Columma ©ntoemtp m tfce Cttp of JSeto gorfe V^^> >rf)ool of Bental anb ©ral g>ur§&)( Reference Ltbrarp A TEXT-BOOK OF GENITOURINARY DISEASES CASPER PRESS REVIEWS OF PREVIOUS EDITIONS From The London Lancet. " The name of Prof. Casper is sufficient in itself to guarantee the high quality of any work dealing with the branch of surgery with which his name is associated. The original German edition of this work is known all ovc the world as a standard treatise on genito-urinary affections. " We may say at once that the translation has been well done, so that it reads almost as an original work. The translator's additions are judicious. We can speak very favorably of Casper's treatise in its English dress; it should prove useful to many." From The Johns Hopkins Bulletin. "The book is concise and should be very useful for students. The addi- tions which Dr. Bonney has made to the German edition have distinctly increased the value of the book." From The Medical Record. "The translator and the publishers of this volume have rendered a com- mendable service to English-speaking readers in presenting an English version of Casper's text-book, which represents the technic of one who for some years has been regarded as an authority of the greatest eminence in his field." From The American Journal of Dermatology and Genito-Urinary Diseases. "The present work has a double value from the fact that it has been written by an acknowledged authority on the subject whereof he speaks and, in the second place, in that it has been edited by such a. competent genito- urinaiy surgeon. It is written in a thorough, conscientious manner, with a little inclination to be conservative, and it can be safely recommended as a reliable guide, both to physicians and students. As a text-book, it certainlv stands as the peer of any." From The New Orleans Medical and Surgical Journal. " One of the best texts on the subject, it is a fortunate thing that it has been placed at the command of English-speaking readers. The diction is simple, the system good, the illustrations numerous and selected for their practical utility. Besides, we have the experience of Casper given with the authority of a master. Dr. Bonney has done well his work as translator, and has furnished valuable annotations and additions. The book is to be sincerely commended and also heartily recommended to our readers." From The Dublin Journal of Medical Science. "We can confidently recommend the treatise as one of the soundest and best we have ever read in connection with this important subject. The translation is well done and reads pleasantly and smoothly." From The Annals of Surgery. " The book is eminently practical, and will rank high among the text- books on Genito-Urinary Diseases." A TEXT-BOOK OF GENITO-URINARY DISEASES Including Functional Sexual Disorders in Man BY DOCTOR LEOPOLD CASPER Professor in the^University of Berlin Translated and Edited with Additions BY CHARLES W. BONNEY, B. L., M. D. Assistant Demonstrator of Anatomy, Jefferson Medical College, Formerly Surgeon to the Southern Dispensary, Philadelphia, etc. Second Edition, Revised and Enlarged WITH 230 ILLUSTRATIONS AND 24 FULL-PAGE PLATES, OF WHICH 8 ARE IN COLORS PHILADELPHIA P. BLAKISTON'S SON & CO. 1012 WALNUT STREET 1912 uc b03j Copyright, 1909, by P. Blakiston's Son & Co. a .bo* Printed by The Maple Press York, Pa. TO FRANZ KONIG, PROFESSOR OF SURGERY AND MEDICAL PRIVY COUNSELLOR, THIS VOLUME IS DEDICATED AS A TOKEN OF ESTEEM. Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofgenitoOOcasp AUTHOR'S PREFACE TO THE TRANSLATION. The cordial relations which have long existed between Germany and America, and which it has recently been endeavored to make more intimate , are better expressed by acts than by words. Accord- ingly it affords me great pleasure to see my Text-Book of Urology appear in American vesture. An English-speaking surgeon first led me into the realm of genito- urinary diseases, and it is with a feeling of satisfaction and gratitude that I think of him, my honored teacher, Sir Henry Thompson, of London. Although his profoundly scientific yet withal eminently practical publications were familiar to English-speaking nations, they were little known in Germany, and so, twenty years ago, I became his exponent, translating and publishing his " Stricture of the Urethra " and " Lectures on Diseases of the Urinary Organs." I hope the following pages will prove to my American and English colleagues that Sir Henry's teaching fell upon fertile soil; and that they will show how urology has developed both as to scientific advancement and technical improvement. I take this opportunity to thank my colleague, Dr. Bonney, for the diligence, comprehensive knowledge, and unremitting interest which he has manifested in the work of translating and editing the book. Leopold Casper. PREFACE TO THE SECOND EDITION In preparing the second edition of this book I have endeavored to make a thorough revision, rearranging certain sections of the text, amplifying others and adding such new material as it seemed ad- visable to incorporate. A number of American urethroscopes, cystoscopes and other in- struments have been described; the treatment of acute posterior urethritis and chronic urethritis has been more thoroughly discussed; the operation of circumcision has been carefully described, chiefly for the benefit of the general practitioner, who is often called upon to perform it; an article on the anatomy of the kidneys has been written; syphilis of the kidneys has been elaborated, and a considerable number of new editorial notes have been made. The revision of the article on the treatment of hypertrophy of the prostate has been done by Professor Casper. His views, based upon a further experience of two years with radical operations, are com- prehensively stated. A few new illustrations have been inserted, for some of which I am indebted to my student, Mr. M. L. Elsinger. To the members of the profession who have received the book so cordially, and to the reviewers and correspondents who have ex- pressed such favorable opinions of it, I hereby render sincere thanks. Charles W. Bonney. 320 SOUTH ELEVENTH STREET, PHILADELPHL4, January 1, 1909. EDITOR'S PREFACE TO FIRST EDITION. This book is offered to English-speaking practitioners and students of medicine with the belief that it represents the best teaching of genito- urinary diseases which is at present available. I trust they will concur in my opinion, that it reflects the combined result of large clinical experience, modern methods of research, and conserva- tive judgment. Although the translation is by no means literal, yet some effort has been made to adhere as closely to the original text as clearness, precision, and the intrinsic idiomatic differences of the two languages would permit. The discussion of radical operations for hypertrophy of the pros- tate has been rewritten conjointly by the author and myself. My own annotations and additions have been placed in brackets. The technic of a few operative procedures not given in the German edition has been described, and many new illustrations have been added. I desire in this place to express my deep appreciation of the will- ing assistance which Professor Casper has given me in the prepara- tion of this edition, and also to render acknowledgment to the numer- ous gentlemen who have loaned pathological specimens or drawings. I am particularly indebted to Professors Keen and Coplin, of Phila- delphia; Young, of Baltimore; and Bransford Lewis, of St. Louis. I also wish to thank the publishers for many helpful suggestions. Chas. W. Bonney. 320 SOUTH ELEVENTH STREET, PHILADELPHIA, August i, 1906. XI CONTENTS GENERAL SECTION. PAGE I. Examination of the Patient 2-5 1 . Frequency of Micturition 2 2. Changes in the Urinary Stream 3 3. Pain 4 4. Admixture of Blood with the Urine 5 II. Physical Methods of Examination 6-54 1. Examination with Sounds and Catheters 6 2. Urethroscopy 12 3. Cystoscopy 22 4. Digital Examination of the Bladder 51 5. Examination with the Roentgen Rays 52 III. Physical, Chemical, and Microscopic Examination of the Secretions 55-84 1. Physical Properties of the Urine 55 2. Chemical Examination of the Urine. ' 57 3. Microscopic Examination of the Urine 68 SPECIAL SECTION. I. Diseases of the Urethra and Penis 85-205 1. Anatomy of the Urethra 85 2. Urethritis ' 88 3. Lymphangitis and Lymphadenitis 100 4. Folliculitis, Perifolliculitis, and Periurethral Abscess .... 100 5. Paraurethral Fistulae 100 6. Cowperitis and Pericowperitis 101 7. Extragenital Complications of Gonorrhoea 101 8. Treatment of Urethritis 109 9. Chancroid of the Urethra 129 10. Acuminated Condylomata of the Urethra 130 11. Syphilis of the Urethra 130 12. Stricture of the Urethra 131 13. Injuries of the Urethra 160 xiii XIV CONTENTS. PAGE 14. Urinary Infiltration and Urinary Abscess 164 15. Foreign Bodies in the Urethra 166 16. Tumors of the Urethra 172 17. Urethrocele 175 18. Tuberculosis of the Urethra 175 19. Malformations of the Urethra 176 20. Fistula of the Urethra 183 21. Injuries of the Penis 185 22. Balanitis 186 23. Phimosis and Paraphimosis 187 24. Chancroid 194 25. New Growths of the Penis 198 26. Elephantiasis 201 27. Cavernous Infiltration and Induration of the Penis 201 28. Lymphangitis 202 29. Lymphadenitis 203 II. Diseases of the Urinary Bladder 206-302 1. Anatomy and Physiology 206 2. Cystitis 208 3. Tuberculosis 226 4. Foreign Bodies 248 5. Vesical Calculus 250 6. Tumors 266 7. Injuries 278 8. Parasites 281 9. Valves at the Neck of the Bladder 282 10. Ulcer 283 11. Diverticula and Hernia 284 12. Varices 287 13. Malformations 287 14. Anomalies of the Urachus 288 15. Prevesical Phlegmon 290 16. Neuroses of the Bladder 290 III. Diseases of the Prostate Gland 303-407 1. Anatomy and Physiology 303 2. Absence, Atrophy and Cysts 305 3. Injuries 307 4. Inflammation 308 5. Hypertrophy 322 6. Tuberculosis 379 CONTENTS. XV PAGE 7. Concretions and Calculi 386 8. New Growths 389 9. Syphilis 400 10. Parasites 401 1 1 . Neuroses 403 [V. Diseases of the Testicle, Epididymis, Spermatic Cord and their Coverings 408-451 1 . Anatomy 408 2. Congenital Diseases of the Scrotum and Testicles 409 3. Retention of the Testicle 410 4. Congenita] Hydrocele 413 5. Injuries of the Scrotum and Testicle 414 6. Open Wounds of the Scrotum and Testicles 416 7. Eczema, (Edema, Erysipelas and Phlegmon of the Scrotum. 41 6 8. Tumors of the Scrotum and Tunica Vaginalis 417 9. Tumors of the Testicle and Epididymis 419 10. Tuberculosis of the Testicle, Epididymis and Vas Deferens. 42 2 n. The Operation of Castration 426 12. Syphilis of the Testicle and Epididymis 428 13. Orchitis 430 14. Epididymitis 433 15. Deferenitis or Funiculitis 438 16. Acute Hydrocele 439 17. Chronic Hydrocele 440 18. Galactocele, Hematocele and Spermatocele 446 19. Hydrocele of the Cord 448 20. Varicocele 449 V. Diseases of the Seminal Vesicles 452-461 1. Anatomy 452 2. Examination of the Seminal Vesicles and their Secretion.. . .453 3. Malformations 454 4. Injuries 454 5. Acute Spermatocystitis 455 6. Tuberculosis 457 7. Cysts and Hydrocele 459 8. Concretions 460 9. Tumors 46 1 VI. Diseases of the Kidneys and Ureters 462-563 1. Anatomy and Physiology 462 XVI CONTENTS. PAGE 2. General Considerations Concerning Examination of the Kidneys 467 3. Congenital Malformations and Displacements 475 4. Circulatory Disturbances 480 5. Hemorrhagic Infarct; Thrombosis and Embolism of the Renal Arteries 48 1 6. Acute Diffuse Nephritis 483 7. Chronic Nephritis 486 8. The Nephritis of Pregnancy 494 9. Amyloid Degeneration of the Kidney 495 10. Fatty Kidney 496 11. Pyelitis and Pyelonephritis 497 12. Hydronephrosis 505 13. Pyonephrosis 510 14. Tuberculosis of the Kidney 517 15. Renal and Ureteral Calculi 524 16. Tumors of the Kidney 533 17. Tumors of the Renal Pelvis and Ureter 538 18. Cysts of the Kidney 539 19. Movable Kidney 541 20. Parasites of the Kidney 544 21. Syphilis of the Kidney 546 22. Peri-, Epi-, and Paranephritis 549 23. Injuries of the Kidney 550 24. Contusions of the Kidney 551 25. Aneurysm of the Renal Artery 552 26. Neuralgia of the Kidney 553 27. The Operations of Nephrotomy and Nephrectomy 556 28. Examination and Diseases of the Ureters 560 VII. Functional Disturbances op the Sexual Organs 564-633 1. Physiology 564 2. The Abnormal Loss of Semen 573 3. Sexual Neurasthenia 577 4. Impotentia Virilis 582 5. Sterility in the Male 616 Sterilitas e defectu seu deformatione ; aspermatism ; azoo- spermia. 6. Index 635 GENITOURINARY DISEASES. GENERAL SECTION. To the physician who has studied the diseases of the urinary organs carefully a most satisfactory field is offered. Among these diseases, as among all others, there are incurable afflictions which baf- fle human skill, but yet a large number of cases are curable, while in others the experienced and resourceful physician is able to bring about improvement and assuage the agonizing pain to which the patients are so frequently subject. Oftentimes by some simple, though exactly appropriate procedure, he will be able to confer almost instantaneous freedom from suffering. On the other hand, the inexperienced, through improper treatment, may do great harm, which perhaps it will not be possible to remedy. Therefore, if consciousness of being able to relieve suffering lend increase to the physician's sum of happiness, and interest in the study of the diseases in question incite him to keep on the alert, so likewise should the realization that deficient knowledge may lead to the inflic- tion of injury awake in him the desire thoroughly to master this branch of medicine and surgery. It scarcely need be said that training in general medicine is necessary for the accomplishment of such a purpose. Only those who have directed their vision upon the entire organism, those who have dealt not with a " part of the whole", but with " the whole in all its parts" can expect to obtain results; but he who adds to his general knowledge that special skill without which urology cannot be successfully pursued will come little short of attaining the object desired. The acquisitions made to this branch of medicine during the last decade, acquisitions as gratifying as they are great, enable us in the majority of instances to make a quick and exact diagnosis. The whole subject is summarized in the sentence: "qui bene diagnoscit, bene curat." The diagnostic expedients at our command are : — I. Interrogation of the patient. II. Physical methods of examination. III. Chemical, physical, and microscopic examination of secretions and excretions. 