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ESSAYS ON 
 GENITOURINARY SUBJECTS 
 
ESSAYS 
 
 ON 
 
 GENITOURINARY 
 SUBJECTS 
 
 BY 
 
 J. BAYARD CLARK, M. D. 
 
 ASSISTANT GENITOURINARY SURGEON TO BELLEVUE HOSPITAL, CON- 
 SULTING GENITOURINARY SURGEON TO THE ELIZABETH GENERAL 
 HOSPITAL, FELLOW OP THE NEW YORK ACADEMY OF MEDI- 
 CINE, MEMBER OP THE AMERICAN UROLOGICAL ASSO- 
 CIATION, MEMBER OP THE AMERICAN ASSOCIATION 
 OF GENITOURINARY SURGEONS, ETC. 
 
 NEW YORK 
 
 WILLIAM WOOD AND COMPANY 
 
 MDCCCCXII 
 

 /.Lu^i 
 
 v vi f-i 
 
 Copyright, 1912 
 By WILLIAM WOOD AND COMPANY 
 
 Printed by 
 
 The Maple Press 
 
 York, Pa. 
 
PREFACE 
 
 Through the kindly interest which has been 
 shown in a number of these papers and the 
 many requests for reprints which have ex- 
 hausted my supply, I have been tempted to 
 bring these essays together in the form of a 
 small book. 
 
 An endeavor has been made to bring 
 each topic up-to-date by appending a short 
 description of such recent acquirements as 
 have been added to the subject dealt with. 
 
 In the first chapter the description of 
 cryoscopy has been allowed to remain 
 although the method has been practically 
 abandoned. 
 
 For the right to a new appearance of 
 Chapters II, III, IV, V, and VI, I am in- 
 debted to the Medical Record, the New 
 
PREFACE 
 
 York Medical Journal, the Medical News 
 and the Journal of the American Medical 
 Association. 
 
 In the last three chapters which are 
 newly written the writer has tried to fer- 
 tilize the subjects considered, by a some- 
 what different angle of view than is usually 
 given them. 
 
CONTENTS 
 
 I Cystoscopic Diagnosis in Vesical and 
 
 Renal Surgery 3 
 
 II Tuberculous Kidney 29 
 
 III Gonococcic Infections and the Physi- 
 
 cian's Responsibility 49 
 
 IV Some Necessary Principles in the Diag- 
 
 nosis OF Surgical Conditions of the 
 
 Upper Urinary Tract 81 
 
 V Gonorrheal Prostatitis loi 
 
 VI Comparative Value of Some Urethral 
 
 AND Other Germicides 129 
 
 VII On What is New in Genitourinary 
 
 Surgery 141 
 
 VIII Is Genitourinary Surgery Justified as a 
 
 Special Branch of Medicine ? . . . . 149 
 
 IX The By-ways of Prostatectomy . . . .159 
 
 X The Gonococcus 169 
 
CYSTOSCOPIC DIAGNOSIS IN VESICAL 
 AND RENAL SURGERY 
 
CHAPTER I 
 
 CYSTOSCOPIC DIAGNOSIS IN VESICAL AND 
 RENAL SURGERY 
 
 The degree of importance that the cystoscope, 
 with its modern improvements, has attained 
 in the diagnosis of bladder and kidney affec- 
 tions, is not yet generally appreciated. 
 
 A review of some of the more recent work 
 which has been done by the aid of the cysto- 
 scope, with a resum^ of those conditions in 
 which cystoscopy is especially indicated in its 
 relationship to surgery, will be of interest to 
 those seeing this class of cases. 
 
 It is not intended to demonstrate the virtues 
 
 of cystoscopy as a method to replace the longer 
 
 established means of diagnosing diseases of 
 
 these organs, but to show what it has added 
 
 to these means in bringing to light those con- 
 
 [3] 
 
VESICAL AND RENAL SURGERY 
 
 ditions of the urinary tract so difficult of 
 diagnosis. 
 
 The Bladder is the seat of a number of well- 
 known pathological conditions in the early 
 and accurate diagnosis of which the cystoscope 
 plays the most important r61e. 
 
 Tumors. — Of all vesical conditions there are 
 none which depend so absolutely upon the 
 cystoscope for diagnosis as neoplasms. The 
 symptoms, subjective and objective, though 
 suggestive, are never sufficient to leave upon 
 the mind an image of the real condition. It 
 is when the new growth is actually seen, and 
 its site, its size, its form, its character in detail; 
 whether one or two or more; if possible, 
 whether sessile or by a pedicle attached, are 
 noted, that we are in a position to suggest a 
 diagnosis. There are but a few conditions 
 that stand in the way of successful cystoscopy 
 in these cases; i.e., where the urethra cannot 
 be made to receive a cystoscope, w^here the 
 
 [4] 
 
VESICAL AND RENAL SURGERY 
 
 bladder is entirely filled with new growth, 
 where the transparency of the medium intro- 
 duced cannot be kept momentarily clear and 
 in advanced cases of malignant disease, which 
 cause unusual irritability or contraction of 
 the bladder. When the patient is seen early 
 enough most of these difficulties are swept 
 away. 
 
 Stones. — It is said that Guyon, of Paris, is 
 able to determine the size, the character, and 
 sometimes the number of calculi in the bladder 
 by means of the metal searcher. The oppor- 
 tunities are certainly not given to surgeons of 
 this part of the country to attain such skill, 
 nor is it necessary, for the cystoscope can be 
 used with as little risk and as little discomfort 
 to the patient as the stone searcher, and with 
 an infinitely more satisfactory result. The 
 exact position of the stone is learned, and 
 whether it be encysted or free ; the number of 
 stones, if not too many, is ascertained; and 
 
 [5] 
 
VESICAL AND RENAL SURGERY 
 
 what is more, the state of the bladder wall and 
 existing complications are noted. After lith- 
 olapaxy it is especially important to see whether 
 all the particles of stone have been gotten rid 
 of, for if a small fragment remains it will serve 
 as a nucleus for new calculus formation. 
 
 Prostatic Hypertrophy. — There are a certain 
 number of cases where the urethral distance or 
 tortuosity, where the cystitis or the easily 
 excited hemorrhage puts cystoscopy out of 
 the question. In these cases a correct esti- 
 mation of the extent and character of intra- 
 vesical enlargement or vesical complications, 
 as tumor, stone, etc., cannot be made, and, 
 therefore, we cannot expect to institute such 
 effective treatment nor give by surgical inter- 
 vention such uniform results as in the other 
 and fortunately larger class, where by the 
 cystoscope we learn the vesical aspect of the 
 prostate, the internal orifite, the has fondy 
 and the condition of the bladder, its mucous 
 
 [6] 
 
VESICAL AND RENAL SURGERY 
 
 membrane, its musculature, its ureters and 
 their doings ; and with this knowledge proceed 
 to treatment. 
 
 Foreign Bodies such as pins, pieces of 
 catheter, silk sutures, etc., are met with at 
 rare intervals in'the bladder, and are generally 
 very easily identified. 
 
 Other vesical conditions which are studied 
 by the cystoscope, such as cystitis, vesical 
 tuberculosis, ulcers, varicosities, diverticula, 
 vesicles and bulbous edema, will not be con- 
 sidered in this paper, as they do not come 
 under the head of those affections ordinarily 
 requiring surgical intervention. 
 
 The Kidneys. — Through the agency of the 
 cystoscope and ureteral catheterization it has 
 become possible to make the diagnosis in 
 cases where the most careful observation of 
 all clinical signs leaves the real condition un- 
 determined. But besides diagnosis, perhaps 
 the most important realm of usefulness lies 
 
 l7] 
 
VESICAL AND RENAL SURGERY 
 
 in the field upon which we are just entering, 
 where a true estimate of the functional activity 
 and ability of the separate kidneys is sought. 
 And here is added a new responsibility for 
 all those doing kidney work, and an obligation 
 to every patient of this class ; for to remove the 
 kidney on one side without having previously 
 attempted to determine the functionating 
 power of the other gland, which is destined to 
 perform the entire work of renal elimination 
 for the body, is surgery which should be no 
 more. 
 
 As to Diagnosis. — Before the day of the 
 cystoscope the observation of the clinical 
 picture, with its characteristic subjective 
 symptoms, and the exact examination of the 
 urine, with the objective knowledge gained 
 through palpation and percussion, were the 
 means we had at hand to solve the difficult 
 diagnostic problems of the urinary system. 
 The value of these means is not contended, 
 
 [8] 
 
VESICAL AND RENAL SURGERY 
 
 but in many cases they are insufficient. To 
 show how misleading are subjective symp- 
 toms : There may be pain in the left kidney 
 when the right is the seat of disease. That 
 pain which is characteristic of the pres- 
 ence of bladder or kidney stone may be en- 
 tirely absent. Great urgency of micturition 
 is most often due to trouble about the vesical 
 sphincter or prostatic urethra, yet pyelitis and 
 renal calculus may cause this same frequency. 
 With pain in the glans penis the trouble may 
 be either in the bladder or the kidney. Pain 
 may come in attacks, as is ordinary with 
 kidney stone; yet pyelitis or temporary 
 blocking of the ureter may give the same kind 
 of attacks. 
 
 For objective symptoms we have the urine 
 alone to reply upon, in very many instances, 
 but its change from normal, its admixture with 
 blood or pus or bacteria or whatever it may 
 be, tell us but part of the story. It does not 
 
 [9] 
 
VESICAL AND RENAL SURGERY 
 
 tell us from which kidney or ureter, or whether 
 from the bladder or urethra, the abnormal 
 elements arise. Here, then, is indication for 
 the cystoscope and urethral catheter, with 
 which positive information is gained in the 
 following manner: 
 
 It is a good rule first to employ the simple 
 cystoscope, which is smaller of caliber and 
 gives a broader field of observation. A 
 general survey of the bladder is made and 
 vesical complications, if present, are noted. 
 The attention is then centered about the 
 ureters, and indications of disease higher up 
 are here carefully looked for. The mucous 
 membrane around one or the other ureter may, 
 for example, show ulceration or small tuber- 
 cles, suggestive of descending tubercular 
 infection of the kidney and ureter of that 
 side. The ureteral lips may be thickened, 
 and the orifice patent and devoid of its 
 normal function of opening and closing as 
 
 [lo] 
 
VESICAL AND RENAL SURGERY 
 
 the little jet of urine is emitted, which gives 
 evidence of some hindrance to the passage of 
 urine below this point, and the possibility of 
 consequent upward infection. The lips of 
 the ureter may be pouting or its mucous 
 membrane more or less prolapsed, which 
 condition occurs with blocking of the ureter, 
 usually by calculus not far above its orifice. 
 Finally, we note with especial care the tiny 
 stream of urine itself, the action of the 
 ureter-mouth, the amount of urine, the 
 intervals between the issued jets or drops, 
 and the character of the secretion as it 
 appears, whether bloody or mixed with pus, 
 or thickened as by mucus. The difference 
 between the two sides is then observed. 
 If one or both sides fail to functionate such 
 fact is noted. 
 
 In this way, before attempting to collect by 
 ureteral catheterization the separate urines, 
 we have come into possession of much 
 
 [II] 
 
VESICAL AND RENAL SURGERY 
 
 valuable information, for we have ascertained 
 that the trouble comes not from urethra or 
 bladder, but from above these points. We 
 have also gained evidence as to the side of 
 the lesion and suggestions as to its nature. 
 The ureteral catheter now gives us the 
 means to determine more exactly the site of 
 the lesion, and by analysis of the urine thus 
 obtained, its nature. Without question the 
 only accurate method of obtaining the sepa- 
 rate urines without fear of admixture or 
 contamination with the urine from the 
 opposite side or from the bladder is by ureteral 
 catheterization. This procedure is applicable 
 and possible in the majority of cases. That it 
 is accomplished with but little discomfort to 
 the patient and little danger of infection 
 stands to-day proved by ample experience. 
 
 Among those conditions of the kidneys 
 brought within the scope of this means of 
 diagnosis are: Renal tuberculosis, unilateral 
 
 [12] 
 
VESICAL AND RENAL SURGERY 
 
 nephritis, pyelitis, pyonephrosis, pyeloneph- 
 ritis, hydronephrosis, atrophic kidney, single 
 kidney, and at times new growths. In 
 addition must be mentioned those instances 
 where the ureteral catheter is used as a sound 
 to detect abnormal constrictions and blocldng 
 of the ureter by stricture, stones, new growths, 
 etc. Kelly, of Baltimore, says that he has 
 demonstrated the presence of stone by bring- 
 ing a ureteral catheter tipped with impres- 
 sionable wax in contact with it. Tilden 
 Brown and others have introduced the 
 catheter incasing a fine metal stylet as far as 
 the kidney pelvis, and then by a radiograph 
 have demonstrated a dislocation of the 
 kidney or cleared up the differential diagnosis 
 between abdominal tumor and kidney. 
 
 Before speaking of the determination of 
 renal sufficiency the names of v. Koranyi, of 
 Budapest; Casper and Richter, of Berlin; 
 Kummell, of Hamburg, and Albarron, of 
 
 [13] 
 
VESICAL AND RENAL SURGERY 
 
 Paris, should be mentioned as those men who 
 by patient work and painstaking experiments 
 have done the most in perfecting those means 
 we now have at hand to estimate the functional 
 ability of the respective kidneys. No more 
 than a brief sketch of this subject will be 
 attempted, as the writer's object is simply to 
 bring the main points to the attention of 
 those whose interest will lead them further in 
 this line of thought and work. 
 
 We have seen how by ureteral catheterization 
 we can make anatomical diagnoses of kidney 
 affections; so is it possible to turn this same 
 means to account in making functional diag- 
 noses of the kidneys, which, in other words, 
 means a measure of the amount of work of 
 these organs — not of their united power how- 
 ever, but the estimate of what each indi- 
 vidual kidney can do. This is the important 
 thing from a surgical standpoint. 
 
 We are confronted in every case of surgical 
 
 [14] 
 
VESICAL AND RENAL SURGERY 
 
 kidney disease by these questions : How much 
 kidney parenchyma capable of work still 
 exists ? Is it sufficient to perform its function 
 of ridding the body of the waste products of 
 metabolism? How is this work divided and 
 to what extent does each kidney participate ? 
 The importance of gaining this knowledge in 
 every case of suspected kidney disorder of a 
 surgical nature is emphasized when one sees 
 in the literature what a number of cases have 
 been reported, where only a single kidney is 
 found, where the kidney of one side has in 
 part or entirely degenerated, or where al- 
 though the second kidney was present, it 
 was so far diseased that on removal of the 
 opposite organ it was incapable of performing 
 sufficient work to maintain life. When to the 
 cases which have been observed and reported 
 are added those which have not come to 
 autopsy, and therefore could not be reported, 
 although they undoubtedly occurred, we see 
 
 [15] 
 
VESICAL AND RENAL SURGERY 
 
 that it is possible very considerably to lessen 
 the mortality in surgical kidney disease, if 
 we are able to determine this question of 
 sufficient or insufficient renal function. 
 
 The methods to this end which have been 
 used and proved of practical value will be 
 mentioned, and those means which are not 
 to-day found useful, though worthy of our 
 respect for having paved the way for better 
 things, will be omitted. 
 
 The Determination 0} the Freezing Point 
 0} the Blood and Urine (Cryoscopy.) — This 
 method depends upon that physiological 
 power possessed by the kidneys, which so 
 regulates the osmotic pressure that it main- 
 tains in those fluids with which it has to do, 
 namely the blood and urine, a constant 
 measurable degree of molecular concentration 
 which is determined by their freezing points. 
 As the concentration of the fluid is increased, 
 
 so is its freezing point lowered below that of 
 
 [16] 
 
VESICAL AND RENAL SURGERY 
 
 distilled water. It is to be understood when 
 molecular concentration is mentioned that the 
 concentration in an osmotic sense is meant, 
 for a purely physical molecular concentration 
 can exist without influence upon the point at 
 which the fluid freezes, for example, the 
 amount of albumin in the urine of kidney 
 patients influences the specific gravity while 
 it has no bearing on the lowering of the freez- 
 ing point. A. V. Koranyi and others have 
 shown that the blood of individuals with 
 normal or sufficient kidney function freezes at 
 — 0.56 degrees C, that the urine in these 
 cases freezes at from — i.o degrees to — 2.0 
 degrees C. Where the kidney function is in- 
 sufficient, the molecular concentration of the 
 blood is increased and the freezing point is 
 lowered, and with this goes a higher freezing 
 point for the urine. 
 
 When the normal freezing point of the blood 
 
 tells us that there is enough healthy kidney 
 
 2 [17] 
 
VESICAL AND RENAL SURGERY 
 
 parenchyma to free the body of its waste prod- 
 ucts, it does not show which kidney, or 
 whether each kidney in part, is carrying on 
 the work. For this information we rely on 
 the freezing of the separate urines, along with 
 the chemical and microscopical examination, 
 the phloridzin test, etc. 
 
 Backmann's cryoscopic apparatus is the one 
 ordinarily used. It consists of a cylindrical 
 jar about 6 inches high by 4 inches or 5 inches 
 in diameter. This is filled with a freezing 
 mixture of ice and salt, in the center of which 
 is placed a tube about 1 1/2 inches in diameter. 
 In this latter is placed a somewhat smaller 
 tube so that an air space between the two 
 exists, insuring an even conduction of cold 
 to the inner tube which contains the blood or 
 urine to be tested. Fifteen to twenty cubic 
 centimeters is the amount found most con- 
 venient, and in this is placed the thermom- 
 eter with scale divided into hundredths of 
 
 [18] 
 
VESICAL AND RENAL SURGERY 
 
 degrees; alongside of the thermometer is a 
 
 mixer made of platinum wire and bent at its 
 
 lower extremity so as to encircle the lower 
 
 end of the thermometer; a cork perforated 
 
 for the thermometer and mixer closes the 
 
 tube. 
 The freezing point of distilled water is first 
 
 determined and afterward that of the urine; 
 the difference between the two is the freezing 
 point sought. This for the urine is desig- 
 nated after the plan of Koranyi by A and 
 for the blood by 8. While freezing, the speci- 
 men is constantly stirred by the mixer and 
 the column of mercury is closely watched. 
 It moves first rather slowly, but with increasing 
 velocity it sinks until it has reached a point 
 some distance below the freezing point, 
 when in consequence of the warmth set free 
 by freezing it rises to the point at which it 
 freezes and there remains for a short time, 
 during which the reading is made. 
 
