther back. 

The force of the stream depends upon the force of contraction of the de- 
trusor muscle of the bladder and the amoimt of the obstruction or interference. 
The force normally depends upon a variety of circumstances. If the bladder 
muscle is tired by long retention in normal conditions, the stream is weaker. 
It is also weaker in old people. Any condition which injures the bladder mus- 
cles or interferes with free circulation, wdll cause the force of the stream to be 
diminished. 

The stream loses its force in a variety of nervous conditions, notably in 
scleroses of the cord (tabes and lateral sclerosis), and in other diseases of the 
brain and cord in which the action of the detrusor is impaired. In the pres- 
ence of any obstruction of the stream, there is usually a period of compensa- 
tion at first, during which an increased muscular action overcomes the re- 
sistance, and the stream remains normal in force. Later, however, an atonic 
condition of the bladder develops and the force of the stream is diminished. 
This is especially the case in hypertrophy of the prostate, in stricture of the 
urethra, etc. 

In prostatic hypertrophy the bladder wall may be strong and the urethra 
of large size, as is evidenced after the passage of a large-sized catheter and the 
escape of a forceful stream of urine through it, and yet if no catheter is passed, 
the prostatic obstruction will be found sufficient to slow and diminish the force 
of the stream. 

The force of the stream is also lessened when the bladder contractions are 
interfered with, where there are adhesions of the omentum, tubes or intestines 
to the bladder, displacements of the uterus, pressure of pelvic tumors and inflam- 
matory exudates. 

The rhythm of the stream means its normal iminterrupted flow, beginning 
with a strong, steady stream and gradually diminishing. The last drops are 
then expelled by a contraction of the accessory nmscle. In old people, the last 
part of the act is considerably less forceful and the same may occur in people 
who retain their urine for a long time. 

Interruption in the stream of urine, know^n sometimes as urinary hesitancy, 
or urinary stammering, occurs in a variety of conditions. These include many 
in w^hich there is dysuria, the interruption then being due to a necessary relaxa- 
tion of the auxiliary muscles of micturition. Another cause of interruption 
of the stream is a spasmodic contraction of the vesical sphincter, such as occurs 
in acute inflammations in and about the neck of the bladder, as, for example, 
in acute prostatitis. Finally, the stream of urine may be interrupted in cases 
in which the bladder itself is free from disease, as in spinal diseases in which 
the vesical reflex is increased, causing a contraction of the sphincter during the 



DISTUKBANCES OF MICTURITION 265 

act, which interrupts the stream. Inflammations of the rectum, acting reflexly 
upon the bladder, may also produce the same effect. 

When small stones, pediculated growths, or tonguelike projections of pros- 
tatic tissue are present, the stream may be interfered with. 

Retention of Urine 

This term designates an inability on the part of the bladder to empty itself, 
because of loss of power or obstruction. It is variously classified as complete 
or incomplete, according to the degree of retention ; acute or chronic, depending 
upon the duration and severity of the attack; and traumatic, paralytic or ob- 
structive, referring to the nature of the cause.* 

Complete retention, from whatever cause, is a condition in which the pa- 
tient cannot pass any urine from the bladder; it is incomplete when he can 
empty it only in part, a certain residuum of an ounce or more, remaining in 
the bladder. The urine which passes represents the excess over this residuum, 
or the transient urine. Acute retention occurs when the patient suddenly finds 
that he cannot pass any urine, though he may never before have had any diffi- 
culty. It is chronic when for a long time he has not been able to empty his 
bladder; and paralytic when his inability to void urine is due to paralysis of the 
bladder wall, owing to disease of either brain or cord. 

Retention is obstructive when, owing to some growth or impediment in or 
about the neck of the bladder or at some point of the urethra, either no urine 
or not all of it can be forced out. It is traumatic when some wound gives rise 
to an impediment, either within the urethra itself or on the outside, which 
presses upon it. 

Occasional acute attacks of retention may be due to operations, alcoholism, 
profound temporary stupor, or voluntary refraining from urinating. 

The loss of power is variously referred to as paralysis, paresis and atony. 
There is really very little difference between certain degrees of these conditions. 
Complete paralysis of the bladder is found when, on account of some brain or 
cord lesion, it is incapable of expelling any urine; partial paralysis, when the 
bladder is not able to empty itself fully. Paresis is another name for partial 
paralysis, and atony is a condition where, through lack of power, the bladder 
wall cannot force out all the urine. Both in atony and paralysis, the bladder 
may be constantly distended by urine to a certain extent, perhaps to its utmost 
limit, as a passive sac, and the excess of this residuum may dribble away in- 
voluntarily (overflow incontinence) ; or it may be expelled in small quantities 
by repeated acts of urination in the ordinary way, accompanied by great strain- 
ing and assisted by the voluntary contractions of the muscular wall of the 
abdomen. 



• Guiteras, "Retention of Urine," N. Y, Medical Journal, May 20-27, 1899. 



256 SPECIAL URINARY SYMPTOMS 

The causes of atony are: Overdistention by neglecting to urinate, involun- 
tary retention in cases of fever and coma, and urethral obstructive conditions. 
The muscular coat of the bladder may be paralyzed from any cause that will 
induce loss of muscular power in other parts of the body, and the paralysis may 
affect either the detrusor urinje, or the sphincter vesica^, or botli at the same 
time. Power may be diminished or wholly lost, and this impairment of func- 
tion may be temporary or permanent. 

The muscles of the bladder which expel or retain the urine are only partially 
under control of the will. Thus the contraction of the detrusor is involun- 
tary, being occasioned as a reflex from the stimulus of the urine in the 
bladder. When sensibility is diminished and the presence of urine no longer 
acts as a stimulus on the detrusor, the result is urinary retention. The com- 
pressor urethrie must relax under the influence of the will before the contents 
of the bladder can escape. 

It is well to remember also that the bladder muscle may be directly paral- 
yzed by overdistention, as already stated, or by inflammation extending from 
either its mucous or its serous coat. 

Causes. — Acute Retention. — Acute or temporary retentions may be due 
to operations on or about the external genitals, anus or rectum, or upon parts 
of the body quite distant from this locality, bringing about a spasmodic inability 
to urinate. It may also be due to acute alcoholism ; to large doses of opium, 
belladonna or hyoscyamus, especially when given by rectum; or to profound 
temporary stupor, such as occurs in typhoid fever or other adynamic diseases. 
Voluntary refraining from urinating until the bladder is so full that its walls 
are unable to contract, as when one is in company where no opportimity is af- 
forded, is also at times a cause of retention. It may also be found in pregnant 
women, due to some displacement of the uterus, which presses upon the bladder. 
If it occurs after delivery, it is due to displacement of the bladder or to the 
effect of long pressure upon its neck during delivery. 

Acute attacks may also occur during chronic obstructive conditions, such 
as stricture or enlarged prostate from various causes. 

In the majority of cases, retention is due either to organic nervous lesions 
or to obstructions involving the urethra or prostate. 

C'liRONic Retention (Complete or Incomplete). — Certain organic nervous 
diseases cause retention. 

In paraplegia, in hemiplegia, in locomotor ataxia and in lateral sclerosis, 
we may haA-e complete or partial retention due to motor paralysis. 

In Pott's disease, we may have retention with incontinence, due to paralysis 
by interference with the vesico-urethral nerve centers. 

In injuries of the brain and spinal cord the same applies. These are at- 
tended by important changes in the urinary system as well as in the urine. 
These changes do not seem to be connected with the particular locality of the 



DISTURBANCES OF MICTURITION 267 

injury. They occur almost uniformly, whether the injury affects the lumbar, 
the dorsal or the cervical region. 

In the various forms of spinal sclerosis, there may be more or less complete 
retention, in the earlier stages of a spasmodic nature (during the stage of ex- 
citement), and, later, due to paralysis. 

The Obstructive Causes. — They are principally situated in the prostate or 
the urethra, although vesical calculi may enter the neck of the bladder and 
lodge there. Displacement and fracture of the pelvic bones, especially of the 
pubes, may also cause obstruction. 

Prostatip causes of obstruction are acute prostatitis, prostatic hypertrophy, 
tumors, cysts, calculi or tuberculosis. 

The urethral cause is usually a stricture. The retention may be due to an 
acute congestion of the mucous membrane or of the submucous tissue about this 
lesion, or it may be a late symptom dependent upon the great obstruction offered 
by the stricture itself. In either case, it is apt to be preceded by a his- 
tory of fatigue, cold or alcoholic excesses. Spasm of the urethra aids in 
closing the canal. Foreign bodies or calculi in the urethra may also cause 
retention. 

Atresia is another cause. This may give rise to complete retention in the 
new born, if the urethra is impervious ; or, if it is slightly pervious, the trouble 
will come on gradually. This latter condition is really a congenital stricture. 

Wounds of the urethra also give rise to retention, either by causing a con- 
gestion or an exudate which narrows its caliber, or by pressing upon its walls 
on the outside and thus rendering it impervious. 

Extravasation of urine, due to rupture of the urethra from an injury or 
wound, or to rupture of a urethral follicle, may allow of sufficient leakage of 
urine into the surrounding tissues, either in the pendulous portion of the urethra 
or the perineum, to block completely the canal by its pressure. 

Abscesses or cellulitis starting in the urethra or surrounding tissue may also 
exert enough pressure upon the urethra to shut it off. 

Symptoms. — The symptoms of retention vary in a marked degree. In 
an acute attack of retention, such as occurs after an operation or during a fever, 
the patient complains of pain steadily increasing in the suprapubic region, and 
of a sense of fullness and inability to micturate, associated with a constant de- 
sire. On palpation over the pubes, there is a feeling of tenderness and disten- 
tion, and perhaps a globular tumor can be seen (Fig. 221), extending up toward 
tlie thorax. Kectal examination may reveal a tumor filling the pelvis like a 
gravid uterus. 

Chronic complete retention rarely occurs, as an overflow incontinence usu- 
ally renders it incomplete. It may be observed, however, in certain cases of 
paralysis or obstruction. In complete retention, such as occurs in some cases 
of paralysis, the patient may not have been able to void a drop of urine for 



258 



SPECIAL URINARY SYMPTOMS 



months. There is, however, when the bladder is full, a sensation, or, in cases 
of paralysis, where sensation is not perfect, a knowledge of how long it takes 
the bladder to fill, so that the individual knows when the time has arrived to 
have recourse to the catheter. 

In chronic incomplete retention, the symptoms are different, as all cases 
have residual urine, and the condition often develops so slowly that the pa- 




FiG. 221. — The Outline or the Abdomen in a Case or Retention. 

tients do not know that they cannot empty their bladders until they have been 
so informed by the physician after an examination. A patient with a weak 
bladder may carry for many years about a pint or more of clear urine as a 
residual deposit, which its weakened walls cannot throw off. An excess of the 
fixed residuum produces a desire to urinate, and the patient, mainly by volim- 
tary contraction of the abdominal muscles, is able to void this excess. 

In chronic incomplete retention, acute attacks of complete retention occur 
principally when there is obstruction to the escape of urine in the form of 
stricture or enlarged prostate. 

A patient with prostatic hypertrophy suffers from chronic incomplete re- 
tention, in addition to which his bladder is usually atonic and chronically 
inflamed. The usual symptoms are those of congestion, pain, frequency of mic- 
turition, in addition to which the urine is thick and foul-smelling if cystitis has 
developed. After overeating or drinking, or exposure to wet or cold, these 
patients suddenly find that they cannot pass urine. As the bladder dilates, they 
have a feeling of pain and a sense of retention, which is usually relieved by 
the methods which we shall mention under Treatment. 

Cases of acute attacks of retention due to stricture are also common. Here 
also there is usually a certain amount of residual urine in the bladder. In bad 
cases, the urethra behind the stricture is dilated, at times even as far back as 
the neck of the bladder, which itself becomes dilated and no longer acts as a 
sphincter, giving rise to an overflow incontinence. In such cases, it is often 
difficult to expel any of the remainder of the urine. Great straining and pro- 
lapse of the rectum may accompany the efforts. 

In chronic incomplete retention, where the bladder cannot empty itself, cys- 



DISTURBANCES OF MICTURITION 259 

titis usually develops, after which sufficient bacteria remain in the residuum to 
contaminate the fresh urine flowing into it. 

Diagnosis. — When one is called to see a case of suspected retention of urine, 
it is necessary to ascertain first if it is really retention, and then inquire care- 
fully into the history of the case : whether it is complete or incomplete ; and if 
complete, whether it is an acute attack or not ; and if an acute attack, whether 
the patient has had others of a similar nature. It is then important to know 
if there is any other symptom, general or local, which may give us some clew 
as to the cause of retention; also to ascertain age and family history. 

To be sure of an attack of retention, there are certain other conditions that 
must be excluded, as anuria, rupture of the bladder and extravasation of urine. 

It is strange how generally anuria and retention are confounded with one 
another. Anuria is a condition where either the function of the kidney has 
ceased or the urine is prevented from entering the bladder, whereas, in reten- 
tion, the bladder contains urine, but cannot empty itself. If no urine can be 
passed by the urethra, and it is a question between anuria and retention, a bi- 
manual examination per rectum and suprapubically will usually disclose the 
presence of a large fluid tumor if it is retention, and a catheter inserted into 
the bladder will draw off a quantit^" of urine in vesical retention and none 
in the case of anuria. 

Rupture of the bladder can be distinguished from retention, as in the former 
case there is no well-defined globular tumor present, and a catheter passed by 
the urethra will bring away only a slight amount of urine and blood. The 
patient will complain of great pain and tenderness in the suprapubic region 
and perhaps of strangury. If the rupture extends into the peritoneal cavity, 
general abdominal pain, an elevation of temperature, and rapid pulse will soon 
follow. 

In extravasation of urine, vesical retention may also be present on account 
of the pressure of the exuded urine on the urethra and it may be impossible to 
pass an instrument into the bladder on this very account. The extravasation 
can be seen as a swelling in the perineum, external genitals, or even extending 
to the abdominal wall. 

The history of a case of retention will reveal a great deal, as will a survey 
of the symptoms. For instance, if there is history of an operation on the geni- 
tals or about the rectum, an acute attack of retention can be ascribed to that 
source. If the patient has had a stroke of apoplexy, a fracture of the skull, or 
is suffering from a disease of the cord, or other evidences of paralysis, we can 
assume that the retention is due to one of these causes. To show that injury 
to the cord is followed by bladder dilatation, I will quote an experiment of 
Budge, who found that division of the cord in the lower dorsal region was fol- 
lowed by increased reflex action of the sphincter and a greater degree of dis- 
tention of the bladder than could be produced after death. 



260 SPECIAL UKINARY SYMPTOMS 

It is rarely that retention is so complete that not a drop of urine can be 
passed, but we do at times observe cases in complete and partial paraplegia 
in which not a drop can be voided without the catheter. 

Having excluded paralysis as a cause of retention, we should then look for 
some local trouble to account for it. If the patient is a man oA'^er fifty-five years of 
age, with a history of trouble in urinating, the stream coming tardily, and if he 
has suffered from such frequency of urination as to be obliged to get up often 
at night, and if, on certain occasions, he was unable to pass his urine except 
when aided by a hot bath or by hot local applications, we can assume that he 
has some prostatic trouble, and can examine him per rectum and per urethra 
to see if obstruction is present there. If an enlargement is found, it is prob- 
ably occasioned by senile prostatic hypertrophy. Of course, there are other 
prostatic troubles that may give rise to enlargement, as acute prostatitis, malig- 
nant tumor, tuberculosis and cystic conditions, but these are rare. If the patient 
is a man between twenty-five and fifty years of age, has had several attacks of 
urethritis, and has recently urinated with increased frequency and with some 
difficulty and pain, his urethra should be explored for stricture, and if one of 
small caliber is found, it is probably the cause of his retention. 

Treatment. — The treatment in retention of urine varies and depends upon 
the cause, form and degree of the trouble, and may be divided into temporary, 
palliative and radical methods. It is my intention to consider the different 
forms from the standpoint of degree and cause. 

Acute Attacks of Complete Retention. — In acute attacks of complete 
retention, such as occur after operations in toxic, comatose conditions, or fevers, 
the surgeon should insert a soft-rubber catheter into the bladder and draw off 
one pint of the urine. If then hot applications are made over the pubes, the 
patient will probably be able to pass urine, after an hour, without difficulty. If 
not, the catheter should again be introduced at the end of two hours, and again 
every three hours, until spontaneous urination has been reestablished, drawing 
off each time only a pint of urine. This will usually take place after a few 
catheterizations, although sometimes it requires a longer period. 

Acute Attacks of Complete Retention Occurring in Cases of 
Chronic Incomplete Retention. — Attacks of this nature, occurring in 
people who have a certain amount of residual urine habitually, are those most 
commonly encountered. They usually occur in men suffering from stricture 
or enlarged prostate and are generally caused by exposure to cold or wet, dissi- 
pation, or by excesses in eating or drinking. Here the patient suddenly finds 
that he cannot urinate, although he has been able to pass a fair amount at fre- 
quent intervals, for some time. 

This is a critical moment for him, as it is often here that his future woes 
begin. A case in this condition should be handled with the greatest care, as 
the bladder and, perhaps, the ureters and pelves of the kidneys are more or less 



DISTURBANCES OF MICTURITION 



261 



distended or congested and in a favorable condition to be infected. The cathe- 
terization should, therefore, be made under the strictest asepsis or antisepsis, 
and care must be taken to avoid lacerating, wounding or bruising. (See chapter 
on Asepsis and Antisepsis.) . 

The treatment of these attacks, or exacerbations of chronic ones, is the same 
as that of an acute attack independent of a chronic condition; namely, to pass 
a catheter and draw off a pint of urine, another pint in two hmirs, and then a 
pint CA^ery three hours until the patient can urinate spontaneously, as has just 
been mentioned. Frequently, however, a catheter will not enter, in which case 
the patient should have a hot sitz bath, which may enable him to pass a small 
amount of urine while seated in the water. If, however, he is unable to pass 
any urine in this way, he should then have a hypodermic injection of a quarter 
of a grain of morphin, hot applications over the pubes and perineum, and should 
lie down for about an hour, when another attempt should be made to catheterize 

him, at first with a small soft-rubber cathe- 
ter, and, if unsuccessful with such an in- 
strument, then with a woven one with an 
olivary tip. If the patient is an old man, 
an elbowed woven catheter should be used. 
In case these measures do not meet with 
success, he should be given another hot sitz 
bath and another attempt at catheterization 
should be made. 




Fio. 222. — The Blasucci Catheter. 
Contains a mandrin with a pliable filiform giiide at its end, seen in the bladder. 



SPECIAL URINARY SYMPTOMS 



Sometimes, when other catheters fail, the Blasucci instrument can be 
passed (Figs. 232, 223 and 224). If this attempt fails and he cannot pass 




««i^ 



urine, he should be aspirated suprapnhically and a pint of urine with- 
drawn, after which lie should he aspirated every four hours until he is able 




DISTURBANCES OF MICTURITION 263 

to urinate spontaneously, or a catheter can be passed. In case such a re- 
sult is not obtained, an operation should be performed, preferably a perineal 
section. It is very rarely, however, that an immediate operative procedure has 
to be resorted to, as these patients are almost always able to pass sufficient urine 
to be relieved if a catheter cannot be inserted. In case it is difficult to pass the 
catheter at any time, when one finally enters, it is prudent to tie it in for twenty- 
four hours and insert a plug, which can be withdrawn every two or three hours, 
until the bladder is empty. In twenty years of the most active practice in 
bladder surgery, I cannot recall having had to aspirate more than three 
patients. 

The best lubricant is glycerin ; next to this, Casper's prescription : 

^ Hydrarg. oxycyanat gr. iijss ; 

Glycerini f 5vss ; 

Tragacanth gr. xlvj ; 

Aquse dist. sterilizat fSiij. 

The mixture is put up in tubes. 

In case a catheter does not easily pass with such lubricants, half an ounce 
of sterile olive oil, which is more than the anterior urethra will readily hold, 
should be injected and held in for several minutes in the hope that some of it 
will pass through the stricture and lubricate its walls. Before allowing any 
oil to escape from the meatus, while the urethra is still somewhat dilated, an 
attempt should be made to pass a catheter or filiforms. 

If a catheter can be introduced into the bladder, it may be allowed to re- 
main as a retained catheter. It should be plugged, and every two hours, until 
the bladder is empty, twelve ounces of urine should be withdrawn. 

In case neither a soft-rubber nor woven catheter can be introduced, an en- 
deavor should be made to pass a filiform. If successful and some urine escapes 
by its side, it may be left in place, in the hope that the urine will drain oflF by 
its side; or a metal tunneled catheter may be forced over it into the bladder, 
thus allowing as n^uch urine to be drawn off as we desire. 

I do not advocate this latter procedure, however, unless it is considered 
desirable to operate immediately afterwards. 

If a patient cannot pass urine and an instrument cannot be introduced that 
will allow the escape of urine, then there are but two things to do. One is to 
perform paracentesis (aspiration), and the other a radical operation. 

It is probable that by keeping the patient in bed and resorting to the palli- 
ative methods already referred to, he will be able to urinate spontaneously in 
a few hours, but only in small quantities ; or else the congestion will go down 
sufficiently to allow the catheter to be passed. Patients may be aspirated fre- 
quently, each time but a pint of urine being withdrawn ; I have known a patient 
to be aspirated over one hundred times without any ill effects. 



264 SPECIAL URINART SYMPTOMS 

Paracentesis should always be performed by the suprapubic route. The 
point for the introduction of the instrument should be in the median line, just 
above the symphysis. The trocar should be pushed inward and downward for 
about two inches, the stilet should then be taken out and a certain amount of 
urine withdrawn (Fig. 225). A piece of plaster should be placed over the 
puncture and the patient put to bed. 



Fio. 226. — Pabacentesis. The grooved cannula or an aspirating needle is thrust through the ab- 
dominal and bladder walla, just above the pubes toward the tip of the foreGager, which is in the 
rectum just aliove the proetatic base and acts as a guide. 

The complete emptying of the bladder at once may produce a distention of 
the blood vessels of the urinary tract and a consequent engorgement of its sur- 
face. Within a few hours, the urine may contain a little blood (hematuria), in- 
dependent of mechanical injury. If the urinary tract was infected before or 
during the catheterization, the temperature may rise, the tongue become dry and 



DISTURBANCES OF MICTURITIOX 265 

brown, and the patient may develop a condition known as urinary fever. If the 
patient's kidneys are damaged, even if no infection is present, the kidneys may 
become congested, resulting in uremia and death. The renal congestion may 
even give rise to death in a few hours from suppression. 

The conservative method recommended of gradually evacuating the bladder 
may be used with advantage in cases of retention. It consists, first, in evacuat- 
ing about one pint of urine by catheter, which should be plugged and retained. 
At intervals of two hours, until the bladder is empty, the plug should be with- 
drawn and twelve ounces of urine allowed to escape. 

Chronic Complete Retention Due to Paralysis. — In chronic complete 
retention due to paralysis, such as occurs in cases of transverse myelitis, the 
patient should be catheterized every six hours. 

Chronic Complete Retention Due to Obstruction. — In chronic com- 
plete retention due to obstruction, the treatment should be the same as in chronic 
cases due to paralysis, if this is possible. These cases are, however, almost al- 
ways due to hypertrophy of the prostate or to stricture, so that, in the former 
condition, we should be obliged to use an elbowed soft-rubber or woven catheter. 
In such cases, pain, irritation and tenesmus are often so great that the catheter 
may have to be passed more frequently in order to give the patient relief. In- 
ternal urinary antiseptics, bladder irrigations of antiseptic solutions by means 
of the catheter, and antispasmodics by the mouth or rectum, should be given. 

Chronic Incomplete Retention Due to Paralysis. — In chronic incom- 
plete retention due to paralysis, the bladder w^all is partially paralyzed, residual 
urine is present, and cystitis is apt to occur. Here the frequency of catheteriza- 
tion should depend on the amount of residual urine present; if four ounces, 
once a day; four to eight oimces, twice a day; eight to twelve ounces, three 
times a day ; over twelve ounces, four times a day. 

If, in addition to this, cystitis is present, we should wash out the bladder 
every day or two through the catheter with some antiseptic solution, as one of 
boric acid or silver nitrate, and give internally a urinary antiseptic. 

In all cases of chronic incomplete retention, the treatment of the inflamed 
and atonic wall of the bladder is to be considered. A patient may live for years 
with a chronic cystitis, if his bladder is treated properly. This trouble is gen- 
erally not curable, but few inflammatory conditions yield to treatment with 
more gratifying results to both the physician and the patient. 

The methods of toning up an atonic bladder are: By using remedies which 
will excite contraction of the bladder wall, such as strychnin, cold sponging, 
or douching over the pubes, and counterirritation to the spine. 

Civiale recommended cold-water injection into the bladder, beginning with 
tepid water and gradually decreasing the temperature to 60° F. This should 
be done after emptying the bladder. Two or three of these injections may be 
given one after another. These generally excite contractions, which, once hav- 



266 



SPECIAL URINARY SYMPTOMS 



ing begun, will bring about favorable results. The daily injections for a fort- 
night will usually cause marked improvement. 

The faradic current given by placing one pole over the lumbar or hypogas- 
tric region, and introducing the other into the bladder in the form of a hard- 
rubber sound, with a metallic tip, is often of great service. This, should be 
moved around until it comes in contact with the different parts of the bladder 
wall for five minutes at a sitting. Various preparations, such as those of iron, 
strychnin and other tonics, are recommended. 

Chrpnic Incomplete Retention Due to Obstruction. — In chronic in- 
complete retention due to obstruction, we have a very common condition, such 
as is usually seen in cases of enlarged prostate or tight stricture. The treat- 
ment of the bladder in these cases should depend very much on the amount of 
residual urine. The bladder should be catheterized as often as indicated and 
irrigated with an antiseptic solution. A urethral stricture, if present, should be 
dilated. 

Radical Treatment. — The causes of complete or incomplete retention, 
when obstruction is due to mechanical interference, should be treated by opera- 
tion, as recommended in the respective chapters on these subjects : urethrotomy 
for urethral stricture and prostatectomy for prostatic hypertrophy. 

The classification of retention of urine is as follows : 



(1) According to the degree of 
retention 



(2) Degree of intensity and dura- 
. tion 



(3) Cause 



" Complete — ^when no urine can be passed. 
Incomplete — when not all the urine can be 
passed. 

" When the patient suddenly 
finds it impossible to urinate. 
An acute attack taking place 
during chronic incomplete 
retention, is really an acute 
exacerbation. 

""When the patient habitually, 
for a considerable time, has 
not been able to empty his 
bladder. 



Acut( 



Chronic 



Obstructive. 

Traumatic. 

Paralytic. 



In the following table I classify them according to acute and chronic, speak- 
ing first of the purely acute; then those purely chronic, which will be divided 
into complete and incomplete. 



DISTURBANCES OF MICTURITION 



267 



Acute attacks of complete reten- 
tion may be due to 



Chronic retention (complete or 
incomplete) 



Acute parenchymatous prostatitis. 

Follicular prostatitis. 

Stricture or prostatic hypertrophy. 

Alcoholism. 

Temporary stupor. 

Voluntary refraining from urinating. 

Fever, as typhoid. 

Pregnancy. 

Urethral calculus. 

Extravasation of urine. 

Periurethral abscess or cellulitis. 

Fracture of the pelvis. 

Paraplegia "1 _ .. 

TT • 1 • >-trom disease or miury. 

Hemiplegia J '* *^ 

Tabes and lateral sclerosis. 

Pott's disease. 

Prostatic hypertrophy. 

Prostatic tumors or cysts. . 

Urethral stricture. 

Atresia in the newborn. 



In chronic cases of partial retention (that is, when there is residual urine 
present), the patient may suddenly find that he cannot urinate, thus making an 
acute attack of retention. In paralytic and chronic obstructive cases, there may 
be an overflow retention or incontinence. 

Incontinence of Urine 

Definition. — True incontinence is the involuntary discharge of urine through 
the urethra. False incontinence is a condition in which an irresistible desire 
to urinate occurs, causing the patient to void every few minutes, or giving rise 
to precipitate urination. 

Varieties and Causes. — The following table shows the varieties of true in- 
continence and their causes: 



I. Retention with Incontinence oe Overflow Incontinence. 



(1) Due to an obstruction in the 
vesico-urethral path 



(a) Strictures of the urethra, trau- 
matic or acquired. 

{h) Chronic enlarged prostate. 

(c) Foreign bodies, stones, tumors 
blocking the path; outside 
pressure ; or cystocele. 



268 



SPECIAL URINARY SYMPTOMS 



(2) Due to a change in the nerv- 
ous mechanism of the blad- ^ 
der 



(a) Locomotor ataxia ; myelitis ; pa- 
ralysis. ( Bladder paralyzed. ) 

(6) Comatose conditions; apoplexy; 
cerebral concussion; narcotic 
poisoning. (Consciousness of 
desire abolished.) 



Senile atrophy of the bladder. 



(3) Due to a loss of muscular J 
tone of the bladder \ 

11. Without Retention. — Due to insufficiency of, or interference with, 
the sphincter mechanism from the following causes : 

(a) Enuresis noctuma in children. 



(1) Idiopathic or functional 






(2) Mechanical 



(6) Nervous and physical incon- 
tinence in adults; hysteria; 
neurasthenia. 

Stone or foreign body or tumor in 
the neck of the bladder, partly 
holding the sphincter open. 

(3) Tuberculosis of the neck of the bladder, giving rise to loss of tissue 
from ulcerations that prevent its uniform closing.^ 

For prostatic 

abscess. 

For stricture. 

For perineal 

p r o s t a - 

tectomy. 



(4) Traumatic,^ after 



(a) Perineal section 



(5) Atonic, affecting the sphinc- 
ter only 



(b) Bottini operation. 

(c) Forcible dilatation of sphincter. 

(d) Fracture of the pelvis affecting 

sphincter. 

(a) After childbed, witli subinvolu- 
tion of the uterus. 

(h) In old women, with atrophy of 
the geni to-urinary organs. 



^ This condition described by many authorities is probably rare, as the author has never 
seen a case of true incontinence in vesical tuberculosis that he could prove to be such either by 
clinical methods or post-mortem findings. Many cases of false incontinence in vesical tuber- 
culosis resemble true incontinence so closely as to be mistaken for it. 

* Childbirth, with tearing of the vesical sphincter usually given as a cause of incontinence, 
has been omitted from this table, as in fifty-five thousand (55,000) cases in one of the largest ly- 
ing-in hospitals in the world, no such case has been recorded. Its presence on the list together 
with the usual causes might mislead the practitioner for whose use this table has been prepared. 



DISTURBANCES OF MICTURITION 269 

Clinical Features. — The clinical types which can be distinguished are as 
follows : 

(1) Dribbling. 

(2) Sndden discharge of entire contents of the bladder at intervals, giving 
bladder time to fill np. 

(3) Discharge of the contents of bladder by steady pressure over it. 

(1) Dribbling. — This is characteristic of overflow retention in true in- 
continence. In most cases the accumulation of urine gradually overcomes the 
resistance of the sphincter and the urine begins to dribble out. 

As the bladder keeps filling up, there being usually polyuria in these cases, 
the dribbling continues, with interruptions. Usually the overflow dribbling of 
retention appears at night, but later continues through the twenty-four hours. 
Dribbling may occur without retention in those cases of incontinence in which 
the sphincter is interfered with. (See Table II, 2, 4.) Sometimes in these 
cases the discharge of small amounts of urine may be brought about by sudden 
jars, such as occur in coughing, sneezing, etc., while the bladder may retain 
its contents during sleep. Slight dribbling is also due to a few drops of urine 
collecting in dilations behind strictures, in cases in which the bladder sphinc- 
ter holds. 

(2) Sudden Discharge of the Entire Contents of the Bladder at 
Intervals, Giving the Bladder Time to Fill up Again. — The involuntary 
discharge of large amounts of urine in a steady stream, from time to time, while 
the fluid is retained in the intervals, is characteristic of enuresis noctuma in 
children; of cerebral conditions accompanied by coma; of narcotic poisoning, 
concussion, epilepsy, etc., in which cases the patient does not feel any desire 
to urinate, though the bladder be full. 

(3) Discharge of Urine by Steady Pressure on the Bladder. — This 
is a symptom indicating the reverse of the above, namely, a lowered reflex sus- 
ceptibility of the organ, and occurs when the reflexes are generally lowered in 
locomotor ataxia, myelitis, etc. This form of incontinence is characterized by 
the fact that the contents of the bladder can be readily expressed when pressure 
is made upon the suprapubic region. The pressure oli the bladder, however, 
that usually causes such incontinence, is a fibroid or subinvoluted uterus, an 
abdominal or pelvic tumor, or, in some cases, the weight of the intestines in 
ptosis, or of the omentum when standing. 

Diagnosis. — True incontinence is distinguished from false by the subjective 
presence in the latter of the desire to urinate. We must be sure, of course, to 
exclude cases of willful discharge of urine in bed, etc., for the purpose of malin- 
gering. 

If an examination, general and local, fails to reveal the causes of true incon- 
tinence, we can assume that the case is one of false incontinence. 

Among the causes of false incontinence are the following : Acute inflamma- 



270 



SPECIAL URINARY SYMPTOMS 



tion of the posterior urethra in very nervous individuals ; any of the causes of 
true incontinence which have not reached the point where they are beyond the 
control of the will; acute prostatic troubles; and tuberculosis of the bladder. 
The last-mentioned is the most common and typical of all causes and should 
always be suspected. 

Treatment of Incontinence. — Strictures, where there is but slight dribbling 
after urinating, due to dilatations behind them, are usually situated anteriorly, 

and dilatation or internal urethrotomy should be 
resorted to. In cases in which there is overflow 
incontinence, the stricture is usually deep-seated 
and of long standing, and would require an exter- 
nal urethrotomy. When due to enlarged prostate, 
the gland should be enucleated, or a Bottini opera- 
tion performed, or catheter life resorted to. For- 
eign bodies and stones holding the sphincter open 
and occluding to a sufficient degree, to cause re- 
tention, should be removed. Tumors should also 
be removed if the growth has not involved too 
much tissue. 

In locomotor ataxia, myelitis and paralysis, 
the bladder should be emptied four times in twen- 
ty-four hours, and should be washed with silver 
solution and a urinal be worn (Fig. 226). Some- 
times in cerebral lesions, the condition improves 
somewhat, but in diseases of the spinal cord there 
is rarely any improvement. Cases in which the 
bladder is atonic should be treated by nitrate-of- 
silver irrigations, by electricity to the inside of 
the bladder, injections of cold water and internally 
by iron and strychnin. 

In enuresis nocturna in children, the child, if 
a male, should be circumcised. He should be ex- 
amined for a congenital urethral stricture, which 
should be cut if present. lie should sleep with a 
knotted towel about him and with the knots behind his back. lie should be 
awakened at a certain time to empty his bladder. Internally, he should have 
hyoscyamus and bromid before retiring. If five years of age hyoscyamin, gr. 
•^; bromid, grs. v. 

In cases of hysteria and neurasthenia, bromid, belladonna and hyoscyamus 
should also be given. 

Fibroid tumors pressing on the bladder should be removed. A uterus press- 
ing upon it should be fixed in place by shortening the ligaments or by anchoring 




Fio. 226. — The Method op Wear- 
ing A Urinal. The rubber 
urinal is strapped about the 
hips. The external genitals fit 
in the pouch below the pubes, 
from which a tube runs down 
to a reservoir on the inner side 
of the leg. 



CHANGES IN THE AMOUNT OF URINE 271 

it to the abdominal wall, well up. Bad tears of the bladder sphincter during 
childbirth should be immediately repaired. Extensive cuts through the sphinc- 
ter at the time of operations for stricture or prostatic abscesses, in the Bottini 
prostatotomy, or in perineal prostatectomy, may give rise to an incontinence, 
for the treatment of which no satisfactory remedy has yet been devised. Time, 
electricity, prostatic and vesical douches, and tonic remedies may benefit them ; 
but many of the bad cases are never cured. 

Subinvolution of the uterus after childbirth should be treated by curettage 
and ventral suspension. 

In many cases of incontinence, the cause of which cannot be discovered by 
the history, examination, or urinary analysis, the patients are relieved by symp- 
tomatic treatment. 

In women cystocele is a frequent cause, in which case they are readily cured 
by an anterior colporrhaphy and repairing the perineum. 

A prolapsed uterus should be suspended, and an anterior colporrhaphy or 
perineorrhaphy performed, if indicated. 

There is no other condition in urinary diseases so trying to the patient as 
urinary incontinence; therefore, every means should be taken to discover and 
remove the cause. Cystoscopy should give us a clear idea of the condition of 
the bladder. If no cause is seen and if no disease of the nervous system is 
discovered, an exploratory laparotomy should be performed with the object of 
seeing if there is any interference with the bladder function from the outside. 
A large gynecological service leads me to believe that, in women, such inter- 
ference is due to adhesions of the bladder to the neighboring structures, and that 
the consequent displacement and interfered function of the bladder is more com- 
mon than was formerly supposed. 

n. CHANGES IN THE AMOUNT OF URINE 

POLYUEIA 

The term polyuria indicates an increased secretion of urine and is a symp- 
tom, not a disease. There is, however, a form of polyuria which seems to exist 
independently of any other condition and is known as ** essential polyuria " or 
poly uric diabetes. 

The term polyuria is usually applied to cases in which the amount of urine 
exceeds two liters in twenty-four hours. It must be carefully distinguished 
from frequency of urination, because, as we have seen, the latter may exist 
with a normal amount of urine. The amount of urine for twenty-four hours 
should be accurately measured before making a diagnosis of polyuria. Malin- 
gering by the patient who may add water to his urine should be excluded. 

Etiology. — Transient polyuria may exist from extraneous causes in health, 
and can usually be made out without difficulty, as in people who drink large 



272 SPECIAL URINARY SYMPTOMS 

amounts of cold water and consequently have a polyuria of remarkable degree 
within a few hours. Warm enemas, and warm fluids drunk give rise to a poly- 
uria. The same is true of a cold bath, while a hot bath diminishes the amount 
of urine secreted. The ingestion of diuretics and other therapeutic measures 
also transiently increases the urinary secretion. Other important causes of 
polyuria are sudden emotions, epileptic seizures, nervous strain, mental appli- 
cation occurring especially in those not accustomed to it, causing a polyuria 
which disappears as soon as the mental work is discontinued. This may be 
termed " nervous polyuria." 

The polyuria of convalescence is another type of the transient fonn. This 
includes the increase in the amount of urine noted at the end of many diseases. 
The object of this is to rid the system of certain products which are excreted 
in large amount, as, for example, the clilorids in pneumonia. 

A convenient division of the polyurias occurring from organic diseases is 
into the moderate polyuria, reaching up to four liters, and the marked polyurias, 
reaching as high as ten liters and over. The moderate type, according to Merek- 
len, indicates disease of the urinary organs, while the marked polyurias are 
seen in diabetes mellitus and diabetes insipidus. 

The causes of polyuria may be thus tabulated, after Castaigne's description : 

A. MODEKATE POLYURIAS 

I. Due to Renal Disease. 

(a) Chronic interstitial nephritis. 
(6) Amyloid kidney. 

(c) Reflex congestion of the kidney. 

(d) Pyelonephritis. 

(e) Tuberculous kidney. 

II. Due to Heart Disease, 

Permanent in persons with cardiosclerosis. 

III. Due to Liver Disease, 

Cirrhosis (sometimes). 

IV. Due to Nervous Causes, 

Hysteria. 

Epilepsy. 

Exophthalmic goiter. 

^ Cerebral hemorrhage. 

Meningitis. 

_. _ - Sclerosis of the cord. 

Keflex from ^ ^ , 

Ueneral paresis. 

Sciatica. 

Mental strain. 



CHANGES IN THE AMOUNT OF URINE 273 

B. MARKED POLYURIAS 

I. Glycosuria — diabetes mellitus. 

II. Uricacidemia — nitrogenous diabetes. 

III. Phosphaturia — phosphatic diabetes. 

IV. Diabetes insipidus — hydruria. 

The urologist is especially interested in the first group of polyurias, due to 
renal disease. Even if interstitial nephritis and amyloid kidney have been 
excluded, there may be a polyuria due to trouble further down in the urinary 
tract The urethra, bladder, prostate and ureter should be examined to make 
sure of their integrity. Frequently strictures, chronic cystitis and hypertro- 
phied prostate are reflex causes of a polyuria, or else the ascending infection to 
which they give rise produces a pyelonephritis and so gives rise to a polyuria. 
(See Table A, I, a, b, c and d.) With the latter there will be purulent urine 
from the pelvis of the kidney on ureteral catheterization, while with the reflex 
form of polyuria in these conditions the urine will be clear. 

Anuria 

Definition. — The word anuria is derived from an, without, and ouron, urine. 
It means, therefore, literally a total absence of urinary secretion, although, clin- 
ically, we understand by anuria the absence of urine from the bladder, which 
is ascertained by the introduction of a catheter into this organ after the patient 
has failed to urinate for some time. 

Etiology. — Anuria may be due either to an arrest of secretion of urine 
(nonobstructive anuria) or to an obstruction in the ureters (obstructive 
anuria). 

A. Nonobstructive Anuria — A Suppression of Urine. — A cessation of 
the secretion of urine may be induced (1) by disease of the secretory apparatus 
of the kidney, (2) by circulatory disturbances affecting the renal circulation, 
(3) by certain nen^ous affections, or (4) by toxic agents. 

(1) Anuria due to lesions of the kidney may occur in either acute or chronic 
nephritis. In acute nephritis due to scarlet fever or other causes, there may 
be suppression of urine due to a degeneration of the epithelium of the tubules, 
with or without involvement of the glomeruli. In chronic nephritis the kidney 
may become so atrophied and sclerosed that it no longer contains sufficient secre- 
tory elements to maintain the process of excretion. The anuria of chronic 
nephritis, however, is more frequently the result of a complicating passive con- 
gestion, or an edema of the interstitial tissue which so compresses the urinary 
tubules that secretion is arrested. 

(2) Anuria due to circulatory disturbances is produced by a venous stasis 
in diseases of the heart, or else by large double infarcts of the kidney. In the 



274 SPECIAL URINARY SYMPTOMS 

former type, the chief factor is the dilatation of the right ventricle, which pro- 
duces venous stasis of the kidney. There is always a disease in the kidney in 
such cases, and the venous stasis suffices to produce edema of the interstitial 
tissue and thus to choke the tubules. Cases of double plugging of the ureters 
by desquamation, as in scarlet fever, or by suppuration products, in cases like 
nephritis, or of othe^ origin are reported. Such cases must, however, be very 
rare, the lesion existing by far more commonly as unilateral. 

(3) Anuria due to nervous causes may depend on a variety of conditions. 
Complete suppression of urine has been noted in some cases of hemiplegia from 
fracture of the skull. More frequently, however, anurias are due to reflex in- 
hibition of secretion. It appears that an irritation in one kidney c^n so affect 
the other organ reflexly, that anuria may follow. Thus may be explained the 
anuria of renal colic, following operation upon the kidney or injury of that 
organ. Extensive bums may also produce reflex anuria, although the absorp- 
tion of toxins may have something to do with these cases (Castaigne). 

In hysteria, the anuria is probably also reflex, although the exciting cause 
is not always apparent. 

(4) Toxic anurias may occur in the course of infectious diseases such as 
cholera, scarlet fever and in acute peritonitis and affections of the colon and 
small intestines. The toxins probably act by affecting the renal tissue, as well 
as by disturbing the circulation. 

B. Obstructive Anurias. — The second group, the obstructive anurias, are 
of great interest to the modern surgeon, particularly because they can be reme- 
died by timely intervention. 

They result either from the blocking of the lumen of the ureter or from 
its compression or kinking. Among the obstructive causes we have, foremost, 
renal calculi. The mechanism and pathology of this form of anuria has been 
described in the chapters on calculus of the kidney and of the ureters, respec- 
tively. It has been said that it is not necessary to have a stone in both ureters, 
but that the presence of stone on one side often acts reflexly by inhibiting the 
secretion of the opposite kidney. This is a course of events which Guyon has 
described, but it is probably of rare occurrence. In most instances, the anuria 
due to stone on one side arises because the opposite kidney had not been 
working for some time, and when the calculous kidney, which alone was 
capable of excreting urine, was blocked, a total suppression of urine resulted. 
Albarran has gone so far as to say that calculous anurias may exist without 
the actual presence of a calculus in the ureter at the time when the symptoms 
occur. 

Compression of the ureter may produce anuria in such conditions as cancer 
of the bladder, the prostate, the uterus or the kidney. Kinking of the ureter 
in floating kidney may be accompanied by obstructive retention on one side and 
arrest of secretion on the other. 



CHANGES IN THE AMOUNT OF URINE 275 

Symptoms. — Anuria can exist for a long time without giving rise to any 
symptoms. It also occurs at times with astonishingly few symptoms. The 
phenomena of renal insufficiency and of uremic poisoning, which are described 
elsewhere under the heading of Uremia, come either slowly or suddenly, ac- 
cording to the type of uremia, acute or chronic, which develops as the result of 
the suppression of urine. Usually the first symptoms are gastro-intestinal in 
character, including nausea, anorexia, vomiting, eructations and either consti- 
pation or diarrhea. Headaches, restlessness and other nervous phenomena of 
uremia are also among the early symptoms. Patients with anuria may die 
within a few hours, showing the acute form of uremia in its most pronounced 
type. They may also live for days and even weeks without showing any acute 
symptoms and linger on toward a slow death with the manifestations of chronic 
uremic poisoning. 

The occurrence of a nonfunctionating kidney on one side is more common 
than it is generally thought to be. I have occasionally seen such an organ, both 
larger and smaller than normal, due to some suppurative process, calculus, tu- 
berculosis or some other cause, where the parenchyma had been destroyed and 
nothing but a sclerosed mass or shell remained. I have cut into such kidneys 
at operation and had little or no bleeding. In a case where such a kidney is 
present, if the remaining organ is suddenly incapacitated, an attack of anuria 
would occur. 

Diagnosis. — It is comparatively easy to recognize the existence of anuria 
by passing a urethral catheter, which at once differentiates this condition from 
retention. The important point, however, is to determine the cause. The 
first thing to do, if possible, is to determine the presence and seat of the ob- 
struction. This may be done by palpation and by ureteral catheterization. 
The presence of obstruction will at once suggest the treatment of the con- 
dition. 

If the anuria be transient it may be preceded by or accompanied with a 
clinical picture of renal colic ; or there may be a history of traumatism, or of an 
operation either on the abdominal organs or upon the kidney. 

If the anuria is more or less permanent, we should first exclude the pres- 
ence of chronic diseases, such as affections of the kidney or of the heart or 
of acute infectious or toxic conditions. If the anuria comes on suddenly, 
it is usually due to calculi, though hysterical anuria should not be lost 
sight of. 

A word should be said of the hysterical type of anuria. Usually the pa- 
tient presents some of the peculiarities or stigmata of hysteria. Charcot noted 
also a certain compensation between the anuria and the vomiting which seemed 
to alternate; thus, when the patient, who was a woman, urinated 3 grams of 
urine, she had 1 liter of vomitus. When the urine increased to 206 grams, she 
vomited only 362 grams. Hysterical anuria is a tissue anuria and not glandu- 



276 SPECIAL URINARY SYMPTOMS 

lar. In other words, there is a more or less complete suspension of the proteid 
katabolic function of the digestive epithelium of the organism. A very inter- 
esting and rather puzzling feature of these cases is that hysterical subjects may 
have anuria for a number of days or even for several weeks without showing 
any uremic symptoms whatever. 

Treatment. — The medical treatment of anuria is the same as that described 
elsewhere under the heading of Uremia. 

Treatment of Obstructive Anurias. — In case the history of anuria 
points to a surgical cause — such as an attack of renal colic on the one side, the 
passing of calculi, pain in the loin on one side for a considerable time, a puru- 
lent urine without symptoms of frequency, or a hematuria following exertion — 
the case should be immediately examined, not only by palpation, but also by 
cystoscopy and catheterization of the ureters. If one ureter is found obstructed, 
even though the other catheter enters the kidney, an incision should be made 
in the loin of the obstructed side, a nephrotomy performed, the pelvis examined 
and a catheter passed down the ureter to the seat of obstruction. The kidney 
should then be drained and the treatment of the ureteral obstruction postponed 
until the patient has recovered from the attack of anuria, in case this tem- 
porary operation is successful. 

The result of the hemorrhage accompanying the operation will benefit the 
patient the same as bleeding in uremia, and saline solutions can be given by the 
rectum, or into the tissues or a vein, as indicated. 

Oliguria 

Oliguria, or diminution in quantity of urine, is noted in a variety of patho- 
logical conditions, affecting either the urinary tract or the general system. 
Temporary diminution is noted in health, and should be carefully distinguished 
from true oliguria. This term should not be employed unless the change in 
the amount of urine is well marked and continues for several days, and unless 
all extraneous causes can be excluded. 

The conditions under which the urine is diminished in quantity in health 
have already been considered under the heading of Urine Analysis. They are 
briefly: Exercise, free perspiration and not drinking sufficient water. In dis- 
ease the urine is diminished in acute nephritis, especially after scarlet fever, 
in acute congestion of the kidney, in the acute stages of chronic nephritis and 
often in the last stages of chronic nephritis, accompanied by uremia. The urine 
is also diminished in conditions of stasis of the kidney due to heart disease. 
Among the general conditions which produce oliguria and which are important 
to the urologist, are shock after anesthesia or after operations on the genito- 
urinary organs. Oliguria is also noted in fevers, where it is accompanied by a 
concentration of the urine. Other causes of oliguria are prolonged diarrhea 



CHANGES IN THE CHAKACTER OF THE URINE 277 

and vomiting, such as occurs in some diseases as cholera or yellow fever. The 
urine is markedly diminished in quantity in all diseases in the last stages be- 
fore death. 



m. CHANGES IN THE CHARACTER OF THE URINE 

Hematuria 

Definition. — Hematuria means the admixture of blood in the voided urine, 
no matter from what source the blood is derived. Clinically, the term is ap- 
plied only to cases in which the amount of blood is such as to be perceptible to 
the naked eye on inspection. The presence of a microscopic amount of blood 
is not clinically styled hematuria. 