2 GENERAL SECTION. I. INTERROGATION OF THE PATIENT. The interrogation of the patient is begun by taking an accurate anamnesis. It must be learned what diseases have occurred in the patient's family and of what maladies his near relatives died. Special attention must be given to tuberculosis, rheumatic or gouty affections, and lithiasis, because they are diseases in which heredity plays an indisputable role. As to other incidents of family history the rules of general medicine are applicable. Concerning the patient . himself, we must endeavor to ascertain whether he has ever had gonorrhoea, syphilis, scarlet fever, or other significant diseases. After having obtained information concerning the beginning of his present illness, its mode of onset, its course and duration, the special interrogation of the patient should be begun. This special interrogation relates to a series of symptoms which are present in one form or another in a large number of diseases of the genito-urinary tract. Certain ones are pathognomonic of certain dis- eases. The special interrogation, by directing our attention along definite lines, makes diagnosis more easy, although we must not be led into making a diagnosis solely upon the statements of the patient with- out resorting to the other methods of investigation appropriate to his case. To do so would be only to fall into error. The object of ques- tioning the patient is to arrive at a diagnosis, and we should avoid ask- ing questions which are unnecessary and perhaps distasteful to him. We are not justified, however, even though only the slightest doubt exists, in basing our diagnosis entirely upon this examination. The questions to be asked relate to : 1. The frequency of micturition. 2. Changes in the urinary stream. 3. The presence or absence of pain. 4. The admixture of blood with the urine. I. FREQUENCY OF MICTURITION. A healthy person urinates about five times in twenty-four hours. As the normal quantity of urine voided in twenty-four hours is about 1500 cubic centimeters (50 ounces), the average capacity of the bladder may be given as 300 cubic centimeters (10 ounces). It has been observed that a large number of diseases of the genito- CHANGES IN THE URINARY STREAM. 3 urinary tract are associated with increased frequency of urination, although in this respect marked differences exist. First of all, it is evident that a distinction must be made between those affections in which the quantity of urine is considerably increased, and those in which no increase occurs. If the capacity of the bladder has remained intact, patients having diseases of the first class will naturally urinate more frequently than healthy persons. Among such diseases may be mentioned diabetes mellitus, diabetes insipidus, chronic interstitial nephritis, and urina spastica. In the second class, although the quantity of urine voided is normal, increased frequency of micturition is caused by inflammatory conditions of the urinary organs, as for example, acute posterior urethritis and cystitis. It is especially characteristic of this class of diseases that the urgency of urination is present both day and night. In sharp contrast to these diseases are the neuroses of the bladder, which are peculiar in that they cause frequent micturition only during the day, the patients being able to hold their urine throughout the entire night. In hypertrophy of the prostate and vesical calculus a decided differ- ence exists between the number of urinations which occur during the day and the night. In the former they are much more frequent at night, while in the latter patients not uncommonly sleep the whole night through without having to pass their water once, although activity dur- ing the day increases the number of their urinations. Mere suggestions should suffice to illustrate the importance of the interrogation. In our discussion of individual diseases we shall refer most frequently to this symptom. From what has already been said it will be seen that it is necessary to question the patient with the utmost precision on this subject. This may be done by asking him if he urinates oftener than a healthy person, or oftener than he formerly urinated. If an affirmative answer be received, then it must be ascertained whether the increased frequency exists both day and night, or only during the day; whether it is more .manifest at one time than at another; and whether rest or exercise exerts any influence upon it. 2. CHANGES IN THE URINARY STREAM. It is a constant symptom of every stricture of the urethra for the stream of urine to become smaller. This is so pathognomonic that it 4 GENERAL SECTION. may be said, the narrower the stricture, the smaller the circumference of the stream. In the worst cases there is no stream at all, the urine being voided drop by drop. In contradistinction to this condition there is a symptom which is present when the bladder has lost its tonicity, or when an obstruction exists near its neck; this symptom consists in diminution of the projec- tile power of the urinary stream. The urine can no longer be forcibly expelled in an arched stream, but falls almost perpendicularly down- wards. This symptom is observed in disturbance of the central nerv- ous system affecting the vesical centers or paths of conduction, and especially in hypertrophy of the prostate. In vesical calculus, when the stones are small and movable, urination may be suddenly arrested if a stone is carried toward the neck of the bladder in such a manner as to occlude its opening. In conformity with our knowledge of the changes which occur in the stream, we should ask our patients whether they have noticed that the stream has become smaller, that it has lost force, or that it has been suddenly interrupted. 3. PAIN. Pain is a symptom which is present in a large number of genito- urinary diseases, and yet it is one from which many conclusions can be drawn if its investigation be minutely conducted. In the first place, we must get information concerning the location of the pain, whether it be in the region of the kidneys, over the bladder, or in the urethra; if it be in the urethra we must find out whether it be near the end of the penis or in the deeper portions. It must also be learned whether the pain supervenes during urination or occurs independently thereof, and whether exercise increases and rest lessens it. The value of this interrogation in enabling us to make a diagnosis will become apparent when we cite, for example, that the pain of renal colic occurs on the side corresponding to the diseased kidney and radiates along the ureter down into the groin ; that in vesical calculus it is most pronounced at the end of the penis; that in stricture of the urethra it occurs at the site of the obstruction ; and that in hypertrophy of the pros- tate and prostatitis a dull aching pain is often felt in the perineum and rectum. Vesical calculi often cause pain independently of micturition when the patient is moving about, and also at the end of micturition; in stricture the pain is generally felt only when the patient urinates, while ADMIXTURE OF BLOOD WITH THE URINE. 5 in affections of the neck of the bladder spasmodic pain follows the act and lasts for some time thereafter. It is hardly necessary to state that there are many exceptions to these rules, concerning which we shall have something to say when discussing the individual diseases. 4. ADMIXTURE OF BLOOD WITH THE URINE. The question whether the patient has ever passed bloody urine is one of great importance. It is unnecessary to ask the patient about the actual condition of his urine, because a thorough examination of it can be made; but as there are many genito- urinary diseases in which haemor- rhage occurs only at long intervals, inquiry as to the former occurrence of haematuria should always be made. Urinary haemorrhage is most frequently associated with tumors, cal- culi, and tuberculosis of the kidney, and with tumors and stone of the bladder. Gonorrhceal inflammation of the neck of the bladder also often produces it. In many cases the patients cannot give particulars as to the beginning of this condition, while in others they are able to supply valuable data. If haemorrhage always takes place under the influence of motion it be- speaks the existence of vesical or renal calculi. Tumors of the kidney are characterized by bleeding which occurs suddenly, comes on without apparent cause, lasts a long time, and is not easily controlled by treat- ment. The influence of rest, so favorable upon haemorrhage due to stone, amounts to nothing in this form of haematuria. If haemorrhage supervenes at the end of micturition, we may conclude with reasonable certainty that the location of the disease is at the neck of the bladder. This form of haemorrhage, called terminal urinary haemorrhage, is typical of gonorrhoeal inflammation at the neck of the bladder, but it has also been observed in vesical calculus. If the data obtained by interrogating the patient as just described lead to the formation of certain suppositions concerning the nature of the malady with which we have to do, it behooves us to verify these sup- positions by resorting to exact methods of examination, which we shall now proceed to describe. PHYSICAL METHODS OF EXAMINATION. II. PHYSICAL METHODS OF EXAMINATION. By physical methods of examination are meant those in which we employ our three principal senses, hearing, touch and sight, in a systematic manner for obtaining important diagnostic data. We shall refer to details when considering special diseases; at present we shall merely mention a few generalities. We use percussion to give us information concerning the presence of an abdominal tumor; thus, differentiation between tympany and dull- ness may help us to decide whether we have to do with a tumor of the kidney or with another kind of new growth. Palpation is of great importance in the recognition of diseases of the kidneys, prostate, testicles, and epididymis. The sense of sight renders inspection possible in the broadest sense of the word. We can examine the region of the kidneys and bladder, the testicles, etc., with the naked eye. The hidden recesses of the uro-genital tract early prompted the pro- fession to search for expedients which would enable us to use our sense of sight in these deeper and inaccessible portions. The skill of modern times has brought such aids to a high degree of perfection, and by their use our power of diagnosticating has been considerably augmented. We will now turn our attention to these ingenious devices. I. EXAMINATION WITH SOUNDS AND CATHETERS. Sounds and catheters are introduced into the urethra and bladder partly for diagnostic and partly for therapeutic purposes. For both it is fundamentally important to possess adequate knowledge of the instruments and the way in which they are used. For practical purposes we differentiate between inflexible instruments made out of metal, and flexible ones such as vulcanized rubber catheters, and catheters and sounds made of silk and coated with a mixture of rubber and varnish. The vulcanized rubber catheters are generally called Nelaton catheters. A good article of this kind is the so-called Jaques patent catheter, although other excellent ones are manufactured both in Germany and France. They are not very durable and care should be taken to see that they contain no cracks. A cracked catheter should never be used, as it may be broken off in the bladder. EXAMINATION WITH SOUNDS AND CATHETERS. 7 The best of these catheters are those having a blind end and a cylin- drical or slightly conical shape. For certain purposes the Nelaton catheter having a Mercier curve commends itself. In this modification the apex of the instrument forms an angle of 25 — 40 with the shaft. (Fig. 1.) The varnished instruments are called for short silk-web catheters, sounds, or bougies. Excellent qualities are now on the market. The firms of Vergne, Porges, Rondeau Freres, and Eynard, of Paris, and Ruesch, of Cannstatt, prepare a stable, smooth and readily flexible article. Cotton-woven instruments are not durable and therefore are to be discarded. The usual form in which these instruments are used is with the olivary tip, the shaft being long, the neck tapering, and the end expand- ing into a small knob resembling an olive in shape (Fig. 2). The use of conical bougies, formerly so much in vogue, is to be deprecated, because they are difficult of introduction and may injure the urethra. Of these sounds and catheters a large number of the ones most fre- quently used should be kept on hand; of the catheters, from No. 12 to 20 will be found most necessary, while of the sounds all sizes will be re- quired. The smallest sounds, from No. 1 to No. 4, are called filiform bougies; they too should have an olivary tip (Fig. 3). The silk- web catheters are also manufactured with the Mercier curve. Recently silk-web catheters bent into a pronounced curve have been placed upon the market; they are very useful for many purposes (Fig. 4). Finally there are the sounds with a double curve, les sondes bicoudees, as they are called by the French (Fig. 5). The instruments known as stricture searchers, or bougies a boule, consisting of a cylindrical staff of uniform size with a knob attached to one end, though much used in France [and also in America] may be dispensed with. [Although these instruments may be useful in locat- ing granular patches and areas of infiltration in the anterior urethra, misleading and pernicious results have frequently been obtained by their employment. I have demonstrated time and again that in a normal and perfectly healthy urethra resistance is encountered as the head of the instrument passes from the bulbous into the narrow mem- branous portion, and have seen not a few cases diagnosticated and treated as stricture in which the apparent contraction depended entirely upon the natural anatomical structure of the parts.] PHYSICAL METHODS OF EXAMINATION. ii U o '** e *sssi EXAMINATION WITH SOUNDS AND CATHETERS. Fig. 6. Fig. 7. Fig. 10. Brodie's Catheter. IO PHYSICAL METHODS OF EXAMINATION. Metal catheters and sounds have been made out of many different materials, such as lead, tin, silver, and German silver. It is unessential which of these substances is chosen; nickel or silver plated instruments answer every purpose. The only thing of importance is the curve of the instruments, which must be adapted to the various uses to which they are put. In general they must fit the curve which the urethra makes in its fixed part. Metal instruments having very short beaks (Fig. 6) are to be re- jected as incorrect; the stone searcher is the only instrument of this kind which it is permissible to use (Fig. 7). When searching for stone it is necessary to have a sound with as short a curve as possible, in order that it may be moved about freely in the bladder without touching the bladder wall. A properly curved instrument for general use is shown in Figure 8. For old men, especially prostatics, a catheter with the curve bent almost at a right angle with the shaft has done me good