 [19] 
 
VESICAL AND RENAL SURGERY 
 
 The usefulness of this method, as pointed 
 out by Casper and Richter, is that it is a test 
 of the renal activity as a whole, whereas the 
 methylene blue or other similar tests show 
 only the power of the kidney in one phase, 
 and therefore give no idea of its natural 
 functionating ability in eliminating the total 
 of the solid molecules. 
 
 As mentioned before, it is the combination 
 of ureteral catheterization and the freezing 
 point determination of the separate urines 
 which is of especial value in forming judg- 
 ment as to the power of each organ; for it 
 is the comparative values which we wish to 
 obtain. The phloridzin test is an added 
 proof of what each kidney is capable of, 
 when used in conjunction with the freezing 
 point determination. The action of this drug 
 is chiefly on the kidneys and its result a so- 
 .called phloridzin-glycosuria. Small amounts 
 
 (.005 grams), injected subcutaneously, are 
 
 [20] 
 
VESICAL AND RENAL SURGERY 
 
 best suited for the results and are in no way 
 harmful. The effect lasts but about three 
 hours, beginning fifteen to thirty minutes 
 after injection. The test is based on the 
 amount of sugar excreted, but a delay in the 
 sugar elimination is also a factor. The 
 phloridzin method is useful because expressi- 
 ble in figures and comparative results of the 
 two sides indicate the amount of functionating 
 parenchyma present. 
 
 The elimination of nitrogen or its chief 
 representative urea, when taken as a measure 
 of the work of both kidneys, is of unstable 
 value, for patients with kidney disease have 
 periods of good and bad N-elimination. 
 Even healthy individuals may have periods 
 of retained nitrogen. On the other hand, 
 an estimation of the amount of nitrogen from 
 each kidney gives, in a differential way, a 
 valuable index of the renal ability, and 
 considered with those methods already men- 
 
 [21] 
 
VESICAL AND RENAL SURGERY 
 
 tioned, forms an important link in that chain 
 of evidence we seek. 
 
 Since the appearance of this paper a new 
 phase has been added to our idea of measur- 
 ing kidney abihty. The brilhant work of 
 Geraghty and Rowntree with phenolsul- 
 phonephthalein holds the promise of a simple 
 and more accurate means, and a test of 
 far broader application than those that 
 have gone before; such as cryoscopy, elec- 
 trical conductivity of the urine, the color and 
 phloridzin tests. 
 
 For a working knowledge of the phenol- 
 sulphonephthalein test for estimating renal 
 function the reader is referred to the authors 
 of this work. I will give here only an outline 
 of this test in its technical application. 
 
 One cubic centimeter of the solution of the 
 drug containing 6 mgm. is injected subcu- 
 taneously and the time is noted. The patient 
 
 [22] 
 
VESICAL AND RENAL SURGERY 
 
 empties his bladder and a catheter is aseptic- 
 ally introduced. The urine is allowed to 
 drain into a test tube containing a drop of 25 
 per cent, sodium hydrate. On the appear- 
 ance of the drug there is a marked pink color 
 and the time is again noted. The catheter 
 can then be withdrawn, or clamped if the 
 case is one of urinary obstruction. At the 
 end of one hour the urine is collected and 
 again at the end of the second hour in a 
 second receptacle. The specimens are made 
 strongly alkaline with the 25 per cent, sodium 
 hydrate solution which brings out the purple 
 red color. They are then diluted to exactly 
 one liter with distilled water. They are then 
 compared with a standard solution containing 
 a known amount of the drug to the liter. A 
 Dubosc colorimeter is used for the color com- 
 parison or a set of test tubes filled with solu- 
 tions of known strength is employed, and 
 the reading made. 
 
 [23] 
 
VESICAL AND RENAL SURGERY 
 
 In a series of several hundred normal cases 
 the originators of this method found that the 
 drug appeared in the urine in from five to 
 eleven minutes, 38 to 60 per cent, (average 
 50 per cent.) being excreted in the first hour 
 after its appearance in the urine, and 60 to 
 85 per cent, for two hours. The elimination 
 being practically completed in the two hours. 
 In a second series of cases intra-muscular and 
 intra- venous injections were used. With the 
 intra-muscular injections the time of appear- 
 ance is about the same but the output averages 
 5 to 10 per cent, more for the first hour. 
 Following intra- venous injections the drug 
 appeared in from three to five minutes and 
 from 35 to 45 per cent, of the drug was elimin- 
 ated in the first fifteen minutes, 50 to 65 per 
 cent, in the first half hour and 6^ to 80 per 
 cent, during the first hour. The intra- 
 muscular method for general use is recom- 
 mended. With the normal cases as a stan- 
 
 [24] 
 
VESICAL AND RENAL SURGERY 
 
 dard patients with nephritis, uremia, cardiac 
 and cardio-renal lesions, patients with urinary 
 obstruction of the lower urinary tract, and 
 unilateral and bi-lateral surgical diseases of 
 the kidneys were studied. Delay in elimin- 
 ation of the drug and decreased percentages 
 of elimination during the standard periods of 
 collection, constituted the degree of failure 
 of the kidneys studied in carrying out their 
 normal function. 
 
 [25] 
 
II 
 
 TUBERCULOUS KIDNEY 
 
CHAPTER II 
 
 TUBERCULOUS KIDNEY 
 
 The following case is reported because the 
 steps toward diagnosis were interesting, as 
 illustrating the usefulness of the cystoscope, 
 the cryoscopic examination of the blood, and 
 in this instance the radiograph. 
 
 Case. — B. McM., a young Irish woman, 
 single, twenty-eight years old and employed 
 as a domestic, was very kindly sent to me for 
 diagnosis and treatment by Dr. F. Tilden 
 Brown. She was admitted to Trinity Hospi- 
 tal November 27, 1904. 
 
 Her father died of pleurisy at the age of 
 forty-one, otherwise her family history was 
 unimportant. She came to this country six 
 years ago. She had always been perfectly 
 
 [29] 
 
TUBERCULOUS KIDNEY 
 
 healthy and able to work. Three years ago 
 she commenced to suffer occasionally with a 
 rather sharp pain in the lumbar region, which 
 would last an hour or two, and which she 
 thought was more on the right side than on the 
 left. This continued for a little over a year, 
 when she first noticed that she had to pass 
 her urine more frequently than usual and that 
 it was attended with some discomfort. The 
 pains in the back at this time seemed to dis- 
 appear and the frequency of micturition in- 
 creased rapidly, until at the end of a month 
 she was compelled to urinate every fifteen or 
 twenty minutes during the day, and five or 
 six times at night. The discomfort which had 
 attended urination developed into a burning 
 pain, most intense as the last few drops of 
 urine were being voided. 
 
 She then consulted a physician, who ex- 
 amined her urine and told her she was suffer- 
 ing from catarrh of the bladder. Internal 
 . [30] 
 
TUBERCULOUS KIDNEY 
 
 remedies were prescribed, but the condition 
 was not relieved. Five months dragged along 
 in this way and she then entered a hospital, 
 where she remained for six weeks, during that 
 time she received as treatment irrigations of 
 the bladder. When she left the hospital her 
 urination was somewhat less frequent but 
 more painful. She returned to work, and for 
 a little over a year she attended to her duties, 
 in the meantime receiving by way of treat- 
 ment more bladder irrigations. At this time 
 she noticed that she occasionally passed a 
 little blood at the end of urination. She lost 
 thirty pounds in weight, from 156 to 126 
 pounds, and had become too weak to attend 
 to her work any longer. 
 Physical Examination. — The loss of weight 
 
 was evident, but she was not emaciated. 
 Somewhat anemic, cheeks flushed; heart and 
 lungs were normal; abdomen, except for the 
 following, was normal : the lower pale of right 
 
 [31] 
 
TUBERCULOUS KIDNEY 
 
 kidney could be felt, but no more than in 
 many healthy females ; it did not appear to be 
 enlarged; there was no tenderness. The only 
 point of tenderness on pressure was over the 
 urinary bladder. The external genitals were 
 normal ; bimanual examination revealed noth- 
 ing abnormal further than tenderness of the 
 bladder. The patient was put to bed on a 
 light, nourishing diet, the only medication 
 being five grains of salol three times a day, by 
 way of preparation for a cystoscopic ex- 
 amination a few days later. 
 
 November 28. — ^First day after admission to 
 hospital, the urine analysis of a catheterized 
 specimen showed a cloudy pale amber urine, 
 specific gravity 1.012, amphoteric reaction, a 
 trace of albumin, no sugar, no bile, small 
 amount of indican, urea .81 per cent, and 
 chlorides 1.14 per cent. The microscope 
 showed a small amount of mucus, a moderate 
 amount of pus, no blood or casts, a few 
 
 [32] 
 
TUBERCULOUS KIDNEY 
 
 bladder epithelia. No tubercle bacilli were 
 found. 
 
 At the end of a week the following observa- 
 tions were made: An afternoon rise of tem- 
 perature of 6/10 to 8/10 of a degree F., a pulse 
 between 70 and 80, average amount of urine 
 for twenty-four hours, 47 ounces, average 
 number of times urine was passed in twenty- 
 four hours, ten; average amount each time, 
 between four and five ounces; urination a 
 little less frequent during the night; patient 
 sleeping well during intervals, and preserving 
 a fair appetite. 
 
 Up to this time there was nothing upon 
 which to build a diagnosis. The history was 
 merely suggestive. The physical examina- 
 tion and the urinary analysis simply bore out 
 the previous supposition of a bladder affection. 
 
 December 7. — Under cocaine anesthesia a 
 thorough cystoscopic examination was made. 
 The base of the bladder on the right side was 
 3 [33] 
 
TUBERCULOUS KIDNEY 
 
 slightly hyperemic, especially the trigone. 
 The right ureteric orifice was about three times 
 larger than its fellow, elliptical in form, margin 
 thickened and rigid, all muscular action had 
 gone; it remained open and its cavity was 
 highly inflamed, small jets of cloudy urine 
 issued infrequently. Backward and to the 
 right of this ureter-mouth for about 2 cm., a 
 cord-like elevation of the mucous membrane 
 could be seen ; this I took to be the thickened 
 intra-mural portion of the ureter. At about 
 the upper extremity of this was an irregularly 
 ulcerated area about one centimeter in diam- 
 eter; leading from this upward to the fundus 
 of the bladder was a narrow ulcerated path 
 which terminated in another irregular ulcera- 
 tion, which was twice the size of the first ; this 
 was flecked with small grayish-white patches, 
 and was surrounded with ablush of hyperemia. 
 Except for a low grade of inflammation which 
 gave the mucous membrane a slightly softer 
 
 [34] 
 
TUBERCULOUS KIDNEY 
 
 appearance, the rest of the viscus was negative, 
 including the left ureter mouth, which gave 
 forth at frequent intervals, jets of clear urine. 
 
 This examination made, to my mind, 
 tuberculosis of the right kidney extremely 
 probable. Frequent examinations of the urine 
 for tubercle bacilli were then instituted, and 
 continued for about three weeks without 
 avail. Guinea-pigs were then inoculated but 
 died of sepsis within a week or ten days. 
 Tubercle bacilli were found, however, on two 
 occasions within this time in the urine. They 
 were in very small numbers but character- 
 istically grouped. 
 
 The next step in the process of diagnosis 
 was to obtain the separate urines, with a 
 view not only of learning more accurately the 
 condition of the diseased organ, but of 
 getting an estimate of the functionating 
 capacity of its fellow. 
 
 On January 3, a catheterizing cystoscope 
 
 [35] 
 
TUBERCULOUS KIDNEY 
 
 was introduced. It was found impossible to 
 advance a catheter beyond the mouth of the 
 right ureter, on account of obstruction un- 
 doubtedly due to its diseased condition at 
 that point. The left ureter was easily cath- 
 eterized and i6 c.c. of clear, light-colored 
 urine obtained. This, on examination, was 
 of neutral reaction, no sugar or albumin pre- 
 sent, urea 1.5 per cent. The microscope 
 showed a few red blood cells and epithelia, 
 which commonly occur with the use of the 
 ureteral catheter. No tubercle bacilli were 
 found. 
 
 It will be seen that this urine was that of a 
 healthy kidney and that the abnormal ele- 
 ments previously obtained came from the 
 right kidney and ureter, with the bladder 
 participating. 
 
 To make more sure of sufficient renal 
 function, Dr. Alfred T. Osgood was good 
 enough to determine the freezing point of the 
 
 [36] 
 
TUBERCULOUS KIDNEY 
 
 blood, which was —0.55 degrees C, thus 
 showing no undue molecular concentration. 
 
 I then took the patient to Dr. L. G. Cole, 
 who took an excellent radiograph. The 
 picture added much weight to the evidence 
 already collected, for it showed a shadow of 
 considerable density, the outline of which 
 softened out almost too gradually to be mis- 
 taken for a stone. A growth of firm con- 
 nective tissue replacing parenchyma seemed 
 the most likely interpretation, and the correct 
 one, as the specimen later showed. 
 
 The diagnosis was then as follows : Primary 
 tuberculosis of the right kidney with extensive 
 destruction of the organ and extension of the 
 process to the bladder. The left kidney func- 
 tionally capable of carrying on the work of 
 elimination for the body. 
 
 On January 18, 1 removed the right kidney 
 by the extraperitoneal route. 
 
 Pathological Examination of Kidney. — 
 
 [37] 
 
TUBERCULOUS KIDNEY 
 
 Weight, 144 grams; length, 10.5 cm.; width, 
 4.5 cm.; thickness, 4.5 cm. Gross appear- 
 ance: The surface retains the type of fetal 
 lobulation. Through the capsule are seen 
 many small foci about pinhead size, which 
 resemble miliary tubercles. These are most 
 numerous about the central zone of the 
 organ. There is a marked engorgement of 
 the vessels beneath the capsule and an exten- 
 sive subcapsular hemorrhagic exudate, giving 
 a dark red color to almost the entire extent of 
 the sufrace. Section through the convexity 
 of the organ in its longitudinal axis shows the 
 following: Average length of pyramids, 2.8 
 cm.; average thickness of cortex, 0.6 cm. 
 A thin hemorrhagic zone beneath the capsule. 
 Cortex very light-gray color, markings oblit- 
 erated, line of junction with medulla indistinct, 
 in places indistinguishable. Occasional small 
 gray bodies, pinhead in size, which resemble 
 tubercles. 
 
 [38] 
 
TUBERCULOUS KIDNEY 
 
 The medulla has almost lost its identity by 
 being converted into a grayish fibrous tissue, 
 in which there are abscess cavities, the largest 
 measuring 2 cm. in diameter. The two 
 largest of these cavities encroach on the cortex, 
 and are lined by cheesy-looking material, and 
 about one is a considerable hemorrhagic 
 exudate. 
 
 The pelvic wall is thickened and contracted. 
 Its mucosa has a rough, cheesy-looking 
 appearance. At one point in the fibrous 
 portion of the wall, is a hemorrhagic exudate 
 1.5 cm. in diameter. 
 
 The blood-vessels show some thickening. 
 
 Microscopic Examination. — Connective tis- 
 sue system. The capsule is represented by a 
 thin, ragged layer of fibrous tissue which is 
 permeated by inflammatory exudate. Be- 
 neath the capsule there is a layer of vascular 
 fibrous tissue of considerable thickness. The 
 fibrous tissue passes into the medulla in 
 
 [39] 
 
TUBERCULOUS KIDNEY 
 
 places as broad bands of connective tissue. 
 The fibrous tissue is quite cellular and there 
 are many areas of small, round-cell infiltra- 
 tions. There are many miliary tubercles 
 scattered through the newly formed tissue. 
 They are mainly fibrous in the cortex, but in 
 the medulla they are represented by large 
 areas of coagulated necrosis surrounded by 
 fibrous tissue. Many giant cells are asso- 
 ciated with these tubercles. The newly 
 formed tissue beneath the capsule is infil- 
 trated by hemorrhagic exudate. The capsule 
 of Bowman in many places is much thickened. 
 The intertubular tissue is increased in strands 
 and islands. A few places present the normal 
 amount of stroma. 
 
 Parenchymatous System. — In the fibrous 
 tissue zone beneath the capsule, the tubules 
 have almost entirely disappeared. An occa- 
 sional tubule can be seen much diminished in 
 size with the epithelium desquamated or 
 
 [40] 
 
TUBERCULOUS KIDNEYS 
 
 flattened. Some contain hyaline casts, others 
 hemorrhagic exudate. There is extensive 
 parenchymatous degeneration and disinte- 
 gration of the renal epithelium generally. 
 Some of the tubules are dilated, and their epi- 
 thelium flattened, others have their lumen 
 completely filled by their swollen epithelium. 
 In some instances, the epithelium is entirely 
 desquamated and the tubule empty. Some 
 contain hemorrhagic exudate, others casts. 
 
 Vascular System. — The walls of the large 
 vessels are slightly thickened, in some places 
 the intima, in others the adventitia. The 
 capillaries of the glomeruli are congested, 
 and the spaces about some contain hemor- 
 rhagic exudate. Many of the glomeruli have 
 undergone sclerotic changes, and are repre- 
 sented by islands of the firm fibrous tissue in 
 which is some hyaline change. 
 