Hematuria must be carefully distinguished from hemoglobinuria. The lat- 
ter means the direct passage of the blood-coloring matter into the urine without 
any red blood corpuscles, the urine being acid and of lower specific gravity than 
in hematuria. 

Etiology. — The causes of hematuria are many, the determination of which 
is one of the most important procedures in the clinical study of urinary diseases. 

The etiologic factors may thus be briefly summarized : 

ETIOLOGY OF HEMATURIA 

(Tabulated after Castaigne with Modification) 

I. Traumatic Hematuria, 

(a) Wounds and Injuries of Any Part of the Tract, 

Rupture. 
(1) Urethra \ Urethrotomy. 

Fracture of pubis. 
Wounds. 
Injuries to pelvis. 

Wounds. 
Injuries to loin. 

(fe) Stone in Any Part of the Tract: Foreign Bodies, 

Pelvis of kidney ; ureter. 

Bladder. 

Posterior urethra, 
(c) Sudden Change of Pressure in Bladder, 



(2) Bladder | 

(3) Kidney i 



When a bladder is emptied too suddenly or too completely, in a case of re- 
tention, we may have bleeding from the bladder or even from the kidneys, due to 
congestion. 



278 SPECIAL URINARY SYMPTOMS 

II. Inflammatory Hematuria. 
Anterior urethritis. 
Posterior urethritis. 
Cystitis. 
Pyelitis, acute. 

Acute nephritis. 

Hemorrhagic nephritis. 

Chronic nephritis. Some types in which vessels are changed. 

III. Due to Tumors, 

(1) Prostate. 

(2) Bladder. 

(3) Kidney. 

IV. Due to Tuberculosis. 

(1) Prostate. 

(2) Bladder. 

(3) Kidney. 

V. Due to Parasites. 

Renal parasites ; Bilharzia ; Filaria, etc. 

VI. Due to General Changes in the Blood. 

Smallpox Y'ellow fever Hemophilia 

Typhoid Plague Leukemia 

Purpura fPhosphorus Mt^laria 

Ipoisoning 

Detection of Hematuria. — This has been considered in the chapter on 
The Urine, so far as chemical and microscopic tests are concerned, but there are 
certain gross characteristics to hematuria which aid in its detection and lo- 
calization. 

If bloody urine is allowed to stand for a little while, it deposits a more or 
less abundant sediment. Over this there remains a clearer, but still cloudy, 
fluid. This may be bright red in color, showing that the blood has been freshly 
shed and that it probably comes from the lower part of the tract — from the 
bladder usually. The amount of blood will determine in such cases the exact 
tinge. The more dilute the bleeding, the paler the tint, but fresh blood is al- 
ways red. 

Renal hematuria is characterized by a pale, reddish-brown, cloudy urine, 
the sediment containing no clots, imless they are wormlike casts of the ureters. 
If retained for a long time in the pelvis or in the bladder, in hematurias asso- 
ciated with obstruction, there may be a dark-brown or even black color to 
the fluid. 

. The sediment of bloody urine varies in amount, color and consistency. The 



CHANGES IN THE CHARACTER OF THE URINE 279 

first thing that strikes one is the presence or absence of clots. When the bleed- 
ing is from the kidney or ureters, the clots sometimes assume the appearance 
of dark-red wormlike masses. 

Next to clots, the uriiie may sometimes contain a bloody sediment mixed 
with fragments or masses of tumors. These may be fibrinous or shaggy, or 
they may appear more regular, villous. The deposit may, of course, be also 
mixed with fragments of crystalline substance, particles of calculi, etc. 

When, as very often happens, the blood is mixed with pus, the deposit as- 
sumes peculiar stratifications. In some cases, the deposit of yellowish-gray pus 
is arranged in strata separated by bright-red streaks. This means that a layer 
of pus alternates with a layer of blood cells. In other cases, the purulent (usu- 
ally muco-purulent) sediment is thick, glairy and tenacious, and is tinged a 
distinct red color. These are cases of alkaline urines, in which pus has under- 
gone the glairy change into a viscid mass, as the result of the action of the 
alkali. In these cases, the urine itself is but feebly tinged. There is finally 
another class of cases in which the urine is bright red and the sediment is gray- 
ish or gelatinous. These are usually cases of cystitis, prostatic abscess, or other 
purulent infection of the tract, in which a fresh hemorrhage has taken place as 
the result of some existing cause. 

Diagnosis of the Cause. — The diagnosis of the cause of a hematuria is 
very important and often a puzzling problem. The question is easily solved 
when there is a blood disease manifesting itself in other hemorrhages, as in 
purpura ; when the urine shows signs of acute nephritis, oliguria, high specific 
gravity, albumin, casts, etc. 

Hematurias due to stone are often characterized by an intermittence or a 
remittence; they may be accompanied by pain, and are worse after any form 
of exertion or jarring motion, while hematurias due to tumor and to tuberculosis 
usually occur independent of either pain, exertion or jarring. 

To sum up: — The cause of hematuria must be determined after a careful 
study of the history of the case, a thorough examination of the patient and a 
complete analysis of the urine. If these precautions are taken, one will seldom 
err in determining the pathological process which gives rise to the bleeding. 

Localization of the Bleeding. — Bleeding from the Urethra. — When 
there is bleeding from the anterior urethra the blood oozes or drips from the 
meatus independently of micturition. But when the blood is beyond the cut-off 
muscles, the blood does not ooze from the meatus, but is voided with the urine. 
The two-glass test shows blood in both glasses, the second more than the first, 
because the muscular effort of expulsion brings out any residue of blood that 
may be present in the posterior urethra. 

Bleeding from the Prostate. — Bleeding from the prostate is also char- 
acterized by the same features. In bleeding, either from the prostate or the 
prostatic urethra, the bladder urine may also be bloody, owing to the regurgi- 



280 SPECIAL URINARY SYMPTOMS 

• 
tation of the blood into the bladder. The differential diagnosis will depend on 
age, history, clinical and urinary examination. By washing the bladder through 
a soft-rubber catheter until it is clean and then filling it with water, if the fluid 
escaping through the instrument is free from blood while the remainder voided 
is mixed with blood, the source of the hemorrhage is below the vesical sphincter. 

Hemorrhage from the Bladder. — Hemorrhage from the bladder, if pro- 
fuse, gives a red color to the urine, although, if collected in three glasses, the 
last glass will contain the most blood. If the bladder is washed clean by cathe- 
ter and the instrument is allowed to remain in place for a short time, the blad- 
der contents will again become bloody. At times, the last drops alone contain 
fresh blood. Cystoscopy will usually show us the source of the bleeding if 
there is a bleeding point in the bladder or if it comes from one or both ureters. 

Bleeding from the Ureter. — Bleeding from the ureter is characterised 
by the elongated clots already described, unless it comes from the vesical end 
close to the bladder. 

Bleeding from the Kidney. — Bleeding from the kidney is diagnosed by 
excluding all other sources. The blood is thoroughly mixed with the urine in 
these cases and there is no separate quantity of fresh blood, as in the hemor- 
rhage farther down. In the three-glass test, the patient voids a uniformly 
tinged urine in all three cases. Microscopically, in renal hematuria, we have 
blood casts and renal epithelia, besides the fact that the red blood cells " are 
washed " out and appear as swollen shadow disks scarcely perceptible. 

Having located the bleeding in the kidney, we must next try to find out the 
cause of the symptom. In stone, we have the history of colic, the aggravation 
of the bleeding after exertion or jarring, and the subsidence of it after days of 
perfect rest, while fragments of crystalline masses in the urine will often clinch 
the diagnosis. 

In tumor of the kidney, we have bleeding which appears and disappears 
without apparent cause; emaciation; a tumor in the loin; increasing pain; a 
feeling of weight ; and symptoms of pressure and a varicocele when on the left 
side. Cancer cells and tumor fragments in the urine would complete the 
diagnosis. 

In tuberculous kidney^ a polyuria is very suggestive. When it is accom- 
panied by renal hematuria, the bleeding recurs without apparent cause. Tu- 
bercle bacilli may sometimes be found in the sediment. It is diflScult, however, 
to assign a definite cause for the early hematurias which come in renal tubercu- 
losis before any marked changes have occurred in the kidneys. 

In nephritis, large numbers of red blood cells always indicate the acuteness 
of the condition. In some cases, renal bleeding occurs without previous signs 
of acute or chronic nephritis. (Perhaps the terra " essential hematurias " is 
justified, but in all probability there is some basis for the occurrence of the 
bleeding.) Thus a number of cases have been found, after nephrectomy, to be 



CHANGES IN THE CHARACTER OF THE URINE 281 

early stages of renal tuberculosis, and in certain cases there were found the signs 
of a chronic interstitial nephritis with arterial changes. Castaigne emphasizes 
the value of studying the arterial tension in such cases. If the tension is high, 
we may suspect the presence of interstitial changes in the kidney in cases of 
otherwise unexplainable bleeding. The presence of even slight uremic symptoms 
point to interstitial nephritis rather than to other causes of renal bleeding. 

Which of the two kidneys is bleeding is usually determined nowadays by 
cystoscopy and watching the urine coming from the ureters, and also by ureteral 
catheterization. 

ORDER OF FREQUENCY OF CAUSES OF HEMATURIA 

In the Clinic, In the Hospital, 

Stricture. Stone in bladder. 

Prostatitis. Stone in kidney. 

Eenal calculus. Tuberculous bladder. 

Tuberculous cystitis. Tuberculous kidney. 

Tumor of bladder. Tumor of bladder. 

Prostatic hypertrophy. Stricture. 

Nephritis. Prostatic hypertrophy. 

Ulcer of bladder. Rupture of kidney. 

Carcinoma of prostate. Retention of urine. 

Seminal vesiculitis. Nephritis. 

These two lists simply show the order of frequency in my clinic and hos- 
pital. The causes Avould have been very diflFerent if taken from other hospitals 
with which I am connected. 

Pyuria 

Pyuria means pus in the urine from whatever source. Pyuria may be due 
to any suppurative inflammation in the urinary tract, or to a suppuration in 
some communicating or adjoining organ. It is one of the most frequent symp- 
toms encountered in urological practice. 

We must always satisfy ourselves that pus is actually present and that 
we are not mistaking anything else for it, for urine passed as a cloudy fluid 
may be free from pus, the cloudiness being due to either mucus, bacteria, phos- 
phates or urates. 

Differential Diagnosis. — Every practitioner, therefore, should be familiar 
with the rough clinical tests which are necessary to determine the presence of 
pus immediately after the urine has been passed. 

Mucus. — Normally a faint mucous cloud, which very slowly settles, is pres- 
ent in the urine. It consists of mucus mixed with a few epithelial cells from 
the bladder. It is much more pronounced in women, on account of the admix- 



282 SPECIAL URINARY SYMPTOMS 

ture of vaginal mucus. It is markedly increased in catarrhal conditions of the 
urinary tract, especially in cystitis, prostatitis and urethritis. 

A rough test for mucin, which is the proteid substance contained in the 
mucous cloud, consists in diluting the urine with equal parts of water and add- 
ing acetic acid, until a precipitate of mucin is formed which is soluble in an 
excess of acetic acid. As a general rule mucus may be distinguished from pus 
in the urine by the fact that it floats longer, is less dense and more evanescent 
than pus. 

Phosphates. — Phosphates, when present in excess, or when the urine is 
slightly alkaline, create a diffuse turbidity, which gradually settles on standing. 
A few drops of acetic acid added to such a urine will almost immediately clear 
it up, while, if the turbidity be due to the presence of pus or mucus, it would be 
increased bv the addition of the acid. 

Bacteria. — Bacteria, when growing in large numbers in the urine (see 
Bacteriuria), give rise to a faint cloud which has a tendency to float in the mid- 
dle part of the vessel. This cloud remains practically imchanged by the addi- 
tion of acetic acid. 

Urates. — Urates, w^hen present in excess, form a turbidity which rather 
rapidly deposits as a sediment. The lower the temperature of the urine and 
the greater the acidity (within certain limits), the more apt are urates to pre- 
cipitate. Simply heating a test-tube containing such a urine gently over the 
flame will dissolve the turbidity and clear the urine. If pus were present heat 
would increase the turbidity instead of decreasing it. 

Chyluria. — Chyluria may be mistaken for pyuria. In this condition the 
urine is milky, yellowish-white and shows a film of fat on standing. On 
shaking with ether, the fat is dissolved and the urine becomes normal in ap- 
pearance. 

Pus. — Pus in the urine is characterized usually by a cloudy appearance 
immediately after passing. The cloudiness is usually in proportion to the amount 
of pus. Small amounts of pus may be present in the form of clumps or shreds, 
the urine reaiaining comparatively clear at the time of passing. 

There is not unich difference in the appearance of purulent urines accord- 
ing to the locality of the affection. Urine, clear or slightly turbid, with thick 
threads, points to the urethra; urine which is thick and turbid and tends to 
become gelatinous on standing, points to the bladder; urine which is opaque 
and not thick, but with pus held in suspension, points to the kidney. If it is 
of a light color, a lemonade or even whiter, it is probably from a tubercular 
organ, while if it is darkly colored, it points more to a calculous kidney. The 
light-colored pyuric urine usually occurs when there is considerable polyuria 
with pus and points to a pus kidney, the darker when the urine is more con- 
centrated or bloodv. 

The color of the urine is not much affected by the presence of pus, unless 



CHANGES IN THE CHAKACTER OF THE URINE 283 

there is a large amount, in which case it appears whitish-yellow in color and, 
in decomposing, urine wall assume a dirty gray tint. 

The odor of purulent urine may be either normal, when the urine has re- 
tained its normal acidity, or it may be extremely offensive, putrescent or ammo- 
niacal, or, in still other cases, slightly resemble that of hydrogen sulphid. 
Putrid urine occurs principally when there is decomposing residual urine in 
the bladder or kidney. 

The reaction of purulent urine varies greatly, according to the amount of 
decomposition which the urea undergoes in each particular case. There is no 
sj)ecilic connection between the reaction and the localization of the trouble. 
Formerly it was believed that when the purulent urine was alkaline or ammo- 
niacal, w^e had to deal with a cystitis, while if it were acid, a pyelitis or pyelo- 
nephritis was present. Further advances in urology, however, have shown that 
anunoniacal urine may be obtained with the ureteral catheter from the pelvis 
of the kidney. 

When purulent urine undergoes alkaline fermentation, the pus coagulates 
into gelatinous masses which adhere to the bottom of the vessel. 

Donne's Test for Pus. — This is a rough clinical test which is of great aid 
to the practitioner in distinguishing pus from mucus and other sources of cloudi- 
ness. It consists in allowing the sediment to gravitate to the bottom of a conical 
glass, pouring off the urine which floats over the sediment, and adding the ordi- 
nary solution of caustic potash (potassium hydrate), drop by drop, until the 
gelatinous tenacious mass mentioned above is formed, adhering to the bottom 
of the vessel and slipping out of it en masse. 

Localization. — Having satisfied ourselves that pyuria is present, the next 
step is to determine its source. This we do in several ways. First, we apply 
all the special methods of clinical examination w^hich may have a bearing upon 
the localization of the trouble. The history of the case and the general physical 
examination, including rectal palpation, examination of the urethra, of the 
bladder and of the ureters through the catheterizing cystoscope, are all methods 
which have been described elsewhere and which must be called into play at times 
in determining the source. 

Before w^e proceed to the special methods, however, a few simple clinical 
tests should be applied which will often give us a fair idea of the location of 
the pus : 

Thus, if we can express it from the meatus, the pus is evidently urethral 
and, in man, probably comes from the anterior urethra. Next, if we apply the 
two-glass test and the first urine contains pus and shreds, and the second 
portion, passed immediately afterwards, is clear, it is evident that the dis- 
charge is of urethral origin. If the first and second urines are both cloudy, 
it shows either that the posterior urethra, in the male, is so acutely in- 
volved that some of the pus overflows into the bladder, or, what is more prob- 



284 SPECIAL URINARY SYMPTOMS 

able, that there is an involvement of the urinary tract above the vesical 
sphincter. 

When the whole amount of urine passed is found to contain pus, there is no 
doubt that some affection exists, at least as high up as the bladder, if not higher. 
When this is found to be the case, the special methods, such as cystoscopy, 
catheterization of the ureters, etc., may be applied, in order to localize the 
trouble. 

Considerable information, however, may be gained regarding the case and 
a probable diagnosis may be made, from a detailed urinary examination in cases 
of pyuria, provided this examination is made by an expert in this line of work. 
I want to emphasize strongly the need, particularly in these cases, of confining 
urinary examinations to none but competent men, of whom there are compara- 
tively few, even in our larger cities. 

Attempts have been made to determine the amount of pus in the urinary 
sediment by counting the number of pus cells (Goldberg, Posner). This method 
is faulty, because the pus is generally very unevenly distributed in the urines 
and often occurs in clumps or masses. It is determined with sufficient accuracy 
by centrifugation of the acidified urine, still w^arm (after heating it to assure 
the solution of other sediment), in a tube graduated in cubic centimeters. When 
the urine contains much pus, the sample must be correspondingly diluted, be- 
fore centrifugation, with much saline solution. 

There is no way of telling, from a study of the pus cells found in the urine, 
the locality from which they come. The clew to the localization of the suppu- 
rative processes occurring in the genito-urinary tract, is chiefly the study of the 
epithelial cells that accompany them, and, secondarily, the study of casts and 
blood corpuscles. Although it is true that there are always some cells in a 
urinary sediment whose exact origin is somewhat doubtful, the majority of 
epithelia can be located with fair accuracy and a trained observer can differen- 
tiate the epithelial cells of the kidney from those of the pelvis, the ureter, the 
bladder, the prostate and the urethra. 

When the bladder alone is involved, we find epithelial cells from the vari- 
ous layers of the mucosa of that organ according to the depth of the lesions. 
In ordinary cystitis, the cells from the superficial and middle layers only are 
present. When there is ulceration, the deeper layers add their quota of cells. 

When pyelitis is present, whether due to infection, stone, tuberculosis or 
tumor, a considerable number of pelvic epithelia will accompany the pus. 

If there is also a large number of cells from the bladder, a coincident cys- 
titis exists, which may have been the primary affection. 

When the kidney is involved in the suppurative process, there are in the 
purulent sediment mfiny epithelial cells from the renal convoluted tubules or 
from the straight collecting tubules. If there are at the same time granular, 
epithelial, pus or blood casts, we are dealing with a suppurative nephritis. If, 



CHANGES IN THE CHARACTER OF THE URINE 285 

in addition to all these, there are many cells from the renal pelvis, we have to 
deal with a pyelo-nephritis. 

If the pyuria is intermittent or remittent, we must think of the presence of 
pyonephrosis with intermittent obstruction of the ureter, as stones, or a pyo- 
nephrosis in movable kidney. 

It must be understood that these diagnoses are based on the recognition of 
a considerable number of pus cells and a large number of epithelia from some 
region of the urinary tract. When only a few pus cells and a few epithelia are 
present, we are probably dealing with a nonsuppurative condition or merely 
with a congestion or irritation along the tract. 

Next to the presence of epithelia, the occurrence of casts is important in the 
urinary analysis, as it speaks for the involvement of the kidney. The kidneys 
may participate in the suppurative process or they may be the seat of a secondary 
nephritis of the nonsuppurative type, or both ; in either case, casts may be pres- 
ent. Whenever there are pus casts, that is, casts of any type which are studded 
with pus cells, renal suppuration may be diagnosticated with a reasonable de- 
gree of certainty. It must be remembered, however, that casts are not always 
foimd in suppurative nephritis, any more than they are in the nonsuppurative 
types of nephritis. Their absence, therefore, does not necessarily exclude the 
presence of suppurative nephritis, provided that pus and renal epithelia are 
present in sufficient quantities. 

The size of the casts varies according to the region of the kidney involved 
and something may be known of the extent of the process from this feature. 
W^hen pus casts of large diameters are found, we know that the nephritis has in- 
volved the medullary portion. Casts from the narrow part of the tubules are 
smaller in diameter, next come the casts derived from the convoluted tubules, 
and finally the casts from the straight collecting tubules. When the smaller 
casts from the convoluted tubules have pus cells imbedded in them, we know 
that the cortex has been reached by the affection. Larger-sized plugs of pus 
from the calices are found sometimes in pyelitis. 

Connective-tissue shreds when present in the urine, accompanied by epi- 
thelia and pus, show that there is some destructive process in the urinary tract. 
When the epithelia are renal and the sediment also contains pus casts, the 
presence of connective-tissue shreds is indicative of destructive processes in the 
kidney. 

Having thus localized the pyuria, some further points in the urinary exam- 
ination may often give us a clew as to the cause of the suppuration. Thus, if 
stone be the cause, the unusual abundance of some form of crystals or the occur- 
rence of crystals in solid masses may suggest the presence of a calculus. 

If tubercle bacilli, gonococci or other microorganisms are found in the sedi- 
ment, we have the bacteriological clew to the pyuria. If portions of tumors, 
such as papillomas or malignant growths, are found, a correct diagnosis may 



286 SPECIAL URINARY SYMPTOMS 

sometimes be made from the urine. Unfortimately, these tumor fragments are 
not frequently encountered. 

Having considered the urinary report in detail and compared it with the 
history of the case and the findings of the physical examination, we can deter- 
mine that a suppurative condition exists somewhere in the urinary tract, that 
it is probably due to either obstruction, stone, tumor, or tuberculosis, with in- 
fection. If the urethra is involved, it may be detected by instruments ; if the 
prostate, it may be felt ; if the bladder, it may be seen by the cystoscope ; if the 
ureter, it can be felt by the catheter ; if the kidney or pelvis, the ureteral cathe- 
ters will reveal the condition and the side involved, by the character of urine 
draining from the ureter. 

Pneumaturia 

The term pneumaturia is applied to the evacuation of free gases in the 
urine. The gases are formed in the bladder, or they may enter the organ 
through recto-vesical and vesico-sigmoidal fistulas. 

According to Guiard, the production of COg in the bladder as a result 
of alcoholic fermentation in glycosuric urine is one source of pneumaturia. 
Miller and Senator analyzed the escaping gas in such a case and found it 
to consist of hydrogen and carbon dioxid. The production of this fermenta- 
tion in the bladders of diabetics may be due to a cystitis produced by Bacillus 
coli infection (Schnitzler). 

When a cystitis is due to the growth of gas-forming bacteria, such as the 
Proteus vulgaris and allied forms, there may be a pneumaturia, although the 
urine is free from sugar. Heyse and Favre each found the Bacillus lactis 
aerogenes in a case of pneumaturic cystitis without glycosuria. 

The gas bubbles are usually expelled with the last portions of urine. If 
there is retention, the gases may accumulate and give rise to a false sense of 
vesical emptiness owing to a tympanitic resonance over the bladder. In diabetic 
urine, the reaction, even after this fermentation, is acid ; in other urines, pneu- 
maturic fermentation is accompanied by alkalinity. The external features of 
the urine are the same as in cystitis, or in bacteriuria, as the case may be. 

Gas bubbles have been found at autopsy in the renal pelvis, and the walls 
of the bladder have been found the seat of emphysema in several instances. 

Bacteriuria 

Bacteriuria is a condition in which there is an abundant growth of pathogenic 
germs in the urine, but in which there is very little evidence of an inflammatory 
condition of the urinary tract. Bacteriuria is generally thought to be asso- 
ciated with some lesion along the urinary tract. 

Robert, in 1881 {Brit. Med. Jour., 1881, 11, p. 623), was the first J:.o 



CHANGES IN THE CHARACTER OF THE URINE 287 

describe it. Since then a number of investigators, notably Krogius, Rovsing, 
Jeanbrau, Keyes and others have studied this condition. 

Pathology. — The freshly voided urine in bacteriuria contains large masses 
of bacteria. The urine is cloudy, sometimes opalescent, and the cloud does not 
settle, but on shaking assumes wavy motions (Zuckerkandl). If there is a 
complicating urethritis or prostatitis, the first or second glass may also contain 
pus or shreds, but often the glasses contain nothing but the cloud described. 
No albumin is necessarily present, but the reaction for mucin with acetic acid 
is obtainable. The urine is acid in reaction and has a foul, fecal, rather than 
an ammoniacal odor. The microscope reveals large masses of bacteria, a few 
epithelia and still fewer pus cells or leucocytes. 

The most common germ found in bacteriuria is the colon bacillus (in 83.5 
of 67 cases reported by Jeanbrau), with or without some associated staphylo- 
cocci (Barlow). Less frequently are found the streptococci, the proteus of 
Mauser, the Bacillus lactis aerogenes and the hydrogen-sulphid-forming bacteria 
(Rosenheim and Guzman; Karplus, quoted by Zuckerkandl). The typhoid 
bacillus which, according to Richardson and Gwyn, produces bacteriuria in 
twenty to thirty per cent of typhoid-fever patients, must also be included in 
this group. 

In most cases, the infection is hematogenous or at least descending, from 
the kidney and the pelvis. 

The line of distinction between a bacteriuria with a few pus cells and many 
bacteria and a mild inflammation of some part of the urinary tract with a few 
more pus cells and less bacteria is often perplexing to the practitioner. The 
question as to whether parietal lesions in the urinary tract are needed for the 
development of bacteriuria is still disputed. Most authorities say that such 
lesions always exist and that the mere presence of bacteria in the urinary tract 
does not cause bacteriuria, as has been shown experimentally by the injection 
of bacteria into the tract. They claim that besides these injections a parietal 
lesion must be made before a bacteriuria develops. 

The parietal lesion in bacteriuria is not in the bladder. It is some- 
times in the prostate. Krogius, Ilogge, Goldenberg, Gassman, Keyes and 
the author have observed such cases. It is usually situated in the ureter, the 
kidney and its pelvis, although the lesion may be unrecognizable clinically. 
It may be due to typhoid infection, to the puerperal state, or to prostatic 
hypertrophy. Exceptionally bacteriuria is said to be due to prostatitis and 
vesiculitis. 

Symptoms. — Certain local and general symptoms have been ascribed to bac- 
teriuria. The general symptoms may be due to the colon infection, which is so 
often present in these cases. They are lassitude, headaches, anorexia, intestinal 
disturbances and at times a febrile movement. Locally, there may be the 
syijaptoms of a chronic urethritis, pyelitis, prostatitis, vesiculitis, etc. 



288 SPECIAL URINARY SYMPTOMS 

Treatment. — The treatment consists in the removal of the cause and the ad- 
ministration of hexamethylenamin (urotropin) in doses of seven and a half to 
ten grains three times daily. Local treatment by lavage of the ureters and 
pelvis, by washing the bladder and posterior urethra and by massaging the 
prostate and vesicles, is also indicated according to the source of the trouble. 



CHAPTER XII 

URINARY FEVER (CATHETER FEVER), URINARY INFECTION 

The older authors, among them Velpeau, Civiale and Thompson, spoke of 
urinary fever or catheter fever as a form of natural reaction of the body to the 
shock or irritation induced by the introduction of instruments into the urinary 
tract. It was thought by some that the phenomena of urinary fever which were 
chiefly characterized by a chill, fever and sweating were of nervous origin. 
This was the theory of Von Dittel, who regarded the febrile paroxysm as a 
reflex process induced by the irritation of the nerves of the urethra. Velpeau 
regarded catheter fever as a form of systemic poisoning, in virtue of the en- 
trance of urine into the system through some minute injury resulting from the 
instrumental interference. Thompson distinguished catheter fever, which he 
divided into acute and chronic, from urinary infection proper, which he styled 
pyemic or septicemic fever. The idea that the fever following urethral in- 
strumentation w^as of nervous origin, held sway until light began to dawn under 
the influence of the work of Oliver Wendell Holmes and Semmelweiss on puer- 
peral fever and of the discoveries of Pasteur, Lister and Koch. 

The modern definition of urinary fever, or catheter fever, makes it synony- 
mous with urinary infection, and regards it as always due to the entrance of 
germs or their toxins into the blood. The normal urine in a healthy bladder is 
aseptic and, in the absence of a urinary or general infection, the urine with- 
drawn after death has been repeatedly shown to be sterile. Bacteria become 
lodged with difficulty in the normal bladder imder healthy conditions. When 
there are certain predisposing causes, however, such as congestion, injury to the 
wall, or retention of urine, bacteria may multiply very rapidly. 

The routes which infection may take from the urinary tract into the cir- 
culation are numerous, as have been shown by experiments on animals and by 
a study of numerous autopsies. Thus, it has been shown that, under favorable 
conditions, germs injected into the bladder can pass through the mucous mem- 
brane into the blood and kill the animals through a general infection without 
necessarily ascending to the kidney. In some instances, the infection in the 
blood penetrated into the kidneys and septic foci were found in the latter organs, 
although the ureters and pelves of the kidneys remained free. 

The urethra may also be a portal of entrance for a general infection, espe- 

280 



290 URINARY FEVER AND URINARY INFECTION 

cially after instrumental interference. It has been shown experimentally that 
bacteria could be found in the blood five hours after the introduction of an in- 
strument through a stricture. Bartelsmann and Man (Munchener medizinische 
Wochenschrifi, 1902, p. 21, quoted by Zuckerkandl, loc. cit.) showed that in a 
case in which a stricture was sounded and the instrumentation was followed 
by chills, staphylococci were present in the blood during the chill and the same 
variety of bacteria were found in the urine. 

A point to be remembered in connection with urinary infection is, that even 
when instruments are sterile there may be vesical infection through carrying 
bacteria, which are always abundant in the urethra, into the bladder (Mel- 
chior). In women in whom the urethra is wide and short, there may even be 
spontaneous infection of the bladder from the healthy urethra, the germs pre- 
sumably coming from the vulva. 

In addition to this, we must remember that there are two other ways in 
which germs can enter into the urinary tract. One is through the kidneys from 
the blood, and the other through the intestinal tract. It has been quite thor- 
oughly established by experiments (Biedl and Kraus, quoted by the latter in 
Frisch and Zuckerkandl's *^ Handbuch der Urologie," vol. 1, p. 444), that it 
is not necessary to have a lesion in the kidney in order to have bacteria pass 
through this organ from the blood into the urine. Biedl and Kraus injected 
bacteria into the blood (Staphylococcus aureus. Bacterium coli, anthrax) and 
recovered them within an hour from the urine, although the latter contained 
no blood nor albumin and the kidney was perfectly healthy. Wyssokowitsch 
and others deny the possibility of bacteria passing through the healthy kidney, 
but it is probable that the investigations of Biedl and Kraus, which have been 
confirmed by several other observers, represent the actual conditions. A lesion 
may make it more easy for bacteria to enter the urine, but its presence does not 
seem to be absolutely necessary. 

Bacteria can pass through an injured intestine into adjacent portions of the 
urinary tract, and recent investigations have shown that very slight lesions 
are sufficient to allow the Bacterium coli to pass through the intestinal wall 
and enter the urinary tract. Some authors have even gone so far as to say 
that this transference can go on with a normal intestine, while others, as Kraus, 
say it is probable that no bacteria can pass through the normal intestine, and 
Markus and Faltin (quoted by Kraus) found that constipation, produced arti- 
ficially by closing the anus, was not sufficient to give rise to a passage of bacteria 
from the intestine into the blood. It is quite generally believed, however, that 
the bacteria from the intestine may in constipation either pass into the blood 
and thence into the kidneys and the bladder, or, if the constipation is very 
chronic and especially if lesions exist in the intestine, they pass directly into 
the bladder from the gut. 

Having thus briefly discussed the modes in which infection penetrates into 



CLINICAL TYPES OF URINARY FEVER 291 

the urinary tract, we now turn to the exciters of infection which need only 
be mentioned briefly here, as they have been considered in detail in the chapter 
on The Bacteriology of the Urine. The germs which are concerned in urinary 
infection are the same as those found more or less frequently in pathological 
urine. They are the Staphylococcus pyogenes aureus, albus and citreus; the 
Streptococcus pyogenes ; the Urobacillus liquef aciens septicus ; the Bacillus pyo- 
cyaneus and the Bacterium coli commune. The last-named is the most fre- 
quently responsible for urinary infection, while the staphylococcus and strepto- 
coccus come next in frequency. As regards the gonococcus, this germ itself is 
really not considered responsible for urinary infection as such and, in complicated 
cases of urethritis, in which urinary infection occurs, the latter is usually due 
to the associated secondary germs, although some instances of general infection 
with the gonococcus have been reported in which the patients died of peritonitis, 
septic endocarditis, etc., due to gonococcus infection ( JuUien, " La Blennor- 
rhagie," Paris, 1906). 

Clinical Types of Urinary Fever. — The clinical forms of urinary fever may 
be considered under two general headings, the acute and the chronic types. 
The acute form, however, may be clinically subdivided into the single acute 
paroxysm and the acute prolonged or intermittent form. 

Acute Type of Ueinary Fever. — The acute paroxysm of urinary infec- 
tion is the clinical type which the older authors knew as catheter fever. It is a 
type which is most distinctly referable to a true blood infection, as it is here 
that microorganisms have been most often found in the circulation both in the 
fulminating, rapidly fatal cases, and in the acute cases followed by recovery. 

The acute paroxysm occurs either without warning or after the introduc- 
tion of an instrument. The time which elapses between the instrumentation 

* 

and the appearance of the first symptom varies between several hours and sev- 
eral days, but is usually a few hours. The first symptom is a severe chill, the 
patient having cold extremities, and a pale and cyanotic look. The chill varies 
in duration and severity, lasting from a few minutes to a few hours and may 
cause the patient's teeth to chatter, although usually it is not so severe and 
there is simply a chilly sensation. The respiration may be irregular, but as the 
chill wanes the breathing once more becomes regular. 

The next symptom is the fever, which rises rapidly with frequent and tense 
pulse, rapid respiration and flushing of the skin, the latter being hot and dry. 
The rise of temperature reaches often to 105° F. or more and drops quite rap- 
idly. The fever in a typical case is followed by sweating, beginning with a 
slight moisture and passing into a profuse perspiration. After the sweating, 
the patient complains of fatigue, headache and slight stiffness of the limbs. 

In some cases, there are also during the attack delirium, diarrhea, vomiting 
and dyspnea. The delirium may accompany the chill and need not be regarded 
as important at this stage. The mouth and tongue are dry, especially when the 



tmiNARY FEVER AND URINARY INFECTION 



attack is a repetition of a precetHng odc. There may be bilious vomiting 



and later copious fetid stools. 



1 


r 1 Z 4 5 6 


F 




104 

ton 

IIKJl 
9» 












":""I"":"" 


:::: _ ; :: 


3 


::::i :: 


3» . . \vX.. 




1 \ 


: ±t :: 








. / 1 


,_i i_ . 


::jtc 


3T .JjJ 1 













Fia. 227. — AccTB Urinary Peveh avtbr 
AN Inteiinal Urethrotout. (Aftpr 
Guyon.) Tbese recur occasioiially 
after pnaaing souiidB. 

tion and the number of attacks a] 
first acute attack, in whicli 
the stages of chill, fever and 
sweating do not succeed each 
other regularly, predicts an 
intermittent form with re- 
peated attacks ; but this rule 
is not to be relied upon, as 
frequently the acute attacks 
described above do not run 
their set course. 

In the intervals, the 
patients may suffer from 
weakness, irregular pulse, 
loss of appetite and sleep, 
or they may feel perfectly 
welL 



During the attack, the frequency of respira- 
tion may be accompanied by a sense of op- 
pression constituting dyspnea. The pulse 
is usually irregular, if the infection is 
severe. 

The single acute attack just described 
frequently passes away in a few hours, but 
it may last two or three days. Usually the 
shorter the attack the more severe.it is, but 
these single attacks are rarely fatal. Deaths 
have, however, been reported following a 
chill which resulted from such a slight pro- 
cedure as catheterization of a atrictured 
urethra. In these fatal cases, the chill is 
jirolonged and is followed by collapse, invol- 
imtary defecation, hiccough and gradual loss 
of consciousness. 

It is scarcely necessary to refer to the 
great similarity between these single acute 
attacks and acute malarial paroxysms. The 
rcseuiblance is made still more marked by 
the fact that the acute attack may be re- 
peated after an intermission. The interval 
which is free from fever is variable in dura- 
30 varies. Some authors claim that an atypical 



CLINICAL TYPES OF URINAEY FEVER 293 

The acute attacks may also assume the remittent form in which the fever is 
more or less continuous with acute exacerbationa accompanied by chills. These 
are severe cases, aa a rule, with some of the following symptoms: The tempera- 
ture high, with delirium, prostration and loss of conaciousneas, with a dry 
tongue, a rapid and frequent pulse, vomiting, hiccough and symptoms of bron- 
cho-pneumonia. Pustular eruptions, purpuric patches and rashes resembling 
erythema nodosuui sometimes occur. In some instancea, the affection asaumes 
a pyemic form with suppurations in the muscles, joints, cellular tissue, etc. The 
parotid sometimes becomes inflamed, showing tliat the urinary infection has 
involved the general system. All these local suppurations are extreme, and per- 
sonally I have never seen an involvement of the parotid. 

The prognosis In the prolonged, acute ty)ie, including both intermittent and 
remittent varietiea, should be more guarded than in the primary acute form. 
Usually, recovery sets in from one to three weeks after tlie first paroxysm, with 
a gradual defervescence. It must he understood, that the more continuous the 
fever the worse the prognosis and tluit prolonged fever is of graver import than 
a temporary rise. Recovery has taken place, however, even in eases with dis- 
seminated abscesses. 

OnROKic Type of Uhinaky Fkvek. — The clironic tyjie of urinary fever is 
a frequent form, and is of great clinical importance. It may develop primarily 
as such or follow the acute 
form. The temperature is 
limited in range and inter- 
mittent in type, the eleva- 
tions being moderate, in 
contrast to the sharp rises 
in the acute cases. I'ever 
is not always present and in 
doubtful cases the tempera- 
ture should be taken at fre- 
quent inter\-al3. 

One of tlie constant and 
clinically important symp- 
toms of this form are di- _ „„ ^ „ „ _ „ 

iio. 229. — Cbhonic Urinabt Fevbs, OccDfuUNo IN A Case or 
gcfllive disturbanci'S with Incouplete Retbntion from Pbobtatic UTPEsntOPBT. 

loss of appetite. The pa- (Aft« Gi.yo«.) TheB« attacks u^olly foUow oatheUm>. 

'^' _ ' Won, but may occur lodepcndent of It. 

ticnts lose weight ami be- 
come cachectic, even though there is no fever. "When an acute attack of fever 
occurs, as it docs sometiuics in these eases, the patient becomes prostrated and 
keeps his bed for a day or two. 

The urinary cachexia ])crsists for some time and oven after it is conquered 
the patients remain dyspeptic with sallow complexions for a while. If the 



294 URINARY FEVER AND URINARY INFECTION 

cachexia continues, the patients die of exhaustion, usually with uremic symp- 
toms or with some complication or intercurrent disease. The chronic form of 
urinary infection is especially frequent in prostatics, who are, however, much 
improved by regular catheterization. 

The prognosis of these very chronic types is very poor and especially when 
the cases are connected with chronic suppurative conditions of some part of the 
tract involving gradually the kidneys. 

In general, the prognosis may be said to vary, no matter what the type may 
be, according to the virulence of the germs, the duration of the infection and the 
nature of the urinary lesions present. If the obstruction to the urinary flow 
can be removed surgically and the patient's urinary tract can be made to drain 
well, the prognosis becomes brighter. In the chronic forms, the infection has 
usually become so generalized and has affected the system so deeply that the 
prognosis is naturally least favorable. 

Treatment of Urinaiy Fever. — The first consideration is prevention. This 
consists in so handling our cases during examination and treatment, that no 
infection can occur. For the most trivial surgical procedure, the strictest asep- 
sis must be maintained, according to the principles laid down in the appropri- 
ate chapter. Certain preventive measures may be adopted also before, during 
and after surgical maneuvers on the urinary tract. In preparing for such pro- 
cedures, one of the essentials is rest. Patients who arrive in an exhausted con- 
dition from travel, overwork or loss of sleep, should have one or more good 
night's rest, under the influence of a mild hypnotic if necessary. The bowels 
should be thoroughly moved and a large amount of water should be drunk in 
connection with a urinary antiseptic, as urotropin. 

Just before the examination, especially if the patient has pus in the urine, 
a suppository containing morphin (gr. ^) and quinin (gr. 10) should be 
given, together with an additional dose of urotropin (gr. 15). The examina- 
tion itself should be carried on under the local influence of a weak solution of 
cocain and should the patient begin to tremble, perspire, clutch the table, con- 
tract the limbs, show a spasmodic contraction of the sphincter muscles, complain 
of pain or start to bleed, it is well to postpone the remainder of the examination 
until another time. A small catheter should then be inserted and the bladder 
filled with 1 : 3,000 silver solution, which the patient should be allowed to pass 
out afterwards. It is advisable not to resort to cystoscopy until the patient 
can well tolerate an ordinary instrumental examination. If tolerance is not 
established with the aid of cocain, general anesthesia may be needed for an ex- 
amination of the urethra and bladder. 

I have found that most of the cases of urethral fever that have followed 
examinations in the office, the clinic or the hospital, occurred in patients who 
have had too much instrumentation at the first visit, in other words, where too 
much haste has been used in examining. In the oflSce, it has usually been in the 



TREATMENT OF URINARY FEVER 295 

cases that have come from out of town, accompanied by their physician, when 
both wanted to return on the same day. In the clinic, it was usually in the in- 
teresting cases in which it was necessary to complete the examination in one 
visit, as otherwise the patient might not return. 

Haste in examination is a very bad practice. Business men should be dis- 
couraged from having their cases rushed through as quickly as possible to save 
time. The only cases in which haste is needed are those of retention of urine 
and uremia. In retention, the preliminary treatment should be at once applied, 
including urotropin, a suppository of morphin and quinin and a hot sitz bath. 
The treatment for retention of urine, which has been outlined elsewhere, is then 
to be systematically followed until relief is effected. As soon as thorough 
drainage is established, the symptoms of urinary infection will usually begin to 
improve, and the patient has a good chance of recovery if the urinary flow is 
maintained together with the other necessary therapeutic measures. 

In operating on the urinary tract, certain precautions should be taken to 
prevent urinary infection. Free drainage should always be established. In 
external urethrotomy operations, the parts should be frequently flushed with 
boric-acid solution and afterwards hydrogen peroxid should be injected through 
the urethra and allowed to escape through the perineal opening. The bladder 
may also be washed out with a 1 : 10,000 solution of bichlorid. Wherever pos- 
sible, drainage tubes or catheters should be employed in such a manner as to 
protect cut surfaces from contact with urine. In the after treatment of opera- 
tions, the urethra and bladder should be washed at least twice daily and the 
attendants should see that the drainage tubes act properly and constantly. 
Special precautions should always be taken against infection in passing in- 
struments through strictures, and, after the instrument has been introduced, 
the bladder should be filled with silver solution or some other antiseptic 
fluid, which the patient should be instructed to pass out, thus washing the 
urethra. 

Treatment of the Attack. — During the acute attack, the patient is 
wrapped in blankets when the chill comes on and given hot and alcoholic drinks 
to provoke perspiration. A small dose of quinin should be at once given and 
repeated as indicated. The bowels should be moved and the urinary condition 
should be carefully looked after. Retention of urine, urethritis, cystitis, pye- 
litis and nephritis, should be treated according to the rules laid down in the 
appropriate chapters. 

In the chronic cases, the treatment should be chiefly directed toward the 
gastro-intestinal tract. The patient should be partly on a milk diet and should 
receive frequent doses of laxatives. The digestive function should be stimulated 
by small doses of whisky and bitter tonics. Bathing, followed by frictions to 
stimulate the secretory functions of the skin, are also useful in some cases. 
Three grains of quinin three times a day usually benefit the patient consider- 



296 URINARY FEVER AND URINARY INFECTION 

ably. Whisky is in my hands another valuable remedy and the patients are 
given from two to six ounces a day, depending on the seat of the infection. 
When the lesion is below the kidney, the doses are larger. Citrate of caffein, in 
doses of from one to three grains three times a day, is also very beneficial when 
the patient is in a weak septic condition. 



CHAPTER XIII 



THE HISTORY OF THE CASE 



A THOROUGH consideration of the history of a urinary case is essential in 
making an accurate diagnosis. It is well, as a rule, to allow the patient to tell 
his or her story first, interrupting only to bring out more clearly points of in- 
terest that might have an important bearing upon the condition. It is advisable 
then to take the history in a systematic way, both in order to make it easier 
of interpretation and to have the records that will be of value for future study. 
I will, therefore, present herewith a copy of the cards (Figs. 230 and 231) that 
I am in the habit of using for men and women respectively, showing the meth- 
ods that I have employed for a number of years in a large hospital clinic and 
in my private practice. 

It is my intention to present, first, a brief consideration of each of the head- 
ings in my history chart and the important points they bring to the surgeon for 
consideration, and to outline the steps of the routine examination of a case in 
the office. In other chapters I discuss more in detail individual symptoms and 
groups of symptoms observed in urology. 

Age. — The age of the patient is very important as pointing to the various 
diseases that may occur at certain periods of life. In children, ^^e have but few 
urinary troubles. If there are any, they are due to congenital stricture, espe- 
cially near the meatus, to the irritation of a tight prepuce, to some nervous 
affection or to vesical stone ; all of which give rise to frequency of urination and 
the last named to some pain and tenesmus. 

As the individual grows older, the diseases of youth are to be considered, 
principally due to gonococcus infection and tuberculosis of the urinary tract. 
The varieties of the complications of these two infections are numerous, involv- 
ing the urethra^ bladder, ureter and kidney, as well as the genitals in both sexes. 

In early manhood and womanhood tuberculosis is still common ; calculus is 
more common than in the earlier periods ; the gonococcus infections are slightly 
less common, while their results — stricture, cystitis and diseases of the internal 
genitals (the prostate and vesicles in men and the uterus and tubes in women) — 
are more often brought to our attention. Uterine and renal displacements are 
more common in w^omen, as well as urinary troubles dependent on childbirth. 

297 



298 



THE HISTORY OF THE CASE 



In middle life, tuberculosis is less frequently met with, as are also the acute 
gonococcus infections. Stricture of the urethra is more common, while kidney and 
bladder troubles occur with about the same frequency as in early manhood, as 



N«m« 



iiasnotit 



Address 



kg. 



W«ffr»d b| 



Oat* 



Occupstion 



Fsmity History 



Nstitity 



■■• 3w *» • 



Psst History 



Pftttfft nitt9nr 



. Principal Symptoms 



Pain 



Oischargo 



Characff of Urination 



Charactor of Urina, (pus, blood) 



EXAMINATIOH 



Qonitals 



[Discharga (smear) 



Stand- 



Urino 1st 



2d 



i Prostata 



Vosidas 



lUrina 3d 



Urathra 



Lying- 



/Bladdar 



jUrina <th, (ratidual) 



^Kidnaya 



UBORATORY REPORT ON URINE ANO DISCHARGES 



Ckaf Of Cloudy. Color 



Odor 



Raaction 



Sp. Gr. 



Albumin 




Sugar 


Urta 


Indican 


Total Solids 




Crystals 






Mucua 




Connective tissue 




Rad Blood 






White 




Microorganisms 




Epithelia 


Casts 








Other features 






Oiseharga (smear) 


RamarVa on 


Urina 


and Oischvgas 


















• 







Fig. 230. — Male History Card. 



do also the bladder affections depending on diseases of the spinal cord and 
brain. 

In old age, prostatic changes occur, associated with vesical and renal symp- 
toms of a surgical nature. Malignant tumors and calculi are more frequently 
found. Changes in the kidney, due to circulatory disturbance, take place with 
increased frequency; while tuberculosis and the diseases dependent on gono- 
coccus infection are not so common as in earlier life. 

Occupation. — To know the patient's occupation is useful in determining the 
possible effects of traumatism or of continuous muscular effort, the frequency 
of exposure to cold, wet and other influences of the weather, and the general 
mode of life, sedentary or otherwise. 



RACE 



299 



Civil State. — In men, the civil state, whether single or married or widower, 
has a certain bearing upon some urinary diseases, especially those connected 
with sexual disturbances. Thus gonococcus infections are more common in 



Hw 








Diagnosis 


AddrsM 




*«• 


Referred by 


Dat* 


Occupation 






Nativity 


M. S. W. 


K MwriMi wh«n7 




No. 


of Children • 




Abortions 


Family Histofy 




Pa»t History 






Presant History 


















Principal Symptoms 


Pain 


'Dischar^ 


"Charactar of Urination 


Character of Urino, (pus, blood) 


Menstruation (charactf r of) 


EXAMINATION 


( Kidneys 












F-««.i)G«n!t«'« 


) Discharge 


( Urine 1st 






2 


d 




/uterus 


iTubea 


i«..m.i / Ovaries 


j Urethra 


/ Bladder 












V Urine (residual) 














UBORATORY 


REPORT ON 


URINE AND DISCHARGES 


Oear or Cloudy, Color 




Odor 


Reaction 


Sp. Gr. 