service (Fig. 9). Occasionally even greater curves are useful in this class of cases. A catheter devised by Sir Benjamin Brodie is bent to such a degree that its curve describes a circle (Fig. 10). Similar purposes are subserved by the Benique curve, which is used for sounds as well as for catheters. (Fig. 11.) Fig. 11. — Catheter with Benique Curve. Catheters for the female urethra require only a slight degree of curva- ture. They are made of metal, glass, and celluloid. THE TECHNIC OF CATHETERIZATION. It would be a fruitless task to try to learn the technic of catheterization from a book, as it can only be attained by actual practice. For this reason we shall restrict ourselves to making a few necessary allusions. To pass soft catheters or sounds the penis is lifted up so that the first curve of the urethra becomes obliterated and then the instrument, pre- viously well lubricated, is slowly introduced. Slight resistance is en- EXAMINATION WITH SOUNDS AND CATHETERS. II countered as it passes out of the bulb, but this is easily overcome by constant though slight pressure, the instrument passing readily into the bladder. When using the Mercier catheter care must be taken to have the end of the instrument glide along the upper wall of the urethra. It is self-evident that the employment of any force is to be avoided. This is the first principle to be observed in the introduction of any in- strument into the urethra. The passage of inflexible instruments is performed in three stages. In the first stage the instrument is carried to the bulb. Its outer end is held gently between thumb and fingers and the hand is steadied by placing the little finger on the patient's abdomen; the tip of the instru- ment is then carried toward the symphysis pubis and the penis is lifted up with the left hand and drawn over the instrument. When the tip reaches the bulb the distal end of the sound will have been removed from the abdomen about go°. In corpulent persons it is better to stand on the left side of the patient, and holding the instrument laterally over his left thigh introduce it slowly into the urethra, at the same time swinging the shaft around to the median line of the abdomen. This manipulation is called tour de demi-maitre, while if the instrument be held between the patients thighs it is known as lour de maiire. During the second stage the tip of the instrument must pass from the bulbous into the membranous urethra. In order that it do so the distal end must be carried further away from the abdomen, so that the right angle becomes converted into an obtuse angle. It will help materially . to press on the perineum, against the convexity of the sound or catheter, with the fingers of the left hand, thereby bringing the tip of the instru- ment up against the roof of the urethra and thus preventing it from catching in the bulb. When the catheter enters the membranous urethra the third stage of its introduction begins, in which the instrument is simultaneously low- ered and pushed toward the patient, its outer end being carried down toward the thighs as its tip passes into the bladder. It is of the greatest importance to hold the instrument gently between the finger tips, and not grasp it forcibly with the hand, as by holding it gently one is able to feel whether it is going the right way. When the second stage of catheterization is entered upon, that is, when it is attemped to pass the tip of the catheter into the membranous urethra, the instrument, when lowered, will rotate laterally if its tip 12 PHYSICAL METHODS OF EXAMINATION. catches in the bulb instead of advancing into the membranous portion. If it be held firmly in the hand, rotation cannot take place, and thus a valuable sign as to whether it is following the right direction is lost. ASEPSIS OF CATHETERIZATION. In this present age it is hardly necessary to state that the passage of any instrument into the urethra must be done under the strictest aseptic precautions. The only question which arises is how these precautions may best be observed. In order to avoid repetition we will discuss this question under asepsis of cystoscopy. 2. URETHROSCOPY. Urethroscopy is the term applied to that method by means of which the urethra is illuminated for inspection. Its beginning extends back to the first part of the last century. The large number of urethroscopes Fig. 12. — Casper's Electroscope. which have been constructed may be divided, according to the principle of illumination employed, into those in which the source of light is with- out the body, and those in which the light is carried into the urethra. URETHROSCOPY. 13 The instruments of Bozzini, Segelas, Desormeaux, Cruise, Ftirsten- heim, Grunfekl, and others, all belong to the first group. In 1879 Nitze applied the Bruck method of introducing light into the cavities of the body to the urethra, but it was soon abandoned. Leiter, myself, Otis, and some others returned to the earlier procedures, and constructed instruments in which the light was thrown upon the mucous mem- brane of the urethra from without. Direct illumination of the urethra, which was carried into effect by means of the urethroscope devised by Nitze and modified by Ober- lander, depends for its action upon the light derived from a platinum -u t> wire which is contained within a tube introduced into the urethra and heated to a white heat by means of electricity. This wire, surrounded by a stream of water, is brought close to the spot it is desired to illuminate. Valentine has ) a recently made an ingenious change in this instrument, having substituted a minute Edison lamp for the platinum wire. In the urethroscope dependent upon reflected light a strong Edison lamp generally supplies the illumination. In my instrument a convex lens (Fig. 13 A) is placed over the Edison lamp (Fig. 13 L) for the purpose of strengthening and concentrating the light ; over the lens a prism is placed, which breaks the light in such a manner as to cause its rays 12 A) which is passed into the urethra Fig. -Casper's Electroscope. to fall into the tube (Fig. (Figures 12 and 13). The view obtained with this instrument is so bright that the finest details of the urethral mucosa, as for example, its vascular network, can be plainly seen.* [Valentine's urethroscope (Fig. 14), consists of a sheath, an obturator and a light carrier. After it is inserted the obturator is withdrawn and the light carrier put in position. A lug on the end of the light * The electroscope can also be used for the illumination of other organs if appropriate adjoining pieces be used (Fig. 12 A. K. I. G.) 14 PHYSICAL METHODS OF EXAMINATION. carrier fits securely into a spring slot in the disc and presses against a shoulder on its under side, thus fixing the light carrier firmly to the under side of the tube and preventing it from crossing the field of vision. The light carriers for all tubes of the same length are inter- changeable. Fig. 14. — Valentine's urethroscope. £-** Fig. 15. — Koch's urethroscope. In Koch's urethroscope (Fig. 15) a small auxiliary tube for the light carrier and lamp is placed along the side of the tube proper. This instrument is inserted with both light carrier and obturator in position. Applications or other manipulations may be made directly to diseased parts under direct guidance of the eye. As the lamp is outside the main tube, it does not obstruct the view nor cast shadows, URETHROSCOPY. 15 nor does the cotton catch on the lamp when the applicator is with- drawn. Swinburne's posterior urethroscope (Fig. 16), designed by Dr. George K. Swinburne, of New York, consists of a catheter-shaped tube, 16 centimeters long, with a small auxiliary tube containing light carrier and lamp on the upper side. The light is thrown through a fenestra near the distal end, illuminating the floor of the Fig. 16. — Swinburne's posterior urethroscope. Fig. 17. — Dilating bulb to be used with Swinburne's posterior urethroscope. urethra. The beak of the instrument has a closed end. The window attachment shown in the illustration, when placed in the visual end of the tube and connected with the dilating bulb (Fig. 17) allows the operator to dilate the posterior urethra, and thus secure a more satisfactory view.] Whatever instrument may be employed, urethroscopy has only a narrow range of usefulness, being limited by certain anatomical and mechanical conditions beyond which the interpretation of the urethro- scopic picture is impossible. When an inflexible tube is forced be- 1 6 PHYSICAL METHODS OF EXAMINATION. tween the closely adjacent walls of the urethra, changes in the vessels of the mucosa are produced such as hyperaemia, anaemia, and altera- tions in color and lustre. These disadvantages are increased during urethroscopy of the membranous and prostatic portions, where the tube has to be pressed with some force against one of the walls, thus further interfering with the natural conditions. These things must be borne in mind and an endeavor made to elimi- nate whatever has been artificially produced before drawing conclusions concerning the condition of the urethra. If such a course be pursued, urethroscopy will prove to be a diagnostic expedient which, for certain kinds of cases, cannot be replaced by any other method of investigation at our command. The technic of urethroscopy is exceptionally simple. Tubes having obturators and varying in size preferably from 22 to 28 French are used. A tube is selected that will pass through the external meatus, which, as is well-known, is the narrowest portion of the urethra, without difficulty and without causing pain. The larger the tube the more distinct the urethroscopic picture, but a tube which is too large produces great pain, causes tears in the mucosa, and so changes the entire picture that inferences drawn from it are erroneous. After the patient has urinated, the urethra, if sensative, is cocainized with a 2% solution of cocain, and the tube, smeared with Katheter- purin is passed slowly and carefully down to the bulbous portion exactly as any other urethral instrument is passed. I go beyond this limit for only two reasons; first, when there is cause to suspect the presence of a growth or an ulceration in the posterior urethra, and second, for the purpose of removing such a tumor. In all other cases endoscopic examination of the membranous and prostatic urethra is to be avoided. The passage of a straight tube beyond the bulb causes a stretching of the pronounced curve which the urethra here describes. It frequently gives rise to haemorrhage, and, moreover, so distorts the posterior urethra by the pressure winch it exerts that it is impossible to distinguish between the changes produced by disease and those pro- duced by pressure of the instrument. [These difficulties have been rendered less by the construction of the curved posterior urethroscope above described.] When the tube reaches the bulb the obturator is removed, the mucous membrane is wiped with a pledget of cotton wound around an applicator, the urethroscope is set up, and its tube placed centrally in URETHROSCOPY. 1 7 the long axis of the urethra. The tube is now slowly withdrawn and the eye follows the picture which is presented until the external orifice of the urethra is reached. Thus the entire penile portion of the urethra is examined. In normal cases the following picture is presented : At the end of the tube a tunnel is seen whose base is formed by the edge of the tube, its apex being further back, and its sides being formed by the walls of the urethra. (Griinf eld's central figure.) If the tube lies in the long axis of the urethra, this central figure will form the center of the urethro- scopic picture, having the form of a fossette in the deeper portions, and becoming a mere fissure at the meatus. The wall of the tunnel is formed by the walls of the urethra, upon which the color, lustre, duplicature, and striation of the mucous membrane are to be observed. In almost all parts of the urethra the normal color is white or yellowish white, permeated by a peculiar shade of dark red, which is most intense at and behind the bulb, the color becoming lighter and lighter as the meatus is approached ; in the middle of the urethra it is yellowish red in hue, while at the jossa navicularis and external orifice it is pale yellow or white. The lustre of the normal mucosa is uniform throughout, its upper surface appearing moist, shiny, and smooth. When at rest the walls of the urethra lie in contact with one another in the form of longitudinal folds; if a tube be introduced, the folds assume a radiate arrangement for the reason that the tube lies perpen- dicularly to a cross section of the canal. The radiations vary according to the size of the instrument which is inserted: the smaller the tube, the greater the number of plications, and vice versa (Figs. 18-21), as pressure of the tube against the urethra obliterates them. In the spaces between these folds, striations varying in color from pink to deep red are seen, radiating from the periphery to the center the same as the folds themselves. These striations are caused by blood vessels in the submucosa. If the tube be pressed against one of the urethral walls it will be easily recognized that these striations are not exactly straight lines; they may also be obliterated by central pressure (Figs. 18-21). Likewise, areas of hyperemia and anagmia may be produced by pres- sure exerted in different directions. Sometimes the capillary network in the mucosa can be plainly seen (Fig. 21). PHYSICAL METHODS OF EXAMINATION. Finally, the lacunae of Morgagni, from 6 to 12 in number, may be observed as fine longitudinal depressions. Fig. 18. — Normal urethra in the center of the cavernous portion. Five distinct folds converging toward the center; in three segments striation are seen; in the other two they have been obliterated by the pressure of the tube. The conges- tion in the periphery of these two seg- ments is due to the same cause. Fig. 19. — Normal urethra. Three folds. In the two segments to the left distinct striations are seen. In the periphery of the right segment there is artificial hyperaemia. Fig. 20. — Normal urethra. Five folds. In the three upper segments there is marked striation. In the other two the striations are indistinct owing to the artificial hyperaemia at the periphery. Fig. 21. — Four segments. In the upper one radiate striations are seen; in the left hyperaemia in the periphery; in the right and lower segments the vascular plexus is shown. Fig. 22. — Acute gonorrhoea. Deep red Fig. 23. — Granular urethritis. Elevations color in the periphery to the right and varying in color from dark red to black below. A thick streak of pus passing are'seen near the center in the segments across the field. above and to the right. In the seg- ments to the left and below they are near