 The abscesses described in the gross have 
 an inner layer of coagulated necrosis and an 
 
 [41] 
 
TUBERCULOUS KIDNEY 
 
 outer wall of firm fibrous tissue, in which are 
 scattered a few giant cells. The fibrous 
 tissue is surrounded by a zone of hemorrhagic 
 exudate which infiltrates the chronic inter- 
 stitial change involving the cortex. The 
 hemorrhagic area in the wall of the pelvis 
 shows miliary tubercles, round-cell infiltra- 
 tion, edema and hemorrhagic exudate. 
 
 The patient reacted well from the operation 
 and her post-operative course was uneventful. 
 
 I was most forcibly struck by the immediate 
 and almost complete cessation of her most dis- 
 tressing symptom, namely, the great urgency 
 of micturition. After the first twenty-four 
 hours, during which time she was catheterized, 
 she was able to hold her urine five, six and 
 sometimes seven hours. She enjoyed for the 
 first time in two years, uninterrupted nights 
 of sleep. The point of interest to be noted 
 here, is that the irritating character of the 
 material coming from the diseased kidney 
 
 [42] 
 
TUBERCULOUS KIDNEY 
 
 was the predominating causal factor of the 
 frequent urination, and not the vesical ulcera- 
 tion. The pain which accompanied urina- 
 tion still exists, but is progressively decreasing. 
 
 March 6. — Cystoscopy: The general ap- 
 pearance of the bladder mucous membrane 
 improved. The right ureteric orifice has 
 contracted to one-half its former size, no signs 
 of active inflammation. The ulcers are 
 reduced to about two-thirds their former size, 
 their edges are healthy and there is no 
 surrounding hyperemia. The left ureter- 
 mouth and surrounding area is, as before, 
 normal, clear urine issues from its mouth. 
 The urine analysis gives no evidence of 
 kidney involvement. The patient is passing 
 45 to 55 ounces of urine daily, at almost 
 normal intervals and in normal amounts. 
 The wound has healed but for a small sinus, 
 which is progressing favorably. 
 
 The patient is gaining weight and strength. 
 
 [43] 
 
TUBERCULOUS KIDNEY 
 
 She has gone to country to complete her 
 convalescence. 
 
 It may be of interest to add to this report 
 of tuberculous kidney that over seven years 
 have elapsed and the patient continues in 
 good health. A few other cases of kidney 
 tuberculosis have fallen to my lot in the 
 meantime and like the first the symptoms 
 have been baffling and elusive and more 
 suggestive of a bladder lesion than a kidney 
 involvement. For want of an accurate diag- 
 nosis these poor sufferers had lost much 
 valuable time and received much valueless 
 treatment. 
 
 In the limited number of these cases which I 
 have been fortunate enough to see there has 
 been a striking resemblance. The difficulties 
 in diagnosis have been somewhat lessened by 
 improvements in the cystoscopic apparatus 
 
 [44] 
 
TUBERCULOUS KIDNEY 
 
 and the methods of collecting and studying 
 the renal output. 
 
 After nephrectomy all of the cases which I 
 have been able to keep track of, except one, 
 have gone on to a satisfactory recovery. The 
 excepted one had ureter and bladder so 
 deeply involved in the process that only 
 mitigation of her suffering was secured. 
 
 [45] 
 
Ill 
 
 GONOCOCCIC INFECTIONS, AND THE 
 PHYSICIAN'S RESPONSIBILITY 
 
CHAPTER III 
 
 GONOCOCCIC INFECTIONS, AND THE PHYSI- 
 CIAN'S RESPONSIBILITY^ 
 
 This paper is offered chiefly as a statistical 
 study of the more important lesions caused 
 by the gonococcus, in the hope of giving a 
 better idea of the extent of the disease, and 
 without attempting to teach anything of its 
 pathology, symptomatology, diagnosis, or 
 treatment. 
 
 The belief that gonorrhea and syphilis 
 were but different expressions of a single 
 disease held sway from our earliest knowledge 
 of the existence of these diseases, 2,000 years 
 before Christ, until the latter part of the 
 eighteenth century, when Benjamin Bell, in 
 1782, brought forward his experiments and 
 reasons for separating them. Again, in 181 2, 
 
 1 Read before the Westchester County Medical Society, at 
 Yonkers, November 21,1905. 
 
 4 [49] 
 
GONOCOCCIC INFECTIONS 
 
 Hernandez, by his experiments, tried to 
 demonstrate their nonidentity. The opinion, 
 however, held by these men was not accepted 
 as final until, in 1837-8, or within the memory 
 of many now living, the result of 667 inocula- 
 tion experiments proved conclusively the 
 nonrelationship of these two diseases. 
 
 It remained for Neisser, forty-one years 
 later, in the year 1879, to announce that he 
 had found the specific organism of gonorrhea. 
 In the two decades and a half which have 
 elapsed since then our knowledge of the far 
 reaching character of this disease has made 
 remarkable strides. 
 
 It was not many years ago that gonorrhea 
 was looked upon as a local inflammation 
 which ran in the majority of cases a mild 
 course, ending in complete cure. To-day 
 we recognize in gonorrhea a formidable 
 infection which has invaded practically every 
 tissue of the human body, and from which no 
 
 [50] 
 
GONOCOCCIC INFECTIONS 
 
 class of society is immune. Gonorrhea is 
 said to be the most widespread and universal 
 disease affecting the adult male population. 
 It is estimated that 75 per cent, or more are 
 infected. 
 
 But for rare exceptions the original site of 
 gonorrheal infection in the male is the 
 urethra, and from this situation we may 
 follow its processes of extension and com- 
 plication. It remains for a short period in 
 the anterior urethra, and in a few instances 
 is cured without further extension. The 
 limitation of the process to this location (in 
 the absence of complications) offers the one 
 bright hope of a definite cure and of relief 
 from the uncertainty of indefinite infectious- 
 ness to others. 
 
 Anterior urethritis may be complicated by 
 balanitis, cavernitis, cowperitis, or periure- 
 thral infiltration and abscess, or it may go 
 on to stricture formation. Of 164 cases of 
 
 [SI] 
 
GONOCOCCIC INFECTIONS 
 
 stricture, Sir Henry Thompson gives the 
 period of development as follows: Ten cases 
 occurred during the acute gonorrhea; seventy- 
 one cases developed in one year; forty-one 
 cases developed in three to four years; 
 twenty-two cases developed in seven to eight 
 years; twenty cases developed in twenty to 
 twenty-five years. 
 
 Consequent upon stricture there may occur 
 extravasation of urine, dilatation of the 
 bladder, abscess of the prostate, cystitis, 
 pyelitis, and pyelonephritis. With the latter 
 complications the mortality is by no means 
 low. By continuity of mucous membrane 
 anterior urethritis extends backward beyond 
 the confines of the compressor muscle to 
 become posterior urethritis. 
 
 In what proportion of cases does gonorrhea 
 invade the posterior urethra? Wossidlo, of 
 Berlin, quotes the following authors: Letzel 
 gives it as 92.5 per cent.; Philippson, 86.6 
 
 [52] 
 
GONOCOCCIC INFECTIONS 
 
 per cent.; Rona, 90 per cent. ; and Jadassohn, 
 88.7 per cent. This means that almost nine 
 out of every ten cases go on to the occurrence 
 of posterior urethritis. The gravity of the 
 disease in this situation is marked, not by its 
 danger to the Hfe of the individual, or by the 
 discomfort and pain which it occasions, but 
 by the danger of rendering him indefinitely 
 infectious and perhaps by rendering him 
 sterile. 
 
 When one considers the anatomy of the 
 posterior urethra, its floor divided into two 
 longitudinal furrows by the caput gallinaginis, 
 on each side of which an ejaculatory duct and, 
 in all, from twelve to twenty prostatic ducts 
 open, it is not difficult to understand how 
 easily and with what frequency the gonococcus 
 invades the prostate, seminal vesicles, and 
 epididymides. It is equally easy to appre- 
 ciate, when one thinks of the endurance and 
 long life of these organisms, how it is possible 
 
 [53] 
 
GONOCOCCIC INFECTIONS 
 
 for them to remain for indefinite periods in 
 these deeper structures. 
 
 Many authorities, notably Finger and 
 Frank, at present beheve the prostate to be 
 affected to a greater or less degree in practi- 
 cally every case of posterior urethritis, while 
 Guyon and Furbringer do not think it occurs 
 so often. According to Wossidlo, Montagnon 
 and Erand found the prostate involved in 70 
 per cent, of cases of posterior urethritis; 
 Colombini, in 36 per cent, of acute, 28 per 
 cent, of subacute, and 40 per cent, of chronic 
 gonorrhea. Pezzoli gives 80 per cent, as his 
 figures. Rosenberg, Posner, and Goldberg 
 join in this estimate of its great frequency. 
 The varieties of prostatitis we have not space 
 to consider here. 
 
 That it is a most serious complication we 
 must take passing note of. It is one of the 
 chief phases of gonorrhea which accounts 
 for chronicity, resistance to treatment, pro- 
 
 [54] 
 
GONOCOCCIC INFECTIONS 
 
 longed infectiveness, sexual neurasthenia, 
 sexual inability, and certain occurrences 
 that take place later in life. 
 
 As to the frequency of spermatocystitis, 
 authors differ. Wossidlo, quoting Guyon, 
 Neisser, Thompson, Taylor, Fuller, and 
 others, says it occurs often. Fournier and 
 others maintain its rarity. Lucus out of 
 285 cases of epididymitis found in cases with 
 the seminal vesicles congested. Colombini 
 gave the frequency in cases of epididymitis as 
 62.5 per cent.. Chute found, in 540 patients 
 with affections of the genitourinary organs, 
 that sixty had an inflammation of the seminal 
 vesicles. The importance of epididymitis is 
 marked by its tendency to cause sterility. 
 Finger, of Vienna, gives the following sta- 
 tistics of posterior urethritis complicated 
 with epididymitis : 
 
 Rollet (1862), 2,425 cases, 27.9 per cent. 
 Jullien (1886), 2,500 cases, 15.2 per cent. 
 
 1 55] 
 
GONOCOCCIC INFECTIONS 
 
 Tarnowsky (1872), 5,203 cases, 12.2 per cent. 
 Finger, 1,844 hospital cases, 29.9 per cent. 
 Berg (1882), private practice, 7.5 per cent. 
 Finger, 1,000 clinic cases, 12.5 per cent. 
 Gilbert (1893), 650 cases, 7 per cent. 
 
 Benzler (1898) published the following 
 relationship between gonorrheal urethritis, 
 epididymitis and sterility: 
 
 Those rendered entirely sterile : 
 
 After simple gonorrhea 10.5 per cent. 
 
 After one sided epididymitis. ... 23 .4 per cent. 
 After double epididymitis 42 . 7 per cent. 
 
 Those resulting in the "one child sterility" : 
 
 After simple gonorrhea 17 .3 per cent. 
 
 After one sided epididymitis. ... 13 . 5 per cent. 
 After double epididymitis 20 . 8 per cent. 
 
 This study shows two features of interest. 
 First, that there is a considerable proportion 
 of sterility following urethritis without appar- 
 ent complication, and, second, the high pro- 
 portion of sterility which follows epididymitis, 
 and of the frequency of epididymitis we have 
 already spoken. 
 
 [56] 
 
GONOCOCCIC INFECTIONS 
 
 Gonorrheal cystitis as a complication, 
 although not rare, is not so frequent as it 
 was supposed to be before the adoption of 
 the newer methods of examination, by the 
 employment of which inflammation of the 
 bladder can be ascertained more exactly. 
 Gonorrheal infection of the ureters, the kid- 
 neys, and their pelves is fortunately a rare 
 occurrence, although in later life pyelitis and 
 pyelonephritis may follow upon the obstruc- 
 tion to the urinary flow due to stricture of the 
 urethra. 
 
 I have attempted in a superficial way, and 
 omitting minor occurrences, to give some idea 
 of the frequency with which gonorrhea occurs 
 in the male and affects the different important 
 organs of the male genitourinary tract. In 
 order to appreciate the seriousness of this 
 malady one must know something of its 
 prevalence as well as of its morbid extension 
 in the body. 
 
 [57] 
 
GONOCOCCIC INFECTIONS 
 
 Our American text-books on genitourinary 
 diseases give but meager statistical informa- 
 tion regarding the frequency of this infection 
 and the frequency with which individual 
 organs are affected, so that it is little wonder 
 that the student of medicine and the practising 
 physician often fail to be impressed with the 
 magnitude of this evil and the important racial 
 and social problems connected with it. The 
 insidious nature of the gonococcus and its long 
 periods of symptomless quiescence protect this 
 organism against discovery by those whose 
 minds have not been trained to be ever on 
 the alert for it, so that those who fail to appre- 
 ciate its presence have no criterion upon 
 which to build a theory that it lacks the 
 prevalence that careful clinical experiences 
 have demonstrated. 
 
 In concluding this chapter on the frequency 
 of gonorrheal infection of the male genito- 
 urinary system a word must be added regard- 
 
 [58] 
 
GONOCOCCIC INFECTIONS 
 
 ing the course the disease runs. For it is due 
 to its insidious nature that so many evil con- 
 sequences arise. An initial attack of anterior 
 urethritis without complication may run its 
 course in from four to six weeks. In many 
 cases, however, it is much longer before the 
 healing takes place and the patient is appar- 
 ently cured. This occurrence is, unfortu- 
 nately, far from the rule, for, as statistics show, 
 the chances are nearly ten to one that it will 
 become a posterior urethritis. With the 
 present day treatment and intelligent co- 
 operation of the patient, I believe we 
 should very materially decrease the number 
 
 of cases that go from anterior to posterior 
 urethritis. 
 
 When the disease becomes posterior, and we 
 have seen with what frequency this occurs, 
 the situation is entirely altered. It assumes a 
 gravity in its far reaching consequences to the 
 patient himself as well as to the community 
 
 [59] 
 
GONOCOCCIC INFECTIONS 
 
 that is hard to reaHze. It represents a situa- 
 tion of which the lay mind is deplorably 
 ignorant. So deeply rooted is the traditional 
 notion of the insignificance of gonorrhea, and 
 so well supported is this belief by the absence 
 of pain or annoying symptoms when the dis- 
 ease lapses into its "latent" character, that 
 the individual oftentimes will not beheve that 
 the simple little "drop" which he perceives 
 in the morning or the few innocent looking 
 "shreds" which he can see in his urine, if 
 passed into a glass, may mean that the wife 
 whom he marries, perhaps years later, pays 
 for his sins by receiving an infection that 
 may cost her her life or render her a hopelessly 
 chronic invalid. 
 
 But to return to our subject, the course run 
 by posterior urethritis. It is marked by its 
 chronicity, its resistance to treatment, its 
 proneness to recur, and its uncertainty of 
 
 definitive and permanent cure. To empha- 
 
 [60] 
 
GONOCOCCIC INFECTIONS 
 
 size this, let me recall to mind the frequency 
 with which the gonococcus invades the pros- 
 tate gland, there to set up a mild and painless 
 irritation or lie dormant for years, defying 
 oftentimes the most patient, skillful and ex- 
 perienced treatment. M. von Zeissl sums 
 up the situation when he says that every well 
 informed physician will to-day agree with 
 Ricord, that he well knows when and how the 
 gonorrhea began, but concerning its course 
 and its cure it is impossible to speak with 
 certainty. As to its infectiveness. Morrow 
 says: ''Since no disease is more surely trans- 
 missible in the married relation than gonor- 
 rhea, the man who marries with an uncured 
 gonorrhea will almost certainly communicate 
 his disease to his wife." 
 
 I am aware that I have drawn a gloomy 
 picture of gonorrhea in the male, but I have 
 tried to draw a true one, taking for my 
 
 material the figures and clinical experience of 
 
 [6i] 
 
GONOCOCCIC INFECTIONS 
 
 careful and conscientious observers. Do not 
 draw the conclusion from what I have said 
 that I believe that all men who have had a 
 posterior urethritis to be permanently infec- 
 tious or that all men will suffer in later life 
 from their infections. There may be some 
 who carry latent gonorrhea into their married 
 lives without infecting their wives. This, 
 however, must be very rare. On the other 
 hand, it is not infrequent, long after an 
 apparently complete cure, for a man to marry 
 and infect his wife. The following case cited 
 by Young is an illustration of a not uncommon 
 occurrence : 
 
 A man was treated for three or four years 
 by an excellent physician. He put off his 
 marriage for two years more, and finally the 
 physician, after examining carefully with 
 culture and cover glass preparations, told 
 him he could safely marry. Six weeks after 
 the wedding his wife was brought in with 
 
 [62] 
 
GONOCOCCIC INFECTIONS 
 
 acute tubal disease and peritonitis requiring 
 laparotomy and salpingectomy. 
 
 Besides the mucous membrane of the uro- 
 genital tract that of the nose, the mouth, the 
 rectum, and all too commonly the eye, furnish 
 soil for the gonococcus to grow upon. Of 
 gonorrhea as a constitutional disease in both 
 sexes space does not permit me to do more 
 than speak briefly. It is a comparatively in- 
 frequent sequel to the original mucous mem- 
 brane infection. That the gonococcus or its 
 toxins are conveyed from one region of the body 
 to others by means of the blood or lymph 
 channels has been demonstrated by finding the 
 organism in the blood and in the metastases. 
 That endothelial and connective tissue struc- 
 tures may harbor the gonococcus we have now 
 ample proof. The most frequent example of 
 general infection is found in gonorrheal 
 rheumatism, arthritis gonorrhoica. 
 
 An average of several observers reports it as 
 
 [63] 
 
GONOCOCCIC INFECTIONS 
 
 occurring in slightly over 2 per cent, of the 
 cases. The literature gives us examples of 
 gonorrheal tenosynovitis, bursitis, myositis, 
 periostitis, osteomyelitis, phlebitis, pleuritis, 
 peritonitis, endocarditis, pericarditis and neu- 
 ritis. Gonorrheal lesions of the skin have 
 been noted and reported. 
 