Albumin Sugar 




Urea 


Indican 


Total Solids 


Crystals 






Mucus 




Connective tissue 


Red Blood 




White 




Microorganisms 


Cpithelia 


Casts 








Other features 




Discharge (smear) 


Remarks on Urine and Discharges 





FiQ. 231. — ^Female Histobt Card. 



single people; congestion of the prostate, prostatitis and vesiculitis, from an 
irregular sexual life, are more common in widowers, men in the army and navy, 
travelers for business houses or men in other callings where for various reasons 
the sexual life is not well regulated. 

In women, the question of marriage, childbirtli and abortion has an obvious 
bearing upon the diseases of the genital, and, indirectly, of the urinary tract, 
as causing displacements and the prolapse of the bladder (cystocele), as well 
as disturbed bladder functions due to diseased adnexa. 

Race. — The patient's nativity or race has much to do with the prevalence of 
certain urinary diseases. Thus, in Spanish- Americans, stricture, prostatitis, stone 
and nephritis are most common ; impotence in men and nephroptosis in women. 



300 THE HISTORY OF THE CASE 

In the Italians, we find a prevalence of stone and tuberculous lesions. In 
the Jewish race, diabetes and bladder, prostatic and seminal vesicle disturbances 
are to be looked for. 

Family History. — The family history of the patient is the next heading to 
be filled out on our card. Certain urinary diseases seem to be influenced by 
heredity. The uric-acid diathesis, with its tendency to deposit crystalline masses 
and to form stones, is unquestionably found very frequently in successive gen- 
erations. Bright's disease, arteriosclerosis, diabetes, diseases of the spinal cord 
and brain, hysteria and neurasthenia with their special disturbances in the uri- 
nary function, are all unquestionably influenced by heredity. The existence of 
tuberculosis in the family will always lead to a suspicion of tuberculous urinary 
lesions if the symptoms of a chronic process in the urinary tract are present, 
even though the lungs of the patient show no trace of tuberculous lesions. 

It is said that there is no hereditary predisposition to prostatic hypertrophy ; 
but I have noticed the occurrence of the disease in members of the same family 
and prostatics have occasionally told me that their fathers had had the same 
trouble. The same is said to be true of strictures, to which, according to Thomp- 
son, there seems to be a family predisposition. 

Cancer of the kidney, the prostate and bladder is another disease in w^hich 
the heredity is to be carefully investigated. The predisposition to malignant 
tumors, when present, goes far toward making us watchful for the presence of 
such growths in the urinary tract. 

Past History. — When inquiring for data to be written under this heading, 
we begin at childhood, asking as to the occurrence of infectious diseases. The 
occurrence of scarlatina, diphtheria, etc., will make us think of possible nephri- 
tis. The various diseases gone through at an early age to the present day should 
be noted. Rheumatic attacks are associated with the uric-acid diathesis or 
stone ; protracted coughs point to tuberculosis ; attacks of renal colic indicate a 
stone. These are among the phenomena to be considered in the past history. 
The occurrence and number of attacks of urethritis make us look for stricture, 
prostatitis, cystitis and renal affection ; while syphilis points to bladder affections 
through atony of its walls due to a spinal sclerosis. Traumatism and urological 
or other operations are also to be noted, if they have occurred, as they have im- 
portant bearings on the etiology of the present affection. 

Present History. — Having thus elicited by a few leading questions the 
heredity and past history of our patient, we come to the consideration of the 
present illness, i. e., of the complaint for which the patient needs our assistance. 
Here it is usually best, in order to obtain a consecutive story, to ask when the 
patient last felt perfectly well. Beginning with this data, with a little urging, 
the leading events of the illness will be related to us, which we write down in 
a condensed form on the lines following the heading " present history." 

The patients, in relating their present history, will usually speak of pain, 



PRINCIPAL SYMPTOMS 301 

disturbed micturition, a discharge, the presence of blood in the urine, or the 
passage of urine which they describe as " not being clean." They may also 
complain of inability to attend to their work, not only on account of urinary 
disturbances, but also on account of a feeling of weakness or sickness. Patients 
who complain of weakness and sickness, which may be constant or intermittent, 
may be suffering from some constitutional trouble, as a nephritis, a carcinoma 
or tuberculosis. When such a condition occurs in the form of attacks, it may 
be due to a congestion in some part of the urinary tract, to febrile attacks due 
to impediment to the escape of pus, and to other causes which they cannot 
account for. Loss of weight is generally due to the condition or diseases just 
mentioned. As the leading symptoms, however, are those which I at first out- 
lined, I will take them up more in detail ; and these are so important that I 
have placed them on the card (see Figs. 230 and 231), in order that I may not 
omit any of them in taking the history of the case. 

Principal Symptoms. — The first thing to be asked after the patients have 
given us their version of the present illness is. What is the principal symptom — 
i. e., the one complaint that has led to the visit ? The answer to this question 
will often tell us what the disease is; as, for instance, discharge will lead us 
to believe that the patient, if a man, has a urethritis, especially if it is associated 
with a burning on urination, alone or associated with frequency ; or, if a woman, 
that it comes from her urethra or vagina. A hemorrhage from the urinary 
tract will lead us to think of tumor. The passage of dirty urine will lead us to 
think of pyuria. A sudden, sharp pain darting down the ureter will indicate 
renal calculi passing down the tract, etc. 

Pain. — In the great majority of cases, pain is one of the symptoms, if not 
the leading symptom, complained of. The subject of pain in urinary diseases 
is discussed more at length under the heading of Symptomatology. In taking 
the history, the duration, character, intensity, localization, chief seat and direc- 
tions of pain should be noted. The relation of pain to rest and motion, exercise 
or jarring, micturition, defecation and to the sexual organism, are also points of 
interest. 

The character of pain complained of by patients with urinary diseases, varies 
considerably from the acute, colicky, sudden, sharp pain of stone traveling 
down the ureter, to the feelings of discomfort, dullness, heaviness, or of an in- 
describable irritation of an indefinite kind in some locality. 

Pain in the loin may mean involvement of the kidney and may be either 
surgical or medical. The diseases one must look for when pain in the loin is 
present are renal stone, tuberculosis, tumors, movable kidney, nephralgia, peri- 
nephritic abscess, pyelitis and pyelo-nephritis. The pain in the loin is usually 
in the back, on one side, beneath the free border of the ribs, although it may also 
be found in the corresponding situation in front, or beneath the angle of the 
ribs, in the ileo-costal space. 



302 THE HISTORY OF THE CASE 

The character of the pain may be sharp, as in the passage of calculi, or of tu- 
bercular accumulations, in movable kidney, or in nephralgia from nephritis. 
In these same conditions, a dull pain may be present, or a heaviness, as in tumor 
of the kidney. These pains may radiate down the ureter in the direction of the 
groin or bladder, especially in cases of stone. 

Pain in the ureter is reflected up toward the kidney, or downward toward 
the bladder or testes. It may also have a point of maximum severity, as in a 
displaced kidney, the pedicle of which has become twisted at a certain point 
(DietFs crisis), or in the presence of calculus; the larger, rougher and more 
jagged the stone, the more acute is the pain. 

Suprapubic pain is usually dull and accompanied by a sense of pressure 
and fullness. It is most marked in cases of sudden retention of urine, when 
there is, in addition, a cramplike feeling. It may also be present in inflamma- 
tion ef the bladder from any cause, as from extensions from the urethra, stone, 
tuberculosis or tumor of the bladder, being more marked and more acute in 
cystitis due to stone and tuberculosis. A sense of discomfort or fullness in 
the suprapubic region is frequently due to an involvement of the seminal 
vesicles. 

Pain in the groin, in the male, points to trouble with the testes, the cord 
or with the seminal vesicles. In women, it means involvement of the ad- 
nexa. If the pain is of a dull character, it is due to inflammation of the sem- 
inal vesicles. When there is pressure on the ejaculatory duct on one or 
both sides, from prostatic inflammations, pain in the groin may also be pres- 
ent. Pain in the groin is elicited when the vas deferens is inflamed, or the 
ampulla alone is involved. In epididymitis, due to the extension from the 
urethra along the vas deferens, pain in the groin precedes the pain in the 
epididymis. 

Pain in the perineum in the male is usually due to stricture, deep-seated 
urethritis, posterior urethritis, acute or chronic prostatitis, or prostatic hyper- 
trophy or Cowperitis. In women it usually points to laceration of the perineum 
or hemorrhoids. 

Discharge. — This symptom will be studied more in detail in the chapter 
on the subject. In taking the " present history," however, one of the symptoms 
complained of is often a discharge. In men, we inquire as to the amount, the 
character and time of occurrence of the discharge. If profuse and purulent, 
it points to an acute urethritis ; if very scanty and mucoid, it indicates a chronic 
process. When the discharge is associated with defecation and is glairy or 
glycerinlike, it is due to prostatorrhea or spermatorrhea. In women, a thick 
discharge coming from the vagina, called by some vaginitis, is generally asso- 
ciated with leucorrhea and endometritis, and when accompanied by burning on 
urination, points to a urethritis. In both cases, if acute, the gonococcus should 
be looked for. 



PRINCIPAL SYMPTOMS 303 

Character of Urination. — ^Under this heading, the two chief points to 
be considered are the frequency of voiding urine and any difficulty or irregu- 
larity in voiding it 

Frequency of urination is one of the most important symptoms to be con- 
sidered in urinary surgery, and, next to pain and discharge, is the one princi- 
pally complained of. Frequency, more marked during the day, in men, points 
to stricture, posterior urethritis, prostatitis, vesiculitis, cystitis and vesical cal- 
culus; in women, it indicates cystitis, vesical calculus, urethral stricture, 
urethral caruncle, uterine displacement and growths, and adhesions due to dis- 
eases of the adnexa. Frequency, occurring principally at night, indicates pros- 
tatic hypertrophy and prostatitis, in men; in women, pressure on the bladder 
in certain cases of uterine disease, as fibroma or carcinoma. Tuberculosis of 
the bladder causes frequency of urination both day and night in both sexes. 
Tenesmus at the time of urination, points, in men, to an acute inflammation of 
the posterior urethra, of the vesical neck ; to an acute prostatitis ; to a prostatic 
hypertrophy with congestion or cystitis; to a stricture; to vesical calculus; or 
tuberculosis. In women, it points to cystitis, calculus and tuberculosis of the 
bladder, or urethral caruncle. 

Difficulty in passing urine, in men, points to obstruction as prostatic hyper- 
trophy or stricture ; to vesical calculus, or to atony of the bladder from sclerosis 
of the cord or lesions giving rise to paralysis. In women, the same causes 
may give rise to difficulty, except prostatic hypertrophy, and with the addition 
of cystocele, uterine displacements and prolapse and adhesions to the bladder, 
holding it out of its normal position. Ketention and incontinence of urine will 
be discussed in detail in the chapter on these subjects. 

Character of the Urine. — The patient's impression as to the character 
of the urine is set down under this heading. It enables us to elicit the probable 
presence of blood (hematuria), of pus (pyuria), of a milky substance (chy- 
luria), of a brick-red sediment (uraturia), of ammoniacal fermentation (cys- 
titis), or of sulphurous odor (cystinuria, pyelo-nephritis). Furthermore, a 
general idea of the quantity voided (oliguria, anuria, polyuria), may also be 
obtained from the patient's statement. 

Character of the Menstruation. — On the female card will be seen the 
question, " Character of Menstruation ? " This is not of such great importance, 
but is of some significance, for, although the genital tract in the female is not 
in such close contact with the urinary as in the male, nevertheless they are suf- 
ficiently associated for us to consider the function of the main genital organ. 
An increased flow, or frequency of flow, from the uterus might mean a fibroid 
tumor, an endometritis, or a malignant growth. A cessation of flow might in- 
dicate pregnancy, tuberculosis or change of life. Uterine pain would indicate 
endometritis and displacement, all of which might have an important bearing 
on the bladder of the female., 



CHAPTER XIV 



GENERAL SYMPTOMS 



Before proceeding to the urological examination, which is outlined on the 
chart (Figs. 230 and 231), the general symptoms should be considered and a 
general examination made, more or less minute according to the nature of the 
case. A surgeon, even if he devotes himself largely or exclusively to urological 
conditions, should not neglect to study his patient's general condition in every 
case, and thus avoid that evil of specialization, the overlooking of important gen- 
eral features, in the concentration of his thoughts upon the local condition. The 
patient's appearance, nutrition, gait or posture, the condition of the tongue, 
the character of the pulse, the rate of respiration, the size of the pupils, are 
all signs which offer important diagnostic data and which should never be 
neglected. 

(1) Nutrition. — The size and weight of the individual is important from 
several view points. For instance, tall, spare persons, especially women, are 
more liable to* have movable kidneys, whereas, this affection is usually absent in 
shorter and heavier persons. The reasons for this are fully discussed in Chapter 
XXII. Progressively decreasing weight, in other words, emaciation, may point 
to diabetes ; or when accompanied by local urinary disturbances, to chronic sup- 
purative or tuberculous diseases in that part of the genito-urinary tract. A loss 
of weight is also incident to certain types of chronic nephritis, whereas, an 
extreme form of cachexia would make us suspect malignant disease. 

Obesity sometimes accompanies the earlier stages of diabetes. Increase of 
weight with edettia would at once naturally call attention to renal diseases. It 
may be noted that increase of weight and good muscular development is not in- 
compatible with the presence of nephritis, even in an advanced degree ; and that 
tuberculosis of the kidney in its initial stages, and also when the kidney is half 
destroyed, is seen at times in individuals in apparently perfect health. 

(2) The Skin. — So far as the color of the skin is concerned, a waxy pallor 
is quite characteristic of amyloid kidney, while lesser degrees of pallor occur in 
chronic nephritis. Pallor with a hectic flush, points to tuberculosis, while with 

. pufllness of the eyelids, it points to renal diseases. The pallor of the face of gin 
drinkers, so frequently seen in England, is typical of the nephritis occurring in 
these types of alcoholics. Hepatic disorders, especially those common to indi- 

304 






ODOR 305 

viduals coming from the tropics, are characterized by a yellowish, sallow hue. 
In some diabetic patients the skin is also yellow and peculiarly dry. A sallow, 
yellowish tint is also seen in chronic malaria, while a bronzed hue is character- 
istic of diseases of the suprarenal capsule. 

Along with the color of the skin, we note the condition of the mucous mem- 
brane. The latter is pale in anemic conditions, while the presence of cyanosis, 
represented by blue lips and livid finger nails, would point to badly compensated 
heart disease so frequently associated with renal affections. 

There are a few eruptions of the skin which can be connected with urinary 
disease. In diabetes, we frequently find furuncles and carbuncles, while in the 
advanced stages gangrene may occur. Pruritus occurs in nephritis and diabetes. 
Ecthymatous eruptions, which are sometimes seen on the legs or on other parts 
of the body, occur in patients with constitutional disease which lowers the vital- 
ity of the skin, such as nephritis, syphilis, tuberculosis, alcoholism, etc. 

(3) Posture. — The posture and the gait of the patient may sometimes be of 
value in diagnosis. In ascites, or abdominal tumors, we have a peculiar gait, 
with the body bent backward and the feet spreading widely to aid in the support 
of the added weight. In locomotor ataxia, the well-known, peculiar gait and 
the inability to balance oneself with the eyes closed, is of interest in connection 
with cases of retention of urine and difficult micturition, accompanying lesions 
of the cord. Patients with partial hemiplegia walk with a dragging of one ex- 
tremity and their urinary symptoms are at once referred to the central nervous 
system. Patients walking with a stooping posture, or limping so as to favor 
one side, may be suffering from renal colic, from perinephritic abscess, from 
inguinal adenitis or from epididymitis. 

The position of the patient in bed in renal colic and in perinephritic abscess, 
is such as to avoid the contact of anything with the painful parts. Usually 
the body is bent laterally toward the diseased side. In active renal colic, the 
thighs are flexed and even the upper part of the trunk is bent toward the source 
of the pain. In acute prostatitis and in abscesses about the rectum, the thighs 
are drawn up and the patient sits on one buttock, although he prefers usually 
a reclining position. In vesical pain and difficulty in passing water, the patient 
may squat while in the act of micturition, or stand clutching for some support 
and straining to pass water. These are but a few examples of the various pos- 
tures assumed characteristically by patients with urinary disease. 

(4) Odor. — An abnormal odor discernible on approaching the patient some- 
times gives us a clew regarding the trouble. Thus an ammoniacal odor points 
to incontinence of urine, usually from some obstruction, such as stricture or 
prostatic enlargement or from atony of the bladder due to diseases of the spinal 
cord. A necrotic odor points to the presence of sloughing or gangrenous condi- 
tions affecting the lower part of the tract, or to sloughing venereal ulcers or 
warts. 



306 GENERAL SYMPTOMS 

(5) General Behavior. — The general behavior of the patient is often of 
value in leading us into the right channel for diagnosis. Neurasthenic patients 
exhibit a peculiar uneasiness, with purposeless movements, such as shifting the 
legs, etc. ; they easily flush and pale under questioning, their speech is at times 
thick and hesitant. In hysteria, a vague absent-minded expression of the face, 
a lack of consecutive expression of thought, a rambling speech, often very volu- 
ble, and either extreme anxiety or an unaccountable levity are noted by the 
physician. In sexual neurasthenia, there is usually a touch of melancholia and 
a hypochondriacal tendency to exaggerate all symptoms and to draw a very 
dark picture of the complaint. Thus, from the very appearance of the patient, 
we are often led to think of the possibility of disturbances in the genital organs 
connected with urinary disease. 

In bed-ridden patients, the condition of the mind in such states as uremia, 
urinary fever and sepsis needs attention. The details will be found in the 
appropriate chapters. Here we may mention merely the confusion of ideas, 
the drowsy apathy and the gradual clouding of sensation in uremia. 

(6) The Tongue. — The patient's tongue has a bearing upon the general con- 
dition, though it may not necessarily show anything connected with his urinary 
organs. We may mention, however, the dry, coated tongue of the typhoid state 
accompanying septic conditions (urinary fever, septicemia, pyemia), and that 
a dry tongue should always indicate a serious condition in urinary diseases, 
before as well as after operations on the urinary organs. 

(7) Pulse and Temperature. — The pulse and temperature are to be taken 
in every case in which constitutional trouble is suspected. A rapid pulse with 
high tension would lead us to think of renal trouble, although a patient may have 
normal blood pressure when uremic; a pulse increased in rapidity but not in 
tension, is found in urinary fever or sepsis. A feeble pulse, a dicrotic and easily 
compressible pulse, or, on the other hand, a bounding pulse, may be seen in 
valvular affections of the heart complicating nephritis. 

Whenever fever is found to be present, we should first of all seek the source 
of the rise of temperature by making a careful routine examination of the 
urinary tract The blood should be examined for malaria and typhoid fever 
when fever occurs for any length of time. Many patients are treated for malaria 
for a long time when in reality they are suffering from suppurative renal dis- 
eases or from complicated renal calculus. Fever occurring in a patient leading 
a catheter life or after other instrumentation, would at once arouse the sus- 
picion of urinary fever or sepsis ; the same may be said of fever occurring after 
an operation on the urinary tract. Acute febrile attacks in patients with urinary 
disease, who have previously been in apparently good health, usually point to 
the prostate gland, some complication of the urethra or the kidney. In the 
ordinary form of nephritis, there is no elevation of temperature; but there is 
a distinct febrile movement in the suppurative nephrites, including pyelo- 



RESPIRATION 307 

nephritis, pyonephrosis, abscess of the kidney and stone or tuberculosis in the 
kidney complicated by secondary infection, etc. In abscess of the kidney, the 
temperature may range from 99° to 105° F., falling abruptly when the abscess 
ruptures. In pyelo-nephritis, the range is lower and the type more chronic. 
In pyonephrosis, the type is often of a remittent typhoid character or so 
markedly intermittent as to simulate malaria. When the pus is discharged from 
the kidney after having been retained for a time, there is a remittance or an 
intermittence of fever. In suppurative conditions of the kidney in which there 
is a sudden obstruction to the outflow of pus, as in stone, the fever may set in 
sharply with a chill, followed later by sweating. 

In perinephritic abscess, the patient runs a septic temperature with all its 
characteristics, including great emaciation. Movable kidney may also be ac- 
companied by chills and fever, occurring from time to time if pyelitis is present 
In acute nephritis, there may be an onset of chills and fever and a rise of tem- 
perature throughout the disease. 

There is no characteristic temperature in uremia. When this condition is 
associated wuth acute or chronic inflammatory or suppurative states in the kid- 
ney, the fever of the nephritis dominates the scene. A subnormal temperature 
may be observed during the uremic attack itself. 

In prostatic inflammations, a rise of temperature may be noted, especially 
in the acute form of prostatitis, which is usually ushered in by a chill. During 
the abscess formation, profuse sweating may take place, especially at night. 
Cases of chronic abscess of the prostate may be unaccompanied by fever, or 
only give rise to a very slight febrile movement. In periurethral inflammations, 
sepsis of a varying degree, with or without chills, shows itself, depending on 
the extent and character of the inflammation. Sweating generally accompanies 
these cases. The presence of both pus and urine in the cellular tissue, as in cases 
of urinary extravasation, gives rise to the most severe and fatal sepsis. 

(8) Respiration. — The rapidity and character of the respiration may be al- 
tered in the course of certain urinary diseases. Marked dyspnea may accom- 
pany chronic interstitial nephritis, especially in uremic patients. Rapid and 
shallow respiration may be noted in perinephritic abscess, after injuries of the 
kidney (rupture of the organ), or as a result of the pressure of a large kidney 
upon the diaphragm. The Cheyne-Stokes breathing, noted in interstitial nephri- 
tis with heart disease and in advanced cases of uremia, must also be mentioned. 
Complicating pleurisies or broncho-pneumonias, such as occur in septic patients, 
will, of course, increase the rapidity and alter the character of the breathing. 



CHAPTER XV 



EXAMINATION OF PATIENTS 



It 18 my desire in this chapter to outline the steps in the examination of 
male and female patients in as imiform a manner as possible. The result of my 
study of the different methods of examination, in hospital, clinic and private 
practice, has led me to outline the following system as being at present the most 
convenient for the imiform urological examination of male and female patients. 
Doubtless in the near future, as this specialty develops, better methods will be 
established. 



UROLOOICAT. EXAMINATION OF TATIKNTS 

Position of Patients during Examination 



(1) Patient at 
full length •« 
on table 



Male 

Abdomen. 
Kidneys. . 
Bladder. 

External genitals. 
Discharge (smear). 



^ 1st urine. 

/^v -n. . 2d urine. 

(2) Pataent p^^^^^^^ 

standmsr ^ . , 

^ Vesicles. 

^ 3d urine. 



(3) Patient at 
full length 
on table 



Urethra. 
Bladder, 
4th urine (residual), 



Female 



(1) Patient at 
full length 
on table 

In gynecolog- 
ical position 

(2) Patient 
on commode 



(3) Patient in 
gynecologic- 
al position 
on table 



i 



' Abdomen, 
Kidneys. 
L Bladder. 

External genitals. 
Discharge (smear). 

1st urine. 
2d urine. 



/■ T-r, 



Uterus. 
Tubes. 
Ovaries. 
Urethra. 
Bladder. 
^ 3d urine (residual). 



Examination of the Abdomen. — When the abdomen is examined, the pa- 
tient should lie on the table full length, with the legs extended (Fig. 232). The 
examination of the abdomen is practically the same in both sexes. The upper 
zone, including the liver, stomach, spleen and kidneys, is first palpated, and 

308 



EXAMINATION OF THE ABDOMEN 





LA BORA TO KY 


REPORT Oy 


URIKE AND DISCHARGES 




Clear or cloudy. 




Color. 




Odor. 


Reaction. 


Specific gravity. 


Albmiiin. 




Sugar. 




Urea. 


lutliean. 


Total solids. 


Crystals. 




Mucus. 






Connective tissues. 




Red blooil. 




White. 






ilicroorganisnis. 




Epithelia. 














Casta. 










OtliLT fciitiirea. 




Discliarge (sincar) 












Remarks on uriue i 


md <lisc-li 


argcM 


,: — 






Treat. 















then the lower zone, incliidiiig the siiprapnbii- anil inguinal regions. An en- 
larged liver with a toiigiic-sliH|)ed right lobe, is very fretjiieiitly mistaken for a 



Fia. 232. — Patient Ltino at Fcll LE^ 



Firat step in thp 



of the malA. 



kidney, as is an abscess or a hydatid cyst of that organ, as well as enlarged gall- 
bladder. There is also a variety of enlarged aplecn, with a well-rounded lower 
border, that we should guard against, as it resembles clearly a kidney, as 
do also abdominal granuloma, enlarged postperitoneal glands and tumors formed 
in tubercular peritonitia. 

In urologj', however, the palpation of the kidneys is the most important. If 
they are normal, they cannot be felt and the examination is not accompanied 
by any pain or tenderness. If some surgical trouble is present, they can gener- 
ally be outlined and may be tender on pressure. Tenderness is often not present 
even in kidneys that arc badly diseased. 

A counterbalance table, which is used for all our examinations, gives the 
patient every position, from a lying to a sitting posture. It is well to examine 
the kidneys first while the patient is lying flat, with the logs extended (Fig. 2-331, 
and then with the knees flexed; after this, the back of the table is gradually 
raised until the patient is in a sitting posture (Fig. 234). During these move- 



310 



EXAMINATION OF PATIENTS 




Fig. 233. — Examination op the Kidneys, the Patient Lying Flat. 




Fig. 234. — Examination of the Kidneys, the Patient in the Sitting Posture. 



EXAMINATION OF THE ABDOMEN 311 

RietitB, the examiner should stand on the side of the patient adjacent to the kid- 
ney he is examining. If on the right side, he should have his right hand in 
front on the outer side of the rectus muscle and the left hand on the hack below 
the twelfth rib. The position of the examiner and his hands should be exactly 
reversed in examining the other side. If the examination in the dorsal position 
is not satisfactory, the patient is placed on the healthy side with the knees 
slightly flexed, thus allowing the organs to fall toward the healthy side {Tig. 
235). The object of bimanual palpation is to feel the kidneys between the 



FlQ. 235. — EXAUINIKO IHB KlDNET, WITH TBE PaTI«KT LTIMO ON TH« HbaLTBT SxDB. 

fingers of the two bands. Therefore, the patiput should be instructed to breathe 
deeply, thus increasing the extent of the renal excursion. With every expira- 
tion, the fingers are pressed more deeply in until the kidney region is reached. 
The examiner must not press hard when examining for a movable kidney, as 
it will slip away without his being able to detect it. If the kidney is enlarged, it 
should be ballotted between the bands, as in this way its size, shape and con- 
sistence can be better determined. Sometimes it is advisable to have the patient 
stand during examination. 

In my experience, the variety of kidneys that we are more often called on 
to treat are the movable, the tuberculous, the calculous and the so-called surgical, 
pyelo-nephritis following cystitis. In these cases, the organ is often tender 
and increased in siza In marked cases of hydronephrosis, pyonephrosis and cys- 
tic kidney, the mapping out of the organ is even easier. 

In the lower zone of the abdomen, we may encounter tumors, appendicular 
or intestinal fecal accumulations, an enlarged bladder, with residual urine, and, 
in women, a gravid uterus, tumors of the uterus and adnexa, exudations and 
abscesses due to diseases of the tubes, periurethral and extraperitoneal suppu- 
ration. 



312 EXAMINATION OF PATIENTS 

Examination of the External Genitals. — Male Genitals. — I notice first 
the size and shape of the organs, whether they are well formed or misshapen 
(epispadias, hypospadias, etc.). The condition of the prepuce, the presence or 
absence of such lesions as nodules or ulcerations, verrucae, abscesses, lymphan- 
gitis are noted. 

The meatus is next inspected, it being noted whether it is large or small, 
normal or distorted. An induration at the meatus, with the lips pressed together, 
may indicate the presence of an initial lesion of syphilis, or if ulceration is pres- 
ent, a chancroid infection may be suspected. The presence of urethral discharge 
is also noted at this inspection and a smear should be taken for microscopic 
examination. This is done by sterilizing a platinum wire loop by heating it red 
hot over an alcohol lamp, cooling the loop and taking a drop of the discharge 
from the meatus upon the loop. The discharge is quickly smeared very thin 
upon a clean glass slide, bearing a label with the patient's name or number. 

In each of the examining rooms, a compact equipment is provided for taking 
smears, etc. Slides are kept in a wide-mouthed bottle. A glass rod with a 
platinum loop and an alcohol lamp are also on hand on each table. The loops 
are used for obtaining urethral, cervical, vaginal or other discharges which are 
smeared on the slides in a thin layer. The platinum loop is heated to a red glow 
before and after taking each smear. 

If the discharge is very scanty, it is sometimes possible to obtain a sufficient 
amount by milking the urethra from behind forward and expressing its contents 
into the fossa navicularis, where it can be taken up with a loop. 

Caution must be observed in drawing hasty conclusions as to urethral inflam- 
mations in the presence of a discharge, as many cases of persistent urethral dis- 
charge are due to the presence of an initial lesion or other infection which we do 
not yet understand. 

The urethra is further examined by external palpation along its entire length, 
the presence of nodules, indurations, swellings, abscess formations or fistulj© 
being noted. The testes are next palpated, tenderness, enlargements, nodules, 
etc., of testes, epididymis or cord being noted, indicating the existence of inflam- 
mation, tuberculosis or syphilitic processes, the beginning of malignant tumors, 
etc., as well as the presence of hydrocele, varicocele or hernia. 

Female Genitals. — In order to examine the external female genitals, the 
patient must be brought down to the edge of the table in the gynecological posi- 
tion (Fig. 236) and the same conditions must be looked for as in the male, 
viz. : deformities, swellings, nodules, ulcerations, verrucae, abscesses and lym- 
phangitis. The glands of Bartholini are pressed upon to see if there is a 
purulent discharge from the ducts. The presence of vaginal discharge is noted 
and a smear taken if it is .present. The labia are then separated and the vesti- 
bule sponged with a bichlorid solution, 1 : 5,000. The forefinger of the left hand 
is then inserted into the vagina against the urethra at the point where it leaves 



EXAMINATION OF THE ^AT-E PATIENT STANDING 



313 




the bladder and is then drawn down toward the meatus, making pressure all 

along the canal. In case discharge is seen, it is taken on a slide if there is 

sufficient quantity, otherwise a 

platinum loop is inserted into 

the meatus and an effort made 

to secure a specimen (see 

chapter on Discharges). 

Note. — So far tlio exam- 
inations have been on the 
table in both sexes; but they 
must now be considered sepa- 
rately on account of the dif- 
ference in the anatomy of the 
sexes, I will, therefore, first 
give the procedure in the case 
of the male and then take up 
that of the female. 

Examination of the Male Patient Standing. — The Fibst Ubine. — The 
patient is next directed to stand up and is handed a glass cylinder hy the exam- 
iner. Into this he is instructed to pass a portion of his urine (Fig. 237). Fre- 
quently in the embarrass- 
ment caused by the exam- 
ination, or for some other 
psychical reason, the patient 
is unable to urinate prompt- 
ly at this moment In order 
to aid him as much as pos- 
sible, two measures may be 
adopted. The first is to leave 
him to himself, the second ia 
to allow a thin stream of 
water to trickle from a fau- 
cet in the room in which he is 
being examinee^. This acts 
on the motor centers of the 
bladder through the mental 
impression which su^ests 
F,o.337.-Male Patient Uhin^tino IN *Gi.a«,Ctlindbb. "^nation through the very 

soimd of the stream of water. 

The size, shape and force of the stream is noted, if possible, when the patient 

passes water. A healthy man with a normal urethra and bladder passes a fairly 

large stream^ projecting from his body at a distance of from three to five feet 



314 



EXAMINATION OF PATIENTS 



when standing up. A man with a small meatus has a smaller, but usually a 
forcible stream. A sudden interruption of the stream which begins normally, 
often points to the presence of stone in the bladder. On the other hand, a stream 
which slowly becomes smaller and less forcible points to either some obstruction, 
such as stricture, prostatic enlargement, acute congestion of the prostate, acute 
or chronic prostatitis, or to a lack of tone of the bladder. Further details as to 
the character of the stream will be found in the chapter discussing the subject of 
urination. 

After the first urine is passed, it is held up to the light to see if it is light 
or dark, clear or turbid, and examined for pus, shreds and mucus. The signifi- 
cance of these various elements is considered more in detail under the subjects 
of urine and discharges. 

Second Urine. — The patient is then handed a second glass cylinder, of the 
same size and shape as the first, and is asked to void a second portion of his urine, 
but is warned not to pass the entire contents of his bladder. The second urine 
is inspected in the same way as the first, any cloudiness, shreds or a deposit of 
pus, etc., being noted. 

Prostate and Vesicles. — The patient is then told to bend forward. He 
leans over, resting on his hands placed on a table. The body is at an. angle of 









C 

Fio. 238.- 




A, finger cot unrolled. 

B, finger cot rolled up. 



-The Finger Cot. 

C, piece of gauze to wind about the finger. 
Z>, the hand with the finger cot on the forefinger 
and the piece of gauze wound about it. 



135 degrees to the perpendicular. The examiner places a finger cot on his fin- 
ger (see Fig. 238) and winds a piece of gauze about the base of it to keep 
his finger clean. He then sits behind him and inserts the forefinger of the right 



EXAMINATION OF THE MALE PATIENT STANDING 



316 



hand into the rectum and examines the prostate. He then presses the fore and 
middle finger of the left hand into the groin of the patient, thns pushing the 
vesicle down against the examining finger (Fig. 239). It is strange that much 
experience ia necessary to examine well the internal genitals, hut such is the 
case. The examiner notes the outline of these organs, the presence of nodules, 




Fra. 239. — Examination bt Rectum. The patient louis over the table and the e: 

right foreGiiEer into the rectum, presses the finiters of the left hantl into the stoin, and palpates 
the vesicles bimauually. 



depressions, as well as the general consistence and tenderness of the parts. A 
hard prostate, either normal or small in size, may give rise to frequency of uri- 
nation from a cause which cannot as yet be determined, though probably owing 
to pressure exerted by a very tense external capsule, A prostate which is soft 
and bc^gy indicates a chronic prostatitis, in which case the gland has become 
atonic. Nodules in the prostate show local areas of follicular inflammation or 
simple chronic or tuberculous prostatitis. An intensely tender, hot, swollen, en- 
larged turgid gland, with one or both lobes involved, is characteristic of acute 
prostatitis. An enlargement of the gland in young men without the acute signs 
just mentioned, but usually with nodular swellings, points to a tuberculous proc- 
ess. In elderly men, an enlargement usually indicates prostatic hypertrophy, or 



316 



EXAMINATION OF PATIENTS 



else malignant growth. A shrunken prostate, with an irregular outline and with 
depressions or softened areas, shows the seat of former abscesses which have 
destroyed a part of the prostatic tissue. 

Engorged, thick, tender vesicles point to an acute vesiculitis. Moderately 
distended vesicles with the walls not so thick, although tender, point to a sub- 
acute process, or to congestion, with some retention of vesicular secretion. When 
the vesicles are tender and cannot be outlined, they are probably simply con- 
gested. 

In the chronic condition, vesicles have thickened, atonic walls perhaps full 
of vesicular secretion and inflammatory products, due to a subacute inflamma- 
tion probably associated with a thickening of the neck of the vesicle or pressure 
on the ejaculatory duct by the prostate. The vesicles often have a pasty feeling 
and dent in when pressed with the finger as if full of cheesy matter. Nodular, 
irregular vesicles are the result of chronic inflammation, in consequence of which 
there has been a retention of vesicular secretion. Localized thickenings in cer- 
tain parts of the vesicles are due to stricture or scar tissue ; they may also be 
due to tuberculosis. Small vesicles, hard and irregular, are the result of chronic 

inflammation and partial destruction. If this 
destructive process goes on still further, they 
will probably atrophy until they cannot be felt. 
Third Urine. — During the examination of 
the prostate and vesicles, the organs are gently 
massaged with the finger (Fig. 240). When 
the finger is withdrawn, the patient is instructed 
to void the remainder of his urine in a third 
cylinder. This third urine represents the con- 
tents of the bladder plus the material massaged 
from the prostate and the vesicles into the pos- 
terior urethra. We are now ready, with the 
three cylinders of urine before us, to compare 
them and to draw such conclusions as may be 
warranted from their appearance. 

The first urine contains the washings of the 
urethra plus any elements from the kidney, ure- 
ter and bladder that may be present. The sec- 
ond urine represents that from the bladder, 
ureter and the kidney alone, as all the products of 
inflammation that were present in the urethra 
were washed out by the first urine. The third 
urine, as we have seen, contains, in addition to the second urine, the elements 
massaged from the prostate and vesicles. 

The urines are then sent to the laboratory for examination. 




Fio. 240. — Massage of the Pros- 
tate. The arrow shows the di- 
rection in which the tip of the 
forefinger, moves in this maneu- 
ver. 



•8= S 

at i 



111 I 

.9 S 5 I ■* 

I t I S f 

s I a -a J 



0Jl 



.a S J 



■BasS-s i£a 



i- : 1 1 

S'^^ al &s S ^S 



II "I'll 



EXAMINATION OF THE UKINES 



317 



Examination of the Urines. — The following table represents the chief pos- 
sibilities encountered in examining the three urines at the time the patient passes 
them and indicates in each case the significance of the findings. 



First Urine. 



(1) Clear. 

(2) aear. 



Second Urine. 



I Tv.:-j T'*;n^ Summaiy. 

Third tnne. A (What they »how: parts in- 

{ After massage of the prostate.) ^ volted ) 



Clear. 
Clear. 

Clear. 



Normal urine. 



(3) Qear (small float- 

ing mass, clear) : 

(4) Clear, with heavy Clear. 

shreds. 

(5) Turbid, heavy, Clear. 

shreds. 

(6) Clear, heavy Clear. 

shreds. 

(7) Turbid, heavy Clear. 

shreds. 

(8) Turbid, no shreds. Turbid. 



Clear. 

Slightly opaque, with Prostate. 

dibris. 
Slightly opaque, with 

d^bns. 
Clear. 



(9) Turbid, with 
shreds. 

(10) Turbid, shreds. 



Turbid, shreds and 
flocculi. 
(11) Turbid, shreds. | Turbid, shreds. 



No shreds or flocculi, 
turbid. 



Clear. 

Cloudy, with debris 
Opaque, debris. 
Turbid, no debris. 
No debris, turbid. 

No debris, turbid. 
Turbid, with debris. 



Prostate and vesicles. 
Chronic urethritis. 



Chronic urethritis. 

Urethra, prostate and 
vesicles. 

Chronic urethritis, pros- 
tatitis, vesiculitis. 

Pyuria, bladder kidney 
or both. 

Urethra, bladder, kid- 

• ney or both or phos- 
phaturia. 

Urethra, bladder or kid- 
ney. 

Urethra, bladder pos- 
sible, kidney possible, 
prostate or vesicles, 
phosphaturia. 



This table is quite difiicult to understand. We should first eliminate phos- 
phaturia. If the urine is turbid, therefore, a small amount is poured into a 
test-tube and a little acetic acid is added. If the turbidity is due to phosphates, 
it will at once disappear. This test should be performed whenever both the first 
and second urines are opaque. 

If the urine does not become clear with the acid, another portion of it is 
poured into a test-tube and is shaken with some liquor potassa?. If the turbidity 
is due to pus, a thick coagulum will form and sink to the bottom, leaving a 
clearer upper portion. 

In order to differentiate between inflammatory products massaged from 
the vesicles and those obtained in the third urine? from the prostate, we should 
note the following points: — 

Urethra : 

Urethral shreds. 

Prostate : 

(1) Plugs or comma-shaped bodies are from the mouths of the ducts. 

(2) White thick masses in turbid urine, coming from the dilated and chron- 
ically inflamed ducts. 

Vesicles : 

(1) Sago bodies consist of the coagulated secretion of the vesicles that have 
become molded in the convolutions of the vesicles. 



318 EXAMINATION OF PATIENTS 

(2) Sugar granules, amber colored (or colorless) bodies resembling sugar 
granules. Of the same material as the sago bodies but firmer in consistence, 
not so abundant and smaller. 

(3) Spermatozoa, alive or dead, whole or in broken pieces. 

(4) Plugs of pus coagula mixed with epithelia from the vesicles. 

(5) Membranous flakes that resemble small pieces of skin or membrane 
looking like egg membrane, white in color, consisting of a deposit on the walls 
of the vesicles, of sufficient thickness to come away in pieces. 

(6) Snowflahes, light particles resembling snowflakes, not as heavy as the 
larger flakes. These are recent deposits which have not become formed as a 
membrane. 

The different formations from the vesicles are probably composed of the 
same material, principally globulin, and differ mainly in the length of time 
that they have been secreted and deposited on the mucous membrane of their 
walls ; in the quantity in which they have been secreted ; whether suddenly in 
large amount, or slowly in small quantity ; and whether the secretion is pure 
or mixed with large amoimts of epithelia, spermatozoa, pus and other products 
of inflammatory exudate. After massage and after being allowed to settle in 
a glass alone or mixed with prostatic fluid, or urine, they lose the characteristic 
shapes that they have on escaping and become a blended gelatinous deposit. At 
times, casts of the vesicles are passed after massage, an inch or more in length, 
from one or both vesicles. The casts may be of sufficient size to block the 
urinary stream. It is hard to understand how masses of this size can es- 
cape from the ejaculatory ducts, for I have seen them of the size of a leech, 
so that for a moment the patient's urine would stop and the mass would 
suddenly be expelled with force, followed at once by the remainder of the 
urine. 

Urethral Examination {the Patient on the Table at Full Length), — In ex- 
amining the urethra, I stand on the patient's right. The urethra is first palpated 
by holding the penis in one hand and palpating the outside of the canal with 
the thumb and forefinger of the other. In this way, a follicular induration or 
inflammation, associated with a urethral follicle, a periurethral abscess, scar 
tissue, a foreign body or stone in the canal, may be detected. 

The canal, unless it is acutely inflamed, is then examined with instruments : 
bougies a boule, sounds, catheter or filiform. I first sponge the meatus with 
a cotton ball soaked in bichlorid 1 : 1,000, then take in my right hand a bougie 
a boule (Fig. 241) about the size that I think will just enter the meatus. I dip 
its end into a bottle of glycerin and steady the organ with the fingers of the left 
hand placed on either side of the corona. I then insert the instrument through 
the meatus. In case it will not enter, I take up smaller ones until I find one that 
will pass in easily. If the first instrument passes easily, I go up the scale until 
I find the largest that will go to the bulb. I register the number of the instru- 




I :i 

1 It 

2 si 



1 oS 

1 lis. 
^ -^ f 






I "-•is ^ 
I "^ -i 1 1 

filial 

£5 ° I S'i 

If IliJ I- 

o I S'i 1 1 

S^ i si a 



i .= 1 1 1 
1 1 1 1 1 

; i i 1 1 



URETHRAL EXAMINATION 



319 



ment that passes the narrowest point or points of the canal and the distance of 
these narrowings from the meatus, 

I then take a sound corresponding in size to the bougie a boule, with a short 
beak, and pass it into the urethra following the upper wall. If this glides 
easily into the bladder, I register " Ure- 
thra No. — at meatus " or whatever dis- 
tance from it the narrowing may be and add 
" Sound No. — passes easily into bladder." 

In case the smallest bougie a boule (No. 
6 French) does not pass to the bulb or that 
a sound of that size does not pass through 
the remainder of the urethra, the locality of 
the impediment must he registered. It will 
then be necessary to pass a smaller instru- 
ment — a filiform bougie No. 1 or No. 2 
(Fig. 242). 

If the filiform passes the point of nar- 
rowing at which the larger instrument 
failed to pass, it will be spoken of as a fili- 
form stricture. In case the filiform fails to 
pass, the impediment will be spoken of as 
an impassable stricture. 

When the patient passes a fairly good 
stream and yet a filiform cannot be passed, 
the location of the impediment must be con- 
sidered. If it is in the <ieep or bulbous 
portion of the urethra, the instrument may 
have entered a pocket, in which ease, by in- 
serting a filiform with a spiral end like a 
Xo. 2 and rotating it slowly during its in- 
troduction, the end may pass along the ure- 
thra by the pocket without sliding into it. In 
case the impediment is in the posterior ure- 
thra and the remainder of the canal is larger, it is probably not a stricture, but 
an enlarged or deformed prostate. If the patient is an old man, the condition is 




la, 341— Thb Bouoib \ E 
in(i dowk the t^rethoa 
Strictubbd Abba. 



FiQ. 242. — FiL[FoHM Bora:Ka. 
. 2, with a apira] end. No. 3, with a bend near the ei 



320 



EXAMINATION OF PATIENTS 



probably hypertrophy and a small coude catheter would pass over the impedi- 
ment and into the bladder : while if the patient is a young man who has had a bad 
attack of prostatitis, the impediment would probably be the result of a prostatic 
abscess, a cavity or an irregularity which prevents the entrance of the instru- 
ment. As these conditions are usually in the floor of the urethra, a coude cathe- 
ter which tends to hug the roof of the canal may pass through into the bladder. 
At times the anterior urethra is of large size with smooth walls and the sound 
goes up against an impediment at the bulb or at the neck of the bladder. In 
such a case, we must think of a spasmodic stricture of the cut-off muscle, de- 
pendent on an inflamed condition of the prostate or prostatic urethra in the first 
instance, whereas, in the second instance, of spasm of the vesical sphincter due 
to an inflammation of the bladder neck. In such cases, an instillation of cocain 
solution, or nitrous-oxid anesthesia, may be used in the examination. If noth- 
ing can be passed through a urethra under anesthesia and the patient is able to 
pass some urine although he has symptoms of urinary obstruction, no further ex- 
amination can be made in his case excepting of his urine, and he should be sent 
to the hospital or home for further observation. A few days' rest in bed under a 
treatment of hot sitz baths, diluents, a liquid diet and a large amount of water, 
will probably so change the character of the impediment as to allow some instru- 
ment to pass. Such cases represent, however, a minority of those which come to 
our office. The majority of the cases have urethras of a fair size, that is, over 
15 French. 




Fio. 243. — The Examiner Looking through the Urethroscope at the Urethral Bulb. 



If the patient has but a slight chronic urethral discharge and the canal is 
over 20 French in size, the urethroscope is frequently used at the first visit, 
especially with patients from out of town or those who are accompanied by their 
physicians. 



COMPLETION OF THE EXAMINATION IN WOMEN 



321 



In this case, the urethroscope (Fig. 243) is dipped into glycerin and intror 
duced in the same way as a bougie a boule. The mandrin is then withdrawn 
and a cotton swab is inserted to drv the interior of the tube and the urethra. 
A light carrier is then introduced and connected with the rheostat on the wall at 
the side of the table. By this means, polypi, ulcers, erosions and granular 
patches can be seen and noted on the history card. This particular instrument is, 
I believe, better than any of the other straight tubes for examining the poste- 
rior urethra, on accoimt of the curve near its end, and it is tilted down and 
pushed gently in, hugging the upper wall of the urethra. If it is pushed in too 
far, it will enter the bladder and a gush of urine will follow, in which case, it 
should be pulled dowTi below 
the sphincter, when the flow 
will stop and the posterior 
urethra can be examined. 

Completion of the Ex- 
amination in Women. — 
The first part of the exami- 
nation in women, including 
the abdomen and external 
genitals, was concluded in 
the early part of this chap- 
ter. It now remains to 
obtain specimens of the 
urine and to examine the 
internal genitals. The pa- 
tient is asked to step be- 
hind a screen and to seat 
herself on a commode 
and void urine (Fig. 244). 
The bucket of this com- 
mode has been removed 
and a large funnel put in 
its place, below which a 
glass is placed, in such a 
position that, when the pa- 
tient voids the first urine, it enters the funnel and runs through it into the cylin- 
der below. The nurse then removes it through a door in the side of the commode, 
places a second glass under the funnel and then asks the patient to pass the re- 
mainder of her urine. The nurse then carries the specimens to the examiner, 
who inspects the two specimens before sending them to the laboratory. If the 
first specimen is clear and there are no shreds, it will show that the urethra, 
bladder and kidneys are free from any marked suppuration. If the first is clear 




Fio. 244. — Female Patient Sitting on a Commode. A glass 
funnel is beneath the seat. Bdow the funnel is the glass 
cylinder. 



322 EXAMINATION OF PATIENTS 

with shreds and the second is clear without shreds, it will show a mild urethritis. 
If the first is turbid with shreds and the second is clear, it will show a more 
acute type of urethritis with no other involvement. If the first and second urine 
are both turbid, it will show pyuria or phosphaturia which can be determined by 
the rapid clinical tests of the examining room. If it is pyuria, the source of 
the pus will be determined by the laboratory examination. 

The female patient is then returned to the table, where the examination of 
her internal genitals is continued. (See Fig. 236.) Her perineum is examined 
for lacerations and any cystocele or rectocele noted. The uterus is palpated to 
discover any laceration of the cervix, tenderness, induration, enlargement or dis- 
placement of the organ, free mobility or fixation or the presence of a tumor. The 
ovaries and tubes are then examined for tenderness, enlargement or displacement. 
Exudates of a varying degree, depending upon metritis or salpingitis, are of the 
greatest importance. The speculum is then introduced and the cervix inspected 
for lacerations, ulcerations, or the presence of discharge or hemorrhage. Uterine 
displacements or prolapse, fibroma or carcinoma, or adhesions due to inflamma- 
tion of the adnexa, are all important on account of interfering with the functions 
of the bladder as well as predisposing to cystitis. 

The routine examination of the urethra and bladder is the same in women 
as in men, although, in the former, the passing of instruments is much easier 
owing to the absence of the prostate gland. Urethral lesions are not so com- 
mon in women as in men, but, although strictures are not usually looked for, 
they are more frequently present than is generally supposed. 