the periphery. If we now proceed to a study of pathologic conditions of the urethra, urethritis will be the first to interest us. In the acute stages urethro- URETHROSCOPY. l 9 scopy is contraindicated, being permissible only in exceplional cases where doubt exists as to differential diagnosis between chancroid of the urethra and gonorrhoea (Fig. 22). Several forms of chronic urethritis may be differentiated by means of the urethroscope, a fact which is of some importance in regard to treat- ment. We have long been familiar with the sharply defined circum- scribed areas of hyperemia first described by Furstenheim, which occur on different parts of the penile urethra, and also with the granular Fig. 24. — Chronic infiltrative urethritis. Four folds; no striations; red macula - tion. Fig. 25. — Inflammation of Littre's glands In the upper segment circumscribed redness to the left. In the segments to the left and below hyperemia near the periphery. Fig 26. — Chronic glandular and infiltra- tive urethritis. Only two folds; no striations. In the upper segment a lacuna of Morgagni having dark red edges is seen. Fig. 27. — Chronic glandular and infiltra- tive urethritis. The tube is not cen- tral but lies toward the upper wall. Three folds are seen. To the right and above there is a lacuna of Morgagni and to the right of this a punctate de- posit of pus. There are no striations. The tissues are deep red. patches of urethritis granulosa, which are dark red or black in color, resembling those seen in trachoma (Fig. 23). These forms of urethritis, which are confined to the upper layer of the urethra, are closely related to the infiltrative forms, which occur both with and without glandular changes. Small-celled infiltrations affect circumscribed areas of the submucosa to greater or less extent, sometimes penetrating as deep as the corpora 20 PHYSICAL METHODS OF EXAMINATION. cavernosa. A part of this infiltrate becomes converted into embry- onal connective tissue, which in turn develops into scar tissue (Neelsen, Halle, Wasserman, Finger). As a result of these alterations the appearance of the surface becomes changed. The mucosa, being poorly nourished, looks pale, and in the worst cases has a sinewy white hue; the epithelial cells die and become stratified, as a result of which the lustre of the mucosa is lost. The thickening of the mucosa prevents the formation of folds, or at least greatly reduces their number. The Fig. 28. — Psoriasis of the urethral mucous Fig. 29. — Mucous ulceration. Three seg- membrane. In the upper segment there ments. The ulcer is above; no stria- is a conical white deposit consisting of tions; deep redness in the periphery, thickened epithelium. Fig. 30. — Papilloma of the urethra in the upper segment. The surrounding tissues are deep red; below striations are seen, to the right infiltration. striations are not so well-marked and at times seem entirely wanting. (Fig. 24.) In other cases these changes are not very apparent, glandular affec- tions dominating the urethroscopic picture. We are indebted to Oberlander for a thorough study of these glandular forms of urethritis. The infiltrate attacks Littre's glands, some of which have their orifices on the surface of the urethra, while others empty into the lacunas of Morgagni. Under normal conditions Littre's glands cannot be seen, but when they become inflamed they show as small, round, dark red depressions about as large as the head of a pin, while Morgagni's crypts are long URETHROSCOPY. 2! slit-like openings with everted, deep red edges. When pressed upon by the tube they gape so that the point of a small sound may be pushed into them. These glandular changes are usually associated with more diffuse infiltrations of the submucous tissue (Figs. 25, 26, 27). Finally, there remains to be mentioned a peculiar disease of the urethral epithelium known as psoriasis mucosa, which is also due to local nutritional disturbances, and which was first described by Kollmann and Oberlander. In this disease the surface of the urethra is covered with thick, flat, lustreless white patches, which are firmly adherent at their base (Fig. 28). They are composed of thick layers of dead epithelial cells, both squamous and round as well as cylindrical, which microscopically show only a nucleus and a mass of colorless detritus. All of these infiltrative forms except the last are associated with some narrowing of the urethra, although a marked degree of contraction is not present. They are the strictures of large caliber described by Otis. In true stricture urethroscopy has neither diagnostic nor therapeutic value, because the constrictions can be better felt than seen; moreover, they can be treated better without the endoscope than with it. Ulcerations and tumors, on the other hand, offer a very satisfactory field for urethroscopy. To the first class belong simple erosions, hard and soft chancres, tuberculous ulcers, and degenerated gummata. They are easily recog- nized, as they always produce loss of substance. A true ulcer is always deeper than the surrounding tissue. Erosions result from simple or gonorrhceal inflammation or from the passage of instruments, and may occur in any part of the urethra. They are small spots about the size of a millet-seed and are not covered with epithelium. Soft and hard chancres are usually at or near the cutaneous orifice, although the first also occur in the deeper portions of the urethra. The sense of sight does not enable us to determine whether a chancre is soft or hard, so conclusions as to its nature must be drawn from the accompany- ing circumstances of the case. The area surrounding a soft chancre is usually very red (Fig. 29). In hard sores the infiltration can be felt from without. If tuberculous ulcers are present or suspected, the urethroscope should not be used, as it may cause dissemination of the tubercles. Tubercu- losis of the urethra gives rise to tight strictures which withstand all 2 2 PHYSICAL METHODS OF EXAMINATION. forms of treatment except operation. On the surface of the mucous membrane nodular granulations and ulcers are seen. The tumors affecting the urethra are polypi, papillomata, and carci- nomata. Polypi are very rare ; they are pale, pedunculated little growths which can be plainly seen and easily recognized. Papillomata are more common. They invade all parts of the urethra, but have a predilection for the colliculus seminalis. They are almost always multiple. If they are discovered in the anterior urethra the pos- terior urethra must be examined with the urethroscope. (Fig. 30.) Carcinoma of the urethra is very rare. It produces firm, incurable strictures, which can always be palpated from without and therefore require no urethroscopic inspection. 3. CYSTOSCOPY. Cystoscopy is a term applied to the method of examining the bladder visually by means of an instrument introduced through the urethra. The efforts made to attain this object date from the beginning of the last century. Segalas, Fischer, Desormeaux, Cruise, Fiirstenheim, Stein, and Griinfeld followed the German physician Bozzine, of Frankfurt-am- Main (1807) in an attempt to construct cystoscopic instruments. With the exceptions of some unimportant details their methods were the same. They passed a tube through the urethra into the bladder and reflected light into that viscus from without by means of a mirror. Excluding Bruck's diaphanoscopic method, which was never made practical use of, the attempts of all these investigators may be criticised as being totally inadequate for the purpose for which they were intended. Their illum- ination was defective and, moreover, only a very small area of the bladder wall, scarcely larger than the lumen of the tube introduced, could be seen at one time. It was Nitze who in 1877 first fully recognized this defect and intro- duced two new principles in the examination of the interior of the bladder, as a result of which cystoscopy became a serviceable method. He established the fundamental principle that illumination of a hollow viscus connected with the exterior of the body by a long narrow canal is possible only when the source of light is carried into the viscus itself. Furthermore, he maintained that even if this requisite be fulfilled, satis- factory inspection of the bladder could not be made unless a consider- able portion of its surface could be seen at one view. If both con- CYSTOSCOPY. 23 ditions could be fulfilled, then by moving the instrument about the whole surface of the bladder could be examined. Both were realized when it became possible to carry an electric light into the bladder without causing pain or injury, and to construct an optical instrument magnifying the field of vision. The electric light was devised by Nitze and a Viennese instrument maker named Leiter. It was supplied by a platinum wire heated to a white heat. This wire was covered with glass, the two together being contained in an irrigator which permitted a current of cold water to flow around them while the wire was burning, and thus pre- vent injury of the bladder. It is the same method which Bruck applied to his diaphanoscope illumination. To Nitze belongs the merit of rendering Brack's method of illumination practical for ex- amining the bladder. The 'optical apparatus, somewhat similar to a telescope, was made by the optician Beneche in conformity with a suggestion of Nitze's. The irrigating apparatus around the platinum wire rendered the instrument so complicated and so uncertain of appli- cation that it could be used only with difficulty, or not at all, and for this reason cystoscopy did not gain entrance to the practice of urologists and surgeons. When the Edison lamp succeeded the platinum wire a change was wrought at one stroke. On the point of the catheter-like instrument where the platinum wire formerly was placed, an Edison lamp was at- tached and connected with a battery or accumulator which furnished a beautiful bright light without producing much heat. Thus an unser- viceable instrument was converted into a useful one. The irrigator was discarded as superfluous; the instrument, as easy of introduction as any silver catheter, worked well and safely. The change was an important one for cystoscopy. Since it was instituted the method has won universal recognition and become the common property of the profession. To this change are due the surprisingly favorable results obtained as well as the wide propagation the method has undergone. This improvement in the instrument was made public at about the same time by Nitze and Dittel, the latter being represented by Dr. Bren- ner at the Surgical Congress at Berlin in the year 1879. In order to understand the cystoscope and cystoscopy a thorough knowledge of the second principle enunciated by Nitze, namely, in- crease in the apparent dimensions of the field of vision by means of 24 PHYSICAL METHODS OF EXAMINATION. an optical contrivance is indispensible. This device consists of a tube (R Fig. 31) having an objective (O) at its vesical end and an eyepiece (L) at its external end. The objective consists of one or more lenses which throw a small inverted image (B) of the opposite object (B'), pro- portionate in size to its index of refraction, into the interior of the tube, where it lies close behind the objective and is rein verted by a lens (U) in the middle of the tube and then transferred to its outer end against the eyepiece (B"), which acts as a magnifying glass and enlarges the upright image. (Fig. 31.) When one looks through the eyepiece he sees an image of the ob- ject lying opposite, varying in size according to the distance at which it is removed. In the words of Nitze, "one sees in the inner field of vision that part of the opposite object which lies within an imaginary cone whose axis is perpendicular to the free surface of the objective." R ___ in B B' U B" L Fig. 31. — Optical Apparatus of the Cvstosocpe. The size of this cone varies; the better the objective the larger the cone. In the best instruments which I have seen the divergence of the cone was from 80 to 90 degrees. The size of the opposite surface (bladder) as seen in the inner field of vision, which itself remains con- stant in size, is increased as the objective is moved away, and there- fore the details of the picture become less distinct; it is decreased in size as the objective is carried toward the surface, thus making the details larger and more distinct. The natural size of an object is seen at a distance of about 2 cm. (f of an inch). If the instrument be carried nearer less is seen, but the image becomes plainer and larger, whereas if the objective be moved away more is seen, but the picture is less distinct. From these statements two things bearing on practical cystoscopy may be learned ; first, that as errors may result from increasing or dimin- ishing the size of an object beyond its natural dimensions one should form an opinion concerning the size of the object observed by varying the distance of the objective; and second, that objects such as organs of the body will appear distorted because their more distant portions will be diminished in size while their nearer parts will be magnified. If the CYSTOSCOPY. 25 examiner knows and considers these facts he will be able by a little prac- tice to eliminate the element of distortion in the image and judge cor- rectly as to its size. If we turn our attention to a description of the cystoscope itself, of which there are many, it may be said that the one Fig. 32. — Nitze's Cystoscope I. Fig. 34. — Nitze's Cystoscope II. which is almost universally used and which suffices for nearly all cases consists of a sound having a Mercier curve and a shaft from 22 to 25 cm. (9 to 10 inches) in length. (Fig. 32.) On the tip of the sound is an Edison lamp (E) in a setting which is 26 PHYSICAL METHODS OF EXAMINATION. screwed onto the shaft (F). Under the surface of the lamp is a fine insulated platinum wire which becomes connected with the insulated conducting wire of the shaft when the lamp is attached. (Fig. 33.) In the concavity of the angle formed by the junction of the shaft with the beak of the instrument there is a right-angled prism whose hypotenuse lies in the elongation of the back, while the base falls perpendicular to the long axis of the shaft and the up- right runs parallel with the shaft. (Fig. 33 P.) The surface at the hypotenuse of this prism is silvered, so that when one looks through the funnel at the external end of the instrument he sees the objects opposite the free cathetus of the prism. The optical apparatus previously de- scribed is placed close to this prism, so that one really sees only as much of the opposite bladder wall "as lies within the envelope of an imaginary cone whose axis is perpendicular to the free surface of the prism." (Nitze.) The second cystoscope (Fig. 34), which is especially adapted for examining the fundus of the bladder, but which it is only rarely necessary to use, has its prism (P) placed at the convexity of the angle. At the junction of the shaft and beak a mirror (h) is set and the opti- cal contrivance so placed that when one looks into the instrument he sees that part of the bladder which lies opposite the free surface of the prism (P). Nitze has also invented an instrument which is called the irrigating cystoscope. The object of this instrument is to irrigate during exam- ination whenever the interior of the bladder is made turbid by pus or blood, and so restore its transparency. In construction this instrument is essentially the same as the one first described. (Fig. 35.) Underneath the prism are several small openings which communicate with a canal extending down the end of the funnel. On the side of the instrument there is a larger aperture which also communicates with a canal running the whole length of the instrument. These canals term- inate in two processes (B) and are opened and closed by stop-cocks (C). Thin rubber tubes are attached to these processes. During examina- tion an assistant injects clearfluid (Hydrarg. oxycyanat solution T-5000) through the tap leading to the small apertures beneath the prism. In this way the prism is irrigated and freed from blood or mucus. At the same time the other stop-cock is opened and the turbid fluid allowed to run out. This arrangement, concerning the importance of which we shall have something further to say, gives a more limited field of vision, CYSTOSCOPY. 