 The local and systemic affections of chil- 
 dren, were they considered in detail, would 
 fill a long chapter. It is well known to-day 
 how gonorrheal vulvovaginitis sweeps as an 
 epidemic through the wards of infant asylums 
 and hospitals. During the year 1902 there 
 were 600 admissions to the public wards of 
 the Babies' Hospital in New York, and among 
 this number there occurred seventy cases of 
 vulvovaginitis and ten cases of arthritis. 
 
 Stomatitis, as a mode of infection, has been 
 reported in a few instances. Urethritis is by 
 no means unusual. Pelvic complications in- 
 volving the uterus, the annexa, or the per- 
 
 [64] 
 
GONOCOCCIC INFECTIONS 
 
 itoneum occur from time to time in children. 
 Eight cases of gonorrheal pyemia without 
 discoverable local lesion to account for the 
 entrance of the organisms were reported by 
 Kimball in 1903. 
 
 Out of 58,000 blind persons, the last census 
 of the United States, Scott states that 15,000 
 children lost their sight from gonorrheal 
 ophthalmia. It is said that from 20 to 30 
 per cent, of all the blindness in this country is 
 caused by gonorrheal infection. A large 
 proportion of this occurs as the result of 
 purulent conjunctivitis in children infected 
 at birth. 
 
 At the present day no one doubts that 
 gonorrhea of the genitourinary tract in 
 women is a disease of great frequency. Fin- 
 ger and others give the following records as 
 against Noggerath's opinion that 80 per cent. 
 of all women are affected with latent gonor- 
 rhea: Oppenheimer (1884), in Kehrer's 
 5 [65] 
 
GONOCOCCIC INFECTIONS 
 
 clinic in Heidelberg, examined io8 pregnant 
 
 women and found the gonococcus in thirty, 
 
 which is 27.7 per cent.; Lomer (1885), in 
 
 thirty-two women during the puerperium 
 
 found the gonococcus in nine, or 28 per cent. ; 
 
 Schwartz (1886) examined 617 women, 112 
 
 of whom were suspected of gonorrhea, and in 
 
 seventy-seven cases the gonococcus was found, 
 
 making 12.4 per cent.; Sanger (1889), in his 
 
 series of 1,930 women, found 230 infected, 
 
 which makes 12 per cent. ; Dorn (1890), out of 
 
 1,000 cases, found 10.5 per cent, of the women 
 
 infected; Sigmund, of Vienna, in his venereal 
 
 clinic, found that of 758 public women, 63 
 
 per cent, were affected with gonorrhea. 
 
 The site of election of gonococcic infection 
 
 in the female is as follows : Fabry (1888) found 
 
 the situation of gonorrhea in thirty-eight 
 
 women to be in the urethra and cervix in 
 
 sixteen, in the urethra alone in twenty, and in 
 
 the cervix alone in two; Welander (1888) 
 
 [66] 
 
GONOCOCCIC INFECTIONS 
 
 found the gonococcus in the urethra in 89 per 
 cent, of his cases, and in 43.7 per cent, in the 
 cervical canal; Brlinschke (1891) gave the 
 frequency of the situation of gonorrhea as 
 90 per cent, in the urethra, 37.5 per cent, in 
 the cervix, and 12.5 in Bartholin's glands. 
 Luczny (1891) collected from Olshausen's 
 clinic forty-seven cases. In this series the 
 urethra was affected in forty, the vulva in 
 twelve, Bartholin's gland in seventeen, and 
 the vagina in nineteen cases. 
 
 This evidence points to the urethra as being 
 the favorite site of the original infection. In 
 just what proportion of these cases the in- 
 fection ultimately finds its way to the cervix 
 and from thence to the uterus, tubes, ovaries, 
 and peritoneum, it is hard to say. 
 
 In what proportion of cases the gonococcus 
 invades the bladder and upper urinary tract 
 it is also impossible to say, but that it is rela- 
 tively infrequent as compared with the involve- 
 
 [67] 
 
GONOCOCCIC INFECTIONS 
 
 ment of the generative organs we to-day 
 know. 
 
 Owing to the different anatomical arrange- 
 ments and construction of the genital organs 
 in the female and the difference in their 
 physiological functions (menstruation and 
 pregnancy), the disease varies considerably 
 in its course, action, and seriousness from 
 that in the male. The onset, the course, 
 and the termination of female gonorrhea is 
 so varied, the consequences to the individual 
 and generation are so grave that I hesitate to 
 enter upon a description that must fall so far 
 short of being complete in a limited paper of 
 this kind. The majority of women receive 
 their infection from an individual who has 
 passed from the active into the latent stage, 
 and whose gonococci have decreased in num- 
 ber and to a greater or less extent lost their 
 virulence by the attenuative influence of time 
 
 on an impoverished soil. 
 
 [68] 
 
GONOCOCCIC INFECTIONS 
 
 Let me illustrate by drawing two or three 
 typical pictures. First, a more unusual form 
 of the disease is that of a virulent infection 
 with a sudden onset and acute course. Its 
 beginning is marked by the appearance of acute 
 vulvovaginitis and urethritis, with intertrigo 
 from purulent secretion, and urgency and 
 frequency of micturition set in. The picture 
 may be complicated by an acute suppurative 
 Bartholinitis. The mucous membrane of the 
 vulva, vagina, and urethra are intensely red 
 and bathed in pus. With the invasion of the 
 uterus the symptoms of acute metritis appear, 
 fever and severe pain in the pelvis and across 
 the back, enlargement and exquisite tender- 
 ness of the uterus, with blood and pus pouring 
 from its cavity. The exudate extends into the 
 pelvis and around the tubes and ovaries. 
 Pelvic peritonitis, it may be general peritonitis, 
 follows. Salpingitis and pyosalpinx usually 
 occur. The conclusion may be death or a 
 
 [69] 
 
GONOCOCCIC INFECTIONS 
 
 capital operation or a lifetime of invalidism 
 and sterility. 
 
 The second and more usual type is character- 
 ized by a slow onset with a chronic course, 
 ready to become an active process through 
 the influences of pelvic congestion due to 
 excessive coitus, menstruation, or pregnancy. 
 This form of gonorrhea we see most often in 
 the young wife, married to a man who brings 
 with him an uncured gonorrhea. It is more 
 than likely that he is unaware of the evil he 
 is doing; he may even have the word of his 
 physician that he could safely marry. The 
 young and healthy woman, who never knew 
 what disturbed menstruation or pelvic dis- 
 comfort was, begins soon after marriage to 
 ail; menstruation may become somewhat 
 irregular and attended by increased secretion 
 from the genitals. As time goes on she 
 notices that she becomes more easily fatigued, 
 but she attributes these things to the natural 
 
 [70] 
 
GONOCOCCIC INFECTIONS 
 
 changes that come in newly married Hfe and 
 puts them from her mind . At any time during 
 a passing pelvic congestion, as at a menstrual 
 period, the smouldering infection may light 
 up and, extending from its temporary resting 
 place, invade the uterus. Here it may pause 
 or continue on its way until each pelvic organ 
 of generation participates and they are all 
 matted into one solid mass by the inflamma- 
 tory exudate surrounding them. On the 
 other hand this occurrence may not take place, 
 but she may go on to pregnancy. This condi- 
 tion is not infrequently interrupted by abor- 
 tion, or she may be delivered at term, and the 
 gateways then open for an invasion more 
 rapid and severe than that we have just 
 alluded to. 
 
 Though the streptococcus threatens life and 
 not infrequently causes death, it is, when life 
 is spared, more merciful. The gonococcus 
 holds for its victim a different fate. 
 
 [71] 
 
GONOCOCCIC INFECTIONS 
 
 With the stormy period of the puerperium 
 passed, the tedious convalescence is begun, 
 holding in store perhaps a whole lifetime of 
 suffering, intensified at each menstrual period. 
 With the hope of maternity blighted, these 
 poor women become nervous and hysterical 
 wrecks. By the surgeon's knife they may 
 get relief, but are left castrated women. 
 
 We have seen in these two types of disease a 
 not unfamiliar picture, and one in which the 
 diagnosis is usually plain. Not so obvious, 
 however, are the great majority of cases of 
 gonorrhea in women. The diagnosis, as in 
 latent gonorrhea in men, is difficult, and 
 without the microscope and culture tests is 
 in most cases impossible. Neisser, in his 
 examination of 574 public women, found 216 
 to have gonorrhea, and out of this number 
 there were only twenty-two in whom it was 
 possible to make the diagnosis microscopically. 
 
 The disease, starting insidiously, remains 
 
 [72] 
 
GONOCOCCIC INFECTIONS 
 
 latent; its course is mild, chronic, and 
 often without characteristic symptoms. The 
 woman does not realize that she harbors a 
 serious affection. The only symptom may 
 be a leucorrhea, which disappears for a time 
 only to reappear. There may be a purulent 
 discharge preceding menstruation and fol- 
 lowing it. The menstrual function may be 
 disordered. 
 
 The great danger in this, the commonest 
 form of gonorrhea in women, lies in its being 
 ever ready to extend, when a favorable oppor- 
 tunity offers, to the uterus and the annexa. 
 The consequence of this we see in the obliter- 
 ation of the oviduct, the deviations and 
 adhesions, the suppurative processes, and 
 peritonitis. As to the frequency of pelvic 
 inflammation due to gonorrhea, statistics are 
 not satisfactory. We can, however, arrive at 
 some estimate of its prevalence. 
 
 Weiss says that salpingitis as a continuous 
 
 [73] 
 
GONOCOCCIC INFECTIONS 
 
 infection occurs in from 23 to 70 per cent, 
 of all gonorrheas in women. A percentage 
 variously estimated at from forty to eighty of 
 endometritis and perimetritis is of gonorrheal 
 origin. 
 
 Eighty per cent, of all deaths from pelvic 
 disease in women are due to gonorrhea, 
 quoting Morrow. Price said that in over a 
 thousand sections for pelvic inflammation 95 
 per cent, of the cases were attributable to 
 gonorrhea, and that in 95 per cent, of these 
 the history was reliable and clear. 
 
 As to gonorrhea as a cause of sterility, one 
 author states that 50 per cent, of all involun- 
 tarily childless marriages are made so by 
 gonorrhea of the female organs of generation, 
 of which 45 per cent, are due to marital 
 infection by men. On this point there 
 seems to be but little difference of opinion. 
 Noggerath asserted that 50 per cent, of 
 sterility in women was caused by gonorrhea. 
 
 [74] 
 
GONOCOCCIC INFECTIONS 
 
 Lier-Ascher found, out of 227 women, 121 
 sterile because of gonorrhea. Neisser con- 
 tends that gonorrhea is a more potent factor 
 in the depopulation of countries even than 
 syphilis. He regards gonorrheal infection as 
 responsible for more than 45 per cent, of 
 sterile marriages. In eighty sterile marriages 
 Kehrer found forty-five caused by inflamma- 
 tory and other changes, all of gonorrheal 
 origin. This is upward of 50 per cent. 
 
 Janet, in 1902, while discussing Social 
 Defense Against the Venereal Peril, declared 
 that gonorrhea with tuberculosis, perhaps 
 more than tuberculosis, was the great pest 
 of our age. If we compare from a social 
 point of view the importance of gonorrhea 
 with that of syphilis, gonorrhea is to syphilis 
 as 100 is to I, not only from the standpoint 
 of the number of persons attacked, but also 
 from the standpoint of the gravity of the 
 lesions and their perpetuity. Gonorrhea 
 
 [75] 
 
GONOCOCCIC INFECTIONS 
 
 modifies in a manner often permanent the 
 genital organs of patients, renders them 
 infinitely dangerous for the women they 
 approach, causes all metritides and annexial 
 inflammations which to-day give to surgeons 
 three-quarters of their work, and conduct 
 finally both men and women to sterility. 
 
 It is regrettable that this important matter 
 has received so little attention in American 
 text-books of gynecology and genitourinary 
 diseases, and that students of medicine should 
 start on their career as physicians with such 
 limited knowledge regarding the extent and 
 consequences of this social menace. 
 
 I must unfortunately pass by that phase of 
 the subject which has to do with prostitutes 
 and prostitution with but a single remark, 
 that it is probable that practically every 
 woman of this class, before she has been long 
 
 in the occupation, is gonorrheal and a source 
 of danger. In this class are to be included 
 
 [76] 
 
GONOCOCCIC INFECTIONS 
 
 many women working in stores, in factories, 
 as servants, or in theatrical companies, etc., 
 who expose themselves to this form of 
 infection. 
 
 The Physician's Responsibility. — It may be 
 said, the largest, and surely the saddest, part 
 of this great public evil has its origin in the 
 peoples', our neighbors', our friends', our 
 patients' ignorance of the subject. The only 
 key to the situation is the light of true knowl- 
 edge, and the only source at present of this 
 light is the medical profession, of which you 
 and I are members. 
 
 BIBLIOGRAPHY 
 
 Bierhoff, F. Gonorrheal Cystitis in the Female. 
 Medical News, January 12, 1901. 
 
 Casper, L. Lehrbuch der Urologie, Berlin, 1903. 
 
 Finger. Blennorrhoe der Sexualorgane. Handbuch 
 der Urologie, iii, part 14. Wien, 1905. 
 
 Johnson, J. F. Further Remarks Upon Gonorrhea. 
 Responsibility in Authorizing Marriage, New York, 1904 
 
 [77] 
 
GONOCOCCIC INFECTIONS 
 
 Komfeld. Gonorrhoe und Ehe. Wein, 1904. 
 
 Kimball. Gonorrhea in Infants, with a Report of 
 Eight Cases of Pyemia. Medical Record, November 14, 
 1903. 
 
 Keersmaecker and Verhoogen. Chronic Urethritis, 
 New York, 1901. 
 
 Morrow. Social Diseases and Marriage, 1903. 
 
 Marshall. Syphilis and Gonorrhea, 1904. 
 
 Noggerath. Transactions of the American Gynecologi- 
 cal Society, 1877. 
 
 Scott. Heredity and Morals, 1900. 
 
 Sanger. Die Trip per ansteckung heim weiblichen Gesch- 
 lechte, 1889. 
 
 Von Zeissl. Diagnose und Therapie des Trippers, 1903. 
 
 Weiss. Contributions to the Pathology and Treatment 
 
 of Acute Gonorrhea. Medical News, September 10— 
 17, 1904. 
 
 Wossidlo. Die Gonorrhoe des Mannes, 1903. 
 
 [78] 
 
IV 
 
 SOME NECESSARY PRINCIPLES IN THE 
 DIAGNOSIS OF SURGICAL CONDI- 
 TIONS OF THE UPPER URINARY 
 TRACT 
 
CHAPTER IV 
 
 SOME NECESSARY PRINCIPLES IN THE DIAG- 
 NOSIS OF SURGICAL CONDITIONS OF THE 
 UPPER URINARY TRACT ^ 
 
 It seems appropriate just now to group in a 
 useful sequence such methods, both old and 
 new, as have proved themselves valuable in 
 making diagnoses in affections of the upper 
 urinary tract. For with the advent of newer 
 appliances, such as the ureter catheterizing 
 cystoscope, the various appliances for intra- 
 vesical separation of the urine, and the im- 
 proved x-ray apparatus, there is a tendency 
 to accept too confidently the evidence that any 
 one of these instruments alone may give, 
 without giving due weight to those prelimi- 
 
 ^ Read before the Newark, N. J., Medical and Surgical Society, 
 November i6. 1905. 
 
 6 [81] 
 
THE UPPER URINARY TRACT 
 
 nary steps in the process of diagnosis which 
 lead up to the point where these later date 
 instruments are of real value. 
 
 Unfortunately the idea is becoming prev- 
 alent that urinary diagnosis has become by 
 the aid of mechanical appliances a matter 
 both simple of execution and rapid of com- 
 pletion. It is true that, by the added useful- 
 ness of the improved appliances which we now 
 have, diagnoses are made possible which 
 before were impossible; but it is out of the 
 question to hope to arrive at satisfactory con- 
 clusions in difficult cases without expense of 
 time and study, both clinically and in the 
 laboratory. Therefore those who would look 
 for good results in their endeavors to define 
 the site and determine the character of patho- 
 logical conditions of the urinary system should 
 be prepared to spend both time and thought in 
 the elucidation of these problems. 
 
 Before detailing an order of procedure in 
 
 [82] 
 
THE UPPER URINARY TRACT 
 
 diagnosis, it would be in place to speak of the 
 use of the cystoscope, or rather what has been 
 a misuse of that instrument. Knowing a 
 number of instances where the ureter cathe- 
 terizing cystoscope of different makes and 
 varieties was used as a universal instrument 
 for the exploration of the bladder as well as 
 an aid to diagnosis in ureter and kidney 
 affections, I was led to further inquiry, and 
 experienced the greatest surprise when I 
 learned from the instrument makers how 
 many more ureter catheterizing cystoscopes 
 were sold here in America than those of the 
 simple examining type. 
 
 A well-known firm in Berlin, who manufac- 
 ture the Nitze instrument only, have sold in 
 the United States 800 ureter catheterizing 
 cystoscopes and 350 simple examining cysto- 
 scopes. A large importing and manufactur- 
 ing concern of this city give as their compara- 
 tive sales: ^^ Three catheterizing cystoscopes 
 
 [83] 
 
THE UPPER URINARY TRACT 
 
 to one of the plain examining.'' A New York 
 house has, for some six or seven years, been 
 manufacturing' the Tilden Brown composite 
 cystoscope, which consists of a common 
 sheath with telescopic tubes for direct view 
 catheterizing, and a prismatic telescope for 
 observation. This cystoscope has not the 
 unpleasant feature which the prismatic cathe- 
 terizing instruments have of a shoulder di- 
 rectly behind the beak on the shaft. It is only 
 within the past year that this company has 
 perfected the Otis cystoscope, which is a 
 simple examining instrument of the prismatic 
 type. 
 