Diseases of the bladder are not so common in women, the most frequent being 
tuberculosis. Female bladders, however, are much affected by the condition of 
the surrounding organs and often to a sufficient degree to give rise to the great- 
est suffering and inconvenience. 

Records. — With each history chart, is filed the diagram of the urinary tract 
represented in Figs. 1 and 2 in the chapter on Anatomy, on which any lesions 
found are marked so as to be visible at a mere glance. These diagrams were 
made from a dissection, made at the New York Post-Graduate School (Guiteras, 
Philadelphia Medical Journal, June 2, 1900). 

The examination having been completed and a tentative diagnosis made, 
the line of treatment indicated is recorded on the back of the card and changes 
made on subsequent visits are appended. If an operation is performed, it is 
described and a pathological report of anything removed is added. 

The report of the urinary analysis made from a twenty-four hours' specimen 
is also attached to the history card represented in the chapter on The Urine. 

The entire documentary record of the case, including copies of the corre- 
spondence with the patient or with the family or physician, is filed in an envel- 
ope in a vertical filing case, in alphabetical order. In this way anything per- 
taining to each case is instantly available for investigation. 



CHAPTER XVI 



UROLOGICAL THERAPEUTICS 



In the treatment of patients, the first thing that is expected of a physician is 
a prescription for medicine ; in fact, it seems to be the general idea that every 
symptom indicates a disease that should call for a specific drug. It is true that 
there are certain drugs that are specific ; but in urology proper, no drug has yet 
been found that can be considered as such. It seems, in this branch more than 
any other, that it is important to keep the patient in the best physical condition 
by regulating the diet, digestion, bowels and the amount and variety of exercise 
in those who are up and about ; to protect the surface of the body by suitable 
clothing; and to keep the function of the skin as perfect as possible. Drugs 
should be prescribed to assist nature when functions of certain parts are at 
fault; to reduce congestion and inflammation when necessary; to stimulate 
when the tissues are weak ; and to counteract and destroy infections. 

DIET 

Diet is one of the most important factors in treatment. Many people suffer 
through errors of diet. A visit to health resorts, where people are cured simply 
by leading a regular life, resting or exercising, according to the case, following 
a simple diet and drinking a certain water, or bathing — without taking a drug 
— is a strong argument in favor of the fact that drugs are not always necessary. 

Simple Diet. — Simple food that is easily digested and assimilated, and does 
not give rise to irritating by-products, is then a most important remedy in the 
treatment of disease and especially in urology. A milk diet alone, or combined 
with some mild alkaline water, is the simplest of all diets. Such a one should be 
prescribed in acute nephritis, the severest of all diseases pf the urinary tract. 
It should also be ordered in chronic nephritis, when uremia is threatened or 
present. It can be prescribed to patients suffering from acute parenchymatous 
prostatitis and in prostatic hypertrophy, or in stricture cases, when retention is 
present, due to congestion. It is also recommended in all complications due to 
infections of the urinary tract. 

Simple diet for the patients who are up and about their regular pursuits of 
life, is quite liberal. In this case, fruit, cereals, bread, eggs, milk, fish and shell- 
fish, meat, green vegetables, salad and cheese are regarded as simple diet. It 

323 



324 UROLOGICAL THERAPEUTICS 

is only necessary to eat in moderation food simply prepared ; to take a variety 
rather than too much of any one kind ; to see that the food is prepared in a 
simple and digestible manner ; to avoid stimulants, condiments and rich dishes. 

I think that most of us would be in better condition if we ate nothing fried, 
nothing sweet, no condiments and did not use alcoholics, tea, coffee, or tobacco, 
but such would hardly be practicable in our present manner of living. 

Fruits. — Fruits should be eaten at the morning and midday meals, rather 
than at the evening repast. For breakfast, orange, cantaloupe, peaches, baked 
apple and grape fruit are preferable ; whereas, for the midday meal, any of the 
same varieties can be used, as well as apples, pears or plums. Xo sugar should 
be eaten on the fruit. 

I do not consider berries healthful, as they frequently irritate the intes- 
tines, especially strawberries, although some consider this mechanical irritation 
good in case of constipation. 

Stewed fruit is considered healthier than raw, but is usually too much 
sweetened. 

Cereals. — Cereals are usually taken at the morning meal and eaten gen- 
erally with cream and sugar. They are often rich in starch and oils, and are 
made richer by the addition of sugar and cream. Personally, I think it is a 
mistake to put cream and sugar on cereals, and that it is better to use salt 
and milk. I do not look upon cereals as a necessary breakfast food, but if they 
are to be partaken of, I advocate those made from corn, barley, or oats, rather 
than the wheat products. 

Eggs are the most nourisliing and most easily digested of the nitrogenous 
foods that can be taken, and should be eaten eitlier soft boiled, poached or 
shirred, for breakfast or lunch. 

Bread. — Bread from the ordinary loaf is not advised, unless it is toasted a 
day or so after baking, when it is quite easily digestible. Thin French bread 
and rolls, with a large amount of crust and a small amount of crumb, are more 
easily digested. These can be heated in the oven for a few moments. Hot bread, 
that is, the bread freshly baked, which is composed mostly of the crumb, is most 
indigestible. Corn bread cannot be recommended, as it usually contains too 
much sweetening, for neither much shortening nor sweetening is well tolerated. 

Coffee and Tea. — Coffee and tea are stimulating in the morning and have 
a good effect upon the heart and circulation. Their active principle — caffein — 
is a powerful stimulant and diuretic; but it is a question whether it is not 
injurious to stimulate the heart and blood vessels three times a day, as persons 
so frequently do. 

I do not reconmiend the use of tea and coffee. If taken for breakfast, mild 
cafe au lait, made by adding one tablespoon of freshly ground coffee to half a 
pint of hot milk at the point of boiling, made in a Frencli drip coffee pot, is 
sufficient. The hot milk is usually poured through twice; no water need be 



DIET 325 

used in its preparation. Such a preparation is much more nourishing than a 
cupful of coffee with a small amount of cream. If taken after dinner, a small 
cup of black coffee is sufficient. 

Fishy Meat a^d Vegetables. — Fish, meat, vegetables and greens should be 
taken at the midday and evening meals. For health and good digestion, I 
think that it is better to take a heavier meal in the middle of the day, as the 
lighter meal in the evening would be more easily digested and, consequently, 
would not interfere so much with sleep. In city life, however, especially in 
those who do active brain work, the midday meal should be lighter. I believe 
that two meals a day are better tolerated than three, when taken one at 10 or 11 
A.M., and the other at 5 or 6 p.m. 

Shellfish, as oysters and clams, are good for lunch and dinner. They are 
more easily digested raw, except the so-called soft clams, which are better 
steamed, stewed or baked. 

Soups. — Consomme is good in a light diet and at the beginning of a lunch 
or dinner. Heavier soups may be eaten at dinner, but bisque and creams are 
not recommended. 

Fish. — Fish should be eaten broiled, boiled or baked. The broiled fish is 
the most palatable, but boiled fish is very delicate if properly cooked. Fish is 
more easily digested than meat, especially fish of the smaller varieties — that is, 
weighing less than four poinids. It is a good luncheon food, if the midday 
meal is lunch, or equally good at dinner. It should not be taken with white or 
any rich sauces. A small amoimt of butter sauce is the simplest and best. The 
fish most recommended are sea bass, weak fish, blue fish, black bass, trout, Span- 
ish mackerel, sea trout, white fish, flounder, sheepshead and pan fish. 

Meat. — i[eat should be taken in a moderate quantity. I do not believe in 
eating meat for breakfast, but think it better for the midday or evening meal. 
It is a question how often meat should be eaten. Personally, I think that 
once a day is sufficient, but if partaken of moderately, twice a day is not too 
often. 

In eating meat, it is well to take a variety rather than to confine oneself to 
any particular kind for everyday consumption. It is perhaps difficult to define 
the meaning of meat, but the flesh (that is, the muscle) of animals and birds, is 
generally considered as such, whereas, the internal organs are not, strictly 
speaking, meat. If, then, we accept the classification of meat in its widest 
scope, we have in beef, steaks of different cuts, also broiled, roast, stewed, braised 
and boiled beef. In mutton, veal, pork and animal game, we have certain large 
cuts to roast and boil, whereas the cuts representing steaks, are called chops 
or cutlets. 

The crisp, rich fats that are on the outside of roasted and broiled meats, al- 
though agreeable to the palate, are not tolerated by the stomach and should 
not be indulged in freely. 



326 UROLOGICAL THERAPEUTICS 

In the bird family, we have turkey, goose, duck (domestic and wild), fowl, 
chicken and squabs ; also game birds, as quail, partridge, grouse, woodcock and 
plover. All of the poultry and game birds are usually roasted, but some of 
the poultry is at times boiled, while the smaller game birds are split and 
broiled. 

The internal organs of animals and birds are also edible, as the liver and 
heart, the kidney, the pancreas and the thymus (sweetbreads), and stomach 
(tripe), as well as the brains in animals and the gizzard in birds. These can 
be cooked in various ways, but are not healthy with rich sauces. They are gen- 
erally not as difficult to digest as the muscle flesh is. The preparation of meat 
food in this class should be in the most easily digestible way and they should 
never be fried. 

Vegetables. — The vegetables recommended in the simple diet are, in the 
first class: string beans, green peas, rice; in the second class: spinach, cauli- 
flower, Brussels sprouts and potatoes; in the third class: green corn, shelled 
beans, onions, beets, cabbage and tomatoes. 

Potatoes are a staple article of food, but rich in starch. They should be 
eaten only once a day, baked or mashed. Good rice is one of the most whole- 
some and easily digested articles of food and should be boiled in such a way that 
the grains are separated and it is dry and not soggy. 

Salads. — Salads made of greens are recommended. They should be eaten 
at the principal meal of the day. The varieties to be preferred are lettuce, 
chickory and romaine, served with a French dressing containing but little vine- 
gar and pepper: one part vinegar to four parts of oil, salt and a very little 
freshly ground white pepper. 

CSheese. — Cheese should be eaten sparingly. The Stilton, Edam, Swiss, 
Port Salut, Brie and cream cheeses are recommended. 

Sweets and Desserts. — Sweets are unnecessary and not recommended. The 
least harmful are the sago, rice, tapioca and farina puddings, with very little 
sweetening. 

Alcoholic Beverages. — Alcoholic drinks are contraindicated in all cases of 
urinary diseases and yet, if a patient is below par or septic, they are often given. 
Beers and ales should be omitted in all cases, but light wines and spirits can 
be given in moderation. From one to two ounces or more of whisky a day can 
be allowed in certain cases of chronic nephritis and tuberculosis, while in septic 
cases, more can be given. A light Bordeaux wine (claret alone or mixed with 
water) can be allowed in almost any case excepting in acute nephritis or acute 
urethritis, and is frequently recommended in cases of chronic cystitis. It should 
be limited to eight ounces a day. A light Moselle or Rhine wine is also used 
in some chronic cases. This list is considered very moderate and much larger 
quantities are frequently taken habitually or on special occasions. 



DIET 327 

Diet at Various Meals 

Breakfast. — I do not think that fish, meat or vegetables should be taken for 
breakfast, as more effort is required to digest them. Cereals are too heavy for 
many people, and fruit too full of acids and sugar. I believe that cafe au lait 
with rolls or toast is sufficient for the morning meal. If, however, this is not 
found to be so, two eggs and fruit can be taken. When the period between the 
morning and midday meal is a long one, cereal may be added. 

Midday Meal. — The amount to be taken at the midday meal depends very 
much on what has been eaten at breakfast. If that has consisted of simply 
a cup of coffee, milk and rolls, then fruit and eggs can be added to this second 
meal, although fruit may always form part of the lunch. 

In addition, lunch, as I have said before, can consist of oysters, or clams, 
consomme, fish, meat or internal organs, vegetables and cheese. 

Dinner. — The bill of fare for dinner may contain the same dishes as the 
lunch with, perhaps, a heavier soup, a roast, instead of broiled meat, and a 
salad. Eggs are not considered a dinner food and fruit is not desirable. 

Entrees are frequently not understood by people in this country who live 
away from the centers influenced by French cooking. The preparations known 
as entrees are stews of beef, mutton or veal; meat, poultry and game cooked 
in the casserole ; tenderloin of beef roasted or cut into small steaks and broiled ; 
saddle of mutton, rib or loin chops; sweetbreads, kidneys, brains and tripe. 
They are usually cooked with or served with some vegetable. I simply mention 
a few of the most common on account of lack of space. 

The different varieties of animal and vegetable food already mentioned, can 
be selected from. It is well to eat sparingly and not to think that all of these 
articles should form part of each meal. 

It must be remembered that these are guides to simple food for people 
who have slight trouble with the genito-urinary tract, but are attending to their 
regular work. They can be modified accordingly. 

At one of the hospitals at which I am attending, the diet list shows what is 
given to patients. All the special diseases have carefully selected diets that will 
be foimd under that particular division. 

Hospital Diet 

Fluid Diet: — Milk, broths, bouillon, milk pimch, eggnog, egg lemonade, 
egg albumen, beef juice, strained gruels, cocoa, cocoa shake, koumiss, matzoon, 
liquid peptonoids, lemon and wine jellies. 

Soft Diet: — Soups (without vegetables), oysters, all cereals, milk toast, 
eggs (soft boiled or poached), milk puddings, ice cream, scraped beef, toast, 
junket, tea, coffee, cocoa, milk. 



328 UKOLOGICAL THERAPEUTICS 

Light Diet: — In addition to the above: Chicken, chops, baked potatoes, 
baked apples and fresh fruits. 

For Ward Patients 

Breakfast : — Tea or coffee, milk and sugar, cereal, one half pint of milk, 
bread and butter, meat or eggs. 

Dinner: — Soup, meat, potatoes, one vegetable, bread and butter, one half 
pint of milk, dessert. (Special diet, chicken, chops, broth, etc., from diet 
kitchen. ) 

Supper: — Tea, milk, sugar, bread, toast and butter, stewed or fresh fruit. 
(An extra, meat, eggs, broth, rice, etc.) 

For Private Patients 

Breakfast : — Tea and coffee, cereal, rolls, bread and butter, potatoes, meat, 
fruit 

Luncheon: — Tea and coffee, bread and butter, meat and entree, (Re- 
mainder as ordered. Specially prepared delicacies from the diet kitchen as 
broth, birds, jellies, oysters, etc.) 

Supper : — Tea and coffee, bread and butter, soup, meat, oysters, vegetables, 
dessert. 

Wards (Complete) 

FOR patients in PUBLIC WARDS 

Regular Diet 

Breakfast Dinner Supper 

Tea, coffee, milk and Soup, potatoes, bread Tea, milk and sugar, 

sugar, cereal, one half and butter, one half bread, toast and but- 

pint milk, bread and pint milk. ter, stewed or fresh 

butter. fruit. 

In addition 

Sunday 

Oatmeal, eggs. Roast beef, extra vege- Oyster or clam stew, 

table, baked custard. cake. 

Monday 

Hominy, steak. Beef stew, extra vege- Cold meat, scrambled 

table, bread pudding. ^ggs. 



DIET 



329 



Breakfast 
Oatmeal, liver and bacon. 



Oatmeal, steak. 



Hominy, eggs. 



Oatmeal, fish. 



Oatmeal, minced meat. 



Tuesday 

Dinner 

Roast beef, extra vege- 
table, sago pudding. 

Wednesday 

Roast lamb, extra vege- 
table, rice pudding. 

Thursday 

Roast beef, extra vege- 
table, cornstarch pud- 
ding. 

Friday 

Fish or roast lamb, vege- 
table, bread pudding. 

Saturday 

Mutton or beef stew, 
vegetable, cottage 
pudding. 



Supper 
Boiled Indian meal. 



Gingerbread. 



Boiled rice and milk. 



Milk toast, canned fruit. 



Corn bread. 



Special Orders from Diet Kitchen: — Chops, chicken broth, oysters, birds, 
etc., jellies and custards. 

Peptonized Milk (Cold Process). — Into a clean quart bottle, put pancreatin, 
gr. V, and sodium bicarbonate, gr. xv and one teacup of cold water. Shake and 
add a pint of fresh cold milk. Shake mixture again and immediately place on 
ice. When needed, shake the bottle, pour out required portion and replace 
on ice. 

If the warm process is ordered, prepare as above, but set bottle in water just 
so hot that the whole hand can be held in it without discomfort, about 115*^ F. ; 
keep the bottle there ten minutes. Then put on ice at once to check further 
digestion and keep milk from spoiling. 

Nutritive enema : 

Peptonized milk 5vj ; 

Egg (beaten) No. 1. 

Salt, pinch. 



330 



UKOLOOICAL THERAPEUTICS 



v»^ .^ 




Fio. 245. — Abdominal Exercisb. 




Fig. 246. — Abdominal £xEBCia£« 



S 



u 



EXERCISE 

One of the moat difficult problems that we have to contend with is how to 
keep our walking patients healthy by means of proper exercise. In the mad 
rnsh of daily work in our large cities, but few patients will take the time during 
the day to go through the prescribed exercises, especially those in the open air, 
which are exceptionally beneficial. Very few people exercising at home care 
to go through many movements and therefore as short a list as possible should 
be prescribed for tliem. We must, therefore, endeavor to have them take some 
exercise before beginning the day's work. The most convenient time for this 
seems to be in the morning on arising, preceding the morning bath. 

The exercises prescribed by me are those which bring into play and 
strengtlien the muscles of the abdomen, back, loins and thorax. For home exer- 
cise I believe the pulley weights are the best for this purpose, beginning at first 
with the lighter weights and gradually 
increasing them in proportion to the 
increasing strength of the individual. 

The abdominal exeroisea are taken 

as follows: Lie flat on your back in tlic 
bed before arising, throw the bed- 
clothes over the foot of the bed 
and the pillows over your feet. 
Then clasp your hands behind / 

your head and come to a sitting po-s- ^i 
turc fifty times or more with the legs j | 
stiff. Then kick aside the pillows and Y i 
bring up the lower extremities, held • 
stiff, until they are at right angles with \ 
the body, for the same number of tiriics. '^ /' 

Usually the patient is only able to make '^ \ 

these movements a few times at first, \ 

but the number is easily increased as ^ 

the abdominal muscles strengthen. ' 

Tig. ^4.") shows cxeifiw! in 1h.hI, the palient ly- 
ing flat with the hands In-hind the head and tlie 
legs stiff, bringing the biHly to a silting posture. 

Fig. 2M'i shows tile same iMJsitiim witii the 
body and legs stiff, bringing up the legs and feet 
to right angles. 

Pulley-weight Exercises. — The pulley-weight exercises recommended are : 

First. — Stand erect, facing the pulley weights, with the arms extended 
toward them (Fig. 247). liring the aruis, extended and stiff, down so that the 







Flu. 247,— Back Exbbcibm. 



332 



UROLOGICAL THERAPEUTICS 



hands will reach the feet as nearly as possible without bending the knees. Then 
swing the arms, still stiff, over the head as far as possible until the back is bent. 
This swing from the lowest position to which one can reach to the highest is 
good for the muscles on the front of the chest and abdomen and those of the 
neck and shoulders. 

Second, — Stand erect, with the back to the pulley weight, with the arms 
extended away from the weights, then allow the arms to drop to the sides until 




^% 



I 

— '''ZP- ' 

- ^f^h 



? 



I 



-^ 



Fig. 248. — Front Exercises. 



the hands are as near the pulleys as possible. Sweep the arms forward to a 
right angle with the body and upward and backward as far as you can (Fig. 
248). From this point of extension, bring them down again to the position 
already referred to. This swing is beneficial to the muscles of the front of the 
chest and arms, tlie back, the shoulders and the back of the arms. 

Third, — Stand with one side toward the pulley weights. Grasp the handles 
with either hand, both arms extended toward the pulley weights, one from in 
front and the other from behind the body (Figs. 249 and 250). Both arms 
are then extended as far away from the pulley weights as possible, on the other 
side of the body, imtil at right angles to the side of the body. The arms and 



EXERCISE 



333 



hands then go back to the original position and the movement is repeated. After 
making the desired number of movements, the other side of the body is turned 




FiQ. 249. — Chest and Arm Exercises. 




—-- — -..^--- •--.«»•* 



*•''"•••. 

•1*^' 



,----.1-' 

I 
t 
I 



■:^ 



FiQ. 250. — Chest and Arm Exercises. 



334 



ITROLOGICAL THERAPEUTICS 



toward the pulley weights and the same movements are made, thus giving the 
same exercise to both sides. 




,-■■■'.•• 



Fia. 251. — Chest and Arm Exercibes. 




Fig. 252. — Chest and Arm Exercises. 



EXERCISE 



335 



The muscles brought into action are those of the front of the chest and 
anns, the back and the muscles around and between the shoulders. 

Fourth. — Stand with one side toward the pulley weights, as before. Ex- 
tend both arms toward the pulley weights (Figs. 251 and 252). The arm next 
to the weights will be at full extension and at right angles to the body. "The 
arm away from the pulleys will be slightly bowed over the chest. Then swing 
the arms held straight with no bend to the elbow^s around the front of the body, 
at right angles to the body, to the other side. The arm farthest from the weights 
will then be extended straight and the nearer one will be bowed over the chest. 
Repeat as many times as de- 
sired and then turn the other /CC^J^ 
side to the weights and make 
similar movements. 

This exercises the chest 
and abdominal muscles, the 
back, the muscles of the arm 
and under the arm. 

Fifth. — Stand with the 
back to the pulleys and the 
feet about half a yard apart. 
The arms should be slightly 
flexed, the hands extending 
back toward the machine. 
One hand is then swung 
around in a circle in such a 
way that it passes by the 
front of the body at about the 
level of the shoulder, while, as 
it swings farther, it passes 
around the body to the other 

side until the knuckles point toward the wall behind. In making this swing, 
the body is raised on the ball of the foot on the same side, Avhile the body turns 
at the waist (Fig. 253). 

This is the best movement that can be used by walking urological patients in 
good condition. It exercises the muscles of the legs, thighs, buttocks, abdomen, 
loins, chest, shoulder, the muscles about the shoulder and the upper arms. 

Outdoor Exercises. — Of the outdoor exercises, walking in the fall and win- 
ter, and rowing and swimming in the summer are the best. In w^alking, five 
miles is sufficient at a gait of from three and a half to four miles an hour. Golf, 
when one is properly clothed, is an excellent exercise, as it keeps one walking 
in the open air. In the city, walking to and from business each day is like- 
wise beneficial. 




Fia. 253. — Loin Exercises. 



336 UROLOGTCAL THERAPEUTICS 

Rowing and swimming are of great benefit, provided they are not too vio- 
lently indulged in, or prolonged too much. Long exposure in the water is 
especially weakening. 

Tennis is too violent fcr many, and horseback or bicycle riding is especially 
injurious. Dancing as an exercise is beneficial, if after the dance the patient 
will retire and change the underwear. Sitting in a draught after dancing and 
eating a hearty supper before retiring are not to be commended. Billiards and 
pool furnish a moderate and desirable form of exercise, as they require the 
player to walk around the table and stretch over it, at the same time keeping 
the mind occupied in a pleasant way. 

THE CARE OF THE BOWELS IN XJROLOGY 

The care of the bowels is most important in urology, especially in diseases of 
the bladder, prostate and urethra. The venous circulation in the above-men- 
tioned organs is very closely associated with the rectal plexus, in consequence of 
which a passive congestion in one would be associated with a passive conges- 
tion in the other, while the mechanical pressure of the feces would act as an 
irritant. 

In patients wdio are up and about, this can usually be accomplished by regu- 
lating the diet and prescribing sufficient exercise. In patients who are in a weak- 
ened state from chronic disease, and in bed patients, this is more difficult. 

The results of constipation are renal irritation due to indican and other 
irritating products in the urine; pressure on the prostate and vesicles, and, in 
consequence of this, congestion and frequency of urination ; while later on, a 
neurasthenic condition may develop. 

The diet in cases of constipation should have among other varieties certain 
articles that leave a residue as cereals, prunes, spinach, celery, green salad, fruit, 
etc. The remaining diet should be as usual. 

The patients on arising should drink a large glass of water, then exercise for 
a quarter of an hour. (See prescribed exercises.) After this they should take 
a cold shower and a rub down. Breakfast should then be eaten, after which the 
patient should go to stool as a habit, whether he feels the desire or not. Coffee 
taken with breakfast also assists and many consider smoking a desirable adjunct. 

When, however, the behavior of the bowels under the suggested treatment 
is not what is desired, certain laxatives should be given. These are of two vari- 
ties : waters and drugs. The best of the waters are Apenta and Carabaiia, half 
a glass (4 ounces) of the former or a quarter of a glass (2 ounces) of the latter is 
sufficient to caUvSe a movement when the patient is up and about. When the 
patient is in bed, 6 ounces of the Apenta or 3 ounces of the Carabaiia should 
be given. The best rule for bed patients is to give them the aperient, to be 
followed in three quarters of an hour by a light breakfast with coffee and hot 



WATER AND WATER DIET IN UROLOGY 337 

milk. One hour after breakfast, if the bowels have not moved, an enema of 
soapsuds should be given. 

Of the laxative drugs, eascara is the best. It is well to start in with the fluid 
extract, taking half a drachm every night, increasing or diminishing the dose 
accordingly. Some prefer to take this after meals in smaller doses, alone or 
mixed with other drugs. Of the intestinal laxatives having especial action on 
different parts of the tract, the best are podophyllin and aloin. The first has 
the better effect on the upper part of the intestine, the second on the lower bowel. 
Xux vomica and belladonna are good intestinal tonics. In presenting a com- 
bined tablet or pill, aloes, belladonna and nux can be used ; or podophyllin, 
belladonna and nux ; or extract of eascara mixed with one or all of them. 

The doses for laxative use are : — Aloin, gr. J ; ext. belladonna, gr. -J ; ext. 
nux, gr. ^ ; ext. podoph., gr. -I ; ext. eascara, grs. 2. 

If, in walking patients, the bowels do not move after breakfast with the 
aperient waters or drugs, a glycerin suppository can be introduced. This will 
usually induce a movement in from three to five minutes. In case it fails a 6- to 
8-ounce bottle of Red Raven splits can be taken three quarters of an hour be- 
fore the midday meal. For cases with acute pelvic trouble the aperient waters 
are the best and aloin is contraindicated. 

For those who do not have pelvic trouble, eascara and other drug laxatives are 
the best. Purges can be occasionally taken. Castor oil (half an ounce in sarsa- 
parilla) is given, if there is intestinal fermentation with frequent and unsatis- 
factory movements, and calomel, grs. 3 to 5, in other cases. 

In preparing patients for operation, surgeons differ. Some give calomel or 
compound cathartic pill, followed next morning by magnesia sulphate, o^s, 
while others give simply licorice powder, and citrate of magnesia on the follow- 
ing day. 

In giving calomel, it can be prescribed in -jl^-grain doses every hour for 
ten hours ; or ^ grain every half hour for four hours ; or ^ grain every hour for 
six hours or 3 to 5 grains at one time. In any case, magnesia sulphate, half an 
ounce, or Apenta, 4 ounces, or Carabaiia, 2 ounces, should be given on the fol- 
lowing morning, followed by an enema. 

After the operation calomel can be given with soda bicarbonate in any of 
the above doses, followed by magnesia, and, if the bowels do not move, by an 
enema of soapsuds. In nearly all my postoperative cases I prefer to give 
Apenta water from 4 to 6 ounces every morning and to follow it in three quar- 
ters of an hour by a coffee with milk, and toast breakfast. 

WATER AND WATER DIET IN UROLOGY 

Plain water is without doubt the healthiest beverage for mankind. The 
majority of city dwellers do not drink it as they should. In fact, a great many 



338 UKOLOGICAL THERAPEUTICS 

of the city people drink tea, coffee, beer or ale with their meals, and nothing be- 
tween meals, while many others drink iced water at meal times and between 
meals. Frequently clinic patients, when I tell them to drink water, answer that 
they do not like it and never drink it. 

Water is rapidly absorbed into the blood, increasing the amount of fluid 
plasma, and is eliminated chiefly through the kidneys and the sweat glands. 
An increased amount of water taken daily flushes the kidneys and helps elimina- 
tion through the skin. A normal person should drink about three pints daily, 
the exact quantity varying with the season, the amount of exercise and the 
weight of the individual. 

Varieties of Water. — A number of varieties of water are used: (1) Dis- 
tilled water, (2) rain water, (3) city water, (4) spring water, (5) well water, 
(6) mineral water. The purest of them undoubtedly is distilled water ^ and in 
the absence of a pure natural water this may serve for drinking. Xext in purity 
comes rain water, which makes an excellent drinking water if collected in the 
country, or, if filtered to remove dust, in the city. City water comes from lakes 
and rivers usually at a distance, and is stored in reservoirs and led through 
aqueducts. City water not only is apt to be contaminated with germs, but also 
to contain unpleasant mineral constituents, giving it a peculiar taste or cloudy 
look ; besides this, it may contain lime salts which render it " hard." Such 
water should not be drunk unless it is filtered and boiled. 

Well water is apt to be polluted by sewerage unless the well is properly 
constructed with cemented brick walls and dug deep enough to avoid tapping 
contaminated water (over 30 feet as a rule). 

Spring water is a pure and clear water which always contains more or less 
mineral matter and in reality is a mineral water. Spring water is derived 
from rain water which percolates through the ground until it strikes an impervi- 
ous stratum (rock), when it flows along this stratum until it finds an outlet in 
an unevenly leveled spot. 

Water Diet. — Two quarts of fluid should be taken daily, of which three 
pints should be water. Water should be taken as follows : one glass on arising ; 
the second at 11 a.m.; the third at lunch; the fourth at 5 p.m.; the fifth at 
dinner and the last on retiring. The time when water is drunk makes a decided 
difference in its action. Water taken between meals on an empty stomach has 
a diuretic action and tends to make the drinker thin. Water drunk with the 
meals has no diuretic effect and tends to increase the drinker's weight. After 
operations on the lower urinary tract, the patient should drink large quantities of 
water. If he vomits it, more should be given. I often give a gallon of water 
during the first twelve hours after a prostatic operation. 

Mineral Waters. — A mineral water, in the sense in which this term is used 
by physicians, is one which contains a sufficient amount of mineral matter to 
produce a distinct physiological action aside from that of the simple solvent or 



WATER AND WATER DIET IN ITROLOGY 339 

drinkable quality water. In the strict sense, however, any water containing min- 
erals, as spring water, is a mineral water. The classes of mineral waters used 
in urology are : 

1. Table waters: IndiflFerent or neutral waters containing little mineral 
matter and acting, in virtue of their carbon dioxid, as a pleasant beverage. 

2. Alkaline waters: Contain carbon dioxid, sodium and magnesium bicar- 
bonates. 

3. Alkaline chlorid waters: Contain in addition sodium chlorid. 

4. Earthy waters: Charged with carbon dioxid, contain earthy carbonates 
and sulphates (calcium, magnesium). 

5. Alkaline sodium waters: Contain sodium sulphate as chief ingredient; 
besides sodium bicarbonate and chlorid. 

6. Lithia waters: Contain lithium salts. 

7. Bitter laxative waters: Contain magnesium and sodium sulphates chiefly. 

1. Table Waters. — The class of mineral waters usually known as table 
waters are mild diuretics and stimulants to digestion and circulation, owing 
to their carbon dioxid, and can be given to patients as palatable beverages. 
Among these are the Poland Spring (Maine) and Great Bear Spring (New 
York) waters, that contain but a small amount of alkalies. A more alkaline 
water often used at table in this country is White Rock Spring water (Wau- 
kesha, Wisconsin), containing an appreciable amount of alkaline carbonates. 
The Apollinaris of Ahrweiller (Prussia), the Dorotheenquelle at Carlsbad (Bo- 
hemia), the Rosbach and Selters waters (Germany), the Malvern Springs water 
(England), Condillac (France) and Geyser Spa of California are other exam- 
ples of simple carbonated waters. 

2. Alkaline Carbonated W^aters (Containing Carbon Dioxid and 
Sodium and Magnesium Bicarbonates as Chief Ingredients), — These include 
Saratoga Vichy (Xew York), the French Celestine Vichy, the Salzbrunn water 
and the Xeuenahr water (Germany). Celestine Vichy has in my practice 
proved to be the best general alkaline water that I have given. 

These waters are indicated in inflammatory conditions of the urinary tract, 
es|)ecially of the bladder, in oxaluria, in gout and uric-acid diathesis and in cal- 
culous formation. They are diuretics, and antacids in the urine, rendering it 
alkaline. They also dissolve away mucus, allay inflammation in the bladder 
and act as solvents for uric-acid concretions. They diminish the excretion of 
oxalic acid. 

3. Alkaline-muriated Waters. — The alkaline-muriated waters, which 
contain sodium chlorid in addition to carbonates, are also useful in chronic 
catarrhs of the bladder and renal pelvis. These include the waters of Selters 
and Ems, Saratoga Vichy (Xew York), Plymouth Rock Spring (Michi- 
gan), etc. 



340 UROLOGICAL THERAPEFTICS 

4. Earthy Waters. — Earthy waters containing large amounts of calcium 
and magnesium (carbonates and sulphate), with carbon dioxid and small 
amounts of iron. They are especially useful in chronic conditions associated 
with an abundant secretion of mucus, especially in chronic gonorrhea, in per- 
sistent cystitis, neuroses and hemorrhages of the bladder. They are contraindi- 
cated in the presence of calcium phosphate or carbonate calculi, in which simple 
carbonic-acid waters are best (Geyser Spa, Apollinaris, Selters). The earthy 
waters include a large number of springs here and abroad: 

France : Contrexeville. 

Bohemia: Marienbad. 

Germany: Wildungen. 

United States: Xapa Soda Springs (California), Richfield Springs (New 
York), Mt. Clemens Spring (Michigan), Allouez and Waukesha Springs (Wis- 
consin), etc. 

5. The Alkaline Saline Mineral Waters {Sodium Sulphate Waters). 
— These waters are of great value in gout, in lithemia, in urinary calculi, in 
obesity and in chronic nephritis, especially with albuminuria. 

They usually contain COg and besides sodium sulphate also sodium bicar- 
bonate and chlorid. They should be taken he j ore meals, never during or after 
meals, in amounts of from 6 to 40 ounces (Kisch). They are markedly diu- 
retic, and in large amounts are purgative. They retard nitrogenous metabo- 
lism and increase the waste of fat. They are also solvent of uric acid. The 
following are the principal waters of this class : 

Austria : Carlsbad, Marienbad, Franzensbad. 

Switzerland : Tarasp. 

Canada: Caledonia Springs (Ontario). 

United States: Springdale Seltzer Springs, Boulder County, Colorado; 
Topeka Mineral Wells, Kansas, Geyser Spa (Hot), Sonoma County, Califor- 
nia, Idaho Hot Springs, Clear Creek County, Colorado. 

The Carlsbad Sprudel salt is sold in bottles in this country for the prepa- 
ration of an artificial solution resembling the original water. 

6. Litiiia Waters. — These contain usually very small amounts of lithia 
and are used principally as uric-acid solvents. Whether they actually dissolve 
stones is not yet positively known. They are diuretic and useful in gout, and 
stone in the kidney due to accumulations of uric acid. They are usually taken 
in the morning, the dose being from 4 to 40 ounces (Kisch). 

The chief foreign lithia springs are at Saltzbrunn, Ilomburg, Baden-Baden, 
Ems and Kissingen. A number of lithia springs exist in this country, includ- 
ing those in Arkansas (Lithia Springs), in ^fassachusotts (Ballardville), in 
New Hampshire (Londonderry Lithia), in New York (Saratoga) and in Vir- 
ginia (Buffalo Lithia Spring). 



USE OF WATER IN UROLOGY 341 

7. BiTTEE Laxative Waters. — These contain chiefly sodium sulphate and 
magnesium sulphate, but also magnesium and calcium carbonate. Few of these 
contain carbon dioxid. 

They are purgative waters and are taken in small doses (3 to 8 ounces) in 
the morning before breakfast. They are of great value in emptying the intes- 
tines before operations and in keeping the bowels clear in various condi- 
tions in which this is desirable, as in prostatics, etc. The principal bitter 
waters are: 

Bohemia: Pullna. 

Himgary: Alap, Ilimyadi Janos, Franz Joseph, Apenta, Victoria. 

Spain: Carabaiia. 

Germanv : Friedrichshall. 

United States : Crab Orchard Springs, Kentucky. 

All my urological cases, while bed patients after an operation, are given 
either Apenta or Carabana water every morning. 



USE OF WATER IN UROLOGY 

The Use of Watek Ij^troduced into the Passages ok Excretion, Beneath 

THE Skin and into the Blood Vessels 

Rectal Irrigations. — Rectal irrigations with saline solution are employed in 
a variety of diseases of the urinary organs. They secure a thorough cleansing 
of the bowels ; in shock, they supply heat ; in uremia and other toxic conditions, 
they remove intestinal toxins and secure the absorption of a certain amount of 
salt solution into the blood. Locally, that is, applied to the lower part of the 
bowel, they relieve pain and discomfort in the prostate, the neck of the bladder, 
the vesicles and the posterior urethra. They allay spasm of the vesical sphincter 
and they coimteract acute in- 
flammation in the pelvic organs 
both in the male and female. 
The tube which I employ is 
called the recto-genital tube. It 
is a double-current tube with a Fio. 254. — Recto-oenital Tube. 

curved end (Fig. 254). The 

inflow part of the tube is attached by a nozzle to the rubber tubing coming from 
the douche bag, and extends to the opening in its concavity. The outflow part 
begins in an opening on either side of the tube a little farther from the tip than 
the inflow aperture and ends in a nozzle at the distal end where it is attached to 
a piece of tubing carrying away the fluid into a basin or douche pan. The fluid 
flows into the bowel through the opening in the concavity and flows QUt through 
the side openings. 




342 



UKOLOGICAL THERAPEUTICS 



Technique. — For douching the lower bowel, the patient lies in the bath tnb 
in a reclining position (Fig. 255), or sits on a chair in a similar position (Fig. 




Fia. 255. — Rectal Irriqa-Tions. Patient in bath tub. 

256). A gallon donclie bag is suspended so that its bottom is just on a level 
with the top of the head, or two feet above the pubes. Tlie douche bag is filled 




Fia. 256. — Rectal Irbioatioi^. Patient reclining in chair. 



USE OF WATER IN UROLOGY 343 

with a gallon of salt solution containing a tablespoonful of salt to the gallon, 
the temperature of which, roughly speaking, is as high as can be borne by the 
hand, that is, about lOS'^ to 130° F. 

Before introducing the tube, its tip should be lubricated and the air should 
be expelled from it by allowing some of the solution to pass through. The tip of 
the left forefinger is then introduced just inside the front part of the anal orifice 
and serves as a guide to the tube, the tip of which is gently introduced into the 
rectum, at first with a slightly forward and rotary motion. When it has passed 
up for an inch and a half, it comes in contact with the apex of the prostate. 
The tip should then be tilted back toward the hollow of the sacrum and the tube 
should be pushed up for another inch and a half if the prostate is to be treated ; 
or for three inches if the seminal vesicles are to be douched. When treating the 
vesicles, the tube should be tilted from side to side, so that its inflow opening 
lies over one or the other of the vesicles. 

After the tube has been inserted, the solution is allowed to enter the rectum. 
Should the flow seem sluggish, or be arrested, the tube is probably blocked by 
fecal matter and it should be removed and thoroughly flushed out, when it can 
be reattached and reintroduced. 

In case the sigmoid and colon are to be irrigated, the pelvis should be ele- 
vated and the patient should lie on the left hip. If then the outflow tubing be 
compressed, the solution will run up to the splenic flexure. Turning onto the 
right hip will then allow it to gravitate to the hepatic flexure and sitting up will 
allow some of the fluid to gravitate into the cecum. In urology, douches of the 
lower part of the large intestine are generally used and it is rare that one is 
called upon to wash out the entire colon. 

Vaginal Irrigation. — This should always be given to the patient on her 
back with the hips elevated and a douche pan under the buttocks. The nozzle 
should always be of sufficient length to reach well behind the cervix of the uterus 
and the tip should be introduced along the posterior vaginal wall. 

Although many eminent gynecologists maintain that vaginal irrigations are 
of no benefit in pelvic diseases, my experience has been quite to the contrary. 
I am now speaking of bladder troubles in women which are associated with affec- 
tions of the internal genitals. There is a close relationship between the uterus 
and its aduexa and the bladder, and pressure upon this viscus as the result of 
inflammations or malposition of the female pelvic organs, gives rise to a variety 
of disturbances of the bladder functions. Hot vaginal douches of salt solution, 
prolonged and repeated daily, are very useful in the treatment of inflammatory 
conditions of the uterus and its appendages and have a good effect in relieving 
the bladder symptoms associated with these conditions. In treating cases of 
cystitis depending on or associated with gonorrheal and tuberculous affections, I 
have derived the greatest help from hot vaginal irrigations, especially when the 
internal female genitals were involved. 



344 UROLOGICAL THERAPEUTICS 

Irrigations of the bladder and the urethra in women are the same as in men, 
although the catheter is used in preference to hydrostatic pressure. 

External Applications of Water 

The urologist should be familiar with the effects of water at different tem- 
peratures, applied externally in the form of baths, douches, etc., as these meas- 
ures form an important feature of treatment in urinary diseases. A very brief 
outline of the general principles of hydrotherapy will be given here. 

Cold water when applied externally in the form of a tub shower or tub bath, 
is a vasomotor stimulant which produces contraction of the superficial, and re- 
flexly of the deep blood vessels. Cold baths increase the blood pressure and 
stimulate the activity of all the organs of the body ; but if too greatly prolonged 
the action is reversed ; muscular activity is decreased and circulation is retarded. 
It is of value in treating patients suffering from genito-urinary conditions who 
need a general stimulation, as well as increasing the function of the pelvic 
organs. 

Heat applied externally through the medium of baths, local or general, acts 
as a sedative, dilates the vessels and produces a hyperemia of the skin and con- 
sequent anemia of the vessels of the internal organs. Hot sitz baths, in this way, 
tend to lessen congestion of the pelvic organs. Hot baths also promote sweating 
and fa\x)r the radiation and abstraction of heat. 

Baths. — Baths are divided into general and local. 

General Baths. — General baths may be classified according to temperature 
as cold, from 50° to 75° F.; tepid, from 75° to 95° F. ; and hot, from 105° 
to 115° F. The temperature of the bath room should be about 70° F. 

The hot tub bath acts as a sedative and should be given for from five to 
twenty minutes, with the patient in a recumbent position. The best time to 
take these baths is before retiring and the bath should never be prolonged suf- 
ficiently to make the patient feel weak or dizzy. 

The cold tub bath is a stimulant to metabolism and to excretory activity, as 
well as an excellent general hygienic measure. It should be taken in the morn- 
ing and followed by a brisk rub. Its use is contraindicated in very weak 
patients. The cold tub bath may be used in septic conditions accompanied by 
a high fever, as it is employed in typhoid fever. The bath is begun at a tem- 
perature about 10° lower than that of the patient's body and the body is rubbed 
vigorously while the patient is in the water. The temperature is reduced to 
about 68° F. within fifteen minutes. The duration of the bath should be 
between twenty and thirty minutes. The head should be wrapped in a towel 
immersed in cool water before the patient is placed in the tub and after the 
bath the patient is to be thoroughly dried and placed in a warm bed. 

Tepid baths are to be taken by those who do not react properly to cold 
baths and cannot stand the strong stimulation of the latter. 



USE OF WATER IN UROLOGY 345 

Sea Baths. — Sea bathing is one of the best adjuvants to other treatments in 
chronic urinary diseases of the urethral canal and in all cases in which we desire 
to promote the general health as well as stimulate the nervous system. They 
are especially indicated in neurasthenic patients, provided they are strong 
enough to bear them. Surf bathing, aside from its stimulant thermic influence, 
constitutes a general massage of the body. Swimming is one of the .best 
exercises that can be indulged in. In order to insure the full benefit of a 
sea bath, a full reaction must be obtained and the bath should not be pro- 
longed until the chilly sensations appear. It should be followed by a vigor- 
ous rub. 

Salt baths made by adding sea salt (2 to 5 ounces to the gallon) to an ordi- 
nary tub of water are in a measure substitutes for sea baths and are stimu- 
lants to nervous and glandular activity. They are indicated in weak patients 
who cannot take sea baths. 

Local Hydeothekapeutic Measures. — Of the local measures, we must 
first mention the douche or shower. This may be a vertical rain douche, or a 
movable spray. The temperature used varies from the lowest to the highest 
employed in baths, while in the " Scotch douche '^ the temperature is alternately 
hot and cold. A cold shower is a powerful stimulant and is applied for about 
one minute, at from 50° to 60° F. Warm douches are used as sedatives in 
neurasthenia. The " Scotch " douche applied to the genitals is useful in sexual 
depression. 

Sitz Baths, — Sitz baths may be either hot or cold. They are very useful 
in many urological conditions. They are taken in a special tub holding five to 
six gallons, or enough to reach the pationt^s navel as he sits in it. Ordinary 
washtubs may also be used. The hot sitz bath is sedative, antispasmodic and 
anodyne, and should be given for from ten to fifteen minutes twice a day as 
hot as can be borne. It is indicated in all acute inflammatory troubles of the 
pelvis, especially in the bladder, posterior urethra, prostate and vesicles. Cold 
sitz baths act as a stimulant to muscular contraction, if not too prolonged. 
They are employed in impotence, sexual debility, spermatorrhea, atonic condi- 
tions of the bladder and passive congestion of the pelvic organs. They should 
last for from two to five minutes only and are contraindicated in acute inflam- 
matory conditions of the bladder, prostate, etc. 

Wet Packs, — A method of reducing temperature and inducing profuse 
sweating is known as the " wet pack.'' A woolen blanket is placed upon the 
bed and over this is spread a linen sheet immersed in cool water and well wrung 
out. The patient is placed upon this sheet with his head wrapped in a towel 
wet with water at about 60° F., his arms are raised above his head and the 
sheet is tucked in all around his body; the woolen blanket is then carefully 
folded and tucked over the shoulders and entire body of the patient. A hot- 
water bag is then placed at the feet. The pack is left on until it becomes very 



346 UROLOGICAL THERAPEUTICS 

warm and a second pack, or several successive packs, can be applied until the 
temperature is reduced. 

In urology the wet pack is indicated in febrile states, such as septicemia, 
and in cases of pelvic inflammations. In diseases of the kidneys, the hot pack 
is useful for promoting perspiration and elimination. They are contraindicated 
in patients with weak hearts. 

Sponge Baths. — The cold sponge bath is used as an antipyretic measure in 
place of the cold tub bath, when less active treatment is sufficient, or when the 
condition of the patient is such that it is not advisable to move him about. 
When frequently repeated, it reduces temperatures to a considerable degree. 
The sponge bath should be followed by an alcohol rub, or some alcohol should 
be mixed in with the water. 

Local Use of Cold Water and Ice. — Local inflammatory conditions are fre- 
quently treated by the external application of cold or ice water, either in coils 
or ice bag, while the combined part of the geni to-urinary tract is treated by cold 
water indirectly applied by means of tubes called psychrophores. 

There are two varieties of psychrophores, a urethral and a rectal. They 
are both hollow metallic tubes, closed at one end, with no outlet through which 
water can escape into the urinary or rectal passages. After the psychrophore 
has been introduced into the urethra or rectum, the nozzle is connected with 
the pipe from the douche bag and the cold water flows into the tube in a con- 
tinuous stream, filling the tube, and escapes by an adjoining nozzle through a 
piece of tubing into a douche pan or basin. The metallic surface of the instru- 
ment is cooled and communicates the cold to the tissues with which it lies in 
contact. The psychrophore is used either in the rectum or urethra for passive 
hyperemia of the prostate and posterior urethra, especially in chronic inflam- 
mation of these organs associated with sexual debility, nocturnal emissions, 
spermatorrhea and prostatorrhea. Ice bags are used principally in cases of 
epididymitis complicating gonococcal urethritis. 

Saline Infusion 

Salt solution in the " physiological proportion," that is, 1 drachm to the pint, 
is introduced into the body in such a way as to combat shock, to supply loss of 
fluid due to hemorrhage, or to cleanse the blood from various poisons, as, for 
example, in uremia. The solution is introduced into the rectum or cellular 
tissues, from which it is taken up into the circulation; or else it is injected 
directly into the vein. The three methods of introducing saline solutions are 
called: (1) enteroclysis, (2) hypodermoclysis and (3) intravenous injection. 

(1) Enteroclysis. — This is the simplest of all methods and should always 
be first resorted to in an emergency until the apparatus for the other methods 
can be prepared. It consists in the introduction of a soft-rubber rectal tube 



USE OF WATER IN UROLOGY 347 

of sufficient caliber high up into the bowel and the slow introduction of a salt 
sohition, at 105° to 110° F., containing a teaspoonful of table salt to a pint 
of water. The fiiiid may be introduced throngh a funnel or with the aid of an 
ordinary douche bag and, in either case, the bottom of the reservoir should not 
be raised more than a foot above the pubes so aa to avoid the forcible introduc- 
tion which might be followed by reflex expulsion. The patient's pelvis should 
be elevated or he may be placed iu the Trendelenburg position, unless it inter- 
feres with a surgical operation. 

The saline enema is an excellent measure during or after operations to 
counteract hemorrhage and shock, and some surgeons employ it as a routine 
procedure in operating. One pint of this solution at a time is sufficient and, 
in case strong stimulation is requirc<l, two ounces of whisky can be added. 