27 though withal a clearer one, than other instruments. The instrument itself is somewhat larger, being about 24 to 25 French. pf < m Fig- 35- — Nitzc's irrigating Fig. 36. — Boisseau du Rocher's cystoscope. megaloscope. This irrigating cystoscope has been improved upon, being made with only one canal, which is larger than either of those in the original instru- 28 PHYSICAL METHODS OF EXAMINATION. ment and therefore does not become so easily clogged as did the finer ones. In using the new instrument it is necessary to irrigate and allow the fluid to run out as often as the picture becomes blurred. The size of this instrument is 22 French. Different in construction from any of these instruments is one called the megaloscope, which was invented by Boisscau du Rocher (Fig. 36). It has a lamp (L) at its end on the convex side, and the optical apparatus is introduced separately, a special opening (O) being provided for it at the obtuse angle formed by the junction of the shaft with the shortly curved beak. This opening, which is closed by an obturator during the introduction of the instrument, is used for washing out and filhng the bladder. In addition to it there is a special double irrigating apparatus (CC and MM'; which serves to keep the contents of the bladder free from turbidity during the introduction of the optical apparatus, and which can also be used for inserting ureteral catheters. (Fig. 36.) The megaloscope differs from the cystoscope in that it has no prism, that portion of the bladder wall which lies opposite the optical apparatus being brought into view. The instrument is awkward and unsuitable for use. The late Dr. Giiterbock invented a cystoscope which is very useful in many cases. It differs from all cystoscopes previously constructed in that the cystoscope proper consists of an inner tube (Fig. 37 b.) which is passed into the bladder through another catheter-like instrument (Fig. 37a). For the lamp (L) and prism (P) of the cystoscope-tube there are corresponding notches (F and B) in the outer tube. When using this instrument it is not necessary to wash the bladder out with another catheter, for it can be irrigated through the outer tube (Fig. 37a.) and the inner tube introduced as soon as the bladder has been cleansed and filled with water. Winter has prepared a cystoscope for the female bladder which is thicker and shorter than those used for men. Otherwise it does not differ from the ordinary instruments. As the male cystoscopes give a good view of the female bladder Winter's instrument may be dis- pensed with. For the purpose of fixing pathologic conditions of the bladder, Xitze, and after him the instrument maker W. A. Hirschmann, of Berlin, con- structed a photographic cystoscope by means of which very good pictures of the interior of the bladder can be taken. The principle of this instrument is. that the image in the interior of the tube is CYSTOSCOPY. 29 brought to the ocular end and photographed by a camera which is u — O — PL, be placed there. In Nitze's instrument the camera is round and eccentric (Fig. 38), while in Hirschmann's it is angular (Fig. 39). The latter is 3° PHYSICAL METHODS OF EXAMINATION. easier to handle and also permits of an exceptionally rapid insertion and withdrawal of the plates (Fig. 39). Many cystoscopes for catheterizing the ureters have been devised. For the female bladder Brenner's, which was one of the first, fulfills all CYSTOSCOPY. 3 1 requisites. It has a tunnel on its convex side through which the ureteral catheter is passed; the lamp is also on the convex side, so that one looks straight through the tube into the bladder (Fig. 40). Fig. 41. — Albarran's Ureteral Cystoscope. H D M I) I) Fig. 42 — Casper's Ureteral Cystoscope. An instrument intended for catheterizing the ureters must be appli- cable to both sexes. It must fulfill the following conditions: the catheter must have a variable curve and must remain in the ureter when the metal instrument is withdrawn ; it must be so constructed as 3 2 PHYSICAL METHODS OF EXAMINATION. to permit the introduction of a catheter into both ureters at a single sitting. These requirements are nearly met in Albarran's ureter- gjwimimmimnii* © @@~ © — a i § d -\-0 ^ ® ® SS \ OO © |§ ® ~®^w Fig. 89. — a, Blood-corpuscles showing depressions in center. b and c, shrunken corpuscles, d, swollen corpuscles. cles, and mucus-corpuscles have a round form, but change it by means of amoeboid movements. When perfectly fresh they do not show a nucleus, but have a granular appearence (Fig. 91). In time, and also upon the addition of acetic acid, they develop one to four nuclei from their granular protoplasm, which when highly magnified show nucleoli in their interior. Leucocytes may be mistaken for small round epithelial cells. To differentiate between the two let a drop of Gram's solution run under the cover-glass; the leucocytes will be colored an intense mahogany- brown, while the epithelial cells will be stained light yellow. Mucus and lymph-corpuscles cannot be differentiated under the microscope. 7o CHEMICAL, PHYSICAL, AND MICROSCOPIC EXAMINATION. 2. Epithelium. Various forms of epithelium are found in the urine. The epithelium from the renal tubules,- from the pelvis of the kidney, from the bladder and urethra, from the prostate gland, from the vagina — all these are found occasionally in the urine. It has long been attempted to locate the source of the epithelium by its form. rPOO © O a ol. amygdalae dulc. f 3i, lanolin, ^iv, with excellent results in these cases. For deep urethral applications, silver nitrate and iodine are the ones most frequently indicated.] Then came the era of dilators, the first of which was designed by Ober- lander. As the urethral orifice will not permit the introduction of large instruments he constructed an instrument which, when closed, is about the size of a 16 F. sound, but which can be unscrewed and the branches thus separated after it is introduced into the urethra. *The short tube shown in the illustration may be used for rectal applications. It is to be attached to the cup after the urethral tube is unscrewed. TREATMENT OF URETHRITIS. I2 5 Lohnstein, Kollman and others followed with four and eight bladed dilators. From my own experience I believe mechanical treatment, com- Fig. 130 — Kollmann's dilators. bined with local medicinal measures to be good and useful if prac- tised with great caution and within wise limits. All measures which lacerate the urethra are evil; they add new scars to the old process. At first sounds as large as the urethra will admit are passed twice a week. 126 DISEASES OF THE URETHRA AND PENIS. In the intervals the patient uses injections or receives irrigations. When 23 or 24 F. is reached dilators are used, and of these I prefer the excellent instrument of Oberlander (Fig. 129). [Kollmann's four- bladed dilators are also admirable instruments. (Fig. 130.)] Dilata- tion should not be practised oftener than once or twice a week and the urethra should be stretched very gradually, an increase of not more than 1 mm. being made at each sitting. I have tested the method of simultaneous dilatation and irrigation and see no advantage in it. Perhaps local urethrotomy may lead us further. It is performed with an instrument constructed after the principle of Otis and slightly modified by Kreisl (Fig. 131). With it one or more incisions are made at the site of infiltration. I believe that this pro- cedure is quicker and surer than dilatation. ^mm Fig. 131. — Otis-Rreisl urethrotome. [Urethroscopic examination may show that slight chronic dis- charge or filaments in the urine are due to chronically inflamed urethral glands, superficial granulations which have failed to yield to dilatation, or papillomata. Diseased glands may be destroyed by means of Kollmann's or Oberlander's electrolytic needles, or split open with Kollmann's or Bierhoff's knife. t These instruments are used through the urethroscope under direct guidance of the eye. Kollmann's needle is connected to the negative pole of a battery supplying the constant current and a flat electrode is attached to the positive pole. The flat electrode is placed on the thigh, the needle is passed through the urethroscope and its point inserted into the opening of the diseased gland. From three to five milliamperes of the current are now turned on and the needle left in situ for one or two minutes. Oberlander's double needle may be used in this way, or one needle may be attached to the positive pole and the other to the negative. TREATMENT OF URETHRITIS. 1 27 The current should always be turned off before the instrument is withdrawn from the urethra. Not more than two or three glands should be destroyed at one sitting. From observations made in Wossidlo's clinic, Mundorff states that the delicate scars resulting from this procedure may develop into true strictures if too strong a current be used. Therefore, it is important that only a weak current, as above recommended, be employed. Mundorff advises the use of large steel sounds during the process of healing. The urethral knife serves not only to split open diseased glands, but also to divide infiltrations and delicate bands of cicatricial tissue. Granulations may be touched with silver nitrate or copper sulphate. A solution containing sixty grains to the fluid ounce of distilled water may be used. Papillomata may be snared, or torn off with urethral forceps, and their base touched with the galvano-caustic needle or trichloracetic acid, preferably the former, for the reason that the acid diffuses itself over surrounding healthy tissue unless great care be employed in applying it.] The results attained in infiltrative urethritis are very moderate as regards cure. That such must be the case is self-evident. Until we are able to remove the rigidity of the urethra we cannot expect to arrest a discharge which depends upon this rigidity. This leads to the important question as to what we shall do with those patients in whom we fail to suppress the discharge, that is to say, those in whom a slight secretion persists either in form of a drop at the meatus or as filaments in the urine. According to my experience the whole situation depends solely upon whether a given case is considered infectious, and by infectious we mean only those in which the gonococcus has been found or those which are known to have conveyed infection to the female. In regard to the gonococcus it has already been stated that its isolation sometimes presents great difficulties, and that for this reason the decision as to whether a case is infectious or not may be most difficult. It has been observed that the filaments present in the urine may contain no gonococci and yet these bacteria be present in the secretion obtained with the bulbous bougie. Authentic cases are met with often enough in which a healthy man contracts gonorrhoea from a woman in whom not the slightest evidences of disease are manifest ; conversely, women 120 DISEASES OF THE URETHRA AND PENIS. whose husbands show no recognizable symptoms may develop the disease. Furthermore there are cases in which the urethral secretion is free from gonococci although these bacteria are present in the prostatic secretion; the reverse is also true. We have already mentioned those cases in which the gonococci remain latent for months and then suddenly reappear in the secretion. These conditions enormously increase the difficulty of deciding as to whether a case is infectious, and mistakes doubtless occur. Notwith- standing this, experience has supplied us with certain data which help us in passing judgment. Thus, cases in which gonococci are lurking are characterized by variations in the quantity of discharge, whereas in those free from gonococci the discharge is fairly constant in quantity, although it resists every therapeutic measure. We must see to it that such cases remain under observation a long time so that they can be frequently examined. If the secretion obtained by stripping the urethra, massaging the prostate, and probing with the bougie a. boule has been found free from gonococci after repeated exam- ination, and if they do hot appear after the urethra has been subjected to different forms of irritation, then we may discharge the patient from treatment and also give our consent to his marriage. In my opinion it is not necessary to treat the patients as long as pus-cells continue to be found in the filaments or in the discharge. The shreds often remain permanently. We have already said : " Of two evils choose the lesser. " The greater evil is to subject men thus affected to a protracted course of treatment which frequently not only fails to suppress the secretion, but, moreover, changes a mild type of neurasthenia into a severe one. Herein lies the difficulty of the whole matter. What a large number of men suffering with cerebrasthenia, myelasthenia, impotence, hypochon- dria, melancholia and kindred affections come to us year in and year out ! These people, who unfortunately are often honorable and estim- able members of society, have been reduced to their wretched condition by a "clap which would not heal;" the more conscientious they are and the more they lose faith in the curability of their urethral catarrh, the more certain are they to become the victims of sexual neurasthenia. When they go from one doctor to another and take from each a fruitless, protracted, and usually painful course of treatment, and are forbidden by each to marry, the predisposition to neurasthenia is enhanced. Although excessive treatment is harmful the patient must not be denied necessary attention. It is self-evident that the urethritis should CHANCROID OF THE URETHRA. 