 This is certainly very suggestive evidence 
 that a good many physicians are buying and 
 using the more complicated instrument who 
 have never learned to handle the simple one. 
 The reason for this is perhaps not difficult to 
 explain. The recommendation and descrip- 
 tion by the instrument dealers of how the 
 
 [84] 
 
THE UPPER URINARY TRACT 
 
 ureter catheterizing cystoscope can serve the 
 double purpose of exploring and catheterizing 
 have led many whose knowledge of cystos- 
 copy is mainly theoretical to buy a cystoscope 
 of the catheterizing variety without giving 
 the matter much serious thought. 
 
 The following reasons will make evident, I 
 think, why the use of the ureter catheterizing 
 instrument is never justified until indication 
 for its employment has been elicited by the 
 simple prismatic cystoscope. 
 
 First. From the standpoint of the patient's 
 comfort, a very important consideration, I be- 
 lieve, there is no catheterizing instrument 
 made that can be introduced with as little 
 discomfort as any one of several simple 
 examining cystoscopes of prismatic type, 
 averaging 21 by the French scale, and with an 
 even, rounded shaft, and a gently angulated 
 beak. All the useful catheterizing cysto- 
 scopes are considerably larger of caliber, and 
 
 [85] 
 
THE UPPER URINARY TRACT 
 
 in some varieties the shoulder near the beak 
 for the egress of the catheter or catheters is an 
 added source of discomfort. 
 
 Second, from the operator's standpoint. 
 The simple cystoscope is more readily steril- 
 ized. It is more easily handled and intro- 
 duced. In strictured or naturally small 
 urethrae it is often the only cystoscope that can 
 be introduced. In diseased urethrae, or 
 where there is prostatic enlargement, the 
 minimum of traumatism is important. The 
 simple cystoscope gives a clearer and a larger 
 field of vision. It is therefore possible to 
 arrive at a much more accurate interpretation 
 of the condition of the bladder, the state of 
 the ureteral orifices, and the character of the 
 fluid emitted. 
 
 The knowledge gained by the simple instru- 
 ment may be sufficient for the diagnosis, and 
 catheterism of the ureters or the use of the 
 
 catheter cystoscope would then be distinctly 
 
 [86] 
 
THE UPPER URINARY TRACT 
 
 contraindicated. It is only in those cases 
 where a ureteral catheter has to be employed 
 that we are justified in the use of the instru- 
 ment for that purpose. Dr. Max Nitze, of 
 Berlin, makes it an unfailing rule (where the 
 cystoscope is to be used) first to explore the 
 bladder with the simple prismatic instrument. 
 In the writings of Mr. Hurry Fenwick, of 
 London, the simple prismatic cystoscope 
 stands out with such importance in the 
 diagnosis of kidney as well as bladder affec- 
 tions, that one cannot fail to appreciate the 
 great value in his hands of this instrument as 
 a diagnostic means, even to the practical 
 exclusion of the ureter catheterizing cysto- 
 scope. If one intends to do cystoscopy and 
 hopes for good results in this line of work, he 
 will first possess himself of, and learn to use, 
 the simple prismatic cystoscope. 
 
 A word concerning the use of intravesical 
 urine segregators. There are undoubtedly 
 
 [87] 
 
THE UPPER URINARY TRACT 
 
 cases where these instruments can be employed 
 to advantage, but never with that accuracy 
 which comes when the urine is collected 
 directly from each ureter with a catheter. 
 When these instruments are used, it is essen- 
 tial to precede their employment by cystos- 
 copy in order to determine whether their use 
 is worth while, as intravesical enlargement 
 of the prostate and abnormally placed ureters 
 render the instruments useless. 
 
 Concerning the detection of calculi in the 
 ureter or kidney, the x-rays are probably our 
 most reliable guide, but we must be guarded 
 in our decisions about shadows lying in the 
 path of the ureter. Such shadows have quite 
 frequently of late been seen, and an operation 
 been performed, no stone being found in the 
 ureter. These shadows may be phleboliths, 
 artifacts, or sesamoid bones. By introducing 
 a styletted catheter into the ureter and then 
 taking a radiograph, we can better determine 
 
 [88] 
 
THE UPPER URINARY TRACT 
 
 the situation of shadows that are apparently 
 those of stones in the ureter. 
 
 In setting down the following course of 
 procedures necessary to a diagnosis, the 
 description of instruments and laboratory 
 appliances and of the technique used in their 
 employment is purposely omitted, in order 
 that this paper may not be too long. 
 
 Although it is unnecessary to enumerate 
 here all the surgical diseases to which the 
 kidney and ureter are liable, it is well to men- 
 tion the affections which should always be 
 kept clearly in mind. Renal tuberculosis, 
 primary and unilateral, perhaps heads the 
 list of those conditions which seem to evade 
 a timely diagnosis. The lack of patient and 
 repeated search for the tubercle bacilli and 
 the lack of proper diagnostic measures must 
 be held responsible for failures in diagnosis in 
 the majority of cases. Pyelitis and pyelone- 
 phritis, the variety of which complicates and 
 
 [89] 
 
THE UPPER URINARY TRACT 
 
 SO . often succeeds the infected bladder, the 
 infection of which is due to urinary obstruc- 
 tion by prostatic enlargement or strictured 
 urethra, must be looked upon as not uncom- 
 mon. Pyonephrosis is but the terminal stage 
 of the preceding conditions, plus a certain 
 number of hydronephrosis in which infection 
 follows. Other forms of pyelitis and pyelo- 
 nephritis are those by infection upwards, not 
 consequent upon an obstructed urinary 
 flow, and those in which infection occurs 
 by means of the lymph or blood current. 
 The pyelitis of pregnancy should also be 
 remembered. 
 
 The Bacillus coli communis is perhaps the 
 commonest bacterial agent. Pyelitis due to 
 the gonococcus may be looked upon as rare. 
 It should be remembered that the renal pelves 
 are made more liable to infection by the 
 presence of calculi. 
 
 The diagnosis of kidney stone is perhaps 
 
 [90] 
 
THE UPPER URINARY TRACT 
 
 less difficult than that of many of the other 
 affections of these organs, but nevertheless 
 many mistakes are made in a too hurried 
 verdict on the supposed condition. Stones in 
 the ureter are looked upon as much more 
 common than they formerly were, and their 
 diagnosis is certainly under better control. 
 The foregoing may represent the conditions 
 usually to be thought of first. Less common 
 surgical diseases of the kidneys are new 
 growths, cysts, actinomycosis, and injuries 
 due to external violence. 
 
 Of the ureters, strictures, kinks, and closure 
 of the lumen by the presence of tumors are 
 conditions met with from time to time. 
 
 When a patient comes to us with one or 
 more of the following complaints or signs, we 
 naturally turn our attention to the urinary 
 system : Pain along the course of the urinary 
 tract; disturbances of the act of micturition; 
 pathological conditions of the urine evinced 
 
 [91] 
 
THE UPPER URINARY TRACT 
 
 by the presence of blood, pus, albumin, 
 bacteria, etc. 
 
 The first step should be an explanation to 
 the patient of the fact that in troubles of this 
 nature an accurate knowledge of the condition 
 is essential. In many instances it requires 
 patience and time in order to collect the evi- 
 dence necessary for a diagnosis. Preparing 
 the patient's mind in this way at the outset is 
 much better than promising an early diagnosis 
 and losing the patient's confidence by a 
 failure. 
 
 It is folly to give an opinion without having 
 had sufficient opportunity for observation. 
 For example, there are cases where the finding 
 of the tubercle bacilli must determine the 
 lesion, cases in which we must repeat our in- 
 strumental examination, cases where fever or 
 pain masks the evidence we seek, and cases 
 where the secretion of the kidneys change 
 from day to day. 
 
 [92] 
 
THE UPPER URINARY TRACT 
 
 The history, both general and urinary, can- 
 not be too carefully taken and written down. 
 The physical examination should be a general 
 one, not focusing our attention too keenly 
 upon the urinary tract until we have satisfied 
 ourselves as to the patient's condition as a 
 whole. Proceeding then to the genitourinary 
 organs, if the patient is a male, the external 
 urinary meatus is inspected, so that a smear 
 or culture can be taken if it is deemed neces- 
 sary. He is then requested to pass his urine 
 into two or three glasses. Immediately after 
 this, if the history is suggestive of the presence 
 of residual urine, he is catheterized to deter- 
 mine its amount. 
 
 This time for getting the specimens of urine 
 is carefully chosen before we proceed to pal- 
 pation of the kidneys, ureters, bladder, 
 seminal vesicles, and prostate, otherwise the 
 evidence we seek from the urine, as it is 
 usually passed, might be very considerably 
 
 [93] 
 
THE UPPER URINARY TRACT 
 
 changed by elements artificially expressed 
 during the palpation of these organs. 
 
 Having obtained these preliminary speci- 
 mens of urine we continue the examination by 
 inspection and palpation. We start with the 
 kidneys, ureters, and bladder. Then the 
 external genitalia are examined, and finally 
 the rectal and bimanual examination of the 
 prostate, seminal vesicles, and bladder is 
 performed. If the patient is a female, the 
 preliminary specimens of urine can be col- 
 lected by the catheter, after which we can 
 make the physical examination of the urinary 
 organs. 
 
 The next step is determined by what we 
 have already learned from the history and 
 physical examination, plus what the physical, 
 chemical, and microscopical examination of 
 the urine shows. If it seems likely that one 
 or the other kidney or ureter is involved, the 
 patient's bladder is explored vrith the simple 
 
 [94] 
 
THE UPPER URINARY TRACT 
 
 prismatic cystoscope of the plain irrigating 
 type, as is indicated by the presence or 
 absence of cloudiness in the urine. 
 
 When the patient is catheterized before we 
 fill the bladder for the cystoscopy, this oppor- 
 tunity is taken to obtain by sterile means urine 
 which can be subjected to bacteriological 
 examination, if this is necessary. 
 
 By the cystoscopic examination we can 
 pretty definitely determine whether the trouble 
 lies in the bladder or above, and if the bladder 
 is not the source of the trouble, we can still 
 more definitely localize the disease by a care- 
 ful study of the ureteral mouths and of the 
 jets of urine emitted. 
 
 If, on the other hand, the bladder is the 
 seat of the trouble, it will be unnecessary to 
 collect the separate urines; and in such cases 
 urinary separation and the use of the ureter 
 catheterizing cystoscopes are contraindicated. 
 
 When we have gotten evidence that the 
 
 [95] 
 
THE UPPER URINARY TRACT 
 
 lesion lies in the urinary tract, higher up than 
 the bladder, and if we require for analysis the 
 secretion of the individual kidneys, or wish to 
 probe the ureters to determine their patency 
 or advance a styletted catheter to get an :x;-ray 
 picture, we then have the real indication for 
 the cystoscope which has been especially 
 designed for catheterizing the ureters. The 
 use of this in the proper cases is crowned by 
 the happiest results. 
 
 After the separate urines have been col- 
 lected, the relative action of the kidneys noted, 
 and the urines subjected to thorough analysis, 
 chemical, microscopical, and bacteriological, 
 we come to the point where good judgment 
 and a knowledge of pathological anatomy are 
 telling factors in the summing up of the evi- 
 dence thus far obtained. In cases likely to 
 come to operation, steps to determine the 
 status of the kidneys should be taken before 
 
 we further consider nephrectomy. 
 
 [96] 
 
THE UPPER URINARY TRACT 
 
 It is only by such deliberate and methodical 
 steps in history taking, in examination of the 
 patient, physically and instrumentally, and in 
 the complete analysis of the urine that we may 
 hope to come to a satisfactory diagnosis. 
 
 In reading this article over in order to 
 determine whether it shall be included in this 
 publication or discarded because of that 
 inevitable rust which permeates our methods 
 and ideas of yesterday, I have decided that it 
 shall cast its lot in with the others chosen, 
 and for this reason : it presents a sequence in 
 the steps taken toward a diagnosis which 
 the experience of the six years since it made 
 its appearance, has emphasized the import- 
 ance of making a routine. 
 
 A few important items have been added 
 
 to our equipment. The cysto-urethroscope 
 
 which makes simultaneous inspection of 
 
 bladder and posterior urethra possible ; radio- 
 
 7 [97] 
 
THE UPPER URINARY TRACT 
 
 graphic shadows of the urinary tract distended 
 with solutions of silver preparations such as 
 collargol and argyrol; ureteral catheters in 
 which a lead preparation is incorporated; 
 also for the purpose of the :r-ray shadow. 
 
 Of the phenolsulphonephthalein test men- 
 tion has been made elsewhere. The older 
 models of the catheterizing cystoscopes have 
 been much improved so that to-day we have 
 an instrument the shaft of which is uninter- 
 rupted by that depression near the concavity 
 of the beak which was a source of discomfort 
 and often traumatism. The irrigating system 
 of the newer instruments is easier of control 
 and more efficient. 
 
 When we add these items of recent acquisi- 
 tion to our previous store, we find ourselves 
 in possession of considerable riches of diag- 
 nostic possibiHties, when wisely employed. 
 
 [98] 
 
V 
 GONORRHEAL PROSTATITIS 
 
CHAPTER V 
 
 GONORRHEAL PROSTATITIS^ 
 
 The constancy with which prostatitis occurs 
 when gonorrhea invades the posterior urethra, 
 and the persistent nature of that inflammation 
 after the subjective symptoms, and the more 
 evident of the objective symptoms, have sub- 
 sided, give this condition the right to more 
 consideration. 
 
 That a gonorrheal inflammation of the 
 posterior urethra ever occurs without involv- 
 ing the prostatic ducts to a greater or less 
 degree seems unlikely. Anatomically, there 
 is little to invite a posterior urethritis to the 
 exclusion of the prostate. The character of 
 the epithelia, the scarcity of mucous glands, 
 and the almost vertical direction of the canal, 
 which is distended so much of the time with 
 
 ^ Read before the New York Academy of Medicine (Section on 
 Genitourinary Diseases) November 21, 1906. 
 
 Iioi] 
 
GONORRHEAL PROSTATITIS 
 
 urine and made one with the bladder cavity, 
 are factors against a theory that the prostatic 
 urethra can be affected with a gonorrheal 
 infection without the prostate participating. 
 
 Acute gonorrheal prostatitis — the division 
 of this affection into the catarrhal, the foUicul- 
 lar, and the parenchymatous forms — may 
 well be accepted as expressing the clinical 
 varieties, providing the tendency of one form 
 to merge into another is appreciated. 
 
 CATARRHAL PROSTATITIS 
 
 This form is by far the most frequent of the 
 acute varieties. It is highly probable that 
 with every posterior gonorrhea there is some 
 involvement of the prostate and though it 
 may extend but a short distance into the pros- 
 tatic ducts and be relatively mild, it is obvious 
 that its existence should be appreciated. 
 
 The symptoms of catarrhal prostatitis go 
 
 hand in hand with the symptoms of posterior 
 
 [102] 
 
GONORRHEAL PROSTATITIS 
 
 urethritis — the increased desire to urinate, 
 the cloudiness of both portions of urine, and 
 the characteristic small, round and comma- 
 shaped shreds which so often appear. These 
 filaments, when examined microscopically, 
 are usually small plugs or casts made up of 
 mucus, pus cells, cuboidal and cylindrical 
 epithelia, and gonococci. The prostatic ori- 
 gin of these shreds is not difficult to prove. If 
 after a portion of the urine is voided light 
 digital pressure is made on the prostate, the 
 shreds are squeezed into the urethra and 
 carried out with the urine which is then passed. 
 The danger of manipulating the prostate 
 during an acute inflammation of that organ is 
 ever to be borne in mind on account of its 
 tendency to produce not only an acute epidid- 
 ymitis but an extension of the prostatic involve- 
 ment as well. The clearing up of the acute 
 posterior urethritis is, I believe, seldom 
 accompanied with a resolution of the catar- 
 
 [103] 
 
GONORRHEAL PROSTATITIS 
 
 rhal prostatitis. Its tendency is to go on to a 
 chronic condition. 
 
 The diagnosis must usually be made by the 
 urine, as exairdnation of the gland by the 
 rectum frequently fails to show any change 
 in size or consistence or give any areas of 
 tenderness. 
 
 FOLLICULAR PROSTATITIS 
 
 This may be an extension of the catarrhal 
 form or it may follow directly the onset of an 
 acute urethritis posterior. The process of 
 mflammation extends in a selective way along 
 certain ducts toward the periphery of the 
 gland, and usually in its upper part, there to 
 establish, by purulent or cystic distension of 
 the alveoli, the small nodules or tender areas 
 detected by digital examination. The symp- 
 toms accompanying this phase of acute 
 prostatitis are not unlike those of the previous 
 variety — increased and usually painful urina- 
 
 [104] 
 
GONORRHEAL PROSTATITIS 
 
 tion, the pain intensified at the close of the 
 act; both urines cloudy; and the comma- 
 shaped shreds, which are seldom absent. 
 
 Follicular prostatitis, like the catarrhal, 
 tends to become chronic. The treatment 
 during the acute stage consists in the treat- 
 ment of the urethritis, by the avoidance of 
 bodily exercise, by the avoidance of local 
 manipulation of the prostate, and by the 
 avoidance of constipation, and the institution 
 of such measures as will tend to reduce the 
 existing congestion and inflammation. 
 
 PARENCHYMATOUS PROSTATITIS 
 
 In its milder forms this is clinically identi- 
 fied by the hyperemia or congestion of the 
 entire gland. By the rectum the prostate is 
 felt to be evenly swollen and smooth, and its 
 consistence is elastic or edematous, though, 
 from time to time, only one of the lateral lobes 
 is found thus affected. 
 