(2) Hypodermoclysis. — This consists in the introduction of the salt solu- 
tion sterilized. It is recommended that a small amount of calcium chlorid and 
potassium chlorid be also added (making what is known as Ringer's Solution) 
into the cellular tissues through a hollow tul>c. The temperature of the solution 
should he 105° to 110° F. Tlie apparatus needed is a sterile reservoir of any 
kind connected by rubber tubing to an aspirating neeille. The patient is pre- 
pared as for a surgical oi^ration, the skin being scrubbed and disinfected with 
alcohol and bichlorid. The apparatus is prepared and all the air is expelled 
from the needle before it is inserted. The place selected for the puncture should 

always be one where '' ■'■ " ' '""' ~' ' 

subcutaneous tissue. 
tlie breast and the c 
vcnient; in men, the I 
pectoral muscle at the 

The fluid should I 
should be supplied on 
place. Xot too much 
l)ressure should be 
used at any time 
and the vessel should 
he raised only 
enough to cause a 
cimstant flow. The 
amount of fluid in- 
troduced at one time 
varies. About six 

ounces can be inti» ^^ 257,-b,pop.«,ocl™.. (B>o„ A.hton.) 

duced in an hour 

and from one to two quarts have been introduced within twelve hours (Fig. 
257). Hypodermoclysis is especially useful in septic conditions, in uremia 



348 UROLOGICAL THERAPEUTICS 

and anuria, but, being slower tlian other methods, is less useful in heinorrluige 
and shock. 

(3) IntraTenouB Injection. — In this method the sterile saline solution is 
introduced into a vein at the l>end of the elbow through a sireeial cannula. The 



apparatus required is very similar lo that for hypodennoclysis, exeepling that 
it is advisable to have the jar graduated to determine l)etter the amount of 
fluid entering the circulation. The rubl«?r tubing and cannula must be Bter- 
ilized by boiling, pinned in a sterile towel and allowed to remain there until 
needed. 

The akin is prepared as for operation, a firm bandage is ]>laced over the 
upper arm and tied on the side selected, thus iiujieding the venous flow and 



causing the veins of the forearm and bend of the elbow to bulge out (Fig. 258). 
The median basilic is the vein usually selected because of its large size. It is 
a branch of the median vein and passes obliquely inward across the bend of 



USE OF WATER IN UROLOGY 



349 



the elbow joining with the common ulnar on the inner side of the elbow to 
form the basilic vein. The incision is made over its middle portion. The 
tissues over it are dissected away by blunt dissection and two ligatures are 
placed around the vein « 

(Fig. 259). The distal r\ 

ligature is tied, the proxi- 
mal remains loose. A trans- 
verse incision is then made 
in the vein and the cannula 
is inserted into its lumen 
(Fig. 260, /i, B), while the 
solution is running out of 
the tube, in order that no 
air shall enter the vein. The 
bandage is now loosened, al- 
lowing the solution to run 
into the vein, and if neces- 
sary the proximal ligature 
can be tied around the can- 
nula so as to avoid leakage. 
From one to three pints is 
allowed to run into the vein. 
The elevation of the douche 
jar should be from three to 
six feet above the table. The flow should be at the rate of a pint in a half 
hour. The amount necessary to inject depends on the pulse of the individual, 
which should be carefully watched. 

After the injection is finished, the tube is withdrawn and the proximal 
ligature is tied. The temperature of the solution should be kept constantly at 
least 105° F. in the jar, so as to secure a temperature of over 98"^ F. as the 
fluid enters the vein. This mav be acco!ii])li^hed bv the additicm of fresh hot 
solution. A sterile thermometer is kept in the jar for the purpose of regu- 
lating its contents. 




Fig. 260. — Intravenous Injection. A shows the cannula in 
the vein and the tube extending from it to the reservoir con- 
taining the solution. B shows the opening in the vein, the 
cannula inserted and the vein ligated above and below the 
opening. 



CHAPTER XVII 



ANESTHESIA IN UROLOGY 



There are two varieties of anesthesia, general and local, the former of 
which will probably always be used in most of the major operations, while the 
latter will without doubt be employed more and more as the technique of its 
administration develops. 

Gteneral Anesthesia. — The materials used in general anesthesia are liquids 
which are rapidly diifusible and therefore are readily transformed into gases 
that are inhaled and have a narcotic effect upon the patient. Of these, the ones 
generally employed are ether, chloroform and nitrous-oxid gas. 

Ether is probably the best and safest in all major surgical operations. It 
is administered through inhalers which are usually about six inches in length, 
three inches in width, and five inches in height. Those that are sold as the 
most up-to-date appliances are made wholly or partially of metal with various 
mechanisms for holding gauze and cotton. They can also he constructed from 
paper folded in a strip five inches wide and fifteen inches long, this to be 
enveloped in a towel and then rolled up in oval form of the same dimensions 
already given. In this inhaler, ordinary absorl)ent cotton or gauze is placed and 
it is pinned together at the top, in this way forming a truncated cone. The in- 
haler is placed over the nose of the patient and the fluid is poured into the 
inhaler from above, or from below, either directly into the cone or through some 
apparatus leading to it. 

Ether is also given by the drop method through a special or a chloroform 
inhaler, a process which takes a longer time, but which is considered safer for 
the patient, as he does not receive such a large dose suddenly. 

Chloroform is administered by the drop method. The chloroform inhaler 
is spoon-shaped, made of a wire frame covered with gauze or flannel, and the 
liquid is dropped upon it very much as in the last method described for the 
administration of ether. 

Of the two anesthetics, ether is safer on accoimt of being a heart stimulant, 
although it is supposed to be contraindicated in diseases of the kidney, in which 
case, chloroform is considered advisable. The latter is, however, a cardiac 
depressant, and many deaths have occurred from its use. In a large operative 
service covering many years and many urological operations, I have never had 
a death that I could ascribe directly to ether. 

350 



GENERAL ANESTHESIA 351 

Nitrous oxid is of value for examinations in urology and is also used for 
brief operations, although patients can and have been kept under its influence 
for an hour or more. The gas is contained in a cylinder in a compressed form, 
from which it escapes, on the turn of the valve, into a collapsed rubber balloon. 
When this is filled, the gas slowly passes through the inhaler and is breathed in 
by the patient. It is the safest of all anesthetics. It can be taken on a full or 
an empty stomach. No preparation for the anesthetic is required. There are 
no toxic symptoms following, such as vomiting and nausea. It may be con- 
sidered harmless. 

Dr. C. S. McNeille, the dentist at Cooper Union, who has had unusual 
experience with this variety of anesthesia, in speaking of its action as an anes- 
thetic, says: " All statements in relation to this matter can only be approximate. 
In this office we have given it 259,000 times since 1863 with no deaths. Very 
few deaths in nitrous-oxid anesthesia have been re])orted, and those usually 
came from asphyxia. We have never had a death during an anesthesia. As to 
the advisability of administering the gas on a full or an empty stomach, I would 
say that, in my experience patients have never vomited during an anesthesia if 
the operator or his assistant held the chin well down on the chest of the patient 
and thus let the saliva run forward. I also find that the patients who come 
with an empty stomach are the only ones who have a headache after taking gas. 
Hence I am in the habit of advising them to take a light repast before the oper- 
ation. As far as the time during which we can keep the patient under gas is 
concerned, I would say that I have kept a patient under gas for a surgeon for 
two and a half hours without intermission. The principal thing in keeping 
a patient under prolonged gas anesthesia is to watch the respiration and to give 
the gas so slowly as to prevent the system from IxMng crowded with the vapor. 

"As long as the rate of respiration is satisfactory, in fact as long as the patient 
is breathing, I do not care what the pulse may be doing. A man who knows 
how to give gas, will rarely produce the slightest degree of asphyxia. Should 
marked asphyxia occur, then artificial respiration must immediately be applied. 
As a rule, the patient recovers in from a half to two minutes, but it may be 
necessary to continue for a longer time. I believe that the stage of excitement 
in gas anesthesia is produced by a too rapid administration of the gas, and that 
in giving ether, this stage is the more severe and violent, the more we crowd 
the anesthetic in the first stage. The usual time for producing a narcosis for 
a tooth extraction is one minute. In administering gas, we are guided purely 
by the physiological eflFects and not by the pressure indicator on the reservoir." 

The increasing popularity of nitrous-oxid gas as a general anesthetic has 
brought about its use as a forerunner to ether and chloroform in general anes- 
thesia, so that now, especially in the administration of ether, gas is frequently 
given first, which renders the patient unconscious in a few seconds. Then the 
ether is continued by pouring it into a separate section of the inhaler made for 



352 ANESTHESIA IN UROLOGY 

this purpose, and the patient passes from the influence of one anesthetic to 
that of the other quickly and with but slight disturbance. The method of com- 
bined anesthesia was introduced by Dr. Thomas Bennett, of New York, who be- 
came a specialist in this branch of work. By his well-devised apparatus and his 
skillful manipulation, he is able to give anesthesia, starting with nitrous-oxid 
gas, continuing with ether or chloroform and administering oxygen, if necessary, 
in such a way that the operator feels safe and his composure is never disturbed 
while operating. The result of Dr. Bennett's pioneer work in combined general 
anesthesia has been the devolopmcmt of anesthesia as a specialty, which has been 
taken up by a number of the younger men throughout the country. 

The ease of operating under nitrous-oxid gas has been one of the chief in- 
centives to find other easy methods of using anesthesia and especially to produce 
analgesia without rendering the patient unconscious, a condition which no one 
looks upon favorably and every patient dreads nearly as much as the operation. 
An analgesic condition can be brought about generally and locally by certain 
drugs. The best general analgesic is scopolamin, generally spoken of as the 
scopolamin-morphin injection; but drugs which render the body analgesic are 
rarely used, as they are considered dangerous to the life of the patient. Local 
analgesia or anesthesia is, therefore, preferable. 

Spinal Anesthesia. — Spinal anesthesia has been used considerably in the 
surgery of the genital tract, especially in women. Personally, I have never 
used spinal anesthesia in urological operations, and, judging from what I have 
observed of its effect in the hands of other surgeons, I do not feel inclined to 
advocate its use, although Goodfellow, of San Francisco, and Boyd, of Panama, 
have found it most satisfactory in their work of prostatic surgery. 

This method was introduced in 1885 by Corning, of New Y^ork, and worked 
out by Bier, Quincke and Sicard. It consists in the injection of a solution of 
cocain (or another anesthetic) into the subdural space in the spinal canal. The 
effect of this is to render the entire lower part of the body anesthetic through 
the action of the drug upon the spinal nerve roots in the cauda equina. 

The puncture is made with a long strong hypodermic needle beneath the 
second lumbar vertebra (in children, the third) a little to one side of the median 
line. The patient lies on ys side with legs drawn up. The skin is disinfected 
as for an operation ; then it is anesthetized with a 0.1-per-cent solution of cocain, 
or with the ethyl-chlorid spray. The needle, syringe and solution are sterilized. 
The dose of cocain is 0.01 to 0.02 gram in a syringeful of physiological salt solu- 
tion with one drop of adrenalin. The needle is first introduced and a suffi- 
cient amount of spinal fluid allowed to escape. The syringe is then attached 
and the solution is slowly injected. The needle is withdrawn and the punc- 
ture closed with plaster. Anesthesia occurs in ten minutes. 

Local Anesthesia. — Local anesthesia occupies a very important position in 
urology, as it renders the examination and treatment painless in many cases, 



LOCAL ANESTHESIA 353 

and operations can be performed without pain, or with a minimum amount 
of suffering. 

The methods of applying local anesthesia are by freezing; by application 
to the mucous membrane or skin ; by intra- or hypodermic injections or infil- 
trations ; and by injections into the urethra, bladder and tunica vaginalis. 

Freezing Methods. — Freezing methods have been popular since the intro- 
duction of the ether spray by Richardson in 1866. In the following year, Roth- 
enstein introduced the ethyl-chlorid spray, which supplanted it and has been 
extensively used in minor surgery. 

Ethyl chlorid is a colorless liquid which is sold in glass tubes provided with 
a stopcock. When grasped in the hand and the valve is opened, the warmth 
of the hand suffices to vaporize the fluid. The tube is held at a distance 
of ten to fifteen inches (25 to 40 cm.) from the spot to be operated, the fine 
spray striking the surface, giving it a frosty appearance when it is frozen and 
anesthetized. 

A number of other freezing substances have been introduced since ethyl 
chlorid, but this is as effective as any of the newer preparations. The spray 
must be interrupted when freezing takes place, as permanent damage to the 
tissues may be brought about by prolonged freezing. Personally, I rarely use 
the freezing method, as it is not as practical, nor as far reaching as other local 
anesthetics. 

The Application or Injection of Anesthetic Solutions.^Cocain. — 
Of the large number of anesthetic drugs now known, the preferable one in 
routine work is cocain. Cocain is an alkaloid from the leaves of the coca plant. 
The salt used in local anesthesia is cocain hydrochlorate and is spoken of in 
this chapter as cocain. It is a white crystalline powder, soluble in water and 
alcohol. It has an anesthetizing power when placed upon mucous or serous 
membranes or when injected into the tissues, which was first discovered by 
Koller, of Xew York, who utilized it in anesthetizing the eye in his operations 
on that organ. It paralyzes the nerve terminals of the sensory nerves in the 
skin, the subcutaneous and other tissues, and also paralyzes, in a less marked 
degree, the motor perij)lieral nerves. 

Dosage of Cocain, — The dose of cocain internally is 1 grain (or 6 cgm.) ; in- 
jected intradermically, or into the deeper tissues, the dose is from 1 to 2 grains 
(or 6 to 12 cgm.) ; while, on the skin or mucous membrane or the external 
genitals, 6 grains (or 36 cgm.) or more can be used. 

The dose according to the strength of the solution is as follows: Of a 10-per- 
cent solution, drops 10 are used; of a 4-per-cent solution, drops 25; of a 2-per- 
eeiit solution, drops 50; and of a 1-per-cent solution, drops 100. 

The quantity generally used in this country for urethral and bladder injec- 
tions is \ ounce of a 1-per-cent solution. Chismore, of San Francisco, used in 
his office practice for several years a 3-per-cent solution, of which he was in the 



354 



ANESTHESIA IN UROLOGY 



habit of injecting 3 ounces into the bladders of his patients as a matter of rou- 
tine in crushing vesical calculi. 

Method of Administration. — In the hospital, for intradermic injections, we 
use Bodine's tubes put up by Squibb, each tube containing 1 grain of sterilized 
cocain and a certain amount of salt. The solution is made by breaking the 
tube and adding its contents to 1 ounce of sterile water. The proportion of 
salt in the tube is sufficient to make a solution corresponding to 1 grain of cocain 
in 1 ounce of normal salt solution. We can, therefore, see that : 

Tube 1 (gr. 1), added to water 1 ounce, makes a 1 : 500 or ^ of 1-per-cent 
solution ; the strength and dose for intradermic injections. 

Tube 1 (gr. 1), added to water 2 ounces, equals a 1: 1,000 or iV of 1-per- 
cent solution ; to be used for injections into the deeper tissues. 

For urethra and bladder solutions ^ of l-per-cent strength is used. It, there- 
fore, follows that: 

Tubes 5 in number (grs. 5), added to 2 ounces of water, makes a 1 : 200 or 
^-per-cent solution. 

Generally, however, the tablets of cocain are used for preparing these solu- 
tions, especially in all exploratory and cystoscopic work. Five ^-grain cocain 
tablets to 1 ounce of water, would make a 1 : 200 solution, or ^ per cent. Pow- 
ders of similar strength can be used in place of tubes or tab- 
lets in making these solutions. 

Sterilization of Cocain Solutions, — In the Squibb's tubes, 

the contents are sterile, and it is simply necessary to break the 

tube, letting the powder fall into the sterile water. After 

making solutions from tablets or powder, they should be held 

over a flame and brought to a boil once, as prolonged boiling 

weakens the solution. The solution should be freshly made be- 

fore operating, as cocain solutions spoil quickly. Each powder 

of cocain can contain incorjjorated in it the proportion of salt 

sufficient to make a solution, corresponding to 1 grain 

of cocain in an ounce of normal salt solution for a J-of-1- 

per-cent solution, or by adding 5 grains to 2 ounces of 

water a 1 : 200 solution will be obtained. 

The syringe used for intradermic and deeper injec- 
tions is one holding either 5 c.c. or 10 c.c. of the solu- 
tion. The barrel and piston are both made of glass. 
Both the syringe and needles are sterilized by boiling. The syringe with a 
finger brace is preferable. The needle and syringe should have a simple socket 
joint. For infiltration work, needles bent at right angles to tlie barrels are 
useful (Fig. 261). 

Technique of Injection: Intradermic and Suhdermic, — The syringe should 
be held with the thumb on the piston, and the first and second fingers should be 




Fio. 261. — Strixob por 
Local Anesthesia. 
Needle bent at right 
angles. 



LOCAL ANESTHESIA 



355 



on the crosa piece of the barrel, {See Fig. 262.) Care should be taken that the 
pressure is used only in the axis of the instrument with a free wrist, so as 
not to break the needle. 

A method at our disposal for incising or excising diseased, inflamed or 
suppurating tissues is, first, to isolate this area by surrounding it with an aiies- 




FiQ. 262. — Method of HaiJ>iNa raw Strinoh. 



thetized region carefully mapped out; 
second, to anestlietize a strip of skin 
and then gradually work deeper, to 
render anesthetic, all tlie tissues to be 
included in the field of operation. 

The first principle to be observed 
is that the needle should not be pushed 
forward or reintroduced, save through 
an already anesthetizc<l field. 

The skin and subcutaneous tissue 
is best anesthetized by the following 
niethwl (Fig. 2«;J). The needle is 
pushed inio the skin (not subcutane- 
ously) just far enough to cover the beveled point. Then a little pressure is ap- 
plied to the piston and a small white wheal or bleb is raised which renders the 
skin anesthetic. The needle is withdrawn and the point is now reintroduced at 
the distal margin of the bleb where a new bleb adjacent to the first is made, 
continuing iu this way until a strip of anesthetized skin is obtained for an 
incision. 

If a larger area of skin is to be anesthetized, we can use a modification of 
Reclus and Schleich's infiltration methods on the ground that, if the subcu- 
taneous tissue under an area of skin be anesthetized, the surface will also be- 
come anesthetic after a few minutes. Two points at opposite sides of the area 
are marked on the skin by raising blebs (Fig, 264^ From these points, a 



3. 263. — Method of Makiko the Blebs m 
Ihtkaderuic iNJECmoNB. A showa the punc- 
ture of the firat bleb. The croeecs (x) show the 
introduction of the needle for the Bucceeding 
blebs. Only the first puncture is felt. 



356 ANESTHESIA IN UROLOGY 

long needle is introdnced in a radiating direction into tlie subcutaneous tis- 
sue, injecting cocain always aiiead of the needle and following with the 
point The diagram sliows how tho area is covered anbcutaneously. After 
a few minutes, the entire skin surface over 
this area is anesthetized, which is espe- 
cially applicable in excising ulcerated or 
diseased lesions of the skin, and in obtain- 
ing skin grafts. Other forms, as the oval 
or the diamond, can be injected in a simi- 
lar way, depending on the shape and loca- 
tion of the area to be operated. 

When it is desired to cocainize a see- 
tion of skin and a mass of tissue beneath 

it, the oval or diamond may first be 
Fio. 264. — Thb Swbcptaneoub Method op , , . i ^ i_i v mi. ii 

ANesTOOT.«™ AN Area TO BS Operated marked OUt by four blcbs. Then the CO- 
UPON. Numbers 1 and 2 show the p«intji pain 19 injected deeply into the tissues to 
at which the needlea areinlroduced inra- . j ■! ■ !_■ i ■!. ■ ..i i» ^i . .i 

dialing unes. tlie depth to whu'h it 13 thotight that the 

operation will extend, and while proceed- 
ing with tile operation, an injection can be made from time to time into the 
deeper tissues to he invaded. It is well to remember that 1 : 500 solution is 
used intradermieally and 1:1,000 subdermically. 

The operations that are performed under cocain are usually those of a minor 
type, although many of a major nature are equally successful. It is principally 
indicated in circumcision, meatotoniy, internal urethrotomy, external urethrot- 
omy, vesical lithotomy and operation on any suppurative condition from the 
external urinary meatus to the mouths of the ureters. 

In kidney work, with the exception of cases of perincphritic abscess, a gen- 
eral anesthetic should be used. It is very difficult to keep tho parts sufficiently 
relaxed under cocain anesthesia to deliver a kidney, unless it is very small or 
freely movable. I will take up the tcchni(]ue of local cocain anesthesia more in 
detail under the operations in which it is used. - 

Cocain Poisoning.—Cocain jTOisoiiing is usually manifested suddenly' by an 
attack of vertigo. Often there is a partial or actual enllapse, irregular, weak or 
fluttering pulse, and cold perspiration on the surface of the body. The attack 
may be followed or accompanied by vomiting; sometimes syucojie occurs and 
may last for a few minutes. 

In a certain class of cases, there is a feeling of excitation, the result of irrita- 
tion hy the drug of the brain cortex. It resembles somewhat the period of 
excitement of chloroform anesthesia, ex(repting that consciousness is not so 
deeply affected. The patient becomes excited, noisy, laughing and chattering 
in incoherent delirium. There is frefjuently dryness of the throat, a heavy 
feeling over the heart and distiirhauces of sensation, as a tingling or numbness 



LOCAL ANESTHESIA 357 

of the limbs, or the loss of sense of sight or hearing. The pupils may become 
widely dilated and insensible to light. Sometimes there is twitching of the 
mnscles, or loss of reflexes, while in fatal cases there is usually coma and death 
due to paralysis of the respiratory system. 

Preventive and Palliative Treatment of Cocain Poisoning. — We should 
always be on our guard against poisoning, as cases have been reported in which 
slightly over one grain used hypodermically or injected into the serous and 
mucous cavities has proved fatal. The following precautions are recommended 
by Reclus : 

The patient should lie horizontally while being cocainized and should re- 
main in this position from twenty minutes* to three hours, according to the grav- 
ity of the case. Before the injections are made, the part should be compressed 
by a band above the locality to be anesthetized, and this compression should con- 
tinue for a half hour after the operation. 

If symptoms of cocain poisoning come on at any time, the patient should 
be made to lie flat; the heart should be stimulated by injections of strychnin, 
digitalis or atropin, one or all, according to the pulse ; besides which, friction of 
the body and the extremities should be resorted to. Artificial respiration may 
be needed if breathing threatens to stop. Drops of amyl nitrate should be imme- 
diately used if at hand. In case the trouble is due to a solution in the bladder, 
the viscus should be emptied and washed with saline solution. If there are con- 
vulsions, ether inhalations are indicated. 

In conclusion, I will say that in all uncomplicated cases of urethral surgery 
and in cases of vesical calculus, cocain can be used ; but it is important to have 
an assistant to give the injections and infiltrations, who is accustomed to the tech- 
nique of the administration. For prostatectomies, extirpation of vesical tumors, 
nephrotomies and nephrectomies, it is important to have a special anesthetist of 
the highest possible grade if the operator desires to feel at ease during the oper- 
ation, as in that latter group of cases in my practice, the hemorrhages are often 
alarming. 



CHAPTER XVIII 

DISEASES OF METABOLISM 

URICACIDEMU 

Uricacidemia is the condition in which an excess of uric acid in the blood 
is characterized by various nerv^oiis symptoms and frequently by the local 
phenomena known as gout. 

This does not mean that an excess of uric acid in the urine as shown by 
its analysis indicates the uric-acid diathesis or gout, as is supposed by many. 
These conditions are the result of uric acid retained in the blood and tissues, 
and not of that eliminated with the urine. It may be said, and at times it is 
no doubt true, that the amount of uric acid and urates contained in the urine 
is in proportion to that retained in the body. 

The formation of uric acid in the body and its role in disease are still sub- 
jects of discussion. Formerly it was thought that uric acid w^as a product of 
nitrogenous changes, an intermediate between the foodstuffs and the final 
product of urea. It is thought at present that uric acid is formed by oxidation 
of nucleic acid and that foods rich in nuclei, such as meats, give rise to its 
formation and elimination in large quantities. It is impossible to know, how- 
ever, whether or not uric acid is also derived from some other constituent of 
the food. Excessive accumulation of uric acid in the blood and tissues is more 
frequently the result of imperfect elimination than of increased formation. 
Uric acid is a very insoluble substance and a slight decrease in the alkalinity 
of the blood may cause its retention and accumulation in the tissues. We hold 
at present that uric acid is not formed in the kidney, but in the tissues, in the 
liver and in the spleen. 

The normal amount of uric acid in the urine is from 0.4 to 0.52 grams (G 
to 8 grains) in twenty-four ho\irs. 

The proportion of uric acid to urea is as 1 to 45. 

A deposit of uric acid and urates in the urine does not necessarily indicate 
an excess of uric acid. Such a deposit may occur on cooling, as the result of 
acid fermentation. Urines of high acidity may deposit uric acid, irrespective 
of the absolute quantity of the latter in the specimen. Whether uric acid is 
really increased or not, we can only know by quantitative analysis. 

Uric acid is increased in the urine by an abundant meat diet, containing 
358 



imiCACroEMIA 359 

much nuclear substance and by a sedentary life, often the use of tea and coffee, 
certain drugs, as the salicylates and also in the following diseases : 

1. In acute fevers and in most acute diseases. 

2. After an attack of rheumatism and gout, when normal elimination has 
been reestablished. 

3. In diseases of the lungs and heart accompanied by diminished oxida- 
tion (pneumonia, hydrothorax, chronic heart diseases). 

4. In large abdominal tumors, ascites, respiratory insufficiency. 

5. In diseases of the liver and spleen. 

6. In pernicious anemia and leukemia, due to the destruction of the nuclei 
of the leucocytes. 

7. In diabetes mellitus. 

Uric acid is diminished in the urine by a vegetable diet ; after a diet of milk, 
eggs and dairy products ; after eating cherries and similar fruits. 

It is also diminished in chronic diseases of the kidney and in other condi- 
tions, with a decrease in the amount of urea ; in gout, during acute attacks and 
in chronic wasting diseases. 

Sjnnptoms. — Uricacidemia is clinically characterized by a certain group of 
symptoms, sometimes spoken of as the gouty state. 

Heredity plays an important part, and in many families various manifesta- 
tions may be of frequent occurreAce. 

In addition to attacks of gout proper, a tendency to uric-acid diathesis may 
be responsible for more or less frequent attacks of headaches, neuralgias, sciatica, 
biliousness, affections of the skin, such as eczema, etc. 

Later in life, after the prevalence for many years of uricacidemia, the 
more serious results of the disorder become evident. Arteriosclerosis frequently 
develops, leading to a fatal termination by nephritis, apoplexy, or aneurysm. 

The presence in the urine of an excessive amount of uric acid in crystalline 
form often acts as an irritant to the genito-urinary tract and always renders the 
patient liable to renal or vesical calculus. 

Treatment. — In the treatment of uricacidemia, the fact that gluttony and 
errors in diet are the most frequent etiologic factors must be constantly kept in 
mind. The daily amount of meat and fat-producing foods must be reduced, and 
a vegetable diet substituted. Alcohol must be interdicted altogether. Elimina- 
tion should be favored by the free use of mineral waters, such as Apollinaris, 
Vichy, Selters, as well as by gymnastics and outdoor exercise. 

The long list of \iseful therapeutic agents includes the lithium salts, col- 
chicum, uricidin, piperazin, the salicylates, etc. 

URIC-ACID DIET 

Avoid. — Bisque, cream and tomato soup; corned, dried, smoked, canned, 
preserved or fried meats or fish. Tongue, ham, veal, pork, turkey, beef, lob- 



360 DISEASES OF METABOLISM 

sters and crabs. Highly spiced sauces and peppers. Hot rolls, cakes of all 
kinds ; all cereals, as oatmeal, hominy, etc. ; sirups, sweets of all kinds ; every- 
thing made from corn; potatoes, or vegetables rich in sugar, as beets. (Just suf- 
ficient sugar to sweeten coffee can be used.) Strawberries, bananas and melons. 

Spirits — brandy, whisky, gin and rum ; good whisky is the least injurious, 
taken with meals and well diluted with water. One or two Scotch whiskies a 
day, well diluted, can be taken with meals or after them, if the patient is below 
par ; or a glass of claret with the meaL Heavy wines, also champagne, Bur- 
gundy, beers and ales. 

May Eat. — Oysters and clams, consomme and thin soups (without tomato), 
fish, beef, lamb and chicken, roasted, boiled or broiled, never fried. Salads 
of lettuce, romaine and chicory, with French dressing, consisting of four parts 
of oil to one of Tarragon vinegar, salt and white pepper. Dry toast and light, 
unsweetened, dry bread. Green string beans and peas; spinach occasionally; 
cauliflower and Brussels sprouts, if they can be digested. Apple at lunch and 
grape fruit for breakfast, without sugar, are the least harmful, although no 
fruits are necessary. Lemon is the least harmful. 

N. B. — No tea. Coffee with hot milk for breakfast. 

Water Diet, — One glass of water on arising ; one glass at lunch ; one glass 
at dinner ; one between meals ; one on retiring. Small cup of mild, black coffee 
may be taken after lunch or dinner. 

Dietaries. — The following is the dietary which Sir H. Thompson recom- 
mends in calculous affections: 

" Fish in all forms, except those containing much fatty matter — i. e., her- 
rings, mackerel, eels and the thin part of salmon. Game in all forms. 
Poultry. Lean meat in moderate quantity. Preparations of gelatin, savory 
jelly, or jelly agreeably flavored, but unsweetened. Butter in moderation (this 
is the only direct form of fat admitted, fat in some form being necessary). An 
egg or two on account of their usefulness in all cooking operations. (The ob- 
jection to eggs applies only to the yolks.) Milk in strict moderation, and only 
with tea, coffee or cocoa. It is very undesirable and noxious in large quantity, 
as it contains a large proportion of fat and sugar, and its casein is digested with 
difficulty. It is less objectionable when thoroughly skimmed. Well-made whole- 
meal bread. Oatmeal. Pearl barley. Macaroni and other Italian pastes. 
Some coarse meal is needed to act as an aperient and prevent constipation. 
Whole-meal bread is improved in flavor and texture by an admixture of fine 
(not coarse) Scotch oatmeal, in the proportion of about one quarter to one third 
of the wheat meal employed. 

*^ Dry haricots and lentils are most nutritive vegetables, and should be 
taken made into purees. They are digested with ease and contain much nutri- 
tio\is matter. Rice, sago, tapioca and arrowroot are all useful if treated as 



rNTDICANURIA 361 

savory dishes, and not as sweets. Fresh green vegetables are especially good. 
Fresh green peas and broad beans, well masticated. Light salads are permis- 
sible to persons who digest them easily, but they must not be taken by those 
who digest them with diflSculty. Celery, sea kale, asparagus, tomatoes, potatoes 
and artichokes are all permitted; so also are apples, roasted or baked, without 
added sugar. 

" The following are to be avoided : Rhubarb, gooseberries, currants, strawber- 
ries, raspberries, grapes, plums, pears and all sweet fruit, fresh or preserved. 
Saccharin may be substituted for sugar." 

INDICANURIA 

The urine often contains substances, not necessarily indicative of very great 
departures from health, but rather to be considered as danger signals, not to 
be ignored altogether. Thus, it may contain those known as chromogens, 
that is to say, bodies w^hich do not of themselves color the urine, but subse- 
quently develop a characteristic color under special conditions, either on stand- 
ing or on the addition of agents that cause oxidation. 

Indican may be defined as the chromogen of indigo blue. It arises from 
the absorption on the part of the intestinal canal of the parent substance, indol, 
which itself results from the decomposition of proteids. 

In the human intestine in health, indol is formed in small amounts. It is one 
of the products of the bacterial putrefaction of albuminous compoimds, and is 
physiologically increased on a diet rich in meats or animal food, containing a large 
proportion of proteid. The indol thus absorbed by the intestine becomes in the 
tissues through oxidation a new substance, indoxyl, which is excreted in the urine, 
as a rule in conjugation with sulphuric acid — as indoxyl-sodium or potassium 
sulphate — and also it is found in small proportion as indoxyl-glycuronic acid. 

Pathological Indicanuria. — The clinical importance of the presence of a 
large proportion of indican in the urine has been exaggerated by some, but is 
more apt to be underrated. Its significance in the light of recent researches can 
scarcely be doubted. It affords valuable evidence of excessive proteid decom- 
position in the presence of bacteria ; these are the agents of processes of putre- 
faction that lead to disturbances in the liver, to the various forms of gastritis, 
to constipation and diarrhea and those processes of putrefaction and fermenta- 
tion gathered loosely into the general idea of *^ toxemia and autointoxication." 

Experience shows that an increased output of indican is observed in cases 
of intestinal obstruction, associated with atony and with a deficiency of acid in 
the gastric juice, and in not a few intestinal disorders dependent on a dimin- 
ished flow of bile. According to Simon, the deficiency of hydrochloric acid in 
the stomach is intimately associated with the development of indican. Thus, 
indicanuria occurs frequently in carcinoma of the stomach, in subacute and 



362 DISEASES OF METABOLISM 

chronic gastritis and in those forms of dyspepsia where the motor power of 
the stomach is impaired. It is also present in typhoid fever. 

Examples of excessive albuminous putrefaction and of the bacterial activ- 
ity leading to the formation of large amounts of indican in conditions to be met 
with elsewhere than in the alimentary tract, are afforded by cases of putrid 
empyema, fetid bronchitis and pulmonary gangrene, the importance of which 
has been fully set forth by Von Jaksch. 

Sjrmptoms. — The symptoms of indicanuria are various, and are in many 
cases difficult to trace to their true relation with the output of indol. 

In general, it may be said that indicanuria is commonly associated with gas- 
tro-intestinal disorders marked by flatulence — the sign of bacterial growth — 
and of the nondigestion of fats, prominently disclosed by alternating attacks of 
constipation and diarrhea. A long train of symptoms, nervous, hepatic and 
renal, take their origin in putrefying processes in the intestine, which at the 
same time give rise to the presence in the urine of indigo-yielding substances. 
It becomes necessary, therefore, to examine the urine for indican whenever the 
signs of gall-stone disease appear, whenever there is pain or colic, or jaundice ; 
and though the mere presence of indican should not be regarded as pathogenic, it 
gives a clew to the nature of the disease and its treatment. Thus, a furred tongue, 
injected eye, loss of appetite, headache, torpor, both mental and bodily, tender- 
ness over the liver and abdomen, may occur without indicanuria, but they may 
just as well coexist with it, and such signs should lead us to examine the urine. 

Treatment. — The treatment of indicanuria consists of those remedies w^hich 
are intestinal antiseptics and those which stimulate bile secretion. Ko single 
drug should be used continuously, more benefit being derived by using different 
members of these groups from time to time. 

Salol is the most frequently used and is given in doses of from 3 to 5 grains 
three times a day after meals, either in tablets or capsules. 

Beta-naphthol and naphthalene come next in efficiency and are given in doses 
of 2 to 5 grains in capsules three times a day, after meals. Sodium iodid is use- 
ful in cases in which there are accompanying nervous symptoms, 10 to 15 grains 
in solution being given three times a day after meals. Sodium benzoate is also 
valuable as a remedy and is given in doses of 10 to 20 grains in capsules or solu- 
tion after meals. In cases of hyperacidity due to intestinal fermentation, 
sodium bicarbonate is of value, 10 to 30 grains being given in solution or capsule 
after each meal. Of the remedies used when fermentation or putrefaction is 
due to an insufficient flow of bile, the glycholate and taurocholate of sodium 
are useful. They may be given in capsules, 3 to 4 grains in a capsule, after 
meals, or every three to four hours during the day. Phenolphthalein has of 
late been used when indicanuria is associated with constipation, as it acts as a 
cholagogue and laxative. It is given in capsules or tablets, in doses of from 5 to 
30 grains, before retiring. 



OXALURIA 363 



OXALURIA 



Oxaluria means the presence of an excessive amount of oxalate of calcium 
in the urine. When found occasionally in moderate quantity, these crystals are 
of no clinical significance, as they may appear under normal conditions after 
eating fruits and vegetables containing comparatively large amounts of oxalic 
acid, such as rhubarb, tomatoes, spinach, cabbage, turnips and sorrel. 

Oxalic acid is a product that is formed as an intermediate step in the com- 
bustion process, and conies between urea and uric acid in the series. It is found 
in very small quantities in normal urine in the form of calcium oxalate, but it is 
contained in normal specimens occasionally only, after the urine has been left 
standing for a time. 

Urine containing numerous crystals of calcium oxalate for any length of 
time is not the urine of a healthy individual, and the condition is one that 
should be treated. 

Oxaluria is merely a symptom pointing to a debilitated condition of the 
system. Of the cause of this condition, little is known. Generally, oxaluria is 
associated with conditions of nervous debility, perhaps especially often with 
those arising from sexual excesses. This is so frequently the case, that one 
sliould always be on the lookout for spermatozoa, if, in examining the urine of 
a nervous individual, calcium oxalate is found. 

Oxaluria may also give rise to local irritation in the genito-urinary tract. 
When the crystals are formed in the kidney as they very frequently are, their 
passage through the kidney tubules, pelvis and ureters may give rise to lumbar 
pains or hematuria, or the crystals may collect around epithelial cells and mucus 
and form into concretions in the kidney or renal pelvis, causing renal colic, or 
they may irritate the bladder and urethra, bringing on frequency of urination. 

The urine in cases of pronounced oxaluria is of high specific gravity, often 
reaching 1.040. Even when there are no subjective symptoms of irritation, the 
microscopic examination usually shows the presence of red blood corpuscles, 
mucus and epithelia. 

Treatment. — Regulation of the diet, and exercise, are of the greatest im- 
jx)rtance. 

The diet indicated should be one that limits the amounts of all articles con- 
taining large amounts of oxalic acid. Water, weak coffee and tea are the most 
suitable drinks. Alcoholic beverages are not especially forbidden, but should 
be taken in moderation. 

In order to dilute the urine, the patient should drink water freely. The 
carbonated alkaline waters, such as Apollinaris, are especially useful. Many 
authors, as Klemperer, Tritchler and others favor the bitter waters containing 
magnesia, such as Friedrichshall, Ilunyadi, etc. 

Some cases are greatly benefited by the administration of nitromuriatic acid. 



364 DISEASES OF METABOLISM 

f 

DIET IN OXALURIA 

From the following list of foods, a diet suitable for patients having oxaluria 
niav be selected: — • 

T'ooDs JpERMiTTED. — Clavfis and oysters, consomme and thin soups without 
tomatoes, all kinds of meat and fish (baked, boiled or broiled), stale bread and 
toast. Vegetables: Fresh string and lima beans, green peas, lettuce, chicory and 
romaine salads; later on, Brussels sprouts and cauliflower may be added. 
Fruits: Apples are for lunch, peaches or grape fruit without sugar are the least 
harmful for breakfast in moderation. Cereals: Oatmeal, well cooked, may be 
taken in small quantities. 

Foods Forbidden. — All vegetables not mentioned in foregoing list; espe- 
cially injurious are potatoes, tomiatoes, spinach, rhubarb, beets, turnips, dried 
beans. Fruits: Strawberries, phuns, figs. All sweets are interdicted. Meats: 
All glands such as pancreas, thymus, liver and kidneys, on account of the many 
nucleins contained therein. 

EXTRA DIET IN OXALURIA 

A More Rigid Diet Covering a Longer Period 

First Week. — As purely nitrogenous as possible, may take milk, meat 
(boiled, broiled or roasted), fish, eggs once a day. Nothing fried, pickled, 
salted or canned, or preserved in any way. Should drink pure water, at 
least three quarts a day. Nothing to be taken except those things men- 
tioned. 

Second Week. — To above may be added cucumbers, celery, lettuce and 
asparagus. 

Third Week. — To above may be added raw oysters, oyster broth, green 
peas, string beans, any broth or variety of clear soup. 

Fourth Week. — Grape fruit, lemons and cauliflower may be added, pears, 
peaches, baked apples, grapes in moderation, melons, well-cooked oatmeal in 
small amount and well-toasted or stale wheat bread. 

Interdicted. — Potatoes, spinach, rhubarb, beets, turnips, dried beans, to- 
matoes, strawberries, plums, figs, or sweets added to the above. 



DIABETES AND GLYCOSURIA 

General Consideration 

Diabetes and glycosuria are discussed together in this chapter because they 
are so frequently confused with one another, owing to the fact that, in diabetes 
mellitus, glycosuria is present. 



DIABETES AND GLYCOSURIA 365 

Diabetes. — ^Diabetes is a disorder of the body metabolism, characterized by 
the passing of excessive quantities of urine. There are two forms of diabetes : 
Diabetes mellitus and diabetes insipidus. 

Diabetes mellitus is the most important form. In addition to the polyuria 
and the intense thirst which characterizes both forms of diabetes, we have here 
the presence of sugar in the urine. When diabetes is spoken of without quali- 
fication, this form is usually referred to. 

Diabetes insipidus is a name applied to that form of diabetes which is 
characterized by the passage of abnormally large quantities of normal urine of 
low specific gravity, and by intense thirst. 

Olycosuria. — Glycosuria means the presence of sugar in the urine, from any 
cause, in excess of 0.1 per cent. 

There are three varieties of glycosuria: (1) The alimentary, (2) the toxic, 
(3) the diabetic. 

Alimentary glycosuria occurs in healthy individuals in certain disturbed 
conditions of digestion and elimination ; also in diseases of the liver and of the 
brain, especially when the latter affects the fourth ventricle ; in goiter and after 
injuries. Alimentary glycosuria may occur after the ingestion of large amoimts 
of starch. 

Toxic glycosuria occurs in fevers, after drinking large amounts of alcohol 
and after poisoning with lead, phosphorus, morphin, atropin, chloral, amyl 
nitrite, acetone, carbon dioxid, curare and strychnin. 

Fhloridzin glycosuria should be classed under toxic glycosuria. Although 
phloridzin is a glucosid, the amount of sugar passed after its administration is 
too great to be accounted for by that derivable from the drug. Phloretin, which 
is a derivative from phloridzin, is free from sugar and produces the same result. 

Diabetic glycosuria constitutes the disease known as diabetes mellitus. 

DiABETKs Mellitus 

Pathology and Etiology. — The pathology and etiology of diabetes, like 
those of other disorders of metabolism, has not been definitely determined. The 
glycogenic function of the liver is deranged, and an excess of sugar passes into 
the blood and is eliminated with the urine. The bulk of the sugar thus passed 
is derived from the carbohydrates in the food ; in severe cases, a certain amount 
of the sugar seems to be the result of metabolism of the proteid constituents of 
protoplasm. 

The amount of sugar eliminated in diabetes varies considerably. It ranges 
from a mere trace up to ten per cent and even twenty per cent ; average two to 
three per cent. The percentage of sugar in the urine is by no means an accurate 
index of the severity of the pathological process. 

The total amoimt of urine passed also varies greatly. In mild cases, the 



366 DISEASES OF METABOLISM 

daily quantity may not exceed six to eight pints ; in severe cases, thirty to forty 
pints are often passed. 

The specific gravity is high, varying according to the saccharine contents 
of the urine from 1.025 to 1.060. 

Diabetic urine has a sweetish taste and aromatic odor, increasing or dimin- 
ishing with the amount of sugar. 

Sjnuptoms. — The great prominent general symptom of the disease is in- 
tense thirst, a large quantity of water being required to keep the sugar in solu- 
tion. There is also usually a great craving for food ; in spite of abnormally 
large quantities of nourishment taken and in spite of excellent digestion, the 
patient may lose weight. The skin is dry and harsh, the temperature frequently 
subnormal, the pulse frequent and the tension increased. 

Complications. — Serious complications are frequent, such as acute pneu- 
monia, tuberculosis, diabetic tabes, hypochondriasis, cataract, diabetic retinitis, 
impotence; nephritis is quite common, sometimes due to arteriosclerosis, in 
other cases probably the result of the strain on the renal structure from the 
continual passage of abnormal quantities of sugar. 

Prognosis. — Recovery from true diabetes is very rare. In children, the dis- 
ease is especially fatal ; so-called galloping cases are often seen which carry the 
young patient off in a few days. With advancing years, the disease runs a 
slower course. During middle life, diabetes may exist for ten or fifteen years 
before the fatal termination. In stout individuals, the prognosis is more favor- 
able than in those of slighter build. 

Unless one of the many serious complications, to w^hich the patient is ex- 
posed, sets in, the disease usually ends with diabetic coma. This condition 
closely resembles in its onset uremic coma and, like it, is due to the presence in 
the blood of some toxic agent, which in this case is believed to be acetone. 

Treatment. — The diet and personal hygiene of the patient are of prime im- 
portance. The patient should live a quiet life, free from excitement and worry. 
He must be scrupulously regular in his habits, taking a moderate amount of 
exercise and bathing daily to promote a free action of the skin. The regula- 
tion and restriction of the diet is the most essential part of the treatment. The 
carbohydrates in the food should be reduced and a carefully arranged diet, with 
due regard for variety, should be given. The substitution of gluten bread for 
ordinary bread and saccharin for sugar, should be a part of the dietary regime. 

Among remedies, opium is the one that has specific influence on the progress 
of the disease. Codein given in one-half-grain doses three times a day, gradu- 
ally increasing to six or eight grains during twenty-four hours, will in the ma- 
jority of cases lessen the amount of sugar in the urine materially. As the 
amount of sugar diminishes, the opium may be gradually withdrawn. 

Among other useful remedies, we may mention potassium bromid, arsenite 
of bromin, arsenic, antipyrin, the salicylates, nitroglycerin and strychnin. 



PHOSPHATIJIIIA 367 

DIET LIST 

From Friedenwald and Ruhrah^ " Diet in Health and Disease " 

Foods Allowed. — Meats, eggs, green vegetables, fats. Soups: Chicken, 
beef, veal, mutton, oyster, turtle, terrapin, clam broth (prepared without flour). 
Meats: All meats, except liver. Gelatin jellies. Cheese: All varieties, espe- 
cially cream cheese. Fish: All fish, including oysters, clams, terrapin, lobster, 
shrimp, salt fish. Farinaceous foods: Gluten bread, cakes, biscuits and por- 
ridges, almond cakes and bread, soya bread. Vegetables: Green vegetables, 
spinach, lettuce, romaine, chicory, sorrel, kale, artichokes, endives, pickles, 
cucumbers, cranberries, truffles, mushrooms. Fruits: All acid fruits, sour ap- 
ples, sour cherries, sour oranges, lemons, grape fruit, gooseberries, red currants. 
Nuts: All sorts of oily nuts, such as cocoanut, walnuts, filberts, almonds, butter- 
nuts, pecans, Brazil nuts. Fatty foods: Cream, butter, olive oil, cod-liver oil, 
bone marrow. Drinks: Tea or coffee without sugar, alkaline mineral waters, 
Ehine wines, claret. Burgundy, brandy, whisky. 

Foods Forbidden. — Sugars, starchy foods (rice), sweets of all kinds, liver. 
Vegetables: Potatoes, turnips, beets, carrots, peas, baked beans, cauliflower; also 
sweet fruits, such as dates, grapes, peaches, prunes, bananas, preserves and jel- 
lies. Nuts: Peanuts and chestnuts. Drinks: Sweet wines, cider, cordials, beer, 
'poTtet. 

PHOSPHATURIA 

This is a condition in which an excess of phosphates is passed in the urine. 
Two varieties of phosphaturia can be distinguished, the true and the false. True 
phosphaturia depends upon an absolute increase in the amount of phosphates 
eliminated in the urine as determined by quantitative analysis. 

A mere deposit of phosphates in the urine immediately on voiding or on 
standing, without a relative increase in the total amount of phosphates, consti- 
tutes false phosphaturia. The clinical diagnosis of true phosphaturia can be 
made only: (1) If there is a quantitative excess of phosphates which is con- 
stant (the normal amount excreted in twenty-four hours does not exceed three 
and a half to four grains). (2) If this excess is not controlled by a change of 
diet. (3) If the deposit of phosphates occurs immediately after voiding the 
urine. 

Deposits of phosphates in the urine may occur within the body in cases of 
inflammation or suppuration of the urinary organs, such as cystitis, pyelitis, 
etc. ; especially when there is a decomposition of the urine within the tract, 
the result of an obstruction, as an enlarged prostate or a stricture. Of course, 
such cases cannot, in any sense, be called true phosphaturia. 

This form of phosphaturia is of special interest to the genito-urinary surgeon 
on account of the frequent formation of calculi under these conditions. 



368 DISEASES OF METABOLISM 

The phosphorus eliminated with the urine is derived from two sources: 
from the food and from decomposition of the tissues, especially the pliosphorus 
containing proteids, as well as nuclein and lecithin. 

In the urine, the phosphorus appears in two forms: (1) As earthy phos- 
phates — calcium and magnesium phosphates; (2) as alkaline phosphates — the 
phosphates of sodium and potassium. The alkaline phosphates are more abun- 
dant, the proportion being about two to one. 

The earthy phosphates are held in solution in the urine by the diacid sodium 
phosphate, to which the acidity of the urine is due. 

Whenever the acidity of the urine is neutralized, either before or after 
voiding, the earthy phosphates are precipitated, but they can readily be dis- 
solved by making the urine acid again. 

A vegetable diet, by diminishing the acidity of the urine, will often bring 
about this apparent phosphaturia ; while a meat diet, on the other hand, will 
decrease or cause the disappearance of this precipitate of earthy phosphates by 
increasing the acidity of the urine. 

True phosphaturia, that is, the condition associated with a more or less con- 
stant relative increase in the amount of phosphorus eliminated, must be classed 
as a disorder of metabolism. According to L. J. Teissier, four forms of this 
disease can be distinguished: 

1. Cases with polyuria and with very pronoimced disturbances of tlie 
nervous system, with or without organic changes in the latter. 

2. Cases which are from the beginning or during the later stages of the 
disease associated with fatal affections of the lungs. 