120, be cured if possible. The experienced and judicious physician will be able to tell within a short time what he can accomplish in a given case. If he decides that the case cannot be cured in the ideal sense of the term, then it becomes his duty to assure the patient of the harmlessness of his condition, of the triviality of his affection. It is generally known that this is no easy task. Gonorrhophobiacs want to be treated under all circumstances, even though treatment is painful. They do not trust a physician who assures them that the fila- ments in their urine are of no significance. In spite of this it must be our aim to convince them that what seems to them to be disease is in reality no longer disease, but merely its sequel. Do not deny these per- sons help. They need medical advice. A general hygienic regimen should be prescribed for them. Baths constitute an important part of such a regimen, but it is not necessary for me to describe them in detail as they are known to every well-informed physician. If we follow this course we shall save from neurasthenia many so- called gonorrhceal patients who in reality are not gonorrhceal, and shall also be able to restore to health and strength many neurasthenics whose disease depends upon gonorrhophobia. CHANCROID OF THE URETHRA. Soft chancres of the urethra are of relatively uncommon occurrence. They are located in the anterior part of the urethra, seldom being further back than the termination of the glans. They cause pain- ful micturition and a profuse purulent discharge, which differs from gonorrhceal discharge in that it contains no gonococci and is little influenced by the ordinary injections used for clap. The presence of associated sores on the penis or edge of the meatus, and finally the the use of the endoscope, facilitates diagnosis. From hard sores they are differentiated by abscence of induration and cedematous swelling; the short period of incubation has also some bearing on the case. Hard chancres heal without scar- formation and therefore produce no . strictures; extensive soft sores may lead to stenosis. As to treatment the introduction of urethral cylinders composed of cocoa butter and iodoform is to be recommended. The patient urinates and then a cylinder is passed into the urethra as deep as it will go without producing pain. The meatus is then covered with a pledget of cotton or gauze, so that the iodoform can remain in the urethra for some- time. Under this treatment cure is rapid. 9 130 DISEASES OF THE URETHRA AND PENIS. ACUMINATED CONDYLOMATA OF THE URETHRA. These growths may occur either in association with or independently of others on the external parts. They are generally near the external orifice, but are also encountered in the posterior urethra. They do not differ in any respect from those found on the external structures. Usu- ally they appear as small isolated warts within the urethra; it is very rare for them to grow large enough to cause obstruction. They generally, .though not always, follow gonorrhoea; they may develop in the urethra just as they do on the skin of persons who have never had the disease. The symptoms of urethral condylomata are very slight. They consist of slight burning, scanty discharge which does not yield to injections i and which therefore may simulate chronic gonorrhoea, and occasionally trifling haemorrhage from the urethra, or the passage of blood-tinged urine. With the endoscope they can be brought plainly into view. Treatment requires their removal, because if left they may grow and produce symptoms of stricture, or apparently keep up a gonorrhoea. Those situated near the urethral orifice can be made accessible by everting the meatus, and can then be cut off and their base cauterized with nitrate of silver or trichloracetic acid. Those situated further back may be reached through the cystoscope, if practicable, and cauterized. Often it will suffice to pass large bougies which tear them from their base. SYPHILIS OF THE URETHRA. Syphilis may affect the urethra in three ways: first as the initial lesion, the hard chancre; second as a symptom of secondary syphilis; third as a gumma. The most common of the three is the hard chancre, which has been observed as far back as the coronary sulcus. A hard nodule, which eventually becomes merely a firm indurated mass, is felt from without, although there are no signs of disease on the penis. The urethra is cedematous and the lips of the meatus are swollen, a condition which produces the symptoms of stricture. The sore causes no special symptoms; it simulates gonorrhoea, only the discharge is not so thick, purulent and creamy, but sero-purulent or sero-sanguinolent and does not contain gonococci. The urethra is so swollen and cedema- tous that it is impossible to introduce a tube sufficiently large to enable STRICTURE OF THE URETHRA. 131 anything positive to be determined. Moreover, the introduction of instruments is contraindicated because it may beget lymphangitis. In reference to diagnosis, the condition may be confounded with thick periurethral infiltrates, although these are scarcely if ever so large as the nodules of syphilis; the short period of development- infiltrates require a longer time — the ineffectiveness of antigonorrhceal therapy, the associated indolent buboes, and the appearence of other symptoms of syhpilis all serve to confirm the diagnosis. Secondary syphilitic affections of the urethra consist of exanthe- mata such as occur on other mucous membranes. They occur very seldom and are much more seldom detected. They progress under the guise of gonorrhoea, from which they can be distinguished only by the absence of gonococci, the inefficacy of antigonorrhceal therapy, and the use of the endoscope. Gummata of the urethra are seen more frequently, occurring in the form of circumscribed nodules before disintegration occurs and as ulcers after disintegration has taken place. Their recognition is of great importance, because if not interfered with they may produce con- siderable disturbance. Many urethral fistulae near the meatus owe their origin to an unrecognized gumma. A thorough examination, above all things a careful anamnesis, the presence of other late mani- festations of syphilis, and the fruitlessness of the usual treatment make the diagnosis not difficult. As to treatment it may be said that these secondary syphilitic affec- tions of the urethra do not demand any local measures; they get well under general treatment. In hard chancre Unna's gray plaster may be applied to the penis over the site of the internal sore and a general mercurial treatment instituted, whereupon the ulcers will rapidly heal. For gummata large doses of the iodides are required, 5, 10, or even 15 Grm. (from 75 to 225 grains) a day being given. The result is surprising. STRICTURE OF THE URETHRA. Conception of stricture. If we bear in mind the so often forgotten fact that the urethra when at rest is a closed canal the walls of which are in direct contact, there can hardly be a better definition of stricture than the one given by Sir Charles Bell, who described it as a condition in which the affected portion of the urethra has lost its dilatability. The acceptance of this definition excludes two conditions which, I32 DISEASES OF THE URETHRA AND PENIS. though generally classified as strictures, are not such in reality ; namely, spastic and inflammatory obstruction. The urethra can doubtless be contracted or entirely occluded at any part of its course by spasm or inflammation, as for example, by the cedematous swelling of acute gonorrhoea; these, however are only transitory phenomena, the urethral walls still retaining their elasticity. As soon as the spasm or the inflammation has been subdued by anti- spasmodic or antiphlogistic treatment they reassume their normal exten- sibility. These conditions, therefore, may be considered as spasmodic and inflammatory obstructions, as occlusions and the like, but not as strictures. In contradistinction to them true strictures present a per- manent narrowing caused by plastic changes in the urethral walls. Tumors (epithelioma, sarcoma, fibro- sarcoma) and tubercles which grow from the wall of the urethra, infiltrating it and also sometimes projecting so as partly or entirely to occlude its lumen, are not classed as strictures. ETIOLOGY. If we exclude congenital strictures, which will be discussed under malformations of the urethra, we recognize only two causes for the development of organic stricture: first, inflammation of the urethra, or in other words gonorrhoea; and second, loss of substance in the urethra due to either trauma or ulceration. The vast majority of all strictures are due to the first cause, more than go per cent being of gonorrhceal origin. Simple urethritis hardly ever leads to stricture formation. All strictures which result from loss of substance and consequent production of scar-tissue during the process of healing are to be con- sidered as traumatic. The trauma may consist of a blow or wound from without, of a tear during coitus, injury due to introduction of instruments, or to passage of a calculus through the urethra. Cauteri- zation, as for example, that due to injections of corrosive fluids such as carbolic acid, and destruction due to a wide-spreading chancroid belong in the same category. In my opinion syphilitic strictures do not exist. Hard sores, which seldom affect the urethra, heal without a scar, and urethral gummata produce only a transitory obstruction; after proper constitutional treat- ment is instituted the urethra becomes pervious. PATHOLOGICAL ANATOMY OF STRICTURE. 1 33 PATHOLOGICAL ANATOMY. The origin of urethral stricture will be understood if the origin of the primary causative disease, gonorrhoea, be borne in mind. As in all inflammatory processes there is in the beginning a small- celled infiltration of the affected part resulting either from emigration of leucocytes or from proliferation of connective-tissue cells. The chronicity of the process by which strictures are formed speaks rather in favor of connective tissue proliferation, although as a matter of fact the question as to the origin of the primordial round cells has no bear- ing on the further course of the morbid process. As more and more intercellular substance becomes interposed between these cells they become separated from one another and at the same time change their form. At first round, they later give off processes and thereby become changed into spindle or star-shaped bodies. During these changes in the cells it is observed that the inter- cellular substance is split into the finest and most delicate fibers and fibrils; in short, true connective tissue develops, a so-called scar being formed. If the process continues more connective tissue develops from the newly proliferated or extravasated round cells, so that a well formed tumor, or callus, results. This recently formed connective or scar- tissue possesses a tendency to contract, to shorten, to shrink; accord- ingly the vessels contained within it suffer, and as a result of the ensu- ing impairment of nutrition it gradually becomes paler and paler, eventually causing the white, tendinous striae often found in callous stricture-tissue. The fact of greatest importance, however, is that the tendency of the callous mass to contract and shrink leads to dis- tortion, narrowing, and even complete occlusion of the urethra. Loss of urethral tissue, likewise, be it occasioned by trauma or by ulceration, can only be replaced by scar-tissue having a tendency to contract. The individual stages of chronic gonorrhoea and their transition to stricture are well shown by the microscope. In comparatively recent cases the subepithelial layer of the urethral mucosa is seen to be thickly and evenly infiltrated with leucocytes throughout a wide extent. Some of the glands are considerably dilated and certain parts of the periglandular tissue show a moderately thick infiltration of leucocytes. In cases further advanced the transformation of inflam- 134 DISEASES OF THE URETHRA AND PENIS. matory product into scar-tissue is plainly recognizable. Although the center of this diseased area is already made up of scar-tissue, its borders consist of young granulation tissue rich in round cells. The epithelium of the mucosa undergoes variable degrees of thickening and may become partly cornified. Since the uppermost cells of this necrotic epithelial layer exfoliate and become mixed with the mucous secretion of the glands, that discharge so characteristic of chronic gonorrhoea or gleet is produced. During the further progress of the disease the glands become more or less destroyed. The desquamated epithelium is too dry to assume the form of a discharge, so the latter drys up, and in its place filaments composed partly of round cells and partly of epithelium are washed out by the urine, in which they are easily found. Thus the morbid process may exist for years and pursue its further course unnoticed. The small-celled infiltration also affects the deeper parts, in which it likewise becomes changed into a layer of connective tissue. The corpora cavernosa, the overlying muscles, and the erectile tissue of the penis may all be converted into a firm, dense scar; thus the urethral walls slowly become rigid, unyielding, and in the most advanced cases so closely apposed to one another that a hair can scarcely be passed through. It is seen, therefore, that the specific cause of gonorrhoea has nothing to do with the development of stricture except that strict- ures of gonorrhceal origin show a tendency to invade the deep layers of the urethra, whereas those due to simple urethritis confine them- selves more to the superficial layers; however, a simple traumatic urethritis or one due to any other cause may result in stricture if the inflammatory infiltrate advances deeper into the urethral walls. On the other hand, this hyperplastic connective-tissue formation may not only infiltrate the walls of the urethra, but may also grow out- wards into its lumen. Such free connective-tissue tumors lead to the development of firmly adherent stratifications, as the result of which valves and funicles are formed (valvular stricture). Many chronic gonorrhoeas, then, represent the early stage of stricture, or may even be considered as strictures themselves, being the so-called strictures of large caliber described by Otis. When