 [105] 
 
GONORRHEAL PROSTATITIS 
 
 Although the organ is distinctly sensitive 
 to pressure there is no sharp pain, but the 
 patient experiences a sense of fullness in the 
 perineum. Urination is made more difficult 
 and painful and defecation is attended with 
 pain and discomfort. There is no fever. The 
 condition under appropriate treatment may 
 subside in a few days and all subjective symp- 
 toms disappear or it may go on to chronic 
 prostatitis or take on the progressive course 
 which V7e recognize as the severer form of 
 parenchymatous prostatitis, and which at 
 times ends in abscess formation. Here we 
 find a patient suffering with a painful sense of 
 pressure and swelling in the perineum and 
 rectum. Micturition usually becomes difficult 
 and painful, though in some cases this is 
 absent, while in other cases there is complete 
 retention. Pain may radiate to the glans 
 penis, to the thighs or across the back. Defe- 
 cation may be very painful and erections and 
 
 [io6] 
 
GONORRHEAL PROSTATITIS 
 
 pollutions distressing. Fever may be present 
 and accompanied by chills, though Casper 
 had twenty-one cases which went on to 
 prostatic abscess, and among them only four 
 had a rise of temperature. On palpation the 
 neighboring parts are found extremely sen- 
 sitive, while the rectal examination of the 
 prostate is exquisitely painful. 
 
 The gland is found swollen to twice or four 
 times its normal size. It feels hot and is hard 
 and tense, being sharply defined against the 
 surrounding softer structures. Its surface is 
 smooth, seldom irregular and one side only 
 may be affected. 
 
 Notwithstanding the severity of the process, 
 
 it may not go on to abscess formation, but, in 
 
 from one to two wTeks, the symptoms may 
 
 subside and resolution take place. This, 
 
 fortunately, occurs in the larger proportion of 
 
 cases, which then go on to a chronic condition. 
 
 When suppuration does occur, the clinical 
 
 [107] 
 
GONORRHEAL PROSTATITIS 
 
 picture usually becomes intensified. The 
 pain on urination is increased, ischuria is 
 common and the prostate becomes a pulsating 
 and painful tumor. Rectal tenesmus is con- 
 stant. The temperature rises, the tongue 
 becomes dry, thirst is intense and the appetite 
 gone ; headache and backache ensue. Throm- 
 bosis of the periprostatic venous plexus, or in 
 the prostatic veins themselves, may take place 
 and go on to a typical occurrence of pyemia. 
 It is usually not difficult to detect suppuration 
 in the inflamed prostate. 
 
 Surgical interference is at this moment 
 demanded. If it is delayed, the abscess 
 usually empties itself, and most commonly into 
 the urethra. The urine then becomes loaded 
 with the products of suppuration, and the 
 fever, the dysuria and the rectal tenesmus 
 rapidly subside. It may be that the evacua- 
 tion of pus is incomplete, and in this instance 
 the disappearance of symptoms is delayed 
 
 [io8] 
 
GONORRHEAL PROSTATITIS 
 
 and the process may proceed to a chronic 
 condition. Complications, such as infiltra- 
 tion of urine, gangrene, chronic septicemia, or 
 fistula, at times ensue. 
 
 Next in frequency to the urethra as an exit 
 for the pus, come the rectum and the perineum 
 in the order given. In Segond's collection of 
 I02 cases, perforation occurred sixty-four 
 times into the urethra, forty-three times into 
 the rectum, fifteen times into the perineum, 
 eight times into the ischiorectal space, three 
 times in the inguinal region, twice through the 
 obturator foramen and once each through the 
 navel, through the ischiatic foramen, at the 
 border of a false rib, into the abdominal cavity 
 and into the space of Retzius. The after- 
 results of prostatic abscess may be chronic 
 suppuration, neurasthenia, impotentia gener- 
 andi, stricture of the rectum, etc. It is to be 
 borne in mind that besides the complications 
 
 which not infrequently attend suppurative 
 
 [109] 
 
GONORRHEAL PROSTATITIS 
 
 prostatitis the mortality is considerable. In 
 the 1 02 cases of Segond's referred to above, 
 there was a 34 per cent, death rate. This is, 
 however, considered very much too high 
 according to other observers. 
 
 The treatment of these severer forms of 
 parenchymatous prostatitis is both general 
 and local. The patient should be put to 
 bed, a light diet given and the lower bowel 
 kept empty. Urinary antiseptics should be 
 given and warm applications or sitz baths 
 prescribed. Early in the process the direct 
 application of cold to the prostate by means 
 of one of the instruments designed for that 
 purpose is often apparently of great benefit. 
 The severer pain and dysuria must be con- 
 trolled by opium or its alkaloids. A com- 
 plete retention of urine demands catheteriza- 
 tion. With the breaking down of the process 
 into abscess formation comes the necessity 
 
 for surgical relief. 
 
 [no] 
 
GONORRHEAL PROSTATITIS 
 
 i 
 
 CHRONIC PROSTATITIS 
 
 This condition assumes a degree of impor- 
 tance which the acute varieties cannot 
 approach. On the score of infectiousness 
 acute prostatitis is little to be feared, as the 
 active and painful nature of the condition 
 renders the individual practically incapable of 
 sexual intercourse. On the other hand, 
 chronic prostatitis, which is so often wholly 
 devoid of subjective symptoms, is probably a 
 fertile source of the infection of women. In 
 this connection it is to be especially noted that 
 the great majority if not all of the acute 
 inflammations of the prostate pass on to a 
 chronic condition. 
 
 To divide chronic prostatitis, of which the 
 
 chief etiologic factor is the gonococcus, into 
 
 pathological and clinical varieties is of little 
 
 moment. Clinically, the disease gives little 
 
 evidence that can be put down as surely 
 
 [III] 
 
GONORRHEAL PROSTATITIS 
 
 characteristic of one or another variety, and 
 pathologically we usually find, in the same 
 prostate, changes belonging to various forms 
 of inflammation. At the same time the fact 
 is not to be overlooked that chronic gonorrheal 
 prostatitis varies much in degree and in resist- 
 ance to treatment. 
 
 Symptoms. — The majority of cases of 
 chronic prostatitis run a mild course without 
 subjective symptoms, the patients voiding 
 perfectly clear urine. In others the symptoms 
 are so well masked by the persistence of a 
 urethritis that a precise diagnosis is difficult. 
 In the remaining class, however, some of the 
 characteristic symptoms appear : Disturbance 
 of urination, the changes in the sexual func- 
 tion, abnormal sensations, referred pains, 
 neurasthenia, suffering from pains across the 
 back, down the thighs or in the testicles, con- 
 stipation, pain before and after defecation, 
 headache and mental depression. With some 
 
 [112] 
 
GONORRHEAL PROSTATITIS 
 
 patients frequency of micturition, which may 
 be attended with pain, is the most prominent 
 symptom and to this may be added the sense 
 of not having completely emptied the bladder. 
 With other patients the disturbances of the 
 sexual function seems to stand out as the chief 
 difficulty, such as absence of normal sensation 
 at the moment of ejaculation, pain with the 
 seminal discharge, distressing and persistent 
 erections at night, premature ejaculations and 
 decreasing sexual ability. It is in these indi- 
 viduals that we most frequently see the best 
 marked types of sexual neurasthenia. 
 
 Some authors hold that prostatorrhea is one 
 of the chief symptoms of chronic prostatitis. 
 The writer's experience coincides with those 
 who consider prostatorrhea as an unusual 
 occurrence in this condition. The combina- 
 tion of chronic prostatitis and cystitis is by no 
 means uncommon. In these cases the treat- 
 ment of cystitis without recognition of the 
 8 [113] 
 
GONORRHEAL PROSTATITIS 
 
 prostatitis, and attention to it, proves very 
 disappointing. 
 
 All cases of persistent urethral discharge 
 or a persistent morning drop or those cases 
 with a chronic and constantly recurring dis- 
 charge, should be suspected and examined for 
 prostatitis. 
 
 Diagnosis, — Although the subjective symp- 
 toms give a valuable clue to the condition, an 
 exact diagnosis cannot be made vdthout digital 
 exploration of the prostate by the rectum and 
 what is more important, microscopic examina- 
 tion of the expressed prostatic secretion. 
 
 A knowledge of how the normal gland 
 should feel in the different periods of life is 
 essential to the appreciation of size, configu- 
 ration, consistence and sensitiveness of the 
 diseased organ. The changes in prostatitis 
 noted by palpation are many. The gland is 
 usually larger than normal, although this is 
 by no means always the case, for in some 
 
 [114] 
 
GONORRHEAL PROSTATITIS 
 
 instances it is found markedly atrophic. 
 Frequently one lateral lobe only is affected, or 
 the organ may be very irregular in outline and 
 feel as though it were made up of many lobes. 
 Modulation may be abundant or there may be 
 but one or two nodes and these may vary in 
 size, consistence and location, but they are 
 usually about the size of a pea, hard, and 
 situated nearer the upper part of the gland. 
 The general enlargement of the prostate which 
 results from a parenchymatous prostatitis 
 usually gives an edematous feel to the organ, 
 having lost its normal firm and elastic con- 
 sistence, it becomes, as some authors put it, 
 flabby, this var3dng much in degree. 
 
 The condition following the follicular form 
 is varied. The gland, as a rule, is not so 
 large as in the post-parenchymatous condition, 
 but is usually harder, while here and there 
 distinctly soft spots may be felt and the nod- 
 ules are few or many, localized or scattered, as 
 
 [115] 
 
GONORRHEAL PROSTATITIS 
 
 the case may be. Where there has been sup- 
 puration with escape of the pus, involving the 
 whole gland, or one lateral lobe, or as in the 
 follicular variety, small areas, the character- 
 istic changes of contraction and firm cicatrices 
 result and give that sense to the examining 
 finger. In other cases there is no change in 
 the prostate that can be appreciated by digital 
 exploration, and no degree of sensitiveness; in 
 these cases the diagnosis depends alone on the 
 study of the prostatic fluid. Pain on palpa- 
 tion of the prostate is generally a sign of dis- 
 ease, but by no means always, and painful 
 areas are not infrequently found in prostates 
 otherwise negative to the digital touch. 
 
 The secretion which is collected at the 
 external urinary meatus upon digital com- 
 pression of the prostate, after the urethra has 
 been cleansed by urination or irrigation, con- 
 sists normally of a thin, milky fluid, at times 
 
 slightly viscid. Its specific gravity is but 
 
 [ii6] 
 
GONORRHEAL PROSTATITIS 
 
 little higher than that of water, it is usually 
 faintly alkaline to the litmus test, and consists 
 microscopically of lecithin globules, varying in 
 size and usually present in great numbers, and 
 epithelia which are partly cuboidal and partly 
 columnar. A few leucocytes are normally 
 present and occasionally some red corpuscles. 
 Hyaline bodies of considerable diameter and 
 the so-called corpora amylacea are not infre- 
 quently seen. 
 
 The changes from normal which most 
 commonly take place in the prostatic fluid are 
 in consistence and color. It becomes thicker, 
 often flaky and yellowish or greenish-yellow 
 from the addition of pus. Under the micro- 
 scope there are added to the field of lecithin 
 bodies pus corpuscles in varying numbers, 
 scattered or in clumps, depending on the 
 extent or kind of inflammation. In like man- 
 ner epithelia from the ducts and alveoli are 
 added, and these in different stages of degen- 
 
 [117] 
 
GONORRHEAL PROSTATITIS 
 
 eration. Fat globules may be seen free in the 
 field or in the epithelia or pus cells. 
 
 The corpora amylacea seem to be much less 
 frequently seen in gonorrheal prostatitis. It 
 is to be especially remembered that as long as 
 the presence of pus cells can be demonstrated 
 a pathologic condition exists. Gonococci 
 may be found in the pus cells and the fact 
 that we cannot find them is not proof of their 
 complete disappearance. 
 
 Prognosis. — When is the danger of infecting 
 others past ? When is a chronic gonorrheal 
 prostatitis cured? To these questions no 
 clean cut answer can be given. 
 
 When the urine contains no more shreds or 
 
 other abnormal elements, and the prostatic 
 
 fluid is free from pus cells, and repeated search 
 
 for gonococci with the microscope and by 
 
 culture test fails, certainly we have no grounds 
 
 on which to maintain that the patient is still 
 
 afflicted with an infectious disease. But on 
 
 [ii8] 
 
GONORRHEAL PROSTATITIS 
 
 the other hand, we cannot positively say that 
 such individuals have become noninfectious. 
 
 After a few months or a year we find, in a 
 large number of the cases, the presence of 
 gonococci impossible of proof. Unfortu- 
 nately, the mixed infection, which almost 
 always complicates these cases, renders the 
 task of clearing the prostatic fluid of pus cells 
 exceedingly difficult, if not impossible. Al- 
 though it has been stated that so long as pus 
 cells remain a pathologic condition exists, yet 
 experience has taught that these cases are by 
 no means always infectious. 
 
 From the observation of 120 cases, von 
 Notthaf t has come to the following conclusions : 
 
 I . In the second half year after the infection 
 there was 73 per cent, of the cases in which the 
 gonococci could be proved to be present in the 
 prostatic secretion. In the third half year 
 this percentage fell to 50, in the fourth half 
 year to 18, in the third year to 6. From the 
 
 [119] 
 
GONORRHEAL PROSTATITIS 
 
 end of the third year no gonococci could be 
 found in the prostatic secretion. 
 
 2. In the second half year there were other 
 bacteria besides gonococci found in the pros- 
 tatic secretion. In the fourth half year there 
 were no cases in which a pure gonococcic 
 infection could be demonstrated. 
 
 In a few patients from whom the writer 
 made cultures the results were in accord with 
 Notthaft's series so far as mixed infection was 
 concerned, but in none of the writer's cases 
 were gonococci found by either the micro- 
 scope or culture, yet in five cases out of the 
 eight, considerably over 50 per cent., the 
 infection was less than eighteen months old. 
 In seven out of the eight cases there was a 
 growth of Staphylococcus albus, and in two 
 of these there was added a growth of 
 Bacillus xerosis. In one case there was no 
 growth. 
 
 The conclusions to be drawn are that there is 
 
 [120] 
 
GONORRHEAL PROSTATITIS 
 
 difficulty in proving the presence of gonococci 
 in these older cases of chronic gonorrheal 
 prostatitis, and that other organisms play an 
 active part in the bacteriology of this affection. 
 
 Treatment. — Where a urethritis exists, 
 either anterior or posterior, therapeutic meas- 
 ures designed for the cure of this condition 
 must be instituted. For the treatment of the 
 chronically diseased prostate, massage of that 
 organ by the rectum, constitutes the most 
 important element of the treatment. The 
 bladder should be filled with some such mildly 
 astringent antiseptic as protargol, 1/2 of i per 
 cent, solution. In very many cases dilatation 
 of the prostatic urethra, either by sound or 
 dilator, is helpful in the treatment by virtue 
 of the internal massage and stretching it 
 exerts, especially on the mouths of the 
 prostatic ducts. 
 
 Digital massage, to be useful, must be done 
 
 in a systematic and purposeful manner. 
 
 [121] 
 
GONORRHEAL PROSTATITIS 
 
 Starting at the external upper part of the 
 lateral lobe, the massaging finger-tip works its 
 way toward the median line of the gland, again 
 it is carried to the external border, immediately 
 below the previous path of massage, and again 
 worked toward the center. This is continued 
 until each lateral lobe has been thoroughly 
 gone over. Then the finger is swept over the 
 lateral lobes downward and toward the center, 
 emphasizing the pressure brought to bear on 
 the median line, that the secretion may thus 
 better be expressed into the urethra. The 
 patient then voids the solution which has been 
 left in the bladder, which thus washes out the 
 urethra and comes in contact with the recently 
 emptied prostatic ducts, which as some think, 
 may take up some of the solution on the 
 principle of a sponge which has been com- 
 pressed and is allowed to expand while in con- 
 tact with a fluid. This massage has two dis- 
 tinctly beneficial elements. It empties the 
 
 [122] 
 
GONORRHEAL PROSTATITIS 
 
 alveoli and their ducts of the perverted secre- 
 tions which have accumulated, and it stimu- 
 lates a more active circulation throughout the 
 entire gland. 
 
 Again a warning against the danger of 
 extending the process in massaging a prostate 
 in which there still exists any active inflam- 
 mation. 
 
 The massage which is done very gently at 
 first, should be repeated once, twice or some- 
 times three times a week, depending on the 
 necessity of the case. A few weeks' period of 
 treatment for the milder cases up to many 
 months of treatment for the severer cases, is 
 required. Besides massage, such measures as 
 electricity or heat and cold applied to the pros- 
 tate may in certain instances be helpful. 
 Medicinal suppositories as ichthyol, have a 
 useful place in the treatment of prostatitis. 
 
 The advancement of the patient's general 
 condition cannot be neglected and freedom 
 
 [123] 
 
GONORRHEAL PROSTATITIS 
 
 from worry or other untoward influences must 
 be secured. Favorable progress of the pros- 
 tatitis is appreciated partly by the changes in 
 the gland felt by the rectum, but more especi- 
 ally by the study of the prostatic elements 
 microscopically. Improvement in subjective 
 symptoms is unreliable. 
 
 Although the treatment is usually long and 
 trying, taxing the patience of the physician 
 and his patient, yet with well directed and 
 conscientious care on the part of the physician 
 and earnest cooperation on the part of the 
 patient, the latter will be freed, in the greater 
 majority of cases, from the danger of infec- 
 tiousness and other consequences of chronic 
 gonorrheal prostatitis. 
 
 Since this paper was written my ideas as to 
 the treatment of chronic gonorrheal prostatitis 
 have undergone some changes, until to-day I 
 
 find myself no longer believing in the continu- 
 
 [124] 
 
GONORRHEAL PROSTATITIS 
 
 ous treatment by massage, etc., of these pa- 
 tients. Although the mode of such local treat- 
 ment has not been improved upon, the manner 
 of application has. At present I find it better 
 to give these patients their treatment inter- 
 mittently — three or four weeks' treatment, 
 then three or four weeks' rest. The value 
 of promoting a cheerful and hopeful frame of 
 mind and the encouragement of agreeable 
 outdoor recreation and the establishment of 
 more normal ways of living generally, I try 
 to impress upon my patients is probably of 
 more value than the local treatment, or in 
 other words, without this general improve- 
 ment in one's ways of living the local treatment 
 is oftentimes of little or no use. 
 