3. Cases in which phosphaturia occurs together or alternate with glycosuria. 

4. Cases which cannot be grouped under the foregoing divisions and which 
alternate with oxaluria and uricacidemia, showing often albo a slight albu- 
minuria and a certain relation to gouty states. 

Treatment. — The treatment of phosphaturia requires, first of all, regulation 
of the diet and habits of living, whether the disorder belongs to the true or false 
variety. Among the remedies that have been used successfully in the control of 
true phosphaturia, phosphorus is especially recommended, also nux vomica 
and arsenic. 

To control phosphaturia of the false variety, the conditions producing it 
must be treated. There may be decomposition of the urine in the urinary 
tract, due to inflammation and obstruction. Many cases of false phosphaturia 
simply require a more liberal meat diet ; others call for mineral acids to cor- 
rect gastric fermentations and disturbances of the digestive function. If the 
phosphaturia is accompanied by bacteriuria, urotropin should be given. 

The diet list for a case of phosphaturia may contain meat, eg^, milk, 
cheese, cereals and the legumes, whereas the ingestion of fresh green vegetables, 
fruit and potatoes, should be restricted. 



CHAPTER XIX 

METHODS OF EXAMINING THE KIDNEY 

In the cases that we are called upon to see, we are led to suspect the pres- 
ence of a surgical disease of the kidney by certain symptoms, foremost of which 
is a complaint of pain in the loin ; second, symptoms referable to urination or 
the urine voided ; and third, constitutional symptoms. 

Pain is the most important of these troubles. It may be slight in char- 
acter and may be present constantly or at intervals, or it may come on as a severe 
attack of colic located in the loin and extending down the course of the ureter. 

Pain is most common in renal calculus, especially after exertion, although 
it is also present in varying severity in movable kidney, tuberculosis and 
nephralgic nephritis. 

Frequent and painful urination is a bladder symptom and rarely occurs in 
kidney disease, excepting in renal tuberculosis in cases in which the disease has 
invaded the bladder. Polyuria is also a symptom of renal tuberculosis. 

Hematuria is the s;^Tnptom of renal disease which, next to pain, alarms a 
patient the most and is the reason for the consultation. When hematuria occurs 
in a patient suffering from pain in one loin, it leads us to think of hematuria 
on that side. Hematuria is most characteristic of renal tumor, in which case 
it is spontaneous and often very severe. Xext in order, it occurs in renal calcu- 
lus and tuberculosis. 

Pyuria in kidney cases means infection, as does also fever, and, therefore, 
if either or both of these symptoms occur in a patient with pain in the loin, it 
leads us to think of a septic kidney. With the history of these symptoms, we 
must begin the examination that will finally lead to the diagnosis of the trouble. 

In the examination of a suspected case of surgical kidney, several questions 
have to be taken into consideration. First, Are the kidneys affected or is the 
trouble in some of the other urinary organs ? Second^ Which kidney is dis- 
eased? Is there another kidney? If there is. What is its condition? Third, 
What is the nature of the disease ? Fourth, What is the functional power of 
the diseased kidney and its mate ? Fifth, Is an exploratory operation necesvsary ? 

No. 1 : The Examination of the Urine. — This is most important when con- 
\ sidered in conjunction with other findings. The presence of normal renal prod- 
ucts in the urine in an increased amount, or of abnormal products, both point 

369 



1 



370 METHODS OF EXAMINING THE KIDNEY 

to a renal disturbance. If we find a very large amount of renal epithelia thro\vn 
off, it suggests some mechanical irritation of the kidney or its pelvis. If, in 
addition to this, there are red blood cells and considerable mucus present in 
the urine, the probabilities of renal irritation are much increased. 

The presence of albumin and hyaline casts point either to marked irritation 
of the kidney or to disease. If these casts are granular and epithelial as well 
as hyaline, we have reason to believe that a more severe process, a nephritis, 
exists. If crystals are present in masses of mucus or casts, we are led to think 
of the probabilities of stone. If, in addition, pus is detected, the indications are 
that there is ^n infection of the pelvis ; and if pus casts are also found, it is 
evidence that the parenchyma is also infected. 

An increased amount of urine, of low specific gravity, leads us to think of 
tuberculosis, which the presence of tubercle bacilli would confirm. Atypical 
cells, tumor fragments and the presence of connective tissue lead us to think 
of tumor. Blood in the urine in connection with abnormal renal products, 
suggests tumor, stone, tuberculosis or hemorrhagic nephritis. 

While the urinary findings in a large percentage of kidney cases give us the 
most reliable data upon which to base a correct diagnosis, they are frequently 
but the first incentive to the thorough investigation of the case and only acquire 
a definite significance when considered in connection with the results of other 
methods of examination. 

We will assume that, from the urinary findings, we have decided on the 
presence of kidney disease of a surgical nature and are now desirous of locating 
the trouble. To confirm the diagnosis thoroughly, a further examination should 
include the following steps in the order given : 

No, 2: In which kidney is the disease located ? Is there another kidney, and 
if so, is it normal or abnormal ? 

External physical examination, including: 

(a) Inspection, palpation and percussion. 

(b) Cystoscopy. 

(c) Ureteral catheterization. 

No. 3: What is the nature of the disease? 

(a) Radiography. 

(&) Guinea-pig inoculation. 

No. 4: What is the function of the diseased kidney and its mate? 

(a) Cryoscopy. 

(b) Injections of methylene blue. 

(c) Phloridzin injections. 

No. 5: Is an exploratory incision necessary? 



EXTERNAL PHYSICAL EXAMINATION 371 

No. 2 : In which Kidney is the disease located? Is there another kidney, 
and if so, is it secreting? If it is secreting is the urine normal or abnormal? 

(a) Inspection, Palpation and Percussion. 

Inspection sometimes shows a bulging in the loins and recalls to our minds 
the possibility of hydronephrosis, pyonephrosis, tumor of the kidney, perinephri- 
tic abscess, or rupture of the kidney. A bulging on one side of the umbilicus 
would point to a movable kidney. Very little, however, is learned by in- 
spection. 

Palpation is, on the other hand, a most important method of examination, 
as by this means we notice undue mobility in movable kidney, and enlargement 
when tumor, hydronephrosis, pyonephrosis, pyelo-nephritis, perinephritic abscess 
or a cyst is present. By palpation, tenderness is also discerned, indicating a 
congestion of the kidney, or inflammation, as pyelitis, pyelo-nephritis and pyo- 
nephrosis. A normal kidney in its normal position cannot be felt through the 
abdominal wall. 

Methods of Palpating the Kidney. — The kidney is usually palpated in one 
of three ways: With the patient lying on the back with the knees flexed; in a 
sitting posture; or lying on the healthy side. (See chapter on Examination of 
Patients, Figs. 233, 234 and 235.) 

Palpation with one hand will sometimes show us a movable kidney or one 
that is enlarged. The bimanual method is, however, the most practical and 
gives us a better idea of its size, consistence, mobility and the presence or ab- 
sence of renal tenderness. 

When the patient is examined lying flat on the back with the knees flexed, 
the examiner stands on the side to be explored, facing the patient. If the right 
side is to be examined, the right hand is on the front of the abdomen on the 
outer side of the rectus abdominis muscle and the left hand is on the outer side 
of the erector spinse, just below the twelfth rib. 

The patient is directed to inspire and expire deeply and, during the moment 
of relaxation when the patient is breathing out, the hand on the abdomen pushes 
firmly toward the posterior abdominal wall, in an effort to reach the hand that 
is placed posteriorly. The part of the hand used in examining is the palmar 
surface of the finger tips. If any surgical condition of the kidney is present, 
a sensitiveness is evident, w^hile the normal kidnev is not tender to the touch. 
Movable organs can be felt to glide from under the finger tips and can usually 
be held by anterior pressure above them and palpated wholly or in part. (See 
Fig. 233.) 

Ballottement of the kidney is the pushing of the organ from the finger tips 
of one hand to those of the other, and vice versa, by a series of jars or by gentle 
bimanual palpation. By this means, an enlarged organ is distinctly felt and 
can be outlined and any tenderness noticed. 

The lateral method of palpation consists of placing the patient on the healthy 



372 METHODS OF EXAMINING THE KIDNEY 

side with the thighs antiflexed and the examiner standing hehind the patient's 
back. In examining the right kidney, the right hand is placed on the front of 
the abdomen and the left behind, the same as when examining a patient who is 
placed in the dorsal position. The left hand is often removed from behind and 
placed in front just below the free border of the ribs, as in cases of movable 
kidney. Pressure made at this point in front, sufficiently deep to prevent the 
organ from returning to its fossa, will allow the examiner to outline it more 
easily with the right hand. 

The organ is often palpated in this manner with greater accuracy, and its 
size, consistence and the character of its surface better determined. Kidneys 
are not so easily mistaken for the liver by this means, as we do not have to ex- 
amine over the edge of the latter organ. (See Fig. 235.) 

The kidney can often be more easily felt in the sitting postiire than when 
the patient is lying dow^n, especially in the case of movable kidney. The hands 
sliould be in the same position in relation to the patient when the examination 
is made in the sitting posture as when it is made lying on the back. (See 
Fig. 234.) 

I think that, in palpating the kidney, any ]X)sition or method should be 
used which best enables tlie examiner to accomj)lish his purpose. I always ex- 
amine the patient on a chair-table and change the iK:)sition of tlie patient while 
making the examination from the sitting to the horizontal position. When 
there is a movable kidney, the organ often drops down when the patient is in 
the sitting posture ; or else it can be made to drop by having the patient cough 
or by jostling that region. In such a case, if pressure is made by one hand just 
below the ribs in front, and the back of the table is lowered while the patient 
is perfectly relaxed, the organ is prevented from slipping back into its fossa 
again and can be easily outlined by the other hand. 

The standing position, w^ith the patient resting the buttocks against a table 
or chair, wnll often enable us to palpate the organ in a satisfactory manner. 

Percussion is of value in a negative way, as tympanitic resonance over the 
anterior surface of an abdominal tumor situated in the loin, when the patient 
is in a dorsal position, points to its renal origin, on account of the intestine 
being placed in front of it. Sometimes, if there is a dullness over a tumor in 
the loin by anterior percussion, when the patient is in the dorsal position, it is 
an advantage to inject gas into the colon in order to bring out the relati(m be- 
tween it and the tumor; for, if it then becomes tympanitic, it will show that 
the tumor is behind the colon and therefore, probably, renal. 

Liver dullness is not aifected by gas in the intestine, while the kidney dull- 
ness is obliterated. 

The routine examination of the patient tends to clear up, to a considerable 
degree, the question of Avhether the kidneys are alone involved or not, in cases 
in which this has not already been done. The patient passes urine into a tube. 



CYSTOSCOPY; UEETEEAL CATHETERIZATION 373 

and, if the urine is clear and contains no shreds, it shows that there is no sup- 
purative involvement of the urethra or the tract above it. 

If the first urine is turbid and the second is clear, it shows that the turbidity 
is due to some trouble in the urethra, the prostate or vesicles that empty into it, 
while the clear second urine shows that there is no marked suppuration in the 
bladder or kidney. 

If both the first and second urines are turbid and the first contains shreds 
while the second does not, it shows that the urethra is inflamed and that the 
bladder or kidneys are also involved, unless the turbidity is due to phosphates 
or bacteria. When there are such results, therefore, the urines should be 
examined for phosphates or bacteria (see chapter on Urinary Examina- 
tion), as well as for pus and inflammatory products from the bladder and 
kidneys. 

The physical examination just made has, perhaps, given us some idea as to 
whether one or both kidneys are involved and has brought us one step further 
forward in our systematic examination of that organ. The patient's urethra 
should then be examined for strictures and his prostate for enlargement, as all 
obstructions favor the development of cystitis and suppurative diseases of the 
kidney. The patient's bladder should now be washed out, filled and the cys- 
toscope introduced. 

(h) Cystoscopy. — When the fluid medium is clear, as is shown by exam- 
ining the washings from the bladder in a glass held before the light, the in- 
terior of the organ is examined with the cystoscope. If there is no tumor, 
stone, tul)erculosis, ulceration or inflammation present, the bladder is known 
to be healthy and the mouths of the ureters should be examined to see if both 
are present. In case both ureteral mouths are seen and clear urine comes from 
each, we know that both organs are present and that the kidney trouble is either 
aseptic or but slightly septic. If there is an aseptic disease of one or both kid- 
neys, the fluid in the bladder will remain clear. If the fluid quickly becomes 
opaque, it is a sign that pus is coming from the kidney ; or pus flocculi or blood 
may be seen coming from the mouth of one of the ureters and not the other, 
showing that there is a disease in the kidney from which the abnormal products 
come. 

(c) Ureteral Catheterization. — If the urinary examination has shown 
pathological renal findings of an aseptic nature and the cystoscope has shown 
clear urine coming from pach kidney, the ureters should be catheterized to 
obtain a specimen from either kidney, in order to discover which kidney is send- 
ing forth the pathological products that were noticed in the general urinary 
examination, and, in case both contain such findings, to ascertain the degree of 
the involvement in each specimen. The passing of the ureteral catheters will 
also tell if the ureter is of normal size up to the renal pelvis and, if not, the 
nature and location of the obstruction. 



374 METHODS OF EXAMINING THE KIDNEY 

If one ureter is not seen to excrete, we become suspicious as to the presence 
of the kidney on that side, and, if on catheterizing the ureter we find it goes 
into the renal pelvis and nothing comes away, we suspect a nonfunctionating 
kidney. If the ureteral catheter goes up but a slight distance and no urine 
comes through it, we do not know whether there is an obstruction of the ureter 
on that side that has caused an atrophy of the organ, or whether there is a con- 
genital absence of the kidney. In either case, the patient would, of course, have 
but a single working kidney. In case a turbid and flocculent urine is seen com- 
ing from one kidney while that from the other organ is clear, specimens of each 
should be taken, and after examination the result should be compared with that 
of the general urine. The same test applies to purulent urine coming from 
both sides. 

In case both ureters are seen- to be secreting urine and yet one ureter 
cannot be catheterized, the catheter should be left in the permeable ure- 
ter, and an ordinary small soft-rubber catheter should be passed into the 
bladder; after emptying it, the rubl)er catheter should be retained in order 
to collect the specimen coming from the ureter that could not be cathe- 
terized. 

If the bladder has been found, during our cystoscopic examination, to be 
diseased, we should note this condition and also the presence or absence of 
urethral strictui'e, hypertrophied prostate,' vesical calculus, tuberculosis or 
tumor, all of which are guides to the diagnosis of diseases of the kidney. Small 
ulcers grouped about the mouth of one ureter point to a tubercular kidney on 
that side. 

It may be here stated that suppurative disease of the kidney, when due to 
some cause not situated in that organ or its pelvis, is more frequently secondary 
to urethral stricture, hypertrophy of the prostate, or vesical calculus than to 
anv other causes. 

By the means just outlined, we will be able to discover the presence of 
urethral, bladder, ureteral or renal diseases, and to know which of these four 
points of the urinary tract is involved ; or whether two or more are affected ; and, 
if the disease is renal, to know which side is involved and to form a fair idea 
of the condition of the other organ. We can also judge in a case of renal dis- 
ease, whetlier or not the trouble is due to lesions situated lower down in the 
urinary tract, as obstructions or other troubles in the urethra, prostate, bladder 
or ureters. The comparison of the specimen obtained from each ureter with 
that of the general sj>ecimen from both kidneys, together with the general and 
special examinations already outlined, will probably tell at this time what the 
condition of each kidney is and the nature of the disease. Single (unilateral) 
kidneys and nonfunctionating kidneys are very rare. Tliere are, however, cer- 
tain tests still to be used, the positive results of which are confirmative of our 
present conclusions. 



THE NATURE OF THE RENAL DISEASE 375 

No. 3: The Nature of the Benal Disease. 

(a) Radiography. — If there has been a pain in the renal region on one 
side, if hematuria has followed the pain, if the kidney has been found to be 
tender or enlarged, if crystals have been found in the urine in masses of mucus 
and epithelia, we suspect a case of aseptic nephrolithiasis. If there is a large 
kidney on one side that is painful and tender with the same findings that have 
been mentioned above plus attacks of fever, pus and granular, epithelial and 
pus casts in the urine, we must look for a case of septic nephrolithiasis. The 
suspicion of renal calculus becomes a probable diagnosis if no obstructions to 
the urinary flow have been discovered in the urethra or prostate, nor any tubercle 
bacilli or tumor fragments have been found in the urine. We, therefore, proceed 
to radiograph the patient. 

Radiography should always be resorted to when there is the slightest sus- 
picion of stone and also in all pus cases for which there is no appreciable cause. 
Stones cannot always be detected by radiography, even by the most improved 
tec4mique; but in a large proportion of cases, the shadows have been success- 
fully detected and a positive diagnosis of calculus in the kidney or ureter is gen- 
erally conclusive by the X-ray. 

The difficulties to be surmounted in this work are not only the imperfections 
of the apparatus, excessive fat in the patient, accumulation of feces in the bowel, 
malformations of the kidney and very small stones located in the renal tissues ; 
but also the permeability of renal stones to the X-rays, which is sometimes so 
great that they throw but a faint shadow. This is especially so in cases of uric- 
acid calculi, the most common kind. Stones of oxalate of lime and phosphates 
usually throw a shadow and even small amounts of calcium oxalate will throw 
excellent shadows. 

If the picture is of good quality and if successive pictures taken at inter- 
vals of a few days indicate the presence of stone, the surgeon is able to make a 
positive diagnosis. The radiographist should, however, be able to take pictures 
of a proper quality, and also to interpret them correctly. At least two pictures, 
showing good shadows of stone, should be obtained, before a positive diagnosis 
is made for the purpose of operation. 

Lester Leonard, of Philadelphia, and Caldwell and Cole, of New York, have, 
by their extremely good work, been able to obtain positive findings in nearly all 
cases in which calculus was found to be present on operation. Kiimmel, of Ham- 
burg, has been exceptionally fortunate in his X-ray work and has concluded 
that every stone in the kidney can be detected by a good X-ray plate, of whatever 
composition the calculus may be. 

The important points in obtaining satisfactory results is to have proper 
plates and the requisite technique. In the first place, the bowels of the patient 
should be thoroughly emptied, so that there can be no fecal accumulation in the 
colon over the kidney. Calomel should be taken the night before, a saline laxa- 



376 METHODS OF EXAMINING THE KIDNEY 

tive in the morning and a high cleansing enema after the bowels have moved, 
after which the picture should be taken. The patient should be placed in the 
correct position and submitted to the proper exposure. 

The shadows usuallv lie from four to ten centimeters to one side of the mid- 

« 

die vertebral line, in a location corresponding to the second lumbar vertebra, at 
which point the pelvis of the kidney is usually situated. 

The patient is placed in the dorsal position, the knees and thighs flexed, 
and an adjustable tube of medium softness is used at a distance of 15 cm. (6 
inches) from the abdominal wall. The abdomen is covered with a red screen, 
limiting the area exposed to that of the renal region. A photographic plate 
is placed under the patient's back, corresponding to the opening in the 
screen. The exposure should be short — about one or two minutes. A shadow 
over the suspected kidney usually makes the diagnosis of nephrolithiasis 
certain. 

(6) GriNEA-Pia Inoculations. — In the case of a patient wdth pain, an 
enlarged tender kidney on one side (and polyuria and frequency of urination), 
in whose urine no tumor fragments are found coming from that side and no 
shadow is seen on radiography, tuberculosis of the kidney is suspected, esi)e- 
cially if the individual is losing w^eight and strength. If tubercle bacilli are 
found in the urine coming from the suspected kidney of this patient, the diag- 
nosis is confirmed ; but in case the urine from that kidney does not show tubercle 
bacilli, it should be at the same time injected into guinea pigs. In fact, the 
urine from both kidneys should be examined for tubercle bacilli and injected 
into guinea pigs. 

Guinea-pig inoculations are just as important in renal examinations in cases 
in which tuberculosis of the kidney is suspected, as is the X-ray in cases in 
which nephrolithiasis is suspected. The details of guinea-pig inoculations have 
been described in a chapter on Tuberculosis of the Kidney, and also in the 
chapter on Examination of the Urine to which the reader is referred. The 
positive findings in guinea-pig inoculation are, to-day, an indisputable proof of 
the presence of tuberculosis in a kidney. 

In other cases in which the kidney on one side is enlarged and the patient 
has marked attacks of hematuria, tumor of the kidney is suspected. If after 
examining the urine from the affected side in such a case, crystals and tubercle 
bacilli are not found and guinea-pig inoculations and radiography are negative, 
tumor of the kidney is probably present, and this diagnosis would be confirmed 
by the finding of atypical cells and tumor fragments in the urine from that 
kidnev. 

The examination thus far has sho^vn how we have arrived at the conclusion 
that a kidney is diseased, which kidney it is, the nature of the disease, the con- 
dition of the other kidnev; and it now remains to test the function of the two 
organs and to determine their secreting power. 



FUNCTIONAL CAPACITY OF THE KIDNEYS 377 

No. 4: Functional Capacity of the Kidneys. — The capacity for work, or 
the functional eiBciency of an organ, is an index to its health from a physio- 
logical point of view. An organ may be, to a certain extent, diseased and yet 
able to perform its function satisfactorily. The functional efficiency, or inef- 
ficiency of an organ, may or may not be proportionate to the anatomical lesions. 
It is important to know what lesions are present in the kidney and still more 
so to know the amount of functional efliciency left in the diseased kidney, as 
well as in the organ of the opposite side. 

It is said that a patient can live with a third of the total amount of func- 
tionating renal tissue normally present in both kidneys, but that if there is 
only one fourth of the total functionating renal tissue left, he will die. It is safer 
to have a remaining healthy kidney that contains one half of the total amount 
of the normal kidney tissue of both kidneys than one that contains but one third ; 
but it is also safer to have a remaining kidney with one third of the total amount 
of renal tissue than one with but one fourth, as, in the last case, there would 
be a renal insufficiency that would be fatal. 

By a nephrectomy, we remove the diseased kidney tissue, so that the re- 
maining kidney is relieved of the reflex and toxic influences that the organ has 
had upon it. The function of the remaining kidney improves and it shows 
itself adequate to the needs of the individual. 

In surgical affections, the comparison of the functional state of one kidney 
with that of the other is of {)aramount importance. The removal of one kidney 
which may be functionally useless as the result of a tumor, tuberculosis, etc., 
is not a dangerous procedure if the remaining kidney is perfectly healthy, as it 
wull then be able to take care of the work of both. If the opposite kidney is the 
seat of either the same or of other disease, the removal of the diseased organ is 
contraindicated. Occasionally, however, the disease in the less affected organ 
is so slight that its functional power is suflicient to carry on successfully the 
elimination of the total urine after the removal of the more diseased one. Mod- 
ern surgeons for this reason avoid the removal of any kidney unless the func- 
tional examination of the other organ shows it to be sufficiently healthy. To a 
certain degree, a clew to the pathological lesions and to the amount of work 
a kidney can do is obtained by the chemical and microscopical examination of 
the urine. Y'et this examination is not always sufficient, even when the urine 
from each kidney is tested separately to determine the condition of each organ. 

Estimating Renal Function in Surgical Diseases of the Kidney. — 
In order to determine the functional capacity of the kidneys, a twenty-four- 
hour specimen should be examined. This will tell us the amount of liquid 
and the amount of solid passed. The most important solid is urea and, there- 
fore, this should be taken principally into consideration. 

Knowing the normal amount of fluid passed in twenty-four hours, as well 
as the amount of solid the urine contains, it will be easy to compare the total 



378 METHODS OF EXAMINING THE KIDNEY 

urine from the patient with the normal, as well as the total amount of urea 
passed. Low specific gravity does not mean much, if the amount of solid is 
sufficient in a twenty-four-hour specimen, as a diseased kidney will often give 
off more fluid than a healthy one, and nervous individuals with healthy kidneys 
may also have polyuria. The amount of urea in a catheterized specimen from 
each ureter, if the catheters are allowed to remain in twenty-four hours, com- 
pared with the general twenty-four-hour common specimen of voided urine, 
would give us a good idea of the amount of urine and urea secreted from each 
kidney, and whether, in case the diseased kidney were removed, the remaining 
organ could carry out satisfactorily the renal function of elimination. Gener- 
ally, however, the catheters are left in but one hour and an estimate is made 
between the amount secreted in this time and that passed in twenty-four hours. 

The Comparative Flow of Urixe througji the Ureteral Catheters 
IN Examining the Kidneys. — It is important, while the catheters are in the 
ureters, to note the rapidity and amount of the urine coming from each organ. 
A normal kidney secretes about an ounce an hour and the urine flows in a 
rhythmical manner. If, on introducing a ureteral catheter, an ounce or more 
urine quickly escapes, it shows a dilatation of the pelvis and renal retention, 
occurring either in uronephrosis or pyonephrosis. The turbid urine may be 
white in color, milky, or it may have a yellowish tinge. When white, there is 
but a small amount of solid present, when darker a more concentrated urine. 
The very light colored urine occurs in cases of pyonephrosis in which the kidney 
parenchyma has been almost entirely destroyed. Sometimes nothing but very 
thick pus comes from the ureter and slowly drops from the end of the ureteral 
. catheter, showing that the kidney parenchyma is practically destroyed, that 
the pelvis is not much enlarged and the kidney is secreting but little or no fluid. 

Sometimes a diminished amount of turbid amber or yellow urine comes from 
one kidney and an increased amount of turbid white urine from the other. In 
this case, both kidneys are diseased, probably the first with pyelitis or pyelo- 
nephritis and the second with pyonephrosis. The kidney secreting the turbid 
darker urine, would probably be the more acutely involved of the two, but would, 
contain more functionating renal tissue. In such a case, the general urine 
coming from both kidneys might be the color of lemonade. A general urine 
might also resemble lemonade when normal urine is coming from one kidney 
and a white turbid urine from the other. Again, a general urine may have a 
lemonade color in case one kidney is the seat of parenchymatous nephritis, and 
the other kidney almost destroyed by pyelo-nephritis or pyonephrosis. On the 
other hand, one kidney may secrete a larger amount of urine of a very low 
specific gravity, and the other a turbid-colored urine of a higher specific gravity. 

These variations of the balance of health and disease in the kidnev, as shown 
by the urine, are more likely to occur in tubercular affections of the kidney 
than in any other. In determining the renal function of the two kidneys, it is 



FUNCTIONAL CAPACITY OF THE KIDNEYS 379 

necessary to compare the findings in the urine from one kidney with those of 
the other, as well as with the findings of a specimen taken from the entire 
twenty-four hours' output of urine. 

(a) Ceyoscopy. — It has been proved experimentally that the freezing point 
of a solution is lowered in proportion to the number of molecules dissolved in 
a given volume of the solution, no matter what the weight of the individual 
molecules may be. 

Therefore, the freezing point of the blood or the urine indicates the number 
of molecules dissolved in a given volume of the sample. 

The freezing point of normal urine varies between — 1.3° and — 2.2° C 
When the kidneys are diseased, the theory is that fewer molecules of solids 
are excreted and so the freezing point is higher — that is, nearer to 0°. A 
freezing point in urine higher than — 1° C. is usually regarded as abnormal. 
When the kidneys are almost destroyed by disease, as, for example, shortly 
before death from uremia, the freezing point is often very nearly at 0*^, which 
is the freezing point of distilled water. 

Cryoscopy is, therefore, designed to give us a means of estimating the func- 
tional ca])acity of the kidney. 

Technique, — Sample of urine, twenty-four hours'. 

Amount needed, 10 to 15 c.c. 

Apparatus: — Cryoscope, consisting essentially of a very delicate thermom- 
eter of a special pattern known as Beckmann's. The invention of this ther- 
mometer made the delicate measurements of temperature possible which are 
now used in chemical physics. 

The freezing of distilled water (zero) should always be determined first 
with such a thermometer and anv deviation from zero should be noted as a 
correction. 

The other parts of the apparatus are: A test-tube in which the urine is 
placed, the thermometer fitting into this tube through a perforated rubber 
stopper. A wire or hard-rubber stirrer spiral is used to mix the urine during 
the operation. Outside of the tube is the receptacle for the mixture of ice and 
salt usually employed for the freezing process. 

To read the thermometer, the observer watches the mercury constantly from 
the start. The mercury will suddenly begin to sink and then will stop quite 
low on the scale. Then it will begin to fluctuate rapidly and will rise to a 
point were it will remain stationary. This is the freezing point of the urine 
examined. It is, of course, very important to wait for the " superfusion " to 
cease, as accurate readings cannot otherwise be obtained. By practicing 
with distilled water, one can accustom oneself to bring a mixture of salt 
and ice to a fairly constant temperature. This outside temperature should 
be about two degrees below zero and another thermometer may be used to 
regulate it. 



380 METHODS OF EXAMINING THE KIDNEY 

The error in reading should not be over y|^ of a degree. This is accu- 
rate enough for clinical purposes. 

Clinical Applications of Cryoscopy. — The clinical value of the method is 
naturally limited, owing to certain sources of error, such as imperfect technique 
and variations in the normal freezing point, and owing to complicated lesions of 
the kidney, such as complete destruction of one part of the kidney with corre- 
sponding hypertrophy of another part, etc. 

The chief value of cryoscopy lies in the determination of the relative freez- 
ing point of the urine of each kidney separately, obtained with the aid of the 
ureteral catheter. 

Another, though less important use of the cryoscope is in the diagnosis or 
prognosis of a cystitis or pyelitis when we wish to know if the process is ascend- 
ing into the kidney. 

Cryoscopy of the Urine and the Blood. — The freezing point of the blood 
is determined in the same manner as that of the urine and the two tests are 
used as a check upon each other. Keranyi and others found that normal blood 
freezes at about —0.56° C, a figure which is remarkably constant. When 
the kidneys are diseased and do not excrete as much effete material as nor- 
mally, an increaseil amount of toxic substances accumulates in the blood and 
thus the freezing point of the blood becomes lowered. Abnormal kidneys, there- 
fore, produce a lowering of the freezing point of the blood. It has been found 
that when this point is below — 0.60° C, the kidneys are diseased. 

(1) When the freezing point of the blood is normal and when the freez- 
ing point of the opposite kidney is also normal, the surgeon can safely extirpate 
the affected kidney. 

(2) When the freezing point of the blood is normal and that of the urine 
of the opposite kidney does not fall within normal limits, the surgeon should 
perform a conservative operation, such as nephrotomy, instead of nephrectomy. 

(3) When the freezing point of both blood and urine of the opposite kid- 
ney are abnormal, the surgeon should perform even more conservative opera- 
tions (e. g., incisions of nephrotic sacs) only under the stress of dire necessity. 

(6) Methylene-blue Test. — The object of this test is to determine the 
rate of excretion of methylene blue through the kidneys, in order to estimate 
the functional value of these organs. The coloring matter is injected intra- 
muscularly in a five-per-cent watery solution. Normally, the blue color should 
appear in the urine in half an hour after injecting it. If the appearance is 
delayed to an hour and a half or longer, the kidneys have a diminished per- 
meability. 

While the test is attractive theoretically, it is, unfortunately, unreliable 
clinically. One objection is, that so long as a small amount of parenchyma 
remains healthy, as is often the case in an extensively diseased organ, enough 
methylene blue will appear in the urine promptly after injection. It seems, 



FUNCTIONAL CAPACITY OF THE KIDNEYS 381 

that some kidneys may have a certain selective action upon methylene blue, 
even though diseased, and that they excrete the dye readily, even though they 
may not be capable of excreting the urinary constituents. Conversely, it has 
been found at times that the kidneys may act normally so far as excreting 
urine is concerned, but cannot excrete methylene blue promptly. 

Another source of error is the fact that methylene blue may be reduced in 
the tissues to a chromogen which is excreted as such, and is converted again 
into the blue or greenish dye by boiling the urine with acetic acid. 

The duration of the excretion of a given dose of methylene blue is also an 
uncertain index. The duration may be shortened, the methylene blue being 
excreted more rapidly than normally in both acute and chronic parenchymatous 
nephritis, while it is lengthened frequently in the interstitial form. The length- 
ening of the period of excretion may also be due to compensatory hypertrophy 
of the healthy kidney. In the acute and chronic parenchymatous forms, as well 
as in amyloid kidney, the excretion is not materially modified. While the test 
may he useful in distinguishing the side aflFected by comparing the urines of 
either kidney, it is not a trustworthy guide as a general standard for the func- 
tional value of the kidney. 

Technique of the Test. — One c.c. of a five-per-cent solution of chemically 
pure methylene blue is injected deeply into the buttock. The patient is directed 
to empty the bladder every quarter of an hour and the urine is collected in sepa- 
rate glasses. The time of beginning elimination, the duration and amount of 
coloring matter excreted are noted. Each sample must be tested with boiling 
acetic acid, in order to convert the chromogen that may be present into methyl- 
ene blue. If the dye appears within half an hour, the kidneys are supposed 
to be normal. The elimination lasts normally from thirty-five to sixty hours. 

(c) The Pui.oridzin Test. — This test is based upon the fact that, when 
phloridzin is injected into the circulation, sugar is excreted by the kidney and 
appears in the urine. 

This test is performed by injecting subcutaneously 1 c.c. of a 1 : 200 solu- 
tion, that is, 5 milligrams of the drug. The patient is allowed to urinate before 
the injection and his urine is tested to see that it contains no sugar. The urine 
is then collected each quarter of an hour and each sample is tested for sugar. 
The urine is cleared first by thorough filtering. 

Normally, sugar appears within half an hour to an hour, disappears within 
three or four hours and the total amount excreted is from one to two grams. 
In chronic nephritis, with interstitial changes, the excretion is either dimin- 
i8he<l or abolished, even when no albuminuria is present. 

Israel objects to the phloridzin test and denies that the amount of healthy 
parenchyma is indicated by the amount of sugar excreted. But even if the 
glycosuria is not a measure of the work of the kidney, when there is a marked 
difference in the amount of sugar excreted by either kidney, we can determine 



382 METHODS OF EXAMINING THE KIDNEY 

which of the two works better. When this difference is very marked with a 
very low amount of glucose on one side, we are justified in concluding that 
this particular kidney is probably functionally insufficient. 

Having given the urine the functional tests, in addition to the remainder 
of the examination, we can feel that everything has been done that is required 
in order to determine the condition of the healthy and the unhealthy kidney, 
excepting, perhaps, an exploratory incision. 

No. 6: Exploratory Incision. — ^An exploratory incision is rarely necessary. 
There are, however, cases in which we must resort to it, on account of an ex- 
tremely contracted bladder, hemorrhagic cystitis, sacculated bladder, or such 
an unusual amount of blood or pus in the urine coming down from the kidneys 
that we cannot see the ureteral mouths or the urine coming from them. 

Such difficulties to cystoscopy and ureteral catheterization are seldom en- 
countered, but they are occasionally met with in cases in which there is an 
enlargement of the kidney on one side with findings of renal disease in the 
urine, and, besides, constitutional symptoms that call for operative interference 
in the case of the enlarged organ. Here an exploratory incision should be 
made on the side of the suspected healthy kidney to examine it before operating 
on the suspected diseased one. 



CHAPTER XX 

ANOMALIES OF THE KIDNEY 

Anomalies of the kidney gland proper, and of the renal blood vessels, 
are intimately linked embryologically with the anomalies of the ureter. They 
are all congenital and explained by embryology. Major abnormalities are rare ; 
but minor anomalies — small deviations from the normal type — are, on the 
contrary, rather common. The complexity of the developmental process of the 
upper urinary tract, which is very intricate, easily accounts for the frequency 
of the minor defects. 

The subjects can be treated here but briefly and, in case our readers desire 
further information, we refer them to the " Surgical Diseases of the Kidney 
and Ureter," by Morris (London, vol. i, p. 18). 

Some abnormalities have great surgical importance, while others have only 
an anatomical and embryological interest, and represent transitory fetal stages 
which have become accidentally permanent. 

ANOMALIES OF THE KIDNEY GLAND PROPER 

Anomalies of the kidney gland proper may be classified under four 
headings. 

A. Anomalies of Position. — Congenital ectopic kidneys have been found at 
the sacro-iliac joint, which will be shown later in the chapter on Hydronephrosis, 
over the promontory of the sacrum, just below the bifurcation of the aorta, and 
in the false pelvis just above Poupart's ligament. Such a kidney may be single 
or, what is more frequent, associated with another normally developed and 
normally placed kidney. The vessels are short and multiple, and spring abnor- 
mally from neighboring blood vessels, thereby difl^erentiating such a congen- 
itally misplaced kidney from an ordinary movable kidney secondarily fixed by 
adhesions. The ectopic kidney is fixed in its position and adhesions may be 
present, but the origin of the vessels is evidence of a congenital anomaly. The 
organ may be found in any part of the abdomen, or in the pelvis, and this is 
usually associated with other congenital abnormalities of the genito-urinary 
organs. It is more common in males than in females. 

Kidneys displaced into the pelvis may give rise to disturbances of defeca- 

383 



384 ANOMALIES OF THE KIDNEY 

tion and also of urination, such as frequent micturition and tenesmus; hema- 
turia and pyuria are also seen in these cases. The displaced organs become the 
seat of hydronephrosis or pyonephrosis, with symptoms of pelvic or abdominal 
tumor. The diagnosis can be made theoretically by a pelvic examination per 
vagina or per rectum. The introduction of a ureteral catheter also assists, by 
showing that the ureter appears short and obstructed ; but an exploratory lapa- 
rotomy is necessary for a correct diagnosis, as this will allow us to find the ab- 
sence of the kidney in the renal fossa, and its presence in the pelvis. If, in a 
woman, the organ is so placed as to interfere with childbirth, and if the opposite 
kidney is not diseased, it is best to remove the displaced gland, providing this 
can be done without too much tearing of the surrounding adherent structures. 
( Vagin removed such a kidney by the vaginal route. Israel, in operating on 
such a case, closed the abdominal wound made for exploratory purposes and 
performed an extraperitoneal nephrectomy. Misplaced kidneys are ectoj)ic. 
Displaced kidneys are movable kidneys that have fallen from the renal fossa 
and become fixed where thev final Iv lodged. 

B. Anomalies in Mobility. — These comprise the cases of congenital movable 
kidney. They occupy an intermediary position between an ectopic kidney and 
an acquired movable kidney. There are two types, according to the normal 
or abnormal origin of the vascular pedicle, and the length of the latter. Some- 
times the kidney, instead of being held against the posterior abdominal wall by 
the peritoneum in front of it, has a true mesonephron. 

C. Anomalies in Shape. — The most frequent is lobulation. It is due to the 
persistence of a transitory fetal di8|x>sition and reproduces the type of kidney 
normal in some species of animals. The fissures may be so deep as to give 
the impression of a multiple kidney. According to Kiister, fetal kidneys are 
subject to tuberculosis, and his o])inion is confirmed by other authors. These 
fissures will be noticed in the illustration of single congenital unsymmetrical 
kidney. (See Fig. 205.) 

Hour-glass contraction occasionally occurs^ but it is very rare. 

Sometimes there exists a fusion of two homologous poles of both kidneys, 
the lower ones generally, the upper more rarely. This gives rise to a horse- 
shoe kidney, two subvarieties of which are the sigmoidal kidney and the 
discoidal, placentalike kidney. 

Horseshoe hidney usually shows an isthmus and two free ends which point 
upward. Less frequently, the two ends j>oint downward, the upper poles of 
the kidney having coalesced. One of the kidneys may be much larger than the 
other, and often the bridge or isthmus is composed merely of fibrous tissue. The 
ureters are usually two in number ; sometimes four are present, and run across 
the isthmus from above downward. 

Horseshoe kidneys are usually displaced downward and toward the median 
line, as low as the sacral promontory. Supernumerary renal vessels often occur 



ANOMALIES OF THE KIDNEY GLAND PROPER 385 

in these eases, and a central renal artery may spring from the aorta and supply 
the isthmus. 

Clinically, horseshoe kidney is of importance on account of the possibility 
of an operator inadvertently removing the whole mass as one kidney. Partial 
excisions of horseshoe kidneys have been done by Socin, Konig and others and 
the isthmus has been severed after ligating it, or the hemorrhage has been 
stopped with the cautery. 

The diagnosis of a horseshoe kidney is not simple, and at l)est we may sur- 
mise the presence of this anomaly when we feel an abnormal median renal 
tumor, or see the shadows of calculi very close to the spine. Sometimes a horse- 
shoe kidney can be felt as a pulsating tumor over the aorta, over which a sys- 
tolic murmur is heard. Hydronephrosis sometimes occurs in a horseshoe 
kidney. An exploratory incision is the only positive means of diagnosis. 

Both poles of both kidneys may be fused, forming a variety known as annu- 
lar kidney, often called solitary kidney and considered as a single kidney. This 
we believe to be unjustified, as there are two kidneys and two ureters, and this 
anomaly is simply an exaggeration of the horseshoe type. 

D. Anomalies in Number. — Cases of supernumerary kidneys are few and 
not always well authenticated. The mode of development of the ureter and 
kidney makes one doubtful as to the possibility of sui>ernumerary kidneys. 

Much more important than the anomaly .of excess is the anomaly of default. 
The absence of both kidneys is only a teratological curiosity of the first months 
of embryonic life. The absence of one kidney, either on account of nonforma- 
tion, or of congenital atrophy, is the chief anomaly of the kidney from a surgical 
standpoint. 

Statistics show that single kidneys are very rare, although sometimes they 
appear to be frequent. This is conclusivelv shown by my own experience with 
the anomaly. 

During the eight years that I spent teaching anatomy and operative surgery 
at the Post-Graduate Medical School, with large numbers of cadavers always 
in use, in which both kidneys were dissected or operated upon, I failed to see 
one instance of single kidney, and this, together with the same experience in 
numerous autopsies, led me to believe that such a condition almost never ex- 
isted; I changed my opinion, however, when I encountered three single kid- 
neys in a small hospital service within a period of less than ten months, during 
which time only fifteen autopsies had been performed. This is certainly unus- 
ual, when Guy's hospital reports say that in 4,632 cases, only one congenitally 
single kidney was found in a period of ten years. 

A single kidney may be associated with deformity of the organ or another 
form of anomaly, lobulation. This point is important to remember when oper- 
ating, as when one is not sure that there is a second kidney, suspicions may be 
aroused by an abnormally large and lobulated kidney on the side operated upon. 



ANOMALIES OF THE KIDNEY 



The situation of a single kidney varies considerably: it may be found in 
the loin, or in the median line, at the brim of the pelvis, etc It is usually 
larger than normal, when in a healthy state, and may also be enlarged from 
disease. It is generally found on the right side and more commonly in men. 

The renal vessels are usually absent on the side where the kidney is lacking 
and the ureter as well. Wankiewicz collected statistics of 234 eases of single 
kidney, showing rndiments of the ureter in 17 cases, absence of the kidney on 
the left side in 127 cases, and on the right side in 97 cases, while in 12 the side 
was not given ; malformation of the bladder in most of the cases ; no trace of a 
ureteral orifice in the bladder on the side where the kidney was absent in 74 
cases, while in others a small indentation or diverticulum was found where the 
ureter should have been ; absence of one half of the trigone in some cases, and, 
in others, termination of the single ureter in the center of the bladder. Ac- 
cording to Wankiewicz, therefore, absence of a ureteral mouth occurs in one 
third of the cases of single kidney and may then he detected by the cystoscope. 
A single kidney may be excluded only 
when both ureters can be catheterized 
and are shaped to discharge urine. 

A single kidney is interesting sur- 
gically, because it may become tbe seat 
of an affection demanding nephrectomy, 
such as tnbereulosis or cancer. The 
following case is an example of the kind 
and carries out the views of Kiister in 
that it was a lobulated kidney of the 
fetal type with deep fissures and the 
seat of tiihereiilosis. The patient was 
on my service at the Columbus Hos- 
pital. 

Case I. — Laborer, aged twenty-one 
years, was referred to me for nephrectomy 
for tuberculous kidney. Incision in the 
left loin showed a large left kidney al- 
most divided in halves by a fissure and 
completely riddled with small tubercles 
and abscesses. I removed the organ and 
the patient died of uremia on the eighth 
day after nephrectomy. The right kidney was found congenitally absent, as 
was the suprarenal capsule on that side. Fig. 265 shows the appearance of the 
extirpated single kidney. This organ was 5^ inches long, 3 inches wide and 2J 
inches thick. The kidney resembled a large ripe tomato, only of a deeper red 
color. It was lobulated, there being four quite distinct lobules. The fissures 



Fin. 285. M:N0TB TOBKHCCt.AR ABBCESSEa 

OF A Single Abymmbtmcal K:onet. Note 
the deep fissures and coovolutiona : il was 
5}^ inches long and very thick. (Author's 



ANOMALIES OF THE KIDNEY GLAND PROPER 387 

between these lobules did not extend through the organ. The organ was mahog- 
any red and studded with small tubercular abscesses under the capsula propria, 
varying in size from a pin point to a split pea. The upper pole was larger and 
more involved. The kidney had much fat attached to its capsula propria ; there 
was but one pelvis and one ureter present. 

Microscopical Examination. — The kidney showed intense inflammation and 
numerous miliary tubercles and abscesses, degeneration of the epithelia of the 
tubules, little new connective tissue, periarterial extravasation of leukocytes, epi- 
thelia of the glomeruli thickened and the tubules filled with casts. 

In the place of the right kidney, there was an extension of the right lobe of 
the liver down to the renal fossa on that side, resembling a tongue, about 3^ 
inches in length, 3 inches in width at its upper part, gradually ending in the 
shape of a wedge, slightly twisted on itself. No other abnormality was noticed. 

When an affection developing in a single kidney can be treated conserva- 
tively, as calculus hydronephrosis or pyonephrosis, the outlook is not so gloomy, 
although if the calculus w^ere to obliterate the ureter, complete anuria would 
immediately ensue. A single kidney may be present in persons who are in 
perfect health, and an advanced age may be reached with only one kidney ; but 
it seems that these kidneys, despite their compensatory hypertrophy, are weaker 
and more liable to disease than ordinary normal kidneys. There is said to be 
a tendency to albuminuria in young persons with a single kidney, and also a 
tendency to the formation of renal stones. Hydro- and pyonephrosis from un- 
discovered causes, and chronic nephritis, have also been recorded in single kid- 
neys. It should be noted that, in the two following cases, the diseases from 
which the patients were suffering were in themselves sufficient cause for death, 
and yet in both cases the kidneys were diseased. In these two cases, the patients 
were in the prime of life and it is not illogical to suppose that the single kidney 
created a physiological inferiority, partly responsible for the fatal outcome. 

Case II (On the service of Dr. C. II. Lewis, at the Columbus Hospital). — 
Fireman, aged thirty, died of empyema. Autopsy revealed the presence of a 
single kidney situated on the left side. The right kidney and ureter were absent. 
The left kidney was in normal position, 7 J inches long, 4 inches wide, 2^ inches 
thick ; it was not distinctly lobulated, but there were depressions upon it, giving 
rise to irregularities on the external surface. The lower lobe was wider than 
the upper. Neither kidney nor ureter was found on the other side. 

Microscopical examination made by Dr. Noyes showed degeneration of the 
epithelia in the tubes, and casts, little new connective tissue, few red blood cor- 
puscles, glomeruli showed some cheesy exudation in capsule periphery, con- 
nective-tissue proliferation (Fig. 266). 

Diagnosis. — Acute parenchymatous nephritis. 

Case III (Occurred in the Medical Ward of the Columbus Hospital in the 
service of Dr. Keller and is published by his permission). — Laborer, twenty- 



388 ANOMALIES OF THE KIDNEY 

five years old. Diagnosis, typhoid fever. Died at hospital in the third week 
of the disease. The autopsy showed that but one kidney was present, situated 
on the right side, somewhat lohwlated, with single pelvis and uref«r; on the 
left Bide, neither kiduey, ureter nor suprarenal capsule was found. The kidney 



PlO. 268. SmOLB ASTUMBTRICAL KiDNBT, 7H FlO. 267. SlNQLIlAaTHllBTBICALKlPNBT. MaRK- 

iNCtma LoNo, Rbuovbd at Autopbt. Note cdlt Convolcted, Reuoved at Auiofst. 

the fiuurefl and depreauoDS. (Author's colleo- (Author's collection.) 

was 4 inches long, 2^ inches wide and 2 inches thick. Five or six irregular ele- 
vations could be seen on its surface. 

The microscopical report of Dr. Noyes showed changes of chronic inter- 
stitial nephritis, with the production of a moderate amount of new connective 
tissue, degeneration of tubules in the cortex with exudates, glomeruli filled with 
leukocytes, proliferation of epithelia. The tubules in the medullary portion 
were more normal (Fig. 267), 

ANOMALIES OF THE BLOOD VESSELS 

Vascular anomalies may exist in cases of abnormal kidneys, but they may 
also be found in an otherwise perfectly normal gland. Some o£ these anomalies 
have a surgical interest, although most are mere anatomical curiosities. 

The vessels may be abnormal by their origin, by their distribution or by 
their number. Anomalies of the renal artery are more important, and also 
more common than those of the vein. 

The artery may originate much lower than usual ; this is ordinarily coupled 



ANOMALIES OF THE BLOOD VESSELS 389 

with a congenital ectopy of the gland. Among the anomalies of distribution, the 
most interesting is the premature branching off from the trunk of the renal 
artery of the branch going to the lower pole of the kidney. This artery then 
crosses the ureter near its origin, and may become the cause of an hydro- 
nephrosis; in three cases out of four (English), it passes in front of the ureter, 
whereas in the fourth it passes behind. This artery is not a supernumerary 
vessel, as is sometimes stated; but it is a normal artery of the kidney, which 
cannot be ligated or cut without necrosis of the corresponding part of the gland. 