a certain part of the urethra is infiltrated with round cells which have become partly converted into connective tissue or are in the process of undergoing such an alteration, great rigidity of the affected area is produced. PATHOLOGICAL ANATOMY OF STRICTURE. I35 This portion, although still more or less dilatable, will offer greater resistance to the impingement of the urinary stream than the other parts of the urethra. The narrowing may be very slight, perhaps so slight that a 16 F. sound can easily be passed through it. In such cases the so-called stricture of large caliber exists even though it may not be noticed. The evolution of stricture does not always terminate in the way above described, for the firm, callous masses occasionally, though rarely, undergo still further transformation. Just as bony callus can undergo involution, so likewise can the connective tissue masses from which, stricture is developed pass through a process of retrograde metamor^ phosis. It happens, as Dittel has said, that the greater part of the em- bryonal connective tissue in the callus becomes resorbed, so that a perfectly shrunken and dryer connective tissue remains. In callous strictures the urethra feels thick and cartilaginous, but in this form it is hard, inelastic, and much thinner than in health (scar-stricture, or atrophied stricture). To this class belong strictures produced by ulceration and injury. The degree of narrowing and the amount of dilatability depend upon the amount of substance lost and upon the direction which the injury takes. Small superficial ulcerations which do not go beyond the mucous membrane make only a minimum of narrowing. The deeper the scar goes the more it distorts the urethra. If laceration due to injury extends in the long axis of the canal so that a longitudinal scar results, the contraction will be much slighter than if it occurs in the transverse diameter or in a zigzag direction. Phagedenic chancres situated near the meatus may cause great destruction, as a result of which very narrow and unyielding strictures develop. The macroscopic appearance of strictures varies according as they are of the callous or cicatricial variety. In the first form often nothing is seen but an irregular scar, the surface of which lacks the luster of the normal mucous membrane, the scar itself being firmly adherent to the deeper layers of the urethra. The lumen is perceptibly narrowed. The surface of callous strictures also lacks the velvety appearance of normal mucous membrane. The latter is still visible at certain places, but in the main it is replaced by a dull white, parchment-like tissue : which is smooth on its free surface. The mucous membrane is thick- i36 DISEASES OF THE URETHRA AND PENIS. ened, hard, and adherent to the erectile tissue, forming a scar which is more or less bloodless. The parts behind the stricture arc generally dilated; in slight cases they show merely a little chronic inflammation, but in severe ones enormous pouches with fibrillation and destruction of tissue are present, producing a condition which presents the' appearance of a net- work. (Fig. 132). The site of the stricture is generally in the penile portion, being "most common at the bulb, where it becomes continuous with the mem- branous part. Next the region of the cutaneous orifice is the seat of predilection, while the third rank is held by the entire anterior urethra. >■=! < Fig. 132. — Net-work of tissue behind a stricture. a b f Fig. 133. — Different forms of stricture. Strictures originating from chancres are usually located near the meatus, and gonorrhoeal strictures are generally in the region of the bulb. The latter variety, however, are for the most part mul- tiple, so that in addition to those at the bulb, which are generally the narrowest, others are found further forward in the urethra. Gon- orrhoeal strictures are never situated beyond the membranous urethra. Traumatic strictures may occur anywhere in the urethra, but generally are at the bulb or in the membranous or protatics portion. The form of strictures is very different. Oftentimes the diminution SYMPTOMS OF STRICTURE. 137 in caliber occurs equally from all sides (Fig. 133 b). It may, however, be very irregular, so that the opening of the stricture lies eccentric (a) ; indeed, the urethra may be so distorted by a callus of irregular growth as to present a zigzag appearance, a condition known as sprial stricture (c). Likewise the length of strictures varies within certain limits. They seldom exceed 5 mm. [about \ of an inch], but occasionally several lie so close to one another that they give the impression of a single long stricture. The lumen of the urethra is often little diminished, although it frequently is reduced to the smallest numbers of the French scale, and in extreme degrees of contraction no opening at all can be found. SYMPTOMS, DIAGNOSIS AND PROGNOSIS. In general, strictures produce very slight disturbance, so that in persons who take little care of themselves they are not usually noticed until they are very far advanced in their development. Careful, intelli- gent men observe that it takes them longer to urinate than it should. This fact is explained by physical laws. It takes longer for a definite quantity of urine to flow through a narrow tube than through a wide one. The time required to start the stream of urine is in many cases not longer than that taken by healthy men. The frequency of urination, too, may be entirely normal. It is only when the stricture is very narrow and the patient does not completely empty his bladder that micturition becomes frequent. ' Under these conditions it is self- evident that the bladder will become filled with that quantity of urine necessary to cause micturition in a shorter time than under normal circumstances. This incomplete retention, however, is absent in cases in which the bladder is strong and the stricture not very narrow. Pain may also be entirely absent, but usually the patient complains of a slight burning upon urinating, which is experienced the moment the urine impinges upon the contracted spot. The site of the stricture, then, is also the site of the pain. Only in extreme degrees of stricture is micturition really painful. In such cases the patients are obliged to strain violently in order to force out the urine ; they bend forward so as to secure the aid of abdominal pres- sure, and occasionally employ so much force that the rectum prolapses or cerebral haemorrhages take place. 138 DISEASES OF THE URETHRA AND PENIS. The most striking deviation from the normal is shown by the urinary stream. The narrower the stricture and the more anterior its location the greater the loss of volume in the stream. It becomes thinner and thinner until it is reduced to the size of a thread, and then finally becomes obliterated altogether, the urine being voided only drop by drop. The projectile power of the stream may not be lessened; although small, it can often be cast some distance forward. In extreme degrees of narrowing this power is also lost. In such cases ejaculation of semen is likewise attended with difficulty. The fluid is not ejected forcibly outward, but flows along slowly, or is regurgitated into the bladder. Incontinence of urine, or more properly speaking, overflow of urine from the bladder, is one of the most common occurrences during this stage of the disease. Behind the stricture the urethra is dilated into a funnel-shaped expansion, so that the internal vesical sphincter becomes stretched. The bladder is in a condition of incomplete retention. The urine which rises above the level of the sphincter flows slowly over it into the urethra and passes drop by drop through the stricture. It is there- fore characteristic of this incontinence that the urine is not voided in large quantities, but is passed in drops, so that the patient is constantly wetting his clothing. A highly unpleasant occurrence is the development of sudden com- plete retention in which the patient cannot void a drop of urine. This condition is not entirely dependent upon total occlusion of the urethra, for it happens sometimes when the stricture is not very tight; it may then be due to spasm, or to engorgement superimposed upon the contrac- tion. A cold or the free use of alcohol may cause such congestion or spasm. The urine of men affected with stricture is usually not clear. Owing to impingement of the urinary stream upon the narrowed spot, the latter together with the portion of the urethra behind it becomes inflamed, as a result of which the secretion is augmented and becomes mixed with the urine, in which it appears as flakes or filaments. Oftentimes this catarrhal process extends backward into the bladder and causes a cystitis, which produces turbidity of the urine. In most cases the symptoms and signs already mentioned are suffi- cient to make a diagnosis of stricture probably correct, although they must not be entirely depended upon, for narrow stream, slow micturi- tion, pain, incontinence, and retention occur in other affections, PROGNOSIS OF STRICTURE. 1 39 notably, in paralysis of the bladder and hypertrophy of the prostate. A physical examination must always be made. This consists in passing a soft, not too small olivary bougie into the urethra. I advise against the use of bougies aboule, also called stricture- searchers, because they easily become caught at the bulb even in the healthy urethra, and thus are not adapted to discrimination between the normal and the diseased. The ordinary French silk-web bougies with olivary tip may better be used, as they always pass through the healthy urethra into the bladder. If they are arrested anywhere choose smaller ones until a size is found which just exactly passes. This one will repre- sent the size of the stricture. If several strictures are present a wide one behind one which is nar- row cannot be diagnosticated. After the diagnosis of stricture is made the general condition of the patient must be investigated, because stricture has a whole series of complications and sequels following in its train. We have already spoken of dilatations and pouches behind the stricture, and the inflammatory softening which occurs in them. If urine collects in, these pockets it may undergo decomposition and lead to inflammatory changes in the tissue, giving rise to a condition which is known as phleg- mon when it affects the superficial structures and as urinary infiltration when it involves the deep parts. The tissue becomes disintegrated by pus, the phlegmonous process forces its way more and more toward the surface, and, unless promptly interfered with, breaks externally and forms a urinary fistula. Loss of substance corresponding to the size of the gangrenous slough occurs in the urethra and its coverings. The destructive process is effectuated inexactly the same manner when a follicle behind the stricture inflames, suppurates, and becomes filled with decomposed urine, or when the impingement of the urinary stream produces a tear behind the stricture, or injury is inflicted by making a false passage. In all these cases a rapidly progressing infiltration of urine leading to gangrene may supervene. If the infiltration begins at any point in front of the bulb, swelling, redness, and subsequent discoloration will develop on the penis and scrotum. The phlegmon may extend upward as far as the epigastrium. I once saw suppuration at the arch of the ribs. If the point of egress be behind the bulb, the urine will infiltrate from the perineum backwards toward the rectum, peritoneum, and bladder. A pericystitis with its attendant danger of rupture into the peritoneal cavity is present. I40 DISEASES OF THE URETHRA AND PENIS. If the process progresses in this acute manner it is accompanied by high fever; chills and elevation of temperature as high as 41 C. [105.8 F.] often occur. More frequently, however, the process is slower in its development. On the perineum firm, hard swellings of irregular form are found, which to the inexperienced give the impression of new growths. The usual termination of such slowly progressive inflammations, provided that they do not become diffuse and form infiltrations, is urinary abscess, which if it is not opened seasonably, may gradually involve the contiguous tissues and lead to urinary fistula. The diagnosis of all these conditions will not be difficult if the urethra be examined and the presence of a stricture determined, for then the relatively rapid development of the swelling can be accounted for. Very often, as has already been stated, the stricture is associated with cystitis. This cystitis does not differ from the ordinary forms {quod vide). It heals very rapidly as soon as the stricture is relieved, so that oftentimes no special treatment is needed, dilatation of the stricture in itself sufficing to produce a cure. In consequence of the resistance which the musculature of the bladder has to overcome in forcing the urine through a contracted passage it very frequently hypertrophies. In most cases of narrow stricture of long duration this condition of the bladder will be revealed by the cysto- scope after the narrowing has been overcome. If the obstruction lasts very long it may cause dilatation of the upper urinary tract. The ureters become dilated and the pelvis of the kidneys distended into a sac. Under such conditions infection is not long postponed; the dilated ureters become inflamed and the hydronephrosis becomes converted into a pyonephrosis. That the inflammatory process in the posterior urethra often extends into the duct of the glands the same as in posterior gonorrhoea is easily understood; we observe, therefore, during the course of stricture, epididymitis, prostatitis, and spermatocystitis. The prognosis of urethral stricture is on the whole favorable, although it depends somewhat upon the kind of stricture and its location. The further forward a stricture lies the more difficult it is to cure, so that those situated near the meatus are the most unfavorable of all. Gonorrhceal strictures are much more benign than traumatic. The TREATMENT OF STRICTURE. 