 In many of the cases with long standing 
 disease and no sign of improvement under 
 the foregoing regime, nothing short of a 
 complete change of living conditions is of 
 any avail and these patients should be sent 
 
 [125] 
 
GONORRHEAL PROSTATITIS 
 
 from the city and put under precisely the 
 same influence of environment as is the tuber- 
 culous individual, if we hope to arrest the 
 slow and insidious process of glandular de- 
 struction and look for a satisfactory improve- 
 ment and perhaps cure. 
 
 [126] 
 
VI 
 
 COMPARATIVE VALUE OF SOME 
 URETHRAL AND OTHER GERMICIDES 
 
CHAPTER VI 
 
 COMPARATIVE VALUE OF SOME URETHEAL AND 
 OTHER GEEMICrDES^ 
 
 Tece experiments conducted by Dr. L. A. 
 Wylie and myself which form the basis of this 
 contribution were done under the kind direc- 
 tion of Dr. Charles Norris, director of the 
 pathologic department of Bellevue Hospital. 
 
 The method employed was as follows: 
 To 2 c.c. of the various dilutions of antiseptics 
 to be tested, were added 2 c.c. of salt emulsion 
 of the organisms used. It will immediately 
 be seen that this procedure diluted to one-half 
 the antiseptic solution. To equalize this, 
 double the strength of the antiseptic solution 
 was used. The silver preparations were 
 bought in original bottles and prepared ac- 
 
 1 Read before the American Association of Genitourinary Sur- 
 geons, New York, June i, 191 1. 
 
 9 [129] 
 
URETHRAL AND OTHER GERMICIDES 
 
 cording to directions. The liquor cresolis 
 compositus, under the commercial name of 
 lysol, was from the hospital drug supply. 
 
 In the case of each organism but a single 
 strain was employed. Controls for each 
 organism were made and the average number 
 of colonies, per plate, were noted. The tubes 
 in which the bacteria were exposed to the 
 different solutions of the different germicides, 
 were left for a period of five, fifteen and thirty 
 minutes, respectively. Then one loopful from 
 each tube was mixed into a tube of acetic- 
 agar and poured into a sterile Petri dish. 
 These were incubated at 37 c. and observed at 
 the end of twenty-four and forty-eight hours. 
 The accompanying results are tabulated after 
 the manner of Post and NicoU, whose tables 
 appear in The Journal of the American Med- 
 ical Association, Iv, 1635. 
 
 In the case of argyrol, it is to be noted that 
 our results are not in accord with those of 
 
 [130] 
 
URETHRAL AND OTHER GERMICIDES 
 
 others whose results we have reviewed. We 
 have no explanation for this difference. 
 
 It has already been demonstrated by a 
 number of laboratory workers that the killing 
 power in vitro of the several silver prepara- 
 tions is weak or nil as compared with the ac- 
 tion of silver nitrate. 
 
 It would seem superfluous to add another 
 protest to the list were it not for the deep root 
 this idea has taken that the silver preparations 
 hold some peculiar power not possessed by 
 silver nitrate in its various degrees of dilution. 
 
 The majority of these silver preparations 
 seem to hold a peculiar innocuousness which, 
 along with their taking color in solution, play 
 a part in urethral medication which fortu- 
 nately interferes very little with Nature's 
 efforts toward recovery. In fact, they have 
 constituted a means of cleansing the sur- 
 face, of dilating the urethral canal, and, in the 
 
 case of the more irritating members of their 
 
 [131] 
 
URETHRAL AND OTHER GERMICIDES 
 
 large family, of causing mild and transient 
 hyperemia, which is a real augment to Na- 
 ture's plan. 
 
 For the privilege of subscribing to their use 
 the dues are about fifty times larger than 
 when an equally efficient dilution of silver 
 nitrate is chosen. This is a consideration 
 when suppl3dng a large hospital. 
 
 Bellevueand AUied Hospital spent last year: 
 
 For silver nitrate $ 108.00 
 
 For coUargolum 25 .00 
 
 For protargol 224.00 
 
 For argyrol 910 . 00 
 
 Total $1,267.00 
 
 To determine the power of penetration, 
 Wildbolz, of Bern, has done a series of experi- 
 ments with silver nitrate and protargol on the 
 living mucous membranes of the eye and 
 urethra in dogs — a reduction of the silver 
 being accompHshed by exposure to a Finsen 
 light. In the urethra he used 1:1000 to 
 
 [132] 
 
URETHRAL AND OTHER GERMICIDES 
 
 i:ioo silver nitrate and i per cent, to 3 per 
 cent, protargol solutions. There was some 
 penetration of the metal down to the subepi- 
 thelial tissue. In penetrating power, the 
 silver nitrate easily predominated. 
 
 NUMBER OF COLONIES IN ONE LOOPFUL TEST SOLUTION 
 AFTER TWENTY-FOUR HOURS' INCUBATION 
 
 S 15 30 
 
 Solution Organism Min. Min. Min. 
 
 Argyrol 30 per cent. Strep o o o 
 
 " 30 per cent. Staph o o o 
 
 " 30 per cent. B. coli 000 
 
 " 30 per cent. Gon 70 50 10 
 
 " 10 per cent. Strep 400 
 
 " 10 per cent. Staph o o o 
 
 " 10 percent. B. coli 000 
 
 '* 10 per cent. Gon 90 70 50 
 
 " I per cent. Strep 50 35 35 
 
 I percent. Staph 100 75 100 
 
 I per cent. B. coli iiSoo 500 100 
 
 " 1 percent, Gon 120 50 25 
 
 Protargol 10 per cent. Strep....,,... 25 20 20 
 
 10 per cent. Staph. ....... 100 1 75 
 
 " 10 per cent, B. coli 000 
 
 10 per cent. Gon 30 15 25 
 
 " S percent. Strep 49 31 26 
 
 5 per cent. Staph 150 50 50 
 
 " 5 percent. B. coli o 100 25 
 
 [^33] 
 
URETHRAL AND OTHER GERMICIDES 
 
 Solution 
 Protargol . . 
 
 Silver nitrate. 
 
 . 5 per cent. 
 I per cent. 
 I per cent. 
 I per cent. 
 
 1 per cent. 
 
 . 2 per cent. 
 
 2 per cent. 
 2 per cent. 
 2 per cent. 
 I per cent. 
 I per cent. 
 I per cent. 
 I per cent. 
 
 1/2 per cent. 
 
 1/2 per cent. 
 
 1/2 per cent. 
 
 1/2 per cent. 
 I to 1,000 
 I to 1,000 
 I to 1,000 
 I to 1,000 
 I to 5,000 
 I to 5, 000 
 I to s.ooo 
 I to s.ooo 
 I to 10,000 
 I to 10,000 
 I to 10,000 
 I to 10,000 
 
 5 
 
 Organism Min. 
 
 Gon 90 
 
 Strep 48 
 
 Staph 00 
 
 B. coli 1,000 
 
 Gon 100 
 
 Strep o 
 
 Staph o 
 
 B. coli o 
 
 Gon o 
 
 Strep 6 
 
 Staph o 
 
 B. coU 10 
 
 Gon o 
 
 Strep 10 
 
 Staph o 
 
 B. coli 100 
 
 Gon o 
 
 Strep IS 
 
 Staph 7 
 
 B. coli 600 
 
 Gon o 
 
 Strep 23 
 
 Staph 10 
 
 B. coli 1,000 
 
 Gon o 
 
 Strep 44 
 
 Staph 22 
 
 B. coli 00 
 
 Gon S2S 
 
 IS 
 
 30 
 
 Min. 
 
 Min. 
 
 SO 
 
 35 
 
 44 
 
 39 
 
 200 
 
 150 
 
 700 
 
 200 
 
 35 
 
 25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 
 
 
 
 
 
 
 
 IS 
 
 SO 
 
 
 
 
 
 8 
 
 
 
 
 
 
 
 36 
 
 10 
 
 
 
 
 
 70 
 
 6 
 
 14 
 
 5 
 
 500 
 
 300 
 
 
 
 
 
 40 
 
 IS 
 
 6 
 
 3 
 
 S.ooo 
 
 S.ooo 
 
 
 
 
 
 26 
 
 SO 
 
 5 
 
 3 
 
 00 
 
 00 
 
 40 
 
 20 
 
 [134] 
 
URETHRAL AND OTHER GERMICIDES 
 
 5 
 
 Solution Organism Min. 
 
 Cresol Comp.... lo per cent. Strep o 
 
 lo per cent. Staph o 
 
 lo percent. B. coli o 
 
 lo per cent. Gon o 
 
 S per cent. Strep o 
 
 5 per cent. Staph o 
 
 5 per cent. B. coli o 
 
 5 per cent. Gon o 
 
 2 . 5 per cent. Strep o 
 
 2 . s per cent. Staph 5 
 
 2 . 5 per cent. B. coli o 
 
 2.S per cent. Gon o 
 
 1 . 2 per cent. Strep o 
 
 1 . 2 per cent. Staph 4 
 
 1 . 2 per cent. B. coli 200 
 
 1.2 per cent. Gon 550 
 
 o . s per cent. Strep 3 
 
 0.5 per cent. Staph 8 
 
 o . 5 per cent B. coli CXD 
 
 0.5 per cent. Gon 600 
 
 CoUargolum.. . 2.5 per cent. Strep 15 
 
 2 . 5 per cent. Staph 15 
 
 2 . s per cent. B. coli o 
 
 2 . 5 per cent. Gon 80 
 
 1.25 percent. Strep 25 
 
 1.25 per cent. Staph 00 
 
 1. 25 percent. B. coli o 
 
 1.25 percent. Gon 120 
 
 Cargentos .... 20 per cent. Strep o 
 
 " 20 per cent. Staph 7 
 
 [135] 
 
 IS 
 
 30 
 
 Min. 
 
 Min. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 300 
 
 
 
 
 
 
 
 
 
 
 
 40 
 
 16 
 
 500 
 
 100 
 
 8 
 
 
 
 I 
 
 
 
 
 
 
 
 100 
 
 15 
 
 12 
 
 10 
 
 100 
 
 100 
 
 100 
 
 100 
 
 100 
 
 75 
 
 
 
 
 
 
 
 
 
URETHRAL AND OTHER GERMICIDES 
 
 5 IS 30 
 
 Solution Organism Min. Min. Min. 
 
 Cargentos i i . . ; 20 per cent. B. coli o o o 
 
 " 20 per cent. Gon 18 10 o 
 
 " 5 per cent. Strep 28 20 15 
 
 " 5 per cent. Staph 50 2 20 
 
 " 5 percent, B. coli 000 
 
 " 5 percent. Gon 75 o 50 
 
 00= Infinite number of colonies per plate. 
 
 As to the value of antiseptics penetrating 
 below the surface: In order to check up the 
 work of other experimenters, Derby, of 
 Boston, made a series of observations as 
 follows: He took samples of sterile hydrocele 
 fluid and bovine serum; to i c.c. of the serum 
 he mixed i c.c. of the silver preparation to be 
 tested and to this he exposed the staphylococ- 
 cus. The nitrate of silver, 2 per cent., 
 showed a growth of the organisms after an 
 exposure of from thirty to forty minutes; the 
 protargol, 8 per cent., after sixty minutes; the 
 argyrol, 50 per cent., gave an abundant 
 growth after three and one-half hours. Other 
 . preparations showed the same results. 
 
 [136] 
 
URETHRAL AND OTHER GERMICIDES 
 
 This goes to show how completely the body 
 fluids can destroy the bactericidal power of 
 antiseptics when brought into contact with 
 them, and how little advantage there can be 
 in a drug having the power to penetrate below 
 the surface. 
 
 Literature 
 
 1. G. S. Derby. "An Experimental Study on the 
 Bactericidal Process of Various Silver Preparations." 
 Boston M. andS. Journal, 1906-clv. 341-343. 
 
 2. Muller. ''Ein Kleiner Beitrag zum Kenntniss der 
 Wirkung der Silber verbindungen." Berlin thierarztl, 
 wchnschr, 1902, page 267. 
 
 3. W. A. Puchner. *'The Chemistry of the Organic 
 Silver Compounds." A. M. A. Journal, Chicago, 1906, 
 xiv, II, 1256. 
 
 Professor of Chemistry, University of 111. School of 
 Pharmacy, Chicago. 
 
 4. H. Wildbolz. "Experimentelle Untersuchingen uber 
 die Wirkung von Silber Nitrat und Protargollosungen auf 
 labende Schleimhaute." Ztschr. f. Urolog., Berlin v. 
 Leipz, 1907, 185, 200. 
 
 5. E. B. Cragin. ''The Prophylactic and Curative 
 
 [137] 
 
URETHRAL AND OTHER GERMICIDES 
 
 Treatment of Ophthalmia Moenatonun." Journal of 
 Surgery, Gynecology and Obstetrics, 1907. 
 
 6. J. Burdon Cooper, M. D. B. S., BSc, F. R. C. 
 
 S. S. E. "Argyroris, Including a Preliminary Note on the 
 Action of Silver Salts." Ophthalmoscope, 1907, page i6_ 
 
 7. Lohnstein. "Experimentelle Unterzuchen uber die 
 Wirkung einiger Silberpraparate auf die Harnrohre des 
 Kaninchens." Monatsberichte f. Urologie. Bdg., 1904. 
 
 8. Post and NicoU. "The Comparative Efficiency of 
 Some Common Germicides." A. M. A. Journal, Nov 
 5th, 1910, vol. Iv. 
 
 9. Anderson, J. F. and McClintic, T. B.- "A Method 
 for the Bacteriological Standardization of Disinfectants.' 
 Jour. Infect. Dis., January 3, 191 1. 
 
 10. Phelps, EarleB.- "The Application of Certain Laws 
 of Physical Chemistry in the Standardization of Disin- 
 fectants." Jour. Infect. Dis., January 3, 191 1. 
 
 11. Kendall, A. E. and Martin, Edw. "A Method for 
 Determining the Germicidal Value and Penetrating 
 Power of Liquid Disinfectants." Jour. Infect. Dis., 
 March 6, 1911. 
 
 12. Rideal, S. and Walker, J. S. A. Jour. Royal 
 London Inst., London, 1903. 
 
 13. Chick, H., and Martin, C. J. Journal Hyg.j 
 London, Nov., 1908. 
 
 [138] 
 
VII 
 
 ON WHAT IS NEW IN GENITOURINARY 
 SURGERY 
 
CHAPTER VII 
 
 ON WHAT IS NEW IN GENITOURINARY SURGERY 
 
 For recent attainments in this department of 
 medicine the pubHc, at large, though it is not 
 Hkely to know it, has reason to be grateful, 
 for they deal in the main with what is practi- 
 cally the most important function of the 
 physician — that of diagnosis. 
 
 This little book being in no sense a text- 
 book the reference to what is new will be but 
 tersely given; merely that the progress in 
 this branch of work may be remarked. 
 
 Appended to some of the essays mention has 
 been made or short descriptions given of such 
 of the newer methods or appliances as would 
 help to bring the subjects dealt with up-to- 
 date, they will on that account be omitted 
 
 here. 
 
 [141I 
 
GENITOURINARY SURGERY 
 
 The intra-vesical treatment of papillomata 
 by means of a high frequency current spark 
 has arrested the attention of the genito- 
 urinary surgeon — and wisely, for the results 
 of the cutting operation for these growths 
 has been far from satisfactory owing to the 
 frequency of their recurrence and the alarming 
 percentage of their malignancy. The appli- 
 cation of the high frequency (Oudin) current 
 spark to these tumors is a simple procedure 
 carried out by passing the insulated wire 
 through the catheter canal of a cystoscope 
 and the growth thus cauterized. The opera- 
 tion causes little or no more discomfort than 
 an ordinary cystoscopy for ureter catheteri- 
 zation and one to three or four applications 
 of a few seconds to a few minutes has been 
 sufficient in the majority of cases thus far 
 reported to effect a complete disappearance 
 of the tumor. Although the cases have been 
 
 too few and the time too short to speak 
 
 [142] 
 
GENITOURINARY SURGERY 
 
 definitely as to the permanency of the cure 
 two things are certain, a major operation 
 under general anesthesia is avoided and there 
 is no bladder scar to invite a recurrence. 
 
 It would seem unnecessary to add that the 
 most promising results are to be expected 
 from young growths not deeply rooted. In 
 this connection it might be said to those 
 who have an eye open for urinary ills, verbum 
 sat sapienti. For this mode of treating 
 bladder tumors we are indebted to Edwin 
 Beer, of New York. 
 
 When the news of a complement-fixation 
 test for the diagnosis of gonococcic infections 
 made itself heard, there was reason for 
 rejoicing, even before it was proved to be of 
 any value there was reason for rejoicing, for 
 here was evidence of serious thought and 
 scientific interest being bestowed on this dis- 
 dained and neglected diplococcus. It is 
 hardly a year since Schwartz and McNeil 
 
 [143] 
 
GENITOURINARY SURGERY 
 
 published their experiments applying the 
 complement-fixation test to 324 human sera. 
 The results of these experiments give promise 
 of much needed aid in the diagnosis of certain 
 chronic gonococcic infections, the very cases 
 in which we are in most need of more definite 
 data, in order to afifirm or dispel the fear of 
 the lingering infection. 
 
 The subject of the treatment of gonococcic 
 infections with vaccines or bacterins is, as 
 yet, not concluded. Painstaking work is 
 still beiag pushed along this fine, but at 
 present, with the possible exception of the 
 joint cases, there is little definite evidence to 
 encourage the thought that a distinctly useful 
 means of therapy has been found. 
 