The renal artery itself may be replaced by two, three or even four trunks. 

There may also be renal supernumerary arteries that are small and may 
be severed without interfering with the nourishment of the kidney but may 
give rise to considerable hemorrhage during renal operations. 

An embryologically interesting anomaly of the left renal vein is that in 
which, all other things being normal, the vessel ends abnormally low into the 
vena cava, at the level of the fourth lumbar vertebra, and receives perpendicu- 
larly the vena azygos minor. 



CHAPTER XXI 



KIDNEY INJURIES 



Broadly speaking, there are two varieties of kidney wounds: First, those 
that are inflicted without the wall of the body having been opened or pierced ; 
and second, injuries of the organ by some instrument, weapon or missile that 
has passed through the body wall. The former is called a subparietal (closed) 
injury, and is usually due to a direct blow, a fall, striking on the kidney region, 
or a crush from the wheel of a vehicle ; the latter is called an open wound, and 
is due to a slash or a puncture with a knife, sword or bayonet, or to a pro- 
jectile from a firearm. 

Kidney injuries are rare, if surgical woimds are excluded. In 7,741 cases 
of injuries reported by Kiister, but 10 were renal. Contusions are the most 
frequent, next come gunshot wounds and last incised and punctured wounds. 
I have had 5 cases of subparietal injury and 1 open wound (a stab). 

There is an instinctive tendency to consider all injuries involving the kid- 
ney as dangerous. This idea has been inherited from surgeons who were not 
familiar with renal surgery, but at the present writing operative interference 
has shown us that this fear was not justified and that kidney w^ounds, like the 
wounds of all highly vascular organs, often heal quickly. Experimental sur- 
gery, in the hands of Albarran, Legueu, Paoli, Podvyssotsky, Tufiier and others, 
has taught us that the mechanism of wound repair in the kidney is essentially 
the same as in any other parenchymatous organ ; that is, the proliferation of the 
interstitial connective tissue of the gland bridges the gap between the two edges 
and then permanently replaces this temporary mending in the natural way with 
the aid of a clot. The functionating elements of the gland degenerate and are 
replaced by connective tissue. Scar formation is rapid in the kidney and the 
process of repair has been shown far advanced after six days. The parenchyma 
is substituted by common scar tissue, which is slowly permeated by scant, newly 
formed capillaries. It has been claimed by several that, after the healing of a 
kidney injury, a regeneration of the epithelial cells and the glomeruli takes 
place. I do not believe, however, that such a process is possible, as in such a 
case the kidney parenchyma would have regenerative powers that are not shared 
by other tissues in the body. The epithelial cells of the kidney are so delicate, 
that even a temporary ligature of the renal vein is enough to alter them deeply ; 

390 



SUBPARIETAL INJUKIES 391 

and highly specialized cells do not regenerate. As for glomeruli, one does not 
understand how such a complex formation could regenerate, even in very young 
people. If the glomeruli appear more abundant near a renal scar, it is prob- 
ably because of the shrinkage of the connective tissue in the vicinity. 

There is undoubtedly a compensatory hypertrophy after any loss of sub- 
stance of the kidney, but this is not due to the regeneration of renal elementa 
Compensation in the remaining kidney, after nephrectomy, for instance, is 
established not through formation of new elements, but through an increase in 
size and in functional activity of the surviving elements; for it must not be 
overlooked that we have normally in the body a much greater amount of kidney 
tissue than is necessary for the maintenance of life. Tuffier removed one kid- 
ney in dogs and had to slice off a large part of the other, before he obtained any 
symptoms of urinary insuflSciency. 

SUBPARIETAL INJURIES 

Etiology. — Contusions of the kidney are seen a little more frequently on 
the right side than on the left (142 to 118). They sometimes have taken place 
in both sides ; while cases are on record of the rupture of a single asymmetrical 
kidney, and one case of a ruptured horseshoe kidney. In my series, 3 cases 
were on the right side. The most susceptible age is from ten to thirty, that is, 
the age of greatest muscular activity and liability to accident. Men are much 
oftener affected than women. In my personal cases, eighty per cent occurred 
in men. Kiister gives even as high as ninety-four per cent in men and six per 
cent in women. 

The kidney may undergo rupture as a consequence of a direct violence, such 
as a blow, fall on the loin, kick from a horse ; or of an indirect compression of 
the body between two surfaces, as in elevator-shaft accidents, by the pinning 
of the lumbar region between the buffers of railroad cars, or by the passage of 
a carriage wheel over the costo-iliac space, the body resting flat on the ground. 
The latter two accidents and a fall on the loin are the most common. 

Some claim that a kidney may be ruptured by indirect violence, such as a 
strong muscular contraction when the body is bent suddenly forward or on one 
side; but personally I am inclined to doubt the possibility of a rupture of so 
well-protected and so movable an organ from a mere muscular contraction, 
unless the kidney is very much congested or distended on account of some ob- 
struction to the urinary flow. 

The theories of the mechanism of rupture do not account for all forms of 
renal injuries, but they are the best we have at our disposal at present. 

Pathology. — The pathology of contusions depends on w^hether the fibrous 
capsule is torn through or not. If the capsule is not torn through, the hemor- 
rhage is usually slight, in which case there is a subcapsular ecchymosis or hema- 



392 KIDNEY INJURIES 

toma, or irregularly shaped areas of hemorrhage within the parenchyma near 
the surface or extending as deep as the pelvis. 

True rupture exists when the capsule is torn and the laceration is deep 
enough to communicate with the pelvis of the kidney. Fissures are usually 
found on the anterior aspect of the organ and are transverse in direction or 
radiate from the hilus. Infarcts of the usual wedge shape may follow con- 
tusions of the kidney. In cases of true rupture of the kidney, there is an ex- 
tensive leakage of blood, or blood and urine, into the surrounding tissue, ac- 
cording to whether the excretory channels are torn or not. If the rupture is 
very extensive, the two halves of the kidney are held together by the pedicle 
only, or, in extreme cases, the kidney may be divided into a number of small 
pieces, some of which may be totally detached. 

The perirenal extravasation may burrow down along the ureter and collect 
around the pelvic organs, but it usually collects in the retroperitoneal cellular 
tissue, where it forms a rapidly growing liquid tumor known as a pseudo- 
traumatic hydronei)hrosis. The contents of the tumor resulting from rupture 
of the kidney consist of a brown-red fluid, w^hich it is said may later change to 
amber and resemble clear urine. Personally, I have never seen the clear fluid 
after a rupture of the kidney, and I have cut into these extravasations of very 
large size some time after the injury. Clear fluid I am inclined to regard as 
coming from a rupture of the renal pelvis or ureter. 

Detachment of the kidney from its pedicle is very rare and is accompanied 
by severe, generally fatal, hemorrhage. When death does not occur at once, 
infarction and necrosis of the kidney (extravasation with gangrene of the peri- 
renal tissues) are liable to follow. 

Fracture of the ribs is a frequent complication of renal contusion. The 
peritoneum is torn in some cases of violent injury, an accident more apt to 
occur in children under ten years on accoimt of the firm connection between the 
peritoneum and the kidney at this early age. Other abdominal organs may, of 
course, suffer coincidently with the crushed kidney. 

Symptoms. — The Urine. — ^When a kidney is torn, even slightly, it bleeds 
more or less profusely. Hemorrhage is, therefore, the most important consid- 
eration in the symptomatology of renal contusions. Of all forms of bleeding, 
hematuria deserves the first place, because it is the most frequent and the mast 
characteristic. It occurs in the great majority of cases, even in mild injuries, 
and is lacking only when there is a small tear that does not reach the calices, 
and v^hen the continuity of the kidney with the ureter has been destroyed. It 
will thus be seen that it is not always an alarming symptom per 5C, and 
that its absence does not invariably indicate a mild injury. Hematuria, 
coming on after injury, does not mean necessarily a contusion of the kid- 
ney in the sense that we are considering; for if a calculus is present, the 
bleeding may have been provoked by the traumatism of the stone within 



SUBPARIETAL INJUKIES 393 

the kidney, as after a jar. Blood and urine pressing on the outside of the 
pelvis or ureter may prevent hematuria. 

The hematuria after an injury to the kidney may be profuse at once, or 
slight and subsequently increase; or it may be intermittent. In addition to 
fresh blood, clots or casts of the ureter may be passed, or the blood clots may 
accumulate in the bladder and be discharged with difficulty. It lasts from 
two to eight days in the average cases. In some, it may continue remittently for 
weeks. In infected cases, secondary hemorrhage may occur. 

Certain conditions that affect the character and amount of urine passed 
occur as the lesion begins to interfere with the function of the kidney. Oliguria 
and even anuria may result if a blood clot occludes the ureter. Later polyuria 
may occur, either simply compensatory in character or indicating the presence 
of a traumatic nephritis. Albumen and pus may also be found in the urine, 
indicating the presence of an infection and renal suppuration. Together witk 
hemorrhage, we should look for the general symptoms such as accompany other 
abdominal injuries, and are summed up by the word " shock," symptoms which 
are due to injury to the solar plexus and other of the adjoining nerve plexuses 
as well as the loss of blood. They include pallor, cold extremities, cold perspi- 
ration, a small and rapid pulse, vomiting, vertigo and prostration. If internal 
hemorrhage be severe, there are added to this gradual blanching of the skin and 
mucosae, a thready pulse, anxiety and collapse. If peritonitis comes on later, 
there are the usual general symptoms associated with this complication. 

Local Symptoms. — The local symptoms generally come on at once after the 
injury, although they are sometimes delayed. They include pain of a varying 
character, usually not severe when due only to the injury of the external tissue 
or to fractured ribs. It may, however, be very severe, radiating like that of a 
renal colic, and increasing on movement and often upon respiration. Sometimes 
patients complain of a sensation of something bursting at the moment of injury. 

Retraction of the cremaster and pain in the testis on the affected side, are 
regarded as signs of severe renal hemorrhage and of blocking of the ureters 
by blood clots (Le Dentu). There may also be muscular rigidity over the in- 
jured organ. The renal pain may last for weeks, and sensitiveness on pressure 
persist for a long time. 

Physical Signs. — The skin about the injured loin may be ecchymosed or 
lacerated. Ecchymosis may also follow the connective-tissue sheaths of the 
spermatic vessels and thus reach the external abdominal rings. In certain cases, 
it has been seen to extend over the external genitals. A characteristic feature of 
these ecchymoses due to renal injuries is that they usually reach the inguinal 
ring late — two or three weeks, perhaps, after the accident (Sebilleau, Dumenil, 
Le Dentu) — but it must be remembered that they may also be due to injuries 
of other vessels in the retroperitoneal tissues. 

The swelling may be very slight in mild injuries, but it is always distinct 



394 KIDNEY INJUKIES 

in the more severe forms. It usually comes on suddenly in severe cases and 
depends upon the amount of the effusion of blood and urine. The tumor is usu- 
ally palpable even in mild cases and is dull on percussion, when the swelling 
is sufficiently large to percuss well. 

Complications. — The complications are aseptic or infectious in character. 
Aseptic complications are intraperitoneal hemorrhage, and, rarely, traumatic 
nephritis. Infectious complications are peritonitis, perinephritic abscess and 
pyelo-nephritis. 

Peritoneal Complications. — Effusions of blood into the peritoneum occur 
when the injury includes a rent in that membrane, or when the liver, spleen, 
or some other organ is torn. A septic peritonitis develops within a short time 
when infected urine flows into the cavity along with the blood. However, this 
is fortunately not a common occurrence, as the peritoneum is fairly resistant 
to aseptic urine. According to experiments quoted by Wagner, such urine is 
borne by the peritoneum for forty-eight hours without much damage. As- 
cending and hematogenous infections may also attack the peritoneum in sub- 
cutaneous injuries of the kidneys (de Quervain). 

De Quervain noted that, owing to disturbances in circulation of the colonic 
flexure on the affected side, a certain degree of meteorism was often present 
without any peritoneal involvement. This is a point worth remembering, as 
such tympanites are apt to mislead one into the diagnosis of traumatic 
peritonitis. 

Chronic Traumatic Nephritis. — Chronic traumatic nephritis, as a com- 
plication of subcutaneous renal injuries, deserves a few additional words, as it 
has been the subject of considerable controversy. It is not certain whether a 
diffuse nephritis can follow such an injury, and it is probable that in the cases 
in which diffuse renal lesions were found at autopsy after contusions of the 
kidney, the patient had been suffering from chronic nephritis before the injury. 
Circumscribed nephritic lesions may occur, however, in the areas immediately 
involved. In such cases, which are rare, the albuminuria and the casts persist 
for some time in the urine after the hematuria disappears. Albumin has been 
found in small amounts for a year or more after the injury. 

Diagnosis. — The diagnosis of a renal contusion is possible in a positive way 
when hematuria is present. All other symptoms may lead us to suspect such a 
lesion, but none is sufliciently characteristic. This does not mean that they must 
not be looked for carefully. The existence of a perirenal hematoma, coupled 
with the history of the case, has, however, great value. 

The differentiation between a subparietal renal injury and a renal colic 
due to calculus and preceded by an accidental traumatism, is not always easy. 
The history of the case and the repetition of the attacks at intervals may help 
in making this distinction in the limited time at our disposal in these cases. 
Renal tumors often give rise to pain and hematuria after an accidental blow, 



SUBPARIETAL INJURIES 



395 



and, in Hucb cases, the diagnosis will have to be reserved until the nrine and 
the cachexia give a clew to tlie condition. 

We Lave seen that tlie severity o£ the symptoms ia hy no means a measure 
of the extent of the injury in sulicnlaneous renal traumatism. An exception 
to this, perhaps, is the ra]>idity with which the renal hematoma develops. This 
is usually proportionate to the severity of the injury. 

In eases with slight or absent swelling and pain, but with persistent hema- 
Inria, the cystoscope will show from which side the bleeding comes. Muscular 
rigidity on the affected side is of 
service in doubtful cases. 

In another class of cases, the 
bleeding continues slowly until a 
tumor resembling a small water- 
melon in shape and size develops 
on one side of the abdomen, most 
marked in front {Fig. 268). In 
this case, a lumbar incision should 
l)e made in the ileo-costal space he- 
hind and the contents evacuated. 
The amount of mixed urine and 
blood in sueh cases is often as- 
tounding. 

Prognosis. — The prognosis of 
renal contusions varies with the 
severity of the lesion. The chief 
danger is from complications, and 
recoveries are on record of patients 
who have been in an apparently 
hoi>eIes3 condition. Death may oc- 
cur within a short time as a result 
of collapse from hemorrhage. If 
the patient lingers on, complica- 
tions may be feared. According to ilorris, in rupture of the kidney, its pelvis, 
or ureter, the prognosis, as far as life is conccnied, is less favorable than in 
rupture of other abdominal organs. 

Statistics of mortality from subparietal renal injuries vary somewhat. 
Eldler gives fifty jier cent mortality, Kiistor forty-seven per cent, Kwn thirty- 
three per cent, but Albarran thinks that these figures are exaggerated, as he saw 
seven cases without a death and as Le Dentu notes that recovery took place in 
nearly all eases observed by him. Guyon, at the Xeeker Hospital for the past 
ten years, docs not record a single fatal case. The high morlality figures are 
due probably to the fact that only the grave cases are published. Hemorrhage 



I. 268. — Shape op thb Abdomen iv the Case 
or A RopTDBBD KiDNET. The rupture extoudcd 
inU) the tenal pelvis. There was a slow leakage 
of blood and urine. (Author's case.) 



396 KIDNEY INJURIES 

and suppuration are the most frequent causes of death. Wagner could find 
but three cases on record where the patient recovered from a renal contusion 
complicated by a demonstrable tear in the peritoneum. Kiister considers these 
cases as offering the most unfavorable prognosis. The question of prognosis 
bears directly on the question of treatment. 

Treatment. — In mild and moderately severe cases, renal contusion heals 
spontaneously, in which case there is no place for active surgical interference. 
In fact, such patients, when kept in bed, with strips of adhesive plaster across 
the back, recover quite well in a very large proportion of cases. The usefulness 
of ice bags is doubtful. 

In complicated cases, rest in bed should be maintained for a week or longer, 
.after the swelling and all traces of bleeding have disappeared. Shock should 
be treated in the usual way, but cases of rupture of the kidney must be very 
carefully watched and, if the shock is great, the pulse thready, indicating in- 
ternal hemorrhage, rapidly increasing, an incision should be made and the 
wound in the kidney repaired by suture, if not too extensive. If, however, the* 
kidney is badly lacerated, an immediate nephrectomy is indicated. 

If the renal hemorrhage is found to be active, the kidney must be repaired 
or removed. In two such cases of my own, after evacuating the contents and 
packing the cavity, the hemorrhage ceased. Later I removed the kidney in one 
of these, on account of infection and the great damage done to the kidney. 

Still another indication for operative intervention is given by the late in- 
fection and suppuration of a perirenal hematoma. This may require an opera- 
tion three weeks after the accident. The kidney is sometimes necrotic and has 
to be removed. 

To sum up in a few words : The immediate indication for operation is hem- 
orrhage ; the late indications are perirenal accumulations and infection. 

The results of operative treatment as contrasted with the nonoperative treat- 
ment, are tabulated thus by Morris (vol. i, p. 198). 

In twenty-six cases collected from English and American sources from 1884 
to 1893 inclusive, he found: 

One died of other causes. 

Fourteen treated palliatively, ten died — 70.7 per cent. 

Eleven treated by operation, three died — 27.2 per cent. 

This is not absolutely convincing proof of the superiority of the operative 
method. My personal results to date are: 

One treated palliatively, no death. 

Four treated by operation, one death. 

niustrative Cases. — I will give a brief resume of the five cases of sub- 
parietal injury of the kidney I have had. 

Case I. — Case of subparietal subcapsular injury of the right kidney. The 
patient was a laborer, thirty-eight years of age, who one week before seeking 



SUBPARIETAL INJURIES 397 

admission to the hospital had a fall, striking on the right side. This was fol- 
lowed by pain in the loin and inability to pass urine for twenty-four hours; 
when he finally passed urine, it was red in color. 

Status prcesens: A mass the size of a cocoannt, dnll on percussion behind, is 
felt in the right lumbar region. Local pain and tenderness. No temperature. 

Urine: Of a Burgundy-red color. Specific gravity, 1.022. Albumin, 
twenty-five per cent in bulk. Some leucocytes and abundant red corpuscles. 

Treatment: Kest in bed; milk and Vichy diet; urotropin and Basham's 
mixture. 

Course: The patient remained in the hospital five weeks. At the end of 
the first week, the urine was straw-colored, specific gravity 1.019, of acid reac- 
tion and contained a few blood cells and calcium oxalate crystals. By the end 
of the second week, three weeks after the accident, all traces of blood had dis- 
appeared from the urine, and the tumor was diminishing in size. It could 
scarcely be felt at the time of discharge, five weeks later. 

Case II. — The patient, a laborer, twenty-two years of age, eleven days before 
admission fell while dumping a box of dirt, and struck the ground on the left 
side from a distance of twenty-five feet. He was unable to walk and liad to be 
carried home. A few days later, the painful swelling, that had been gradually 
increasing in size, occupied the 
entire left side of the abdomen. 
The general symptoms increased 
in severity, and the patient en- 
tered the hospital. 

Status prwsens: There was a 
swelling in the left side, resem- 
bling a small watermelon in form, 
dull on percussion (Fig. 268). 
Temperature 101° to 106° F. ; 
pulse, 88 ; respiration, 20, There 
was no visible hematuria. The 
local findings led to the diagnosis 
of splenic rupture. 

Treatment : Operative. An in- 
cision was made in front, along 
the outer border of the rectus 

muscle, and the peritoneal cavity 

, , , J Fio. 269. — RuPTOBB OF KiDNET. ShowB the rent in 

was opened. Ihe gut was found the kidney proper and pelvia of a ruptured kid- 

Stretched between the anterior "ey- The kidney is turned bo aa to show the tew. 

, . . .. , „ 1-1 (Author's case,) 
and posterior peritoneal walls like 

pieces of ribbon, due to a retroperitoneal timior that was pushing forward the ab- 
dominal contents. The patient was accordingly turned and an incision made in 



398 KIDNEY INJURIES 

the loin behind, when two and one half gallons of a reddish-brown bloody fluid 
escaped. The kidney was found ruptured posteriorly, showing a transverse reut 
in the kidney proper extending into tlie pelvis that admitted three fingers. The 
opening was just above and |X)sterior to the ureter. The organ was 8urrounde<l 
by a dense mass of tissue and very adherent to the adjacent parts. The wound 
was packed and drained, but a week later the drainage became impaired, and 
there was much pain and distress. Keopening of wound and removal of two and 
one half quarts of a brownish fluid containing pus. Nephrectomy one month 
later. The patient recovered (Fig. 260). 

Case III. — The patient was a grocer, thirty-one years of age, who three weeks 
previously, following a fall, began to suffer from pain, gradually increasing, and 
swelling in the left lumbar region, with anorexia and constant thirst. No irregu- 
larities of urination. No visible hematuria. 

Status p^cesens: A large tumor, not sharply defined, also sliaped like a 
melon, was felt in the left lumbar region. Temperature, 102"^ to 103"^ F. ; 
pulse, 98. 

Treatment: Operative. A lumbar incision was made, and a large amount of 
a brownish fluid like broken-down kidney tissue was removed. The cavity was 
packed with gauze. Suppuration followed, and the patient remained in the 
hospital for two months, when he was discharged with the wound in the kidney 
healed. 

Case IV. — The patient, a housewife, thirty-six years of age, had complained 
for eight years of occasional pain in the right lumbar region, with fever, last- 
ing from a few hours to days. For some time before coming under treatment, 
she had noticed an increasing fullness in the lumbar region. Examination 
showed a well-defined tumor on the right side, extending from the costal mar- 
gin to the iliac fossa, beyond the umbilicus. There was another bulging in the 
ileo-costal space behind. At this time the patient's temperature was 101° F. ; 
pulse, 94 ; respiration, 3G. She was sent to the hospital in an ambulance, and 
at the time of admission, a few hours after the first examination, her temi>era- 
ture was 105° to 100° F. ; pulse, 130; respiration, 46. No well-defined tumor 
could be outlined in the examination, but there was a general mass over the en- 
tire right side of the abdomen. It was evident that the ride in the ambulance had 
caused rupture of the kidney and leakage into the postrenal space. An in- 
cision was made the next day, and a large amount of blood and pus evacuated. 
The temperature dro})ped at first, but then ran a septic course due to imi)erfect 
drainage. The kidney on removal was found to contain a stone. The outcome 
was death. 

Case V. — The patient was a man twenty-nine years of age, an ironworker 
by occupation, who gave a history of many attacks of malaria. Two years ago 
he had pain in the right loin, lasting four or five days, and tliis had recurred 
since at intervals of four or five months, with a little fever, lasting for hours 



INCISED, PUNCTURED AND GUNSHOT WOUNDS 399 

or days. Four months before coming imder treatment, the patient, while 
lifting a piece of metal, heard something snap on the right side; this was 
followed by faintness and cold perspiration. There was a strong desire to 
urinate, and the urine passed was bloody, remaining turbid ever since that 
time. At the time of admission, the patient had a septic temperature, aver- 
aging 100° F. ; his general condition was bad. A large mass could be felt in 
the right side. 

Treatment: Operative. An incision was made in the loin, and three pints 
of mixed urine, blood and pus were evacuated. A ragged opening was found 
in the lower pole from which protruded a fragment of stone, over an inch in 
length and one third of an inch in width. The wound was packed. The 
temperature dropped after the operation; the wound did not heal and a sinus 
remained, discharging urine and pus. Nephrotomy was performed, followed 
by free drainage of the kidney, and the patient left the hospital one month 
later in good condition. 

INCISED, PUNCTURED AND GUNSHOT WOUNDS OF THE KIDNEY 

Etiology. — Incised and punctured woimds of the kidney are almost always 
due to a thrust, or to a fall on something sharp, as a pointed weapon. The kid- 
ney is generally alone affected, as the wound is usually due to the stab of a knife 
in the back or side, and the opening of the peritoneal cavity is infrequent. Still 
rarer is a complete division of the organ. When the kidney wound results from 
a thrust through the anterior wall of the abdomen, the other abdominal organs 
are usually injured as well. 

The wound may vary considerably in depth and direction. As these wounds 
are often inflicted by septic instruments, it is not surprising that they fre- 
quently become septic. 

Gunshot wounds are rarely seen in civil practice, and in war they are al- 
most always complicated with gunshot injuries of other organs on account of 
the high velocity of modern firearms. Edler states that these wounds constitute 
about one twelfth of one per cent of all gunshot injuries. Only three cases are 
on record in women. 

Pathology. — The bullet may remain in the kidney and become encysted 
there, or it may pass through the organ, or it may graze it and cut off a piece 
of renal substance, or pass through the renal pelvis. Fragments of cloth, bone, 
etc., may be carried with the bullet and remain in the track of the projectile. 
There is always a certain amount of contusion along this tract, and an eschar 
forms in its walls. The kidney may, however, be mashed to a pulp by the 
projectile. The orifices of entrance and exit are of unequal size, the latter 
being usually the larger. Stellate fissures radiate from tlu^se openings when 
the kidney is flaccid, or a long and wide fissure results when it is distended at 



400 KIDNEY INJURIES 

the time of the injury. Unless the pyramids or calices be wounded, no blood 
escapes and there is but little hematuria at first in the average case, though 
blood may accumulate in the perineal space. 

These wounds heal by granulation followed by the formation of cicatricial 
tissue, after the slough has separated from the tissues and has been discharged. 

Foreign bodies carried in with the bullet may become encysted in the kid- 
ney, or pass into the ureter or through the external wound. Fistula? are fre- 
quent sequela?. 

Symptoms. — They are the same as those of contusion ; namely, hemorrhage 
and shock and a wound in the lower region or in the abdomen below the 
costal arch. Pain in the wound, radiating along the ureter, is a very variable 
feature. The hemorrhage may take place externally, internally, or through the 
ureter. 

External hemorrhage alone is exceptional. It is generally associated with 
hematuria. The latter is rarely absent and may be an early sign. The amount 
of hematuria is much greater in proportion to the internal perirenal as well as 
the external hemorrhage. When the outer wound is large, there is considerable 
external bleeding and generally very little lumbar swelling. If the calices or 
pelvis are wounded, urine will be mixed with the blood. In gunshot wounds, 
the immediate hemorrhage may be slight, owing to the presence of a clot, but 
when a slough separates, after five or six days, there may be a profuse secondary 
hemorrhage. Prolapse of the kidney through the wound is extremely rare. 
The symptoms of renal injury may be obscured by those of the other abdominal 
organs simultaneously involved. Retention of urine in the kidney may be 
caused by a clot clogging the ureter. The complications are all referable 
to infection and consist in peritonitis, nephritis, pyelitis and perinephritic 
abscess. 

Diagnosis and Prognosis. — The situation, direction and origin of the 
wound, hematuria, hemorrhage from the external wound, or ordinary extravasa- 
tion, are the chief guides in the diagnosis. In case there is an escape of urine 
from the wound, the odor of the fluid is usually strong enough to prevent errors ; 
but, if there is any doubt, an examination as to the presence of urea can be 
made. ' A digital examination of the wound should be resorted to in doubtful 
cases. Lumbar pain and hematuria are reliable signs of a renal wound in these 
cases. The sounding of gunshot wounds is only permissible imder circumstances 
pointing to the presence of a foreign body. The X-ray will often locate the 
bullet. 

The prognosis is always grave and depends largely upon coincident infec- 
tion, upon peritoneal penetration and upon the participation of the renal pelvis 
and renal vessels in the injury. Albarran gives the general mortality as fifteen 
per cent. Of forty-three cases of punctured and incised wounds of the kidney 
collected by Kiister, ten (twenty-three per cent) ended fatally. The death 



INCISED, PUNCTURED AND GUNSHOT WOUNDS 401 

rate has been considerably lessened by operative treatment. Experience in the 
South African War, according to Morris (vol. i, p. 233) showed that penetrat- 
ing wounds of the kidney, caused by modem small-bore bullets, do not neces- 
sarily have a fatal issue, even when other organs are traversed, and that the 
kidney or the liver may be pierced from before backward or from side to 
side, without any symptoms of importance following. These fortunate cases 
are due to the fact that small-bore bullets do not lacerate and make very small 
wounds — a fact that has altered many aspects of military surgery within 
recent years. 

Treatment. — The general treatment is that of shock and hemorrhage, 
consisting in stimulation for the former, and a hot saline enema or in- 
travenous injection for the latter. A simple antiseptic bandage should be 
placed over the wound, and, if the patient's general condition improves, 
the treatment should be expectant and symptomatic. I do not believe in 
closing the wound, although, if it is very large, the edges can be brought 
together by surgical plaster, allowing sufficient space for the escape of blood 
and bloodv urine. 

If the hemorrhage is severe, and the patient does not rally under stimu- 
lants, the case becomes an emergency one, and a wide lumbar incision must be 
made, the kidney reached and sutured, leaving a drain from the surface of the 
kidney to the outer dressings. If the organ be found too extensively involved, 
a quick nephrectomy should be performed. 

To sum up: Put on an antiseptic bandage with an ice bag over the wound, 
counteract shock, check the hemorrhage, keep the patient quiet and he as con- 
servative as possible. Such are the guiding rules for the treatment of all kid- 
ney wounds. 

ninstrative Case. — I have had only one case of punctured woimd of 
the kidney, a laimdryman, twenty years of age, who was stabbed in the 
loin from behind just above the twelfth rib, and was able to walk to the 
hospital. 

Status prcesens: There was a wound, about three quarters of an inch in 
length, in the lumbar region, and a mass was present resembling an enlarged 
kidney. The patient vomited and complained of pain in the loin. His pulse 
and temperature were normal. 

Treatment: Internally, 15 minims of the fluid extract of ergot given 
every three hours, and urotropin given every six hours. Wet dressings (m 
the loin. 

Course: On the following day, he urinated a quart of red blood and con- 
tinued to pass bloody urine for seven days, when it became clear and he left the 
hospital. Two days later he began to suffer from frequency of urination, void- 
ing every three hours, and on the following day again passed red urine. There 
was severe pain over the pubic region, and the patient reentered the hospital, 



402 KIDNEY INJUEIES 

where he was catheterized and a quart of bloody urine was drawn oflF. At no 
time did he have any fever. The hematuria ceased altogether at the end of 
two weeks after the accident, when he left the hospital. The renal hematoma in 
the loin persisted during the whole time, and was still present on the right 
side at the time of the discharge. 



CHAPTER XXII 



MOVABLE KIDNEY 



Movable kidney is frequently referred to as floating kidney, but more 
correctly speaking a movable kidney is one that has an abnormal range behind 
the peritoneum in a vertical plane, while a floating kidney is one with a meso- 
nephron which floats among the abdominal viscera. 

The kidney is held in place by the fatty capsule which surrounds it, the 
perirenal fascia, the suprarenal capsule to which it is adherent, the renal pedi- 
cle, and through the intra-abdominal pressure. The perirenal fascia (see Fig. 
30) incloses it on all sides, but is open at the lower inner part, in which direc- 
tion the kidney tends to move. There is normally some mobility of the kidney, 
from 3 to 5 cm., greater in women than in men, depending upon the length of 
the vascular pedicle. It may be said that, whenever a kidney can be felt pro- 
jecting below the ribs, moving on respiration and sensitive to the touch, it may 
be considered movable in the pathological sense. The frequency in autopsy 
findings differs greatly from the clinical statistics. For instance, Epstein, in 
compiling postmortem statistics, found that it had occurred once in 500 cases and 
Newman estimated 1 to 1,000; while, clinically, Kutnow found it in 20 per cent, 
Glenard in 22 per cent, Goddard-Danhieux in 35 per cent of women and 21.35 
per cent in men, and Harris in over 50 per cent in women, while in men it was 
present in 2.3 per cent. I believe it is safe to say that it occurs in 10 per cent 
of women, although I think the percentage of those who suffer to any marked 
degree from the mobility is much less. 

Three degrees of movable kidney are spoken of: First, when the lower half 
of the kidney is palpable (Fig. 270, I) ; second, when the entire organ is pal- 
pable (Fig. 270, II) ; third, when the entire organ can both be palpated and is 
freely movable downward and inward (Fig. 270, III). The third degree, ac- 
cording to Glenard, constitutes a floating kidney. The organ is at times even 
more movable and has been found in the female pelvis, from which position it 
has been removed by operators who mistook it for a cystic ovary. When it moves 
away from the loin, its usual rotation is downward and inward, and, as it pro- 
gresses, its lower pole moves forward and its upper pole tends to point backward. 
(See Fig. 270, III). It sometimes pulls on the duodenum and often makes an 

403 



404 



MOVABLE KIDNEY 



extensive excursion with the ascending and hepatic flexure of the colon, espe- 
cially when there are adhesions to one or the other of these viscera. 

In mild degrees of movable kidney, the ureter gives rise to no trouble; but 
when the displacement is marked, it may curve or kink, although still allowing 
the urine to pass through it, but less easily than under normal conditions. This 




Fia. 270. — DiBPi.*ciiiiBHT o 



may interrupt temi>orarily the flow of urine (Fig. 271). When the kinks are 
held by adhesions, the course of the urine may be seriously impeded, giving rise 
to retention of urine in the renal pelvis and attacks of pain. 

The suprarenal capsule does not move with the kidney. The peritoneum 
over the kidney may become loosened and elongated and accompany it in its 
excursion, resembling a mesonephron. 

Etiology. — The etiology of movable kidney is still a subject for discussion. 
Women are predisposed to this condition. The relative frequency in men and 
women is variously estimated from 1 in 7 to 1 in 15. In my practice it is 1 to 5, 
but presumably because my male patients are more numerous. The reason 



ETIOLOGY 



406 



for this predisposition in women is that the renal foii^a, i. c, the bellow in the 
loin where the kidney rests, is shallower in the female. It is also more open 
below and narrower at the upper part, where- 
as in men the fossa is deeper and narrower 
at the lower part. 

The most favorable period for the devel- 
opment of this condition is that of gestation, 
ulthougli it is frequently fonnd in yonng 
girls and has heen re])orted in infants. The 
right side is affected in between 85 and !I0 
per cent of the cases on accoimt of the longer 
pedicle, the pressure transmitted to the kidney 
by the liver during respiration, and pressure 
from corsets, waistbands, belts and girdles. 

Pregnancy is considered an Important 
cause, especially when frequently repeated 
at short intervals and followed too soon by 
exertion, llultiparse are affected more fre- 
qnently than nnllipane, in a proportion vari- 
ously estimated at from 20 to 1, to from 5 
to 1. This tends to show the importance of 
intra-abdominal pressure in the support of 
the kidneys and the fact that the abdominal 
wall, if its muscles are strong and well devel- 
oped, serves as a bandage with the intestine acting as an elastic pad. It also 
emphasizes the imjwrtance of preserving the strength of the abdominal wall. 
In cases where this is much weakened after pregnancy, the woman should 
remain in bed until it has become stronger and, when she resumes her usual 
household duties, an abdominal support or belt sliould be worn. 

A loss of fat is usually spoken of as an important cause, but this is not 
especially noted in the fatty capsule at the time of operation in thin subjects. 

The question as to the eoimection of nephroptosis with general enteroptosis 
has been discussed by many and, according to Glenard, it is but a part of 
enteroptosis, the latter being a disease of general bad nutrition, accompanied 
by the falling forward and downward of all the abdominal viscera. Glenard's 
views, however, are not universally accepted and I think it is safe to say that 
while nephroptosis has no tendency to produce general enteroptosis, that the 
latter condition may assist in producing the former. 

All observers seem to agree that the corset and the tight waistbands of heavy 
skirts in women, and the tight belts supporting the trousers in workingmen, 
are common causes of this condition. Corsets and waistbands supporting heavy 
clothing do evidently have a traumatic influence on the kidney, as the former 



Fio. 271— KiNKiNO or th» Urttbr 

IN DiBPLACGUBHT OT TSB KlDNET. 

This kioluDg of the ureter may 
intemipt temporarily the flow ol 
urine, leading to the (ormatioD of an 
intermittent □ephrydrosis (bydro- 
nephrosis). (Harris, in Reed's " Teil- 
book of Gynecolo^.") 



406 MOVABLE KIDNEY 

in many movements tend to push the liver against the kidney; whereas, if the 
kidney is displaced and it is pressed upon by a thin belt or waistband, the 
weight of the clothes tend to drag the kidney down during certain movements, 
as when the patient bends forward in the act of scrubbing, washing, or in other 
motions of a similar nature. The lifting of heavy weights, reaching for high 
objects, straining at stool, chronic hacking cough, horseback riding and the 
skipping rope also tend gradually to displace the kidney. These can all be 
s2)oken of as repeated traumatisms of a mild character. 

I feel that the claims that sudden traumatism causes movable kidney — such 
as a blow in the loins, a fall upon the knees, buttocks or perineum, a blow on 
the thorax, a sudden muscular strain due to the abrupt stopping of a car and 
other claims of a similar nature which are used in suing cori>orations and 
railway companies — are groundless. In all such cases, if the traumatism had 
been sufficient to displace the kidney suddenly, it would have been grave enough 
to have ruptured the vessels or the renal pedicle and given rise to a dangerous 
hemorrhage, and, perhaps, sudden death. It is really the repeated traumatism 
of a mild character that causes the trouble, as has already been mentioned under 
corset and belt pressure. I believe that persons who suddenly complain of pain 
in the loin after a shock, a car accident or jar, and in whom a movable kidney 
is found on examination, would have shown the presence of such a condition 
had they been examined before the accident ; but as there was no reason for 
such an examination, the presence of movable kidney naturally was not known. 
On the other hand, when a movable kidney exists, a sudden jar or wrench may 
give rise to renal strangulation and thus bring on symptoms that might induce 
one to believe that the mobility had been caused by the recent traumatism. 

Heredity is spoken of as a predisposing cause of abnormal renal mobility. 
This may be true in a way, on account of the liability of the child to have the 
same body configuration as the mother, and, consequently, if the mother had 
a movable kidney, the child would be predisposed to its development, for I 
consider the body form as the principal predisposing factor in this condition 
and all others as slowly contributing causes. 

The Body Index in Patients with Movable Kidney. — Becher and 
I.onnhof, in examining a large number of women, foimd that they could gen- 
erally jud^e from the appearance of the patient's figure whether one of the 
kidneys was palpable or not. After reasoning out the whys and wherefores 
of this decision, they made the following scientific observation and deduction: 
First, that more movable kidneys were found in women with a long distance 
from the suprasternal notch to the pubes and a small waist than in women with 
a short trunk and large waist ; second, they decided, after taking many careful 
measurements, that the distance from the suprasternal notch to the upper 
margin of the symphysis pubes, divided by the smallest circumference of the 
abdomen and multiplied by 100, constitutes a body index. Given as a result 



ETIOLOGY 407 

or quotient 75, representing the normal woman, if a number above this resulted, 
say 77 to 80, it could be considered positive that one kidney was movable; 
whereas, if it was below 75, say 73 or less, no movable kidney was present. The 
measurements were computed according to the metric system in centimeters. 



The mathematical index = ^. ^. j— tj X 100 = ^ 

Cu-cumf erence of abdomen 



r75-normal 
77-plus — positive 
^73-minus — negative 



Harris, of Chicago, continued the studies of Becher and Lennhof, but went 
into the subject more carefully, and has, therefore, been able to give to the pro- 
fession a clearer and more comprehensive idea of the ini}>ortance of the body 
form in movable kidney, as well as to depict the shape of the individual predis- 
posed to movable kidney, in contradistinction to one who is not so predisposed. 

Harris divides the body into three zones — the upper, middle and lower — 
by drawing three planes through the body transversely. (See Fig. 272.) He 
takes the tips of the tenth ribs as the landmarks, because they are fixed points, 
whereas the smallest circumference of the body is rather an uncertain location. 
He then proceeds to take certain measurements with the patient lying flat on 
the back. The circumference of the body at the tips of the tenth ribs is first 
measured and a mark is made with a pencil where this line crosses the median 
line. A mark is also made at the lower end of the sternum and the cireum- 
ference is taken at this point also. The breasts must be drawn up, if they are 
in the way, and the circumference should be taken at the end of the ordinary 
respiration. Finally the distance between the upper sternal notch and the 
upper margin of the symphysis is taken, and a line drawn between these two 
points, upon which the length of each zone is noted. These measurements give 
us Harris's Index No. 1, which is simply the jugulo-symphysis, divided by 
the circumference at the tenth rib and multiplied by 100. It is similar to that 
of Becher and Lennhof, but it is more accurate. When this index is above 
77 or 78, the kidney is palpable ; but when it is below these figures, palpation 
is negative. 

By a comparison of the different zones in cases with palpable kidneys, it 
was found that the increased length of the jugulo-symphysis was situated 
chi.^fly in the middle zone, while the upper and lower zones remained practically 
the same. In negative cases, the average circumference of the upper end of the 
middle zone was 77.1 cm., and of the lower end of the middle zone, 69.5 cm. 
On the other hand, in positive cases, the upper circumference of the middle 
zone was 73.46 cm., and 61.9 cm. for the lower circumference. Thus, there 
was a marked contrast between the positive and negative cases in regard to 
the circumference of the lower end of the middle zone. In other words, the 
middle zone was elongated and made narrower, especially at the lower end, 
whenever the kidney was palpable. 



408 



MOVABLE KIDNEY 



Ilarris found that there were still certain sources of error in this method 
of measurement. In taking circumferences, accurate measurements are diffi- 
cult to get in fat subjects, for the breasts are in the way, though pulled up, 
and there is a certain spreading that corresponds to the lower margins of the 
ribs when a corpulent woman lies on her back. For this reason, he deter- 




FiQ. 272. — Anterior View of the Body Di- 
vided INTO Three Zones, the Upper, Mid- 
dle AND Lower, Made bt Drawing Three 
Planes through the Body Transversely. 
The normal female body is drawn in heavy 
black lines. The imperfect female body is 
drawn in dotted lines and is the one predis- 
posing to movable kidney. These outline draw- 
ings show the lateral diameters of the body 
index in the healthy person and in people with 
movable kidney, as determined by Harris. 




Fig. 273. — Side View op the Body and the 
Lines Corresponding to the Antero- pos- 
terior Diameters of the Body Index as De- 
termined BY Harris. Here, also, the heavy 
black lines show the normal person and the dot- 
ted lines the one predisposing to movable kidney. 



mined to use calipers and measure 
diameters instead of circumferences, 
and have the patients standing during 
the measurements instead of lying down. In this way, he measured five diam- 
eters, which gave him very accurately the body form of the patient. 

First Diameter : The widest or upper lateral diameter. This is taken with 
the calipers resting at the widest point of a plane corresponding to the lower end 
of the sternum, usually on the seventh ribs (Fig. 272, No. 1). 

Second Diameter : The middle lateral diameter. This is the greatest dis- 
tance between the lower edges of the tenth ribs (Fig. 272, No. 2). 

Third Diameter: The lower lateral diameter — the widest distance between 
the iliac crests (Fig. 272, No. 3). 



ETIOLOGY 



409 



Fourth Diameter : The upper antero-posterior diameter ; from the lower end 
of the sternum to the spinous process opposite in the same plane as the upper 
lateral diameter (Fig. 273, No. 4). 

Fifth Diameter: The middle antero-posterior diameter; from the median 
line in front to the spinous process opposite on the same plane as the middle 
lateral diameter (Fig. 273, No. 5). 

In order to draw conclusions from his transverse diameters, he divided 
the middle lateral by the upper lateral diameter and multiplied the quotient 
by 100, thus obtaining Index No. 2. The second index refers entirely to the 
middle zone and shows the relation between the lateral diameters of its lower 
and upper ends, or, in other words, the amount of constriction at the lower end. 

Index Xo. 2 arranged as a mathematical problem is solved as follows and 
shows one of many results that may be obtained: 

Middle lateral diameter w ,/x^ _ r73.23 — positive 
Upper lateral diameter "" \85.26 — negative 

Furthermore, all cases below 81.8 were found positive, that is, with mova- 
ble kidney, while all cases above 81.8 were found negative. 
In detail, the measurements of the diameters were as follows: 



Average upper lateral diameter 

Average middle lateral diameter .... 

Average lower lateral diameter 

Average upper antero-post. diameter 
Average middle antero-post. diameter 



In Negative 
Cases. 



23 .62 cm. 
20.2 " 
28.7 " 
16.9 
15.67 






In Positive Cases 



23.85 cm. 
17.44 " 
29.06 
17.03 
14.26 






iC 



Difference. 



. 23 cm. Practically same. 
2 .76 cm. or 13 .6 per cent. 
. 36 cm. Practically same. 
0.13 cm. 
1 .41 cm. or 9 per cent. 



The difference between the upi)er lateral and the middle lateral diameters, 
in negative cases, was 3.4 cm. or 14.4 per cent, and the difference lx»tween 
the upper and middle antero-posferior diameters in these cases was 1.23 cm. 
or 7.28 per cent. In the positive cases, the difference between the upper and 
middle lateral diameters was 6.41 cm. or 27 per cent, while between the upper 
and middle antero-posterior diameters the difference in these cases was 2.8 cm. 
or 17 per cent. 

These figures show that the middle zone diminishes in size from above 
downward nearly 100 per cent more from side to side, and 140 per cent more 
from before backward, in the positive cases than in the negative. This means 
that there is a marked diminution in the capacity of the middle zone in the 
positive cases in which the kidnev can be felt and this diminution grows more 
marked in these cases as we advance in the middle zone from above downward. 

As the upper zone remains practically the same in the two classes of cases, 
any lessening in the capacity of the middle zone must result in a crowding 
of the contents of this space downward — in other words, a greater tendency to 



410 MOVABLE KIDNEY 

a displaced kidney. The above description contains the essence of Harris's 
views and is practically his own wording with his conclusions from the study 
of the body indexes as devised by him. 

The two figures, one of the normal body and the other of the form predis- 
posing to movable kidney, were drawn by Harris and presented to me by him. 
I here take this opportunity to state that, in my opinion, the careful study that 
Harris has made of cases of movable kidney has done more to make clear the 
predisposing cause of this disease than any other writings on the subject. 

Symptoms. — In many instances there are no symptoms in a case of movable 
kidney, as has been ascertained frequently, when its presence was accidentally 
discovered during a physical examination for some other reason than for indi- 
cations of movable kidney. Frequently the severity of the symptoms is by no 
means dependent upon the degree of mobility of the organ, as a slightly movable 
kidney may cause great suffering, while another may be markedly movable with- 
out giving rise to any signs. 

Clinically, there are three types of movable kidney — first, the painful or 
neuralgic; second, the neurasthenic; third, the dyspeptic — according to the 
predominant symptom, although they may be associated in different degrees. 
Pain was present in 90 per cent of the cases in my own practice. 

Pain. — Pain is due to traction on the nerve plexuses and on the peritoneum 
or other organs covered by the peritoneum, esj^ecially if adhesions are present. 
Its character is generally a dull ache, either constant or recurring, and accom- 
panied by a sense of dragging or heaviness. It is usually situated in the loin 
below the twelfth rib and less frequently in front on one side of the umbilicus, 
in the iliac fossa or in the groin. 

Occasionally there are acute, paroxysmal attacks of pain that come on sud- 
denly, starting in the loin and radiating along the ureter, called Dietl's crisis, 
somewhat similar in character to those of renal calculus. During the severe 
attacks, there may be muscular rigidity on the affected side, the kidney may be 
found enlarged and tender from acute congestion, and the urine may contain 
blood. There may be oliguria at times followed by polyuria. These attacks 
usually last for a few hours and sometimes for a few days. They are due to 
kinks or compression of the ureter, causing an increased renal tension and 
resulting in variable degrees of renal retention or temporary hydronephrosis 
(Fig. 271). The records of my own cases show that of those having pain four- 
teen per cent had attacks occurring from every few days to every few months. 
The history of the attacks of pain covered a period of from four months to 
fourteen years. 

In three per cent of my cases, the pain began suddenly and the patients 
attributed the condition to some movement they had made just before they first 
noticed the pain. In one case, the patient stooped over to pick up some 
clothes, since when she has experienced a peculiar sensation in her right loin 



SYMPTOMS 411 

and has had occasional pain of a dull dragging character. Another woman 
first felt the pain come on while raising an awning, since when she has had 
it whenever she does hard work. Of course, the occurrence of the first pain 
coming on suddenly during some particular exertion does not mean that this 
has caused the trouble, but that the stage of mobility had been reached when 
any movement or jar might favor the sudden falling of the kidney or a ureteral 
kinking, causing a sudden pull on the renal or ovarian plexuses. 

Attacks of pain generally increase iii frequency, and sometimes in severity, 
as the case progresses. In twenty per cent of my cases, the pains were dull in 
character. The abdomen was usually relaxed. 

Aervous Symptoms. — The nervous phenomena of movable kidney are 
spoken of as hysterical and neurasthenic. Among these nervous symptoms, 
which differ in various individuals, are irritability, restlessness, depression, 
languor, palpitation, vertigo, a feeling of pressure in tlie head, neuralgia, loss 
of flesh and appetite, and a general impairment of health. The nervous pains 
are generally nepliralgic, sciatic, lumbar or intestinal, and sometimes ovarian 
or testicular. 

Gastro-intestinal or Dyspeptic Symptoms. — Symptoms of this char- 
acter are frequent. Of these, indigestion and flatulency are most common. 
Next in order are constipation, due to pressure or dragging upon the colon, 
gastralgia, nausea, vomiting and other symptoms of gastritis during attacks of 
renal strangulation. Jaundice from duodenal traction or compression of the 
bile ducts, or tugging on the hepatico-duodenal ligaments, is not so common as 
often assumed. Symptoms of appendicitis may be produced as the result of 
compression of the superior mesenteric vessels, and the congestion of the vermi- 
form appendix which follows. According to Edel)ohls, this tendency to apixMi- 
dicitis is found in fifty per cent of women suffering from a movable kidney. 

Among other symptoms, are weakness, dizziness, loss of appetite, throbbing 
in the abdomen on the affected side, headache and constipation. Chills and 
fever have occurred in a few cases, associated with pyelitis and renal re- 
tention. 

Character of Fkination axd the Frine. — In discussing these two symp- 
toms, there are several points to be considered. The character of the urination 
does not differ much from normal, any deviation depending principally on the 
presence or absence of renal retention or strangulation, the latter of which is not 
common. If there is renal retention, a temporary hydronephrosis, there will 
he a diminished amount of urine passed, or oliguria, while the secretion is 
retained in the kidney ; but when the kidney returns to its proper position, a 
larger amount of urine will be voided, which is spoken of as polyuria. 

In renal strangulation, there is a diminished amount of urine during the 
attack, after which an increased amount of a highly colored urine, often con- 
taining blood, is passed. 



412 MOVABLE KIDNEY 

In the usual case of movable kidney, the urinary findings are slight, if any: 
a low specific gravity, a very slight trace of albumin and an occasional hyaline 
cast, or sometimes a few finely granular casts. These findings are due to the 
irritability of the kidney and the strain on both organs incident to the irregu- 
larities of the renal circulation and the urinary excretion. 

Edebohls, in operating on movable kidneys by partially decapsulating the 
organs and fastening them to the abdominal wall, noticed, in cases with this 
variety of urine which closely resembled that of interstitial nephritis, that the 
polyuria, casts and albumen gradually disappeared or diminished. He, there- 
fore, reasoned that, if people with movable kidney passed the same urine as 
patients with interstitial nephritis, movable kidney was the cause of interstitial 
nephritis ; and furthermore, if the interstitial nephritis associated with mov- 
able kidney was cured by partial decapsulation, then any case of chronic nephri- 
tis could be cured by decapsulation, as it gave the kidneys a chance to form 
a collateral circulation with the abdominal wall or with the fatty capsule. This 
was the line of reasoning that led him to recommend total decapsulation of the 
kidney as an operation for the cure of chronic Bright's disease. 

Physical Examination. — Very few practitioners can feel a movable kidney 
unless the mobility is quite marked, as they have not sufficient practice in renal 
palpation. This should not, however, be considered a reflection on their diag- 
nostic ability, as I have seen the best surgeons and internists fail to detect this 
condition when kidneys were movable in a marked degree. Again, I myself have 
sometimes had the greatest difficulty in locating movable kidneys, the movement 
of which the patient could sometimes feel in her abdomen. Such difficulties 
occurred principally in patients with a large abdomen, either from distention 
or from thick walls. This leads me to state that the principal difficulties in 
detecting a movable kidney are, a thick abdominal wall, too firm pressure on the 
part of the examiner, and an unfavorable position on the part of the patient. 

To show the ease with which one can detect a movable kidney at times, I will 
relate the history of a patient whose husband said she was suffering from indi- 
gestion and hives, and that she at that time had an attack of hives on her abdo- 
men which annoyed her considerably and for which condition he asked me to 
prescribe. At the time of the visit, she was examined standing, with her skirts 
lowered and her upper garments raised in such a way as to expose her abdo- 
men, which was the principal seat of the eruption. I at once saw a typical 
band of herpes zoster on her right side and, moving my finger lightly across it 
to see if the characteristic vesicular feel was present, I detected a kidney beneath 
my finger tips which was displaced by the gentle pressure used and which came 
back against them again when the pressure was removed. Since then I have 
seen several movable kidneys which have been as easily demonstrated, and none 
of which I would have been able to detect if I had resorted to the strong pressure 
that I was formerly in the habit of using. 



DIAGNOSIS 413 

A change of position is also a most important procedure. Most patients are 
examined lying flat on their backs with the result that, unless the kidney is held 
down by adhesions, it will go back into its fossa ; and as this fossa, in the right 
loin, has in front and on its side the liver and ribs, it is extremely difficult to 
palpate the organ. It is, therefore, advisable to examine the patient on a table, 
the back and shoulder part of which can be raised so as to allow the kidney to 
fall from its lodgment, if it has sufficient mobility; then, having made firm 
pressure below the lower ribs behind and in front on that side, to prevent the 
kidney from slipping up, the patient should be lowered into the dorsal position 
again while keeping her abdominal muscles lax, so as to allow the examiner to 
maintain his grasp on the deeper tissues below the free border of the ribs. 

If a movable kidney has been prevented from returning to its seat in this 
way, it is held down by one hand while it is being palpated by the other. If 
the pressure of the upper hand is lessened and the pressure of the other hand 
on the lower border of the kidney is increased, it will be felt to glide up under 
the fingers of the upper hand into its fossa. A kidney can often be felt with 
the patient sitting or leaning on the edge of a table, bed or chair, without the 
individual being lowered into the recumbent position. (See Fig. 234.) 

Frequently, it is necessary, in order to palpate the kidney, to place the pa- 
tient upon the healthy side, in a reclining posture, with the shoulders somewhat 
elevated and the knees slightly flexed. In this case, it will also tend to fall out 
of its fossa toward the healthy side of the abdomen. Sometimes, if the patient 
stands with the buttocks resting against a table, so as to relax the abdomen, this 
position is favorable to the detection of movable kidney by palpation. 

An important point in palpating a kidney is to have the patient take a long 
breath, and for the examiner to try to grasp the kidney at the height of inspira- 
tion. The surface of the organ is usually smooth, though sometimes lobular, 
and pressure upon it occasionally produces nausea, besides which it is frequently 
tender to the touch. 

Percussion has been of little value to me and so has inspection, although I 
have seen cases where the contour of the abdomen was changed through enlarge- 
ment of the kidney, or when, together with a loop of distended colon, it exerted 
sufficient pressure on one side of the anterior wall of a relaxed abdomen to make 
it more prominent than on the opposite side. 

Diagnosis. — Movable kidney is at times difficult to diagnosticate. A cal- 
culous kidney may give rise to attacks of renal colic closely resembling the pains 
of movable kidney and it may also be enlarged and have a certain limited ex- 
cursion. A calculous kidney, however, is never as movable and is usually 
harder. X-ray examination may show the presence of a stone. 

Cases of hydronephrosis, due to other causes, have not the mobility of a 
movable kidnev. Tumor of the kidnev, w^hile it may resemble a case of movable 
kidney with hydronephrosis, is associated \vith induration. I recently had a 



414 MOVABLE KIDNEY 

case of renal cancer, in which the mass was freely movable ; in f ^ct, the pedicle 
was so adherent to the peritoneum that I considered it a mesonephron. It is a 
question in my mind whether, in this particular case, the weight of a slow-grow- 
ing tumor produced this mobility, or whether it was originally a movable or 
floating organ which was the predisposing cause of the growth. I know from 
experience that calculi form in the pelvis of a movable kidney, for I have had 
such cases and I have had others in which tuberculosis developed. I can under- 
stand also, how a malignant growth might develop in a kidney of lessened re- 
sistance. It is exceedingly difficult, however, to understand the development of 
a cancer in a movable kidney, although this particular case that I have just 
mentioned, and which was diagnosticated as such, was movable from the renal 
fossa, to below and beyond the umbilicus (Fig. 204). 

Other tumors of the abdomen do not resemble movable kidney to any degree. . 
I have never seen a gall-bladder that could be mistaken for it; neither have 
I seen a spleen which I have mistaken for such a condition. In three patients 
with displaced and movable liver, recently on my surgical service, all my col- 
leagues in the hospital considered them to be movable or displaced kidneys. 1 
demonstrated to them, however, that such was not the case and that although 
movable kidneys did exist, which I anchored, the livers still remained in the 
positions in which they were at the time of the examination. 

Regarding the tumors and cysts of the ovary and uterine tumors, I will say 
that I have never seen an ovarian tumor or cvst that I could mistake for a mov- 
able kidney. In fact, in tumors of the pelvis, the direction of their extension 
is so different — upward instead of downward — and the bimanual pal])ation 
differs so greatly, that I have never found any difficulty; although I realize 
that it must be confusing in some cases, as one of the first nephrectomies that 
was performed was one in which a kidney was removed from the pelvis by mis- 
take, the operator considering it an ovarian cyst. Tumors of the uterus that are 
movable have their mobility in the pelvis, or in the lower abdomen rather than 
the upper. Besides this, their consistency is greater, they cannot be pushed up 
into the renal fossa and bimanual palpation would show them to be wholly or in 
part in the pelvis. 

In case the symptoms point to renal calculus or movable kidney. X-ray pic- 
tures should always be taken, as it is occasionally found that a renal calculus is 
present in a movable kidney. It may also be mistaken for renal tuberculosis, in 
which case a search for the bacilli should be made in the urine and guinea-pig 
inoculation resorted to. The course of the two affections is, however, very dif- 
ferent and signs of constitutional disturbance, loss of weight and strength, a 
septic temperature and the urine findings will determine the presence of the 
more rapidly destructive disease. 

Complications. — The complications are, renal strangulation, already men- 
tioned, hydronephrosis and pelvic or reno-pelvic infection. 



TREATMENT 415 

Prognosis. — Movable kidney has very little influence on longevity, except in 
cases of a complication in which the function of the organ is interfered with 
or the patient's general condition is impaired. The severe type of symptoms 
already mentioned is usually relieved by fixation of the organ. 

Treatment. — Preventive and Palliative. — Under preventive treatment 
must be considered the various predisposing causes that tend to bring about 
movable kidney or increase its mobility. These are tightly laced or badly shaped 
corsets, high heels, or any clothes held up by tight belts or bands in men or 
women who do heavy work by lifting and bending. Certain exercises should be 
avoided, such as horseback riding or other forms of exercise which tend to pull 
or bring a strain on the kidney. Valuable procedures are : A well-fitted, straight- 
front corset or a corset waist with shoulder straps for women; suspenders for 
men; exercise which develops slowly the abdominal muscles and those of the 
loin, in this way tending to increase intra-abdominal pressure and regulate the 
movements of the bowels. Pregnant women should wear well-fitted abdominal 
belts or supports during the last month, especially if they have a flabby abdo- 
men, and should also wear a similar support after childbirth when they are up 
and about again. They should be careful, however, not to leave the bed too early. 

Palliative treatment includes rest in bed, a liberal diet, massage, electricity, 
abdominal supports and the remedies which relieve pain during acute attacks. 
Rest in bed is indicated for women with nervous, neuralgic and mildly painful 
symptoms. The Weir-Mitchell cure is valuable in these cases, as it helps to 
restore the nervous balance. Dr. Weir-Mitchell recommends a liberal diet, by 
which is meant a simple but nourishing one, such as eggs, roast meats — mutton, 
lamb, beef and chicken — fish, green vegetables, rice, cereals and cooked fruits. 
Eggs should be boiled or poached ; the fish, meats and poultry boiled, broiled or 
roasted and the vegetables boiled. Sweets should be restricted and fried foods 
altogether forbidden. In addition milk, malt extract and other adjuncts of a 
milk diet can be used. A small quan- 
tity of coffee in the morning, and 
milk and black coffee after dinner, 
are allowed. 

Massage is a valuable means of 
strengthening the abdominal walls 
and loins, and should be employed 

for from twenty to forty minutes Fi«- 274.— Pomeroy's Elastic Abdominal Sup- 

. PORT FOR Patients with Movable Kidney. 

daily. In this procedure, the aim 

should be not to reach the kidney, but simply to strengthen the abdomen. It 
should never be given sooner than one hour after meals. Electricity, wnth the 
faradic or high-frequency current, is also of value. 

Abdominal supports are appliances which tend to press the abdominal wall 
and its contents upward from the pubes (Fig. 274). They are made of elastic 




416 



MOVABLE KroNET 



WfjbbiDg, similar to elastic st<iekings, and are laced in the hack. Many patients 
require perineal bauds passing between the thigbs to hold tbcm in place. 
Straight-front corsets (Van Orden), if carefnlly constnicte<I, are valuable as 




Flo. 275. — SmAJOHT-moNT Fia. 276. — How thb Cossbt Shodui bb Put on in MoVj(3le Kidmst. 
CoBSBT FOB Movable (Gallant's method.) 

KiDNBT. (Van Orden.) 




Fio. 277A. — Wide STnipa of Adresivb Piabtbb for Suppoktino the ABi>o>fBN. 



TREATMENT 



417 





a simple and practical abdominal support (Fig. 275). Gallant makes a special 
point of the manner of putting on a straight-front corset in women. This should 
be done while she is lying on the back with the pelvis elevated; the corset is 
hooked first at the lowest part over the pubes, after which the remaining hooks 
are adjusted from below upward (Fig. 276). Straight-front corsets have the 
advantage at present of being fashionable, as well as improving the figures of 
women. It is well to wear a thin cloth band under these elastic supports. Wide 
strips of adhesive plaster can also be applied for abdominal support (Fig. 277, 
A, B). Abdominal exercises are, 
however, of the greatest importance, 
as, by developing the muscles of the 
abdomen, they act as a straight-front 
corset. (See chapter on Exercise in 
Urology. ) 

In painful conditions, accom- 
panying strangulation of the kidney 
in Dietl's crises, the patient should 
be treated as in renal colic, by anal- 
gesic remedies, such as morphin, 
bromids, aspirin, antipyrin, or hot 
applications, besides any other meas- 
ures that seem to be indicated. If 
none of the palliative remedies give 
relief and if the patient's general 
condition suffers, or if a complica- 
tion such as painful colic or Dietl's 
crises takes place with increased frequency, a fixation of the kidney should be 
recommended, on the ground that it is better to undergo the trials of an opera- 
tion than to continue to put up with the continued inconvenience and poor 
health connected with a bad movable kidney. 

If hydronephrosis is present, fixation of the kidney should be urged as a 
necessary procedure; whereas, in those cases in which movable kidney is com- 
plicated by a malignant tumor, tuberculosis, or advanced pyonephrosis, nephrec- 
tomy should be perfonned. If a calculus is present, a nephrotomy for its re- 
moval and subsequent fixation of the organ is indicated. 

Nephrectomy for the cure of an uncomplicated movable kidney should never 
be performed. In forty-two such operations reported by Wagner, eleven died, 
making a mortality of nearly twenty-five per cent. 



Fio. 277B. — The Adhesive Plaster Strips 

Applied. 



CHAPTER XXIII 

NONSUPPURATIVE NEPHRITIS 

(Brighfs Disease of the Kidneys) 

The term Bright's disease has given rise to so much confusion that, were it 
not for its long usage, it would be advisable to drop the name. 

Very little was known concerning the diseases of the kidneys until 1827, 
when Bright published the histories of some cases of dropsy with albuminuria, 
together with the autopsy records showing the presence of various kidney lesions. 
From the study of these cases, he concluded that disease of the kidney was asso- 
ciated with dropsy and albuminuria, and the name Bright's disease was given 
to kidney diseases with these symptoms. 

Wilkes, in 1853, described definitely two forms of Bright's disease as nephri- 
tis — the interstitial and parenchymatous — although he admitted that a mixture 
of the two, forming a third type — the diffuse — might also occur. 

Virchow, in 1871, described three forms of Bright's disease: That aris- 
ing from the vessels (the amyloid form), that originating from the epi- 
thelia (the parenchymatous form) and that developing from the interstitial 
tissue ; but he also emphasized that the three forms do not always occur singly, 
but two, or even all three types, are seen frequently in the same kidney. 

In 1879, Weigert published studies which are practically the foundation 
of the modern view of Bright's disease. He claimed that there was no such 
thing as a parenchymatous nephritis without interstitial changes, nor was there 
an interstitial nephritis without epithelial changes. He showed that the many 
varieties of kidney, small and large, white, red and mottled, which were found 
at autopsies and which were made the basis of diiferent classifications, in reality 
depend upon quantitative differences in the amount of congestion, of edema, of 
fatty degeneration and of interstitial changes. 

Brault taught that the best division was, first, acute and chronic nephritis; 
acute nephritis, to be subdivided into transient acute, hyperacute and subacute; 
and chronic nephritis, to be subdivided into nephritis with dropsy and nephritis 
with uremia. 

Since the time of Weigert, the classifications of nephritis, etiologically, 
pathologically and symptomatically, have included hundreds of names, so that 

418 



ACUTE NEPHKITIS 419 

we are pleased to see in the latest book on the subject, by Chauffard, that the 
old terms " acute nephritis " and " chronic parenchymatous, interstitial and 
diffuse " are still considered. This will, therefore, be the classification fol- 
lowed in this chapter. The terms dropsical and uremic nephritis will, however, 
be associated with the names parenchymatous and interstitial. 

ACUTE NEPHRITIS 

Etiology. — Acute nephritis is usually caused by the germs giving rise to in- 
fective disease or to their toxic products. The most important of these diseases, 
are scarlatina, diphtheria, pneumonia, measles, acute articular rheumatism, 
influenza, typhoid^ malaria, smallpox, cholera, yellow fever; while septicemia, 
erysipelas and chicken-pox may also be mentioned as causes. The germs of 
pneumonia and typhoid have been foimd both in the kidney and in the urine. 
In diphtheria, the presence of the toxin has been fairly well demonstrated. 

Pregnancy sometimes gives rise to an acute nephritis of toxic origin, as a 
result of the production of placental toxins passing into the system of the 
mother, that are not properly eliminated. 

Exposure to cold is a frequent and most important cause of acute nephritis 
which is but imperfectly understood. According to Chauffard, cold tends to 
increase the number of germs circulating in tlie blood and to promote the 
passage of germs from the intestines into the circulation. The nephritis due 
to cold, may, therefore, after all be of infectious origin. 

Poisons taken internally may cause acute nephritis, such as turpentine, can- 
tharides, chloroform, ether, mercury, sulphuric and oxalic acids, and the in- 
ternal or external use of carbolic acid, iodoform and tar. Alcohol, and spices 
which irritate the kidneys, may also give rise to acute nephritis, if given in 
large doses. Potassium chlorate, in overdoses, gives rise to hemoglobinuria and 
acute nephritis. Extensive burns and chronic skin diseases which destroy the 
function of large areas of skin are also among the causes. 

Pathology. — The kidneys in acute nephritis are usually large, heavy, with 
tense capsules which are easily peeled off. Their surface is either dark red or 
mottled grayish-red in color, occasionally pale and gray. An incision through 
the convexity into the pelvis shows that their tissues are rather soft and friable, 
their cortex swollen, cloudy, gray and yellow and their medullary portion dark 
and congested. 

Microscopically, there are changes, either in the parenchyma alone, or in the 
interstitial tissue also. 

The epithelia of the convoluted tubules are either in a state of cloudy swell- 
ing or of granular and fatty degeneration. At times, they are almost completely 
destroyed and fill the lumen of the canal. Hyaline, granular, fatty and blood 
casts are found in the tubules. The glomeruli do not show many changes in 



420 NONSUPPURATIVE NEPHRITIS 

the milder cases, save an exudation of albumin within their capsules; in the 
severe cases, their capillaries are filled with blood, sometimes with thrombi 
and their epithelia are degenerated or proliferated. 

If the interstitial renal tissue is also involved, it is the seat of a swelling or 
edema between the fibers. The vessels are. engorged and their walls are in a 
state of acute inflammation. Hemorrhages in various parts of the kidney, for 
example, in the glomeruli, the tubules or the connective tissue, may also be 
found. In severe forms, a small cellular infiltration is frequently seen in the 
connective tissue about the capsules of the glomeruli and between the tubules. 

The inflammation may terminate in complete resolution, or the condition 
may be followed by a chronic nephritis. 

Symptoms. — Acute nephritis may be subdivided clinically into (a) acute 
transient, (fe) hyperacute and (c) subacute or prolonged nephritis. 

(a) The acute-transient form includes a group of nephrites occurring 
during the course of an infectious disease, such as typhoid. There is no edema, 
nor uremic symptoms ; the amount of urine is increased, albumin is considerable 
and blood slight. The sediment contains hyaline and granular casts and a few 
red and white blood cells. 

(b) Hyperacute Nephritis. — This is the result of violent poisoning with, 
bichlorid of mercury, phosphorus, cantharides and other drugs causing great 
renal irritation, or it may develop in the course of acute infectious diseases, as 
scarlet fever or diphtheria. The chief characteristic of this type is the rapidly 
increasing anuria, which is one of the earliest symptoms. It may occur within 
a few hours after taking one of the poisons mentioned and frequently terminates 
suddenly in death. There are no major symptoms, such as edema or uremia. 
Recovery from this form of toxic nephritis is rare and occurs principally in 
cases following an infectious disease. 

(c) The subacute or protracted is the most common clinical type of acute 
nephritis, and its course will be principally considered. It is usually the 
result of acute infection or intoxication, although it may be due to cold. The 
nephritis due to cold and that due to scarlet fever and diphtheria are, perhaps, 
the most typical representatives of this group. 

In both instances, the urine is dark in color, or even reddish, the specific 
gravity is high, the reaction markedly acid. The urea and the chlorids are 
lessened. There is always a considerable amount of albumin, two or three grams 
per liter. Under the microscope, the sediment shows finely and coarsely granu- 
lar epithelial and blood casts, red blood cells, leucocytes and renal epithelia, 
some of which are in a state of fatty degeneration. 

Their general course in the later stages, especially in severe cases, is about 
the same, although their onset may be different. 

In nephritis due to cold, which is also called nephritis a frigore, the onset is 
usually accompanied by violent pains in the back and loins, a sudden rise of 



ACUTE NEPHRITIS 421 

temperature to 101° F. or more, and a pulse of about 100 ; vomiting often occurs 
at the onset. 

An examination of the patient at this time usually shows tenderness on 
pressure over the kidneys, and the organs may be felt to be enlarged. Edema 
then shows itself, usually as a white puffiness of the face, especially about the 
eyelids and over the sternum and later about the ankles. The acute process may 
not extend beyond this stage. In severe cases, the edema increases in the lower 
extremities, and the pleura, the pericardial and peritoneal cavities may become 
involved. Subcrepitant rales may also be heard on auscultation, showing that 
an edema of the lungs is impending. These involvements will give rise to more 
or less dyspnea. In bad cases, symptoms of uremia may now begin, in which 
case there will be a diminished amount of urine, headache, disturbance of sight 
and hearing, and perhaps vomiting and diarrhea may develop. If the uremic 
condition increases, the tongue will become dry and coated, and delirium or 
convulsions may set in, followed by coma and death. The symptoms that I have 
described may all be present in a given case, or only a few of them ; they may 
occur somewhat in the order that I have described or very differently. The 
nephritis may stop at any point in this list of symptoms and the patient re- 
cover. The symptoms of an accumulation of fluid in the serous cavities and an 
edema of the lungs are very serious, while edema of the glottis in itself is 
very dangerous. Albuminuric retinitis forebodes a fatal outcome; convul- 
sions are very alarming ; and a dry tongue, delirium and coma point to a fatal 
issue. 

Scarlatinous nephritis, representing the type of acute nephritis complicat- 
ing scarlet fever, diphtheria and other infectious diseases, occurs during the 
period of defervescence. The symptoms of the onset may be the same as those 
just enumerated in connection with nephritis a frigore. Usually, however, albu- 
minuria is the only symptom noted. On the other hand, the first symptoms may 
be severe, as edema may set in and rapidly become a general anasarca ; whereas, 
other cases may be characterized by uremic symptoms. The later symptoms 
will be similar to those mentioned under Nephritis Due to Cold. It is, on the 
whole, the graver of the forms of protracted acute nephritis. 

In either of the varieties under consideration, an increased flow of urine 
and an increased activity of the skin, as shown by sweating, may come at any 
time during the disease, and recovery take place; or the symptoms will disap- 
pear, with the exception of some albumin and casts in the urine, in which case 
the disease usually becomes chronic. 

Generally, the attacks of subacute nephritis do not reach the stage in which 
the serous cavities become involved, or in which there are marked uremic symp- 
toms. The active stage of the attack usually lasts for three weeks, during 
which time the temperature is but slight or ranges from 99° to 101° F., with 
a pulse of from 90 to 100. If these gradually subside, the patient will prob- 



422 NONSUPPURATIVE NEPHRITIS 

ably recover by the end of six or eight weeks, or else pass into the chronic stage. 
The blood pressure in acute nephritis is from 130 to 150. 

Diagnosis. — Acute nephritis occurring in the course of an infectious dis- 
ease will not be overlooked if we make it a habit to examine the urine for albu- 
men in every case. The history of the patient will show us whether we are 
dealing with an acute nephritis or with an exacerbation of a chronic condition. 
In the latter, the urine shows in the sediment hyaline, fatty casts and fatty or 
degenerated renal epithelia. 

There is also a history of a previous acute nephritis, or an infectious disease. 
The presence of thickened arteries and of hypertrophy of the heart, as well as 
changes in the retina, are also points which show that a chronic nephritis has 
existed for some time and is now in an acute explosion. 

The diagnosis between renal hemorrhages from other causes and an acute 
nephritis with bloody urine is not difficult. In the latter, the urine is dimin- 
ished in amount and contains renal epithelia, leucocytes and hyaline, granular 
and epithelial casts. The presence of fever and edema are also signs which 
help to differentiate the condition from renal hemorrhage. In renal hemorrhage 
due to tumor, atypical cells and tumor fragments would be found in the urine. 
If due to stone, crystals would be present, and if due to tuberculosis, tubercle 
bacilli. The treatment of acute nephritis will be considered later. 

CHRONIC NEPHRITIS 

As we remarked in the introductory chapters, the terms chronic paren- 
chymatous and chronic interstitial nephritis are no longer regarded with favor 
by some modern clinicians. What was formerly known as chronic paren- 
chymatous nephritis some now style chronic nephritis with dropsy, and what 
was known as chronic interstitial nephritis, they call chronic nephritis with 
uremia. However clinicians may call these two general groups, the autopsy 
findings show that, although in all cases of chronic nephritis there is more or 
less evidence of both parenchymatous and interstitial changes, the preponder- 
ance of the disease is either in the parenchyma or the stroma. In comparing 
the autopsy findings with the clinical symptoms during life, it is usually found 
that the cases accompanied by dropsy are of the parenchymatous type and those 
accompanied by uremic symptoms are of the interstitial type. 

Chronic Parenchymatous Nephritis 
(Chronic Nephritis with Dropsy) 

Etiology and Pathogenesis. — This form of chronic nephritis frequently 
follows an acute or subacute renal parenchymatous inflammation, or it may also 
develop without discoverable reason. In the latter case, the real cause of the 
chronic nephritis is not known, but it is supposed to lie in some toxic influence 



CHRONIC NEPHRITIS 423 

which acts upon the kidney through the blood. A variety of causes contribute 
more or less distinctly to its development. Of these, we may mention frequent 
or protracted exposure to cold or dampness ; overnutrition ; undernutrition ; per- 
haps abuse of alcohol; various constitutional diseases, such as tuberculosis, 
syphilis, gout and chronic malaria ; diseases of the heart, especially ulcerative 
endocarditis; and chronic poisoning with lead or mercury. Chronic paren- 
chymatous nephritis may also be the result of a previous acute infection or in- 
toxication, which was apparently cured and reappeared afterwards in this 
chronic form. Among the predisposing causes are unfavorable hygienic sur- 
roundings, overwork and severe physical strain. 

Pathology. — Upon gross examination, the kidneys are generally enlarged 
and the capsule is adherent in places. The consistence of the kidney may vary 
greatly. The surface of the organ is pale white or mottled. An incision through 
the convexity shows the cortex to be narrower than normal, the yellow and 
white finely striated markings obscured. The medulla is not much changed. 
The medullary rays are slightly darker than normal. 

The lesions in this type of nephritis are always scattered through the kidney 
in patches or foci, and the appearance of the organ depends upon the arrange- 
ment of these foci and the amount of changes in the parenchymatous and in the 
interstitial tissues. What is known as the large white kidney, for example, is 
a parenchymatous or a diffuse nephritis mixed with amyloid kidney (Senator). 
It is characterized especially by fatty degeneration of the tubules and the 
glomeruli, and fibrous and hyaline changes in the stroma. 

The large mottled kidney is the result of lesions in patches, involving both 
the parenchyma and the stroma. The minute hemorrhages and venous conges- 
tion in the cortex give rise to the mottled appearance. 

Microscopically, it has been found that all these differences depend upon 
quantitative relations of the pathological changes in the various classes of tissues 
of the organ (Senator). The pathological changes in parenchymatous nephritis 
are found principally in the cortex, especially in the epithelia of the convo- 
luted tubules and less frequently of the straight tubules. These epithelia are in 
various stages of degeneration, from cloudy swelling to complete molecular 
necrosis, and are shed more or less freely into the lumen of the tubules, which 
contain also leucocytes, fat globules, red blood cells and hyaline, fine or coarse 
granular, epithelial, fatty and mixed casts. 

While the type is known as the parenchymatous, there are always some 
changes in the interstitial tissue (diffuse nephritis). Foremost of these is an 
edema of the stroma. In the advanced stages, there may be round-celled infiltra- 
tion or proliferation of the interstitial tissue partly clouding the parenchym- 
atous elements. 

The glomeruli are also affected, showing fatty degeneration and necrosis of 
their epithelia, and an exudate within their capsules. Their capillaries are fre- 



424 NONSUPPURATIVE NEPHRITIS 

quently compressed or blocked by the swelling of the endothelia. The arterioles 
surrounding the glomeruli are also more or less thickened. 

Symptoms. — The symptomatology of chronic parenchymatous nephritis is 
quite clearly defined. There may be a prodromal stage, characterized by a 
fever and lumbar pain, but usually the disease sets in insidiously with slight 
and transient edema, which leads to an examination of the urine and to the dis- 
covery of albumin and other evidences of nephritis. 

The edema first appears on the lower eyelids or on the face, over the sternum 
or at the ankles. Later, it extends to the legs, the scrotum, the abdomen, the loins 
and the rest of the body, after which the edema changes its place according to 
the patient's position. It is greatest in the legs when he stands and greatest 
in the loins and buttocks when he lies in bed for any length of time. Gradually, 
effusions may appear also in the pleura, the peritoneum and the pericardium. 

The extensive edema of chronic Bright's disease is considered by some as 
a means of defense, that is, that the toxins which are not eliminated are stored 
up in the edematous fluid and are thus kept out of the circulation. This theory 
is proved by finding toxic constituents in serous effusions and in edematous 
fluids in chronic nephritis. 

The urine in this form of chronic nephritis is always scanty, clear, of high 
specific gravity and straw or yellow color. The toxins of the urine are composed 
of 85 per cent of inorganic products, the principal of which is chlorid of potash, 
and 15 per cent of unknown organic, substances. There is usually a considerable 
amount of albumin — over 2 grams per liter (^ to § of 1 per cent by weight). 
The ordinary urinary salts may be normal or increased, save the chlorids, which 
are diminished. Their retention in the system when the kidneys are affected 
with chronic nephritis, especially in the parenchymatous form, has been thor- 
oughly demonstrated. 

Renal epithelia, numerous fine and coarse granular, epithelial and fatty 
casts, leucocytes and a few red cells are found in the sediment of the urine. 

C ardio'Vascular symptoms are not pronoimced in this form of nephritis. 
There may be at the start slight weakness of the heart beats ; the arterial tension 
may be at first slightly lowered. If the nephritis turns toward the chronic 
atrophy or interstitial form, we note a rise of blood pressure and a marked hyper- 
trophy of the left ventricle. 

Course. — The course of the disease in this type of nephritis may be either 
rapid or slow. If it is rapid, there is a steady increase in the edema and a 
decrease in the amount of urine secreted. The heart becomes seriously affected, 
the pulse feeble and rapid. Gradually, the other internal organs are involved. 
The appetite fails, the tongue becomes coated, the breath fetid. There are 
often attacks of diarrhea and vomiting. These symptoms, according to some 
writers, are due to the invasion of the gastric walls by edema. The serous 
cavities are next attacked and the edema spreads, giving rise to a hydrothorax. 



CHRONIC NEPHRITIS 425 

When hydrocardium develops, we find a diffused apex beat, dyspnea and a tend- 
ency to syncope. The blood pressure is variable. 

These patients with their tense, swollen skin, which is white and dry, 
present a characteristic appearance. In fatal cases, if death is not due to an 
intercurrent infection, as, for instance, a broncho-pneumonia, it is the result of 
gradual exhaustion and finally edema of the lungs or uremia after a hopeless 
period of disability. 

When the course of the disease is slow in evolution, the edemas are much 
more gradual in their development. The patients are often pale, puffy, with 
a peculiar luster of the eyes (edema of the conjunctiva) and at times complain 
of headaches and other minor uremic signs. 

Diagnosis. — The diagnosis of chronic parenchymatous nephritis is generally 
not diflScult, as edema, pallor and abundant albuminuria are usually well 
marked. It is distinguished from acute nephritis (or from an acute exacerba- 
tion of a chronic nephritis) by the history of the case and by the absence of 
acute symptoms, such as fever and blood and blood casts in the urine. It is at 
times not easily distinguished from amyloid kidney, as amyloid changes may 
exist with such a nephritis. The diagnosis of an amyloid kidney can only be 
made when there is an amyloid enlargement of other organs and when there 
is a history of some cause for an amyloid kidney. In amyloid kidney the 
quantity of urine is large and the color pale, although there may be large 
amounts of albumin. We should, therefore, suspect an amyloid degeneration 
whenever the amount of albumin in a chronic case tends to exceed ten or twelve 
grams in twenty-four hours. In amyloid kidneys, the urine does not contain 
granular casts, save in the very advanced cases. 

Diffuse Nephritis 

This represents the case of chronic parenchymatous nephritis with cardiac 
and vascular changes, which start as a typically parenchymatous type but go on 
slowly toward the atrophic or interstitial form. The urine in these cases is 
more abundant than in the pure parenchymatous, lighter in color, with a lower 
specific gravity and contains a smaller amount of albumin. 

As the disease progresses, and as the heart hypertrophies and the arterial 
tension increases, the edemas grow less marked, but what appears like an im- 
provement is in reality a transition to the interstitial form. 

Chronic Interstitial Nephritis 

Etiology. — The development of this disease must be referred to the long- 
continued action of slight toxic factors, usually of a systemic origin. Concern- 
ing the relation of arteriosclerosis to this form of nephritis, arteriosclerosis may 
be the cause of chronic interstitial nephritis, or, on the other hand, it may be 



426 NONSUPPURATIVE NEPHRITIS 

the result of it, but it is probable that more often both arteriosclerosis and 
chronic interstitial nephritis are the result of the same causes, such as chronic 
poisoning with lead, alcohol, gout or syphilis. Diabetes mellitus may also be 
mentioned as the cause of this form of nephritis. Senator called attention to 
the frequency with which arteriosclerosis and the accompanying interstitial 
nephritis is met with in diabetic patients of advanced age. 

From what has been said concerning the causes of this condition, it will be 
understood that chronic interstitial nephritis is rare in childhood and youth, 
and frequent toward the end of life. The frequency increases with the age 
of the patient, being greatest between fifty and sixty. Men are more frequently 
affected than women, because they are more often exposed to the causes 
above mentioned. Occasionally, there is an hereditary or family predis- 
position toward this disease. The condition has also been found present at 
birth. 

Pathology. — The essential pathological change in this form of nephritis is 
a slow hypertrophy of the interstitial tissue, stroma of the kidney, with a grad- 
ual disappearance of the parenchyma. The appearance of the kidney varies 
with the duration of the disease. In the early stages, the kidneys are normal in 
size or slightly enlarged and mottled. In the advanced fetage, they may have 
shrunken to half their size or even less, one kidney being usually more markedly 
affected than the other. The capsule is generally adherent in places and con- 
tains newly formed vessels. The surface of the kidney is covered with minute 
red or grayish elevations, showing sometimes small cysts among them. On 
section, the kidneys are hard and tough, their cortex shnmken, sometimes ap- 
pearing as a narrow border around the medulla. The medullary rays are also 
shortened, closely packed and darker in color than normal. The visible arteries 
show thickened, gaping walls, and at times there are infarcts of uric acid or of 
calcium salts in the renal tissue. • 

On microscopical examination, the changes are found chiefly in the cortex 
and usually are scattered in patches. The interstitial tissue is greatly increased, 
with here and there some round cell infiltrations. The tuUiles are compressed 
or in places obliterated, their epithelia are in a state of atrophy or fatty de- 
generation or lying loosely detached in their lumen. 

The glomeruli are the seat of a cellular proliferation around their* capsules, 
which compress them and render them incapable of functionating. Their loops 
show increased layers of cells, or else a degeneration of ceUs, swelling of. the 
epithelia and fatty degeneration of the same. The cavities of the glojneruK mliy 
be the seat of an exudate as in the parenchymatous form. Charactew^ic arterio- 
sclerotic changes are found in the arteries of these kidneys. *• * 

Symptoms. — This form of nephritis has always a very slo^v an^d'. insidious 
onset, and the lesions usually exist for years before the condition* is recbgpized. 
The disease may be divided into three stages : 



CHRONIC NEPHRITIS 427 

(1) The stage of compensation, 

(2) The cardiac stage, 

(3) The uremic stage. 

(1) Stage of Compensation. — In the first stage of the disease, there is a 
compensation for the gradually increasing involvement of the kidney. The sys- 
tem in some way accommodates itself to the altered conditions. During this 
stage, there are two classes of minor symptoms that may occur : 

(a) Those due to arterial hypertension and those due to uremic intoxication. 

The symptoms due to arterial hypertension are: Swollen and twisted tem- 
poral arteries ; occasional attacks of anesthesia in the fingers ; slight attacks of 
epistaxis ; noises in the ears and impaired hearing ; occasional vertigo. 

Those due to uremic intoxication are: Headaches, which are not relieved 
by drugs but disappear with rest and diet ; paresthesia, sensation of cold, heat, 
formication ; cramps in the ankles awakening the patient at night. 

(6) The urine in this stage of the disease is increased in quantity, and the 
patient urinates frequently. The urine is pale, clear, usually below 1.010 in 
specific gravity; the total solids are diminished. There is either no albumin 
or merely a trace. 

(2) The Cardiac Stage. — During the cardiac stage, which follows that of 
compensation, the system begins to feel the effect of the diseased kidney. The 
cardiac symptoms of this stage consist in palpitation, attacks of angina pec- 
toris, an increase of arterial tension, hypertrophy of the heart and a bruit de 
galop (galloping sound) which is a marked uremic symptom. 

Complications may set in during this stage, some of which may prove fatal 
before it has fully developed, such as hemorrhages and infections. The hemor- 
rhages may be of great severity, as attacks of epistaxis; retinal hemorrhages 
that may be followed by more or less permanent blindness ; and hematurias re- 
sembling those of renal tuberculosis, stone or tumor, during which there may 
be alarming losses of blood. Hemorrhages into the skin and the mucous mem- 
branes also occur, although rarely, during this stage. Some of the infections 
which may complicate this stage are erysipelas, pneumonia, anthrax and abscess 
formation.* 

(3) The Uremic Stage. — ^During the uremic stage, in addition to some of 
•the sj^mptoms that have already been enumerated under the minor symptoms 
• of compensation are nausea, vomiting, diarrhea and, in the more dangerous 

cases,* convulsions, dry tongue, delirium, stupor, coma. 

Diagnosis. — The diagnosis of chronic interstitial nephritis is usually not 
difiicult when the disease assumes its characteristic clinical type. We should 
. pay special attention to the presence of cardiac hypertrophy, as shown on per- 
cussion by the increased area of cardiac dullness, by a more diffuse pulsation 
and by the apex beat being found in the sixth intercostal space, one to three 
inches to the left of the nipple ; to increased arterial tension, which, instead of 



428 NONSUPPURATIVE NEPHRITIS 

being 130 to 140, would be found to be 140 to 180 or higher; to arterial sclero- 
sis, which would show as thick distended tortuous vessels or, later on, as fibrous 
cords that roll under the fingers; and to a large quantity of urine with a low 
specific gravity and the presence of albumin and hyaline casts. 

There are some cases, however, in which the diagnosis is more difficult, be- 
cause the condition is marked by a predominance of uremic symptoms resem- 
bling chronic bronchitis, gastro-intestinal affections and cancer of the stomach, 
owing to the cachexia present. In still others, the marked delirium has been 
looked upon as a sign of progressive general paralysis. 

Prognosis. — The prognosis of this form of nephritis is always grave. The 
disease is incurable, but the patients may live for years and die from some 
other disease. The only consolation is that the course is usually very slow. 
The prognosis is worse when the symptoms of chronic uremia or heart failure 
are present 

TREATMENT OF NEPHRITIS 

Treatment of Acute Nephritis. — The first steps to be taken are to have 
the patient kept in bed, as rest is most important both for the heart and the 
kidneys, after which an attempt should be made to eliminate the toxins by 
giving a saline purge, such as sulphate of magnesia an ounce, or compound 
jalap powder half a drachm; some physicians prefer calomel five grains. A 
diet which will necessitate as little work on the part of the kidney as possible 
should then be given, such as milk, three pints a day, or milk with one third 
part of Vichy. Wet cups should be applied over the kidneys. After these first 
steps, the patient should be kept on a milk diet ; the bowels should be kept open 
by mild saline laxatives, such as citrate of magnesia, Apenta or Carabana 
water ; and hot-water bags should be kept over the kidneys. The patient should 
be allowed to go on without further treatment, unless severe symptoms set in, 
and may have an uneventful recovery. 

In more severe cases, certain symptoms that call for a vigorous treatment 
occur, such as marked edema with perhaps an involvement of the serous cavi- 
ties, or those of uremia. A hydragogue cathartic should then be gi^en. Ela- 
terium is the most efficient of all hydragogue cathartics and of value in uremia, 
but it must be kept in mind that its action is very exhausting. It is best given 
in combination with the extract of belladonna one quarter of a grain each. 

If this is not sufficient to eliminate the toxins, a hot-air bath or pack should 
be given later. When this fails after waiting for a sufficient interval, pilocarpin 
should be given. This is most useful in the treatment of renal dropsy and gen- 
erally exerts a marked diaphoretic action when given internally in doses of 
from one twelfth to one sixth of a grain. 

If the purge, hot-air bath and pilocarpin, together wdth the saline diuretic, 
are not sufficient to benefit the patient, then venesection should be resorted to. 



TREATMENT OF NEPHRITIS 429 

followed by an intravenous injection of normal salt solution. In this case, 400 
to 500 C.C. of blood should be withdrawn, and the same amount of salt solution 
should be injected. 

When the flow of the urine is scanty, it should be stimulated by giving as a 
diuretic citrate of potash, ten to fifteen grains every three hours, by which the 
severe edema and uremia just mentioned can often be prevented. 

After the dangerous symptoms subside by this means, the patient should 
continue with the milk diet and with saline laxatives if constipation is pres- 
ent. The saline diuretics should be given again, as soon as the urine begins 
to become scanty. If dangerous symptoms again set in, the same vigorous 
measures should be taken to combat them by means of hydragogue cathartics, 
hot packs, pilocarpin or intravenous saline injections. 

Under such treatment, most patients recover ill from six to eight weeks; 
others become chronic ; still others die, especially those developing anasarca and 
uremia. As the patient's acute symptoms disappear and the urine increases in 
quantity and elimination is better, the patient can be gradually changed to a 
more varied liquid or soft diet, as broths, cocoa, bread, crackers, rice and other 
carbohydrates, and sugar and butter can be added if the digestion permits. 
Some also allow easily digested vegetables, such as spinach, cauliflower, string 
beans and peas. In this way, a variety is furnished and the patient is able to 
maintain a partial milk diet for some time. As a beverage, the patient may 
have slightly alkaline table waters, or lemonade, or water slightly tinged with 
wine, 

Benzoate of soda and lactate of strontium have been recommended in the 
treatment of acute nephritis, but they are more suitable for chronic cases. The 
benzoate of soda acts as a urinary antiseptic and counteracts the causative in- 
testinal fermentation through increasing the flow of bile. The lactate of stron- 
tium diminishes the amount of albumin in the urine but does not increase 
the flow. 

For the pain in the loin, dry cups or hot compresses are sufficient. For the 
hematuria, ergot or tannic acid may be given in the following form (Senator) : 

Ergot grs. v (0.3 gram) ; 

Tannic acid grs. ss (0.03 gram) ; 

Powdered gum acacia grs. viiss (0.5 gram). 

To be taken every three hours. 

The constipation which these drugs produce must be counteracted by ap- 
propriate purgatives, such as Apenta or Carabafia water. 

Treatment of Ohronio Nephritis. — This includes preventive, specific, di- 
etetic, hygienic, therapeutic and symptomatic measures. 

Preventive. — The probabilities of a chronic nephritis following an acute 
attack may be very much lessened by very carefully managing its treatment dur- 



430 NONSUPPURATIVE NEPHRITIS 

ing the acute stage and the period of convalescence. This means keeping the 
patient quiet and on a bland diet during the acute stage and by not exposing 
him to bad weather, cold or draught of air while he is convalescing. The diet 
during convalescence should be very simple and moderate, free from condiments 
and with a limited amount of animal proteids ; or it may be salt free if there 
is a tendency to edema, or ^uch a condition is threatening. 

Specific Treatment. — Most cases of chronic nephritis are incurable. 
Therefore, the aim of treatment should be to maintain the general health and 
assist the renal fimctions so that the patient can continue to live without much 
inconvenience. 

Within the last decade, there have been brought forward certain special 
methods of treatment which are intended to reach the disease itself and to im- 
prove the condition more or less permanently. Organotherapy, the use of 
renal extracts, is not yet sufficiently known to be recommended. My own 
personal experience with it has been such as to lead me to prefer the older reme 
dies. The second form of treatment under this category is the surgical, and 
that of the iodids, the former of which is of very little use, except in the case 
of certain complications. 

The Iodids. — Sodium and potassium iodids, or their substitutes, have been 
used in chronic nephritis, especially by the older physicians. I frequently use 
this remedy in doses of two or three grains, three times a day, as a vaso-dilator 
in arteriosclerotic and cardiac changes. It is also supposed to modify the de- 
velopment of the lesions in the kidney and to prevent the formation of inter- 
stitial tissue. Its principal value is in cases of chronic nephritis, in patients 
with lead poisoning and syphilis, when from two to five grains, three times a 
day, should be given. 

The minor symptoms of chronic interstitial nephritis, due to arterial hyper- 
tension and appearing in the shape of headache, occasional vertigo, tinnitus and 
epistaxis, are also combated with potassium iodid, the action of which should be 
carefully watched. Alternately with the iodid treatment, glonoin (solution of ni- 
troglycerin) is recommended by Chauffard and may be given in doses of one to 
two drops. Nitroglycerin has to a large extent taken the place of amyl nitrite in 
conditions where this drug is indicated. 

Surgical Treatment. — About eight years ago, my colleague, Dr. Ede- 
bohls, noticed that many of his cases of movable kidney had in the urine before 
operation a slight amount of albumin and a few hyaline and finely granular 
casts which disappeared after partial decapsulation and fixation of the organ. 
He accordingly concluded, first, that chronic nephritis could be unilateral or 
bilateral, and second, that, if the partial decapsulation employed in nephropexy 
was sufficient to cure nephritis, through the increased blood obtained by the 
anastomosis between the partially decapsulated surface of the organ and the 
adjoining tissues, then a more extensive decapsulation would give a greater 



TREATMENT OF NEPHRITIS 431 

exposed surface for anastomosis and consequently the recovery would be more 
certain. He accordingly advocated and began to perform an operation, called 
renal decapsulation, for the cure of chronic nephritis, which consisted in en- 
tirely removing the capsula propria of the kidneys and replacing them in their 
fatty capsules. He claimed that, by this means, an anastomosis of good-sized 
vessels formed between the kidney and the fatty capsule, resulting in the cure 
of the disease. 

I performed a number of these operations, but was not satisfied with my 
results, and accordingly wrote to many of the leading surgeons of the country, 
asking them to send me a report of the results of their operations. In answer, 
I received reports of 120 cases that had recently been operated upon, 16 per cent 
of which were reported cured, 40 per cent improved, 11 per cent unimproved and 
33 per cent of deaths. The mortality had been greatest in the cases diagnosti- 
cated as diffuse nephritis, 75 per cent of which had died, whereas in the cases 
diagnosticated as parenchymatous and interstitial, there had been about 25 per 
cent mortality in each group. 

Some time after this, I again wrote to the surgeons who had contributed 
before and found that, among those of their patients who had survived the 
operation, 88.5 per cent had since died. The results were accordingly not such 
as could lead me to advocate renal decapsulation. 

There was, however, a class of cases that had been very much benefited by 
operation and this comprised cases of chronic nephritis, associated with hema- 
turia and nephralgia. These cases were cured of the attacks of hemorrhage or 
pain by a nephrotomy. 

The conclusions that J drew from the studies of my own operations and 
those of my colleagues were, first, that total decapsulation of the kidney is an 
unwarranted operation which should never be performed; but that a partial 
decapsulation of a sufficient area of the surface of the organ to assist in its fixa- 
tion is helpful in the case of a movable kidney ; second, that, in cases of a non- 
movable kidney in which there is much tension on account of a tight capsule, 
this will be removed by simply incising the capsule over the convexity; third, 
that, if there are symptoms of unilateral nephralgia or hematuria, a nephrotomy 
is satisfactory, not only as an approved operation, but also as an exploratory 
means of determining a possibly existing surgical disease. 

General Treatment. — Rest in bed is important whenever an acute exacer- 
bation occurs, associated with edemas, scanty or bloody urine, or uremic symp- 
toms, during which time the patient should be treated as a case of acute nephri- 
tis. If it is found that rest in