141 latter are very obstinate and often difficult to influence. All depends upon the nature of the causative injury. Complications endangering life generally arise as the result of neglect. If a stricture is carefully watched and the caliber of the urethra properly kept open, these complications do not arise even though the stricture is not cured. If the condition be allowed to go untreated for years, it leads to the above described processes, such as urinary infiltration, fistula?, hydronephrosis, pyonephrosis, etc. TREATMENT. The treatment of urethral stricture is one of the most satisfactory tasks of the surgeon. With proper skill nearly all cases can be quickly helped. It is self-evident that treatment must be solely mechanical and di- rected to re-establishing the caliber of the urethra. We set forth beforehand that cure in an anatomical sense is hardly ever possible. We have to do with a narrow canal, the passage through which is contracted by the formation of scar-tissue. The scars can be dilated and enlarged, but as every scar has an inherent tendency to contract there will always be danger of their becoming narrow again. Only in those cases in which the stricture can be entirely cut out and the free ends of the urethra re-united can a cure in the anatomical sense of the word be spoken of. We must be satisfied with effecting a cure in the clinical sense, that is, improving the patient's condition by freeing him from all difficulty and keeping him free for a long time. This is thoroughly feasible. The methods of treating stricture may be divided into three groups : 1. forcible bursting of the stricture, which is known as the divulsion method; 2. dilatation; 3. operative procedures by which the stricture is divided or cut away. We will mention divulsion methods first so as to dismiss them from consideration. They are antiquated, their employment is irrational, and they are productive of harm rather than of good. An appreciation of the morbid anatomy of stricture will of itself suffice to show that forcible rupture of a stricture will cause a new scar to form, and there- fore increase rather than relieve the contraction of the urethra. For this reason we will omit a description of the various instruments devised for divulsion; they are solely of historical interest. For the same reason I am opposed to the electrolytic method of 142 DISEASES OF THE URETHRA AND PENIS. treating stricture. Formerly strictures were often treated with caustics. Attempts were made to bore a passage through with these substances, but the method was abandoned because it was seen that cauterization as well as forcible rupture must later prove advantageous to the process of contraction. I am of the opinion that the treatment of stricture by electrolysis can be no more successful than treatment with any other caustic; in the one instance cauterization is effected with chemicals, in the other with the electric current. The above mentioned procedures, moreover, are not at all necessary, as the majority of all strictures can be successfully treated by dilatation. We distinguish gradual temporary dilatation, and continuous dilatation. Gradual temporary dilatation is the proper procedure for nearly all strictures. It consists in introducing into the bladder a soft silk-web bougie of such a size that the stricture will just admit of its passage. The instrument is allowed to remain in the urethra for a few minutes ; to leave it in longer is of no advantage. At the next treatment, which is best given on the second day, the same bougie is passed once and then the next larger number is introduced. The employment of any force whatsoever is wrong; the stricture must be slowly stretched, not torn. With this gradual dilatation much better and safer results will be obtained than if the stricture be forcibly enlarged at one sitting by using several instruments. From the latter course chills and fever not uncommonly result. Moreover, if the stricture is net causing urgent symptoms there is no indication for rapidly widening it. Treatment should be continued slowly and gradually until the urethra will admit a good sized bougie (21-23 F.). [American surgeons continue the dilatation much higher. If the meatus be too small to admit sounds of large caliber, meatotomy may be done or recourse had to dilators. With Kollmann's dilators it will be found possible to attain a higher degree of dilatation than with sounds. The minimum dilatation which I eventually reach with these instruments is 30 F.] As before stated only soft olivary bougies should be used. Metal sounds are'also employed, but I do not deem it advisable to use a smaller one than 16 F. because the slenderness and rigidity of the tip of smaller sizes make the danger of forcing a false passage too great; even the greatest skill and gentleness will not always prevent the point from catching in a lacuna and then making a false passage if it be TREATMENT OF STRICTURE. I43 pushed onward. In these cases, therefore, I always use the soft French olivary bougies. A great deal depends upon the tip of the instrument. It must rest upon a neck which is thinner than the body of the instru- ment. By this construction considerable mobility of the tip is obtained, which makes it easier for it to find its way through the stricture. The pointed conical French bougies are to be utterly discarded. I know of no instrument which can do great damage as easily as these. The point seems to be made for catching in a fold of mucous mem- brane or in the opening of a gland. The after treatment of these cases is very important It consists in passing a bougie at certain intervals so that the caliber to which the urethra has been dilated may be maintained. At first the instru- ment should be passed every two weeks, later every four weeks, and if the same size passes readily the intervals may then be increased to three or six months or even a year. Intelligent patients can be taught to carry out this treatment themselves. Although this procedure will suffice for the majority of strictures, which may be designated as light cases, there are a certain number in which the first requisite of the method, namely, the introduction of a bougie, however small, cannot be accomplished. The difficulty may depend upon inability to find the opening of the stricture, or upon the impossibility of penetrating the stricture because of its narrowness, after the bougie has entered the opening. These are two entirely different conditions which demand a totally different method of procedure. In the latter case, when the tip of the instru- ment has entered the stricture but will not advance, it should be left in situ for a while, after which an attempt to pass it will often prove suc- cessful; it may be allowed to remain as long as an hour. Under these circumstances a certain amount of force may be employed until the tip of the instrument is pushed through the constriction. When the instrument is actually in the opening of the stricture injury can hardly result by pushing it through. The employment of force is not per- missible, however, unless one is absolutely certain of the position of the bougie. If any doubt remain that the tip of the instrument is not in the opening of the stricture, then the employment of force becomes a gross error, which can cause nothing but harm; it is then our duty to find the opening, for which patience and delicacy of touch, but not force, are helpful. The cause of this difficulty in entering the stricture is generally due to the fact that its opening is not central in 144 DISEASES OF THE URETHRA AND PENIS. the axis of the urethra, but is eccentric; the opening, too, may be so narrow that the instrument cannot penetrate it. In the latter case it is well to inject a small syringeful of olive-oil into the urethra and then introduce a filiform bougie. The oil enlarges the opening so that the instrument can often be made to enter it. The same difficulty is encountered in passing an instrument through Jf Fig. 134 — Spiral and bayonet-bougies Fig. 134. — False passage in the urethra. spiral strictures. The point of a straight bougie naturally strikes against the wall of the stricture. Therefore an attempt should be made to pass a spiral or bayonet filiform (Fig. 134). If the stricture is eccentric and its opening cannot be found, the artifice of introducing several bougies down to the stricture and then patiently and gently trying to work one into the opening may be tried TREATMENT OF STRICTURE. 145 with advantage. The value of this procedure has long been known, and it will often succeed after all other measures have failed. This is easily explained. While the point of a single filiform strikes against the wall of the urethra, if four be introduced it is probable that one will hit the opening. At least the chances of such an occurrence are favorable, for if three of the bougies miss the opening the chances of the fourth one reaching it are increased. [It may be necessary to fill the urethra completely with filiforms and then try to insinuate first one and then another through the orifice of the stricture.] Frequently the difficulty of entering the stricture is due to the presence of one or more false passages. (Fig. 135.) The diagnosis of such a case is not easy, although there are certain criteria which are of assistance, such as deviation of the bougie from the median line, perception of an unusually thin layer of tissue between the rectum and the bougie, and especially sudden arrest of the bougie after it has been passed 18 cm. [7 \ inches] or more into the urethra. This sudden arrest is evidence that the instrument is not in the bladder. Since strictures do not occur behind the membranous urethra, and as the distance from the meatus hitherto seldom exceeds 17 cm. [6f inches] the bougie must have penetrated the mucosa, that is, entered a false passage. The only other possibility is that the bougie may have entered the stricture and is firmly held there. This condition cannot be confounded with the one just described, because the clasping of the instrument by the stricture can be distinctly felt, whereas when in a false passage it can be rotated on its axis. If the point be caught in a pocket of the retiform tissue behind the stricture, it will generally be possible to pass it into the bladder by drawing it out a little, turning it on its axis, and then pushing it onward again. The difficulty of passing a bougie when such a complication is present consists in the almost invariable tendency of the instrument to seek the false rather than the true passage. In such cases I have found the following artifice of value: I introduce a moderately slender bougie, one about 6 French, as deep as it will go without forcing it. It will almost always enter the false passage. With this one still in place a second one introduced beside it will often enter the stricture. This is explained by the fact that the false passage is occluded by the first instrument so that the second passes nolens volens into the true opening. With the help of all these measures it will often be possible to over- come strictures which at first seemed impermeable, and when they 146 DISEASES OF THE URETHRA AND PENIS. have once been passed to proceed to further dilatation. There are cases, however, in which these gradual procedures fail. There are circumstances, too, which absolutely indicate rapid dilatation. For example, if a purulent cystitis with stinking, sanious urine is present, or an inflammation of the upper urinary tract with attacks of fever, then a more rapid subjugation of the stricture is necessary. An appropriate procedure here is continuous dilatation. It consists in passing a catheter one size smaller than the stricture into the bladder and fastening it there. This catheter, which must be only a soft silk-web one, is allowed to remain from twenty-four to 'forty-eight hours. Owing to the continuous contact of the catheter with the stricture an inflammatory process develops which leads to softening of the callus and makes it possible after forty-eight hours to dilate the stricture from 4 to 6 mm. without tearing it. The largest instrument passed is then fastened in and at the end of two days another rapid dilatation made, and so forth. In this way stric- tures which are not too hard can be brought up to a caliber of 20 F. or higher in a week. If the stricture is so narrow that recourse must be had to filiforms one should be tied into the urethra. The patient then forces his urine ; out beside the bougie, which acts in the same manner as a retained catheter. This continuous dilatation is a good method for quickly overcoming soft strictures, but is appropriate only when there is an associated cystitis. If the latter be absent and the urine clear, it is contra-indi- cated. The inflammation excited in the urethra almost always extends to the bladder. This viscus becomes infected and cystitis develops. Whenever a catheter is retained the bladder must be irrigated several times daily so as to wash out some of the germs which have gained access and render those which remain innocuous. An injec- tion of 100 cc. [about 3 fluid ounces] of a 1 : 1000 silver nitrate solu- tion, alternating with mercury oxycyanate 1 : 4000, may be given by a nurse every two hours and the fluid allowed to flow out through the catheter. Another very valuable and gladly employed procedure by which a permanent catheter is inserted is that of Le Fort. The methods of Desault and Maisonneuve were the precursors of this one which we are about to describe. The multifarious measures which, as we have seen, are at times neces- TREATMENT OF STRICTURE. 1 47 sary to gain entrance to a stricture show how difficult entrance may often be. Therefore it is not surprising that surgeons long since endeavored to render permanent any opening which they once succeeded in making. It can happen, says Thompson, that the most skillful surgeon may fail to get an instrument through a stricture after having once successfully penetrated it. Acting in accordance with this knowledge Desault used a thin elastic catheter open at both ends, which he pushed down as far as the stricture, and then tried to pass another through it into the bladder. Over this he then endeavored to slide a larger instrument. Maisonneuve's well-known procedure was an improvement on De- sault's. After he had succeeded in passing a slender guiding sound into the bladder he screwed a somewhat thicker flexible bougie onto its external end and then pushed it through the urethra, whereupon the first one became coiled up in the bladder. Upon the second instru- ment there followed a third larger one, and so on until the stricture was considerably dilated at a single sitting. Both these methods are to be rejected because they are nothing more nor less than skillfuly performed divulsions, which, as already stated, we consider injurious. Le Fort's method differs from Maisonneuve's only in that Le Fort allows the filiform guide to remain in the urethra from twenty-four to forty-eight hours before attaching and passing the second instrument, which is preferably a metal catheter such as is shown in Figure 136. Le Fort aims to create inflammatory softening of the stricture by means of the retained catheter, and thereby prepare the way for larger instru- ments. It is not successful in the sense that the metal instrument can always be passed the next day without the employment of any force, but yet it is a very good method which can be used in many cases with great benefit. A slight application of force