 The last six or seven years' trial of tuber- 
 culin in genitourinary tuberculosis has light- 
 ened the burden of prognosis encouragingly. 
 
 In the shortness of this chapter no injustice 
 to the subjects has been intended; they are too 
 
 [144] 
 
GENITOURINARY SURGERY 
 
 important to be but partially described; to 
 have dealt in detail with them would have 
 carried this small volume beyond its design, 
 therefore, they have been but mentioned. 
 
 10 [145] 
 
VIII 
 
 IS GENITOURINARY SURGERY JUSTIFIED 
 AS A SPECIAL BRANCH OF MEDICINE? 
 
CHAPTER VIII 
 
 IS GENITOURINARY SURGERY JTJSTIEIED AS A 
 SPECIAL BRANCH OF MEDICINE? 
 
 The extent to which medical knowledge has 
 grown has forced a division, for the sake of 
 progression and administration, of that knowl- 
 edge; yet we still remain saddled with an 
 awkward problem. 
 
 That which constitutes a specialty and that 
 which justifies it are two different things ; yet 
 they are in very close relation. The clear 
 definition of what any special branch of 
 medicine consists is essential to the life of 
 that special branch. The justification of 
 any special branch of medicine is its results 
 as an organized body in a special field. 
 
 If any general surgeon can prepare himself 
 to treat flat feet as well as the orthopedic 
 
 [149] 
 
GENITOURINARY SURGERY 
 
 surgeon, it makes very little difference to the 
 department of orthopedic surgery; but, if 
 the department of general surgery prepares 
 itself as a body to treat flat feet as well or 
 better than the orthopedic surgeons can, the 
 orthopedic surgeons are threatened with the 
 loss of their flat feet — and justly. 
 
 This hints an analogy to the genitourinary 
 surgeon if he would have his specialty justified 
 as a distinct entity. If the genitourinary 
 surgeons lack the opportunity of being equally 
 skilled in the major operating pertaining to 
 their special field with those in other fields 
 who include portions of the genitourinary 
 system with their own work, would not an 
 extension of the genitourinary work into other 
 fields of labor be advisable ? 
 
 If it is going to be to the best advantage of 
 patients to have their kidneys, ureters or 
 bladder operated upon by the general surgeon 
 or gynecologist then the question of whether 
 
 [150] 
 
GENITOURINARY SURGERY 
 
 genitourinary surgery is justified as a specialty 
 can be promptly answered in the negative. 
 One thing cannot be lost sight of: if scientific 
 advancement is to be a consideration, the 
 responsibility of such refinement of diagnosis 
 as is obtainable to-day must fall upon who- 
 ever essays to bring these cases to their logical 
 conclusion. There is one more thing which 
 is of especial interest to the patient in this con- 
 nection and which cannot be lost sight of — 
 that is the many cutting operations which 
 have been entirely obviated by the use of 
 various cystoscopes, cautery, ureter catheters, 
 functional kidney tests and other bladder and 
 urethral instruments in the hands of those 
 trained in this work. 
 
 The situation of the gynecologist here in 
 this country has an interesting relationship to 
 this problem. As a body they are without 
 the diagnostic training in the urinary system 
 to justify their including the urinary organs 
 
 [151] 
 
GENITOURINARY SURGERY 
 
 in their special field of work. In consequence 
 of this the genitourinary surgeon finds he has 
 much to do with the female urinary tract ; and 
 much of his operative work falls in this field. 
 In consequence of these things would it be 
 strange if genitourinary surgery came to in- 
 clude the genital as well as the urinary organs 
 of both sexes? Would not this help in the 
 general advancement of the cause as well as 
 lend a broadening effect to the character of 
 surgical work as a whole ? 
 
 If the situation of American gynecology to- 
 day holds an interesting relationship to genito- 
 urinary surgery, the position of general sur- 
 gery in this relation is even more interesting; 
 for here we have a large class of the medical 
 profession, so many of whom are frankly in- 
 cluding the surgical care of the genitourinary 
 organs in their field of work; without appar- 
 ently seeking to avoid the many costly errors 
 which arise from the lack of training neces- 
 
 [152I 
 
GENITOURINARY SURGERY 
 
 sary to the accurate diagnosis of diseases of 
 these organs; which they profess themselves 
 capable of caring for to the best interests 
 of their patients. 
 
 The foregoing but reflects a feeling and 
 speaks a healthy discontent — looking to bet- 
 ter things. 
 
 One thing seems certain, that conditions 
 are breeding a larger type of man for genito- 
 urinary surgery ; and there is little doubt that, 
 with the broader education of the medical 
 profession to the rapid advance in genito- 
 urinary surgery in the past ten or twelve years, 
 the up-to-date hospitals in the larger cities 
 will see to it that there is a department and a 
 provision of beds for the proper study and 
 care of these cases. 
 
 To gain a moment's detachment from that 
 narrower viewpoint which is apparently but 
 looking to the advance of but a part of the 
 whole, will perhaps be helpful. 
 
 [153] 
 
GENITOURINARY SURGERY 
 
 It was not so very long ago that the practice 
 of the art of medicine was but a one man's 
 task. All that was useful of medical knowl- 
 edge could be carried in one man's brain. All 
 that was necessary for technical application 
 could be mastered by one man's skill. This 
 meant a coordination of the parts of that 
 knowledge with a single administration centre. 
 The result meant a minimum loss of energy 
 and the strength of such a position can only 
 be appreciated by comparing it with the state 
 of affairs which exist in medicine to-day. 
 Could we but possess an appreciable some- 
 thing which could be called a unit of medical 
 energy, by such a measure we could draw a 
 graphic picture of the loss that has been 
 suffered by the splitting up of medical knowl- 
 edge and the disappearance of an adminis- 
 trative head. 
 
 This brings us face to face with perhaps 
 the most important problem of the medical 
 
 [154] 
 
GENITOURINARY SURGERY 
 
 profession of to-day. The splitting up of 
 medical knowledge; the establishment of 
 separate branches of that knowledge we know 
 were inevitable steps in the evolution of this 
 branch of learning; but, to have lost our 
 head should not have been included in the 
 process. The present transition stage of 
 urban medicine might almost be likened to 
 a river flowing backward; draining an ocean 
 of knowledge and disappearing in rivulets, 
 with the public bathing in the intermediate 
 marshes of chicanery. 
 
 If the medical profession is to be useful to 
 the public for whom it is designed; in pro- 
 portion to the treasures of its present knowl- 
 edge and skill; it will have to administer this 
 knowledge by means of harmonious groups of 
 its individual members, brought together so 
 as to represent the sum of its attainment. 
 
 Until this time comes the justification of any 
 special branch of medicine or surgery must 
 
 [155] 
 
GENITOURINARY SURGERY 
 
 be according to such good results as our 
 present inadequate system of independent 
 specialties is able to show. 
 
 [156] 
 
IX 
 THE BY-WAYS OF PROSTATECTOMY 
 
CHAPTER rX 
 
 THE BY-WAYS OF PROSTATECTOMY 
 
 Prostatectomy is a live, up-to-date subject, 
 even though it deals with the decadent end of 
 human existence, and although our present 
 age is sometimes called a commercial age, it 
 has not in the slightest deterred the progress 
 of the surgeons' art in this direction. 
 
 The argument as between ''catheter life" 
 and prostatectomy in the majority of cases 
 has sunk to almost nothingness in favor of 
 the latter. The worthiness of relieving these 
 aged sufferers of their pelvic predicament by 
 removal of the prostate seems pretty well 
 proven, even after discounting the statistics 
 compiled from carefully selected cases. 
 
 Whatever may be said against the method 
 so much in vogue to-day of adopting for one's 
 
 [159] 
 
BY-WAYS OF PROSTATECTOMY 
 
 own use some one of the several ways of 
 prostatic removal to the exclusion of all other 
 forms of the operation, there is this to be said 
 most emphatically in its favor — that it tends 
 to give the operator the faculty of reducing 
 traumatism and time to the minimum. In 
 hardly any other operation in surgery is the 
 importance of this so distinct. It cuts to 
 the narrowest limits for these aged patients 
 the period of anesthesia, the amount of 
 bleeding and the degree of surgical shock. 
 
 It is not difficult to conceive that most cases 
 of subsequent incontinence take origin from 
 the pre-operative state, therefore to prolong 
 the operation by some trivial variation in 
 technic in the hopes of forestalling this con- 
 sequence — is a questionable hazard. To 
 indulge in refinement of dissection, designed 
 to preserve sexual potency, would seem 
 hardly likely to capture the fancy of most of 
 these aged invalids — considering the stake. 
 
 [l6o; 
 
BY-WAYS OF PROSTATECTOMY 
 
 To dwell on the importance of a rapid opera- 
 tion is well enough, but to bring into view the 
 possibilities of the pre-operative and post- 
 operative attention is the only way to get a 
 perspective of the brilliancy of the results 
 obtainable in the surgical care of prostatic 
 hypertrophy and obstruction of the aged. 
 
 Here the special training of the genito- 
 urinary surgeon seems to be of some advan- 
 tage. In considering the pre-operative period, 
 i.e., the care of the patients leading up to the 
 operation — by way of illustration, the cases 
 may be divided in two classes. 
 
 The first class may, in reaUty, be a first- 
 class surgical risk, in good, general health 
 without cardiac, arterial or renal impair- 
 ment beyond the loss of resiliency to be looked 
 for at that age; the patients in no way worn 
 by a urinary infection or by undue frequency 
 of micturition; these are the good statistic 
 
 makers for whoever operates on them. 
 II [i6i] 
 
BY-WAYS OF PROSTATECTOMY 
 
 The second class present a different problem. 
 In this class drop the cases which are not good 
 surgical risks ; aside from their cardio- vascular 
 systems which may hold a warning, their 
 renal integrity has not only suffered perma- 
 nent changes, but is under the influence of a 
 functional impairment due directly to the 
 urinary obstruction and infection. Add this 
 general systemic influence of faulty renal 
 elimination to the influence of sleeplessness, 
 dysuria, obstipation and septic absorption in 
 a subject already feeble from advanced age 
 and the picture from a surgical viewpoint 
 looks unpromising; and yet, what may be ac- 
 complished for these patients by way of turn- 
 ing them into fairly good surgical risks is 
 oftentimes surprising. 
 
 To gain the prize in these cases one must 
 advance slowly and with caution. To put 
 these patients in bed, unless already bed- 
 ridden, is to invite the machinery to lay 
 
 [162] 
 
BY-WAYS OF PROSTATECTOMY 
 
 down its burden. To shock the patients 
 with sudden and violent catharsis is an error 
 which is sometimes a fatal error. The 
 bladder is to be drained with a catheter, 
 urinary antisepsis is to be employed to the end 
 that the back pressure on the kidneys is 
 relieved that their congestion may subside, 
 that their function of elimination may be 
 slowly resumed, that septic absorption may 
 cease. To burden these kidneys by giving 
 excessively of water to drink is to force them 
 without purpose; gentle diaphoresis, if indi- 
 cated, is of more advantage. As to a pre- 
 liminary general anesthesia and operation to 
 open the bladder supra-pubically or perineally 
 for the purpose of drainage or to shorten 
 another operation, is, in the writer's humble 
 opinion, without excuse; to inflict that added 
 surgical shock on an aged, septic and feeble 
 individual is to court a fatal issue as a final 
 result. The drainage can be accomplished 
 
 [163] 
 
BY-WAYS OF PROSTATECTOMY 
 
 with a catheter or a quick supra- pubic section 
 under local anesthesia, if need be. 
 
 The preparation of the patient for the 
 operation should not be left to attendants 
 versed only in getting ready of younger 
 adults, with good margin of vitality. Food 
 of a Kquid nature and drink should be given 
 up to within a few hours of the anesthesia or 
 just so the stomach will be empty; that the 
 shock of fasting is not felt. The pre-operative 
 catharsis should be led up to gently for a 
 couple of days before operation and, finally, 
 a rectal irrigation can be carefully given just 
 before operating. An opiate an hour or two 
 before the anesthesia smooths the way. 
 
 Of the operation itself we have made 
 mention. The anesthesia is another chapter 
 to be put in the hands of an expert on 
 anesthesia. 
 
 The post-operative care of these patients 
 begins the minute the operation is completed. 
 
 [164] 
 
BY-WAYS OF PROSTATECTOMY 
 
 As gently as these patients are led to opera- 
 tion, as gently are they to be led away from 
 it. The careless loss of body heat through 
 exposure is to be avoided. A "good quality" 
 of pulse is to be made sure of — if need be by 
 intravenous administration of saline solution. 
 The patient is allowed to come out of his 
 light anesthesia without disturbance. Thirst 
 is to be quenched by water and small quanti- 
 ties of liquid food given as soon as the 
 stomach is ready for it. Restlessness is to 
 be relieved by a further administration of 
 morphine if this is wonying the patient; for 
 the wear and tear of such restlessness is more 
 costly than the effect of a little anodyne. In 
 twenty-four hours, or as soon as possible, he 
 should be sitting up, with a watch kept on the 
 pulse and the patient for signs of undue 
 fatigue. 
 
 The bodily habit of activity in the aged is 
 their sheet anchor and a return to such activity, 
 
 [165] 
 
BY-WAYS OF PROSTATECTOMY 
 
 as each one is accustomed, is the goal toward 
 which each must be directed with as little 
 loss of time as possible. 
 
 [i66] 
 
X 
 
 THE GONOCOCCUS 
 
CHAPTER X 
 
 THE GONOCOCCUS 
 
 From a purely academic viewpoint this 
 organism presents a problem of persuasive 
 interest. 
 
 For a good many years now the price of 
 gonococcic infection paid by unsuspecting 
 humanity has been an open book to the 
 medical profession so that there is no need 
 to include that here. The royal indifference 
 with which the world of medicine has swept 
 by this little king of depopulators, only 
 stooping to gather in the coins it scatters on 
 its silent tour of civilization, promises some 
 day to make delectable substance for debate 
 From a scientific standpoint the pathological 
 extensions of this infection offer so few new 
 surprises, that relatively little scientific interest 
 
 [169] 
 
THE GONOCOCCUS 
 
 can be expected. From the standpoint of 
 our ethical obHgation to society this infection 
 is attended with an importance in exact 
 proportion to society's danger from it. 
 
 When thinking people of to-day come to a 
 knowledge of the "professional silence," for 
 instance, which seals the lips of the physician 
 and at the same time the doom of countless 
 trusting women at the marriage altar, then 
 may arise questions which at present it is 
 not perfectly convenient to answer. 
 
 There are a certain number of blind people 
 in the world to-day — statistics say about 25 
 per cent, of them — who owe their condition 
 not so much to the virulence of this germ 
 as indifference to and ignorance of it. Many 
 of these people have learned the etiology of 
 their bhghted existence and are making it 
 their life work to save others from the same 
 fate. 
 
 The thoughtful reader will readily see that 
 
 [170] 
 
THE GONOCOCCUS 
 
 we need only make relatively short excursions 
 into the realm of the gonococcus to discover 
 the riches of that germ as an object of dis- 
 cussion. That it has been found to be an 
 unpleasant topic upon which to exchange 
 views and thus increase the sum of human 
 knowledge is the best excuse that can be 
 offered by the medical profession as an explan- 
 ation of the fact that false pride and preju- 
 dice have had the upper hand of reason. 
 
 The motives which prompt teachers and 
 parents to foster the state of unconsciousness 
 of sex in the young are worthy of the deepest 
 respect, but the trained medical mind which 
 carries this thought a step further and weighs 
 the cost of what is now a traditional fancy 
 against the cost of what may be an actual 
 tragedy, knows the imperative necessity of 
 anti-dating sexual function by sexual knowl- 
 edge as it exists to-day. To expose the 
 young to drowning, let us say, is kinder 
 
 [171] 
 
THE GONOCOCCUS 
 
 than to expose them to the danger of sex 
 death or indefinite and loathsome infec- 
 tiousness. Once one generation of young are 
 safe-guarded by timely training, succeeding 
 generations without the silly confusion of 
 self-consciousness will reflexly forewarn their 
 progeny. 
 
 If human laws and regulations are worth 
 anything, there should be one, until the 
 infection is uprooted, which would make 
 marriage, without a certificate of fitness to 
 marry, a criminal offense. To be compelled 
 to resort to such means is abscheulich, but to 
 feed our young on false conceptions of the 
 future by withholding the truth is to barter 
 honor for dishonor. 
 
 Through many interesting phases the gono- 
 coccus has worked its way up from relative 
 obscurity to a position of racial importance. 
 All civilized countries are thoroughly impreg- 
 nated with it and yet it would be hard to find 
 
 [172] 
 
THE GONOCOCCUS 
 
 any infection to which human flesh is heir, 
 that is as easy to prevent as is gonococcic 
 
 infection. 
 
 How this interesting problem can get by 
 without more academic interest being shown 
 it, even though the medical profession as a 
 whole is so indifferent to it, passes under- 
 standing. The superficial reasoning which 
 has surrounded the whole subject of prostitu- 
 tion and the continuous persecution of these 
 condition-made creatures who are struggUng 
 on under the burden society imposes, but 
 startles sane reflection and adds little or 
 nothing toward the extermination of sex 
 sustaining sickness. 
 
 A good deal of effort has been expended in 
 trying to teach young males how to suppress 
 and arrest the development of the sexual 
 instinct— a perfectly plausible procedure if 
 one could be convinced of its moraUty. And 
 so, here and there, by this means and that, 
 
 [173] 
 
THE GONOCOCCUS 
 
 the isolated wellwishers of humanity go 
 snipping away at the stalk and the leaves 
 of the weed which has buried its roots so 
 securely in the soil of our society. 
 
 The intelligent reader will observe that I 
 have carefully avoided even a suggestion as 
 to the solution of this interesting problem. 
 To give the answer with the riddle spoils the 
 game. 
 
 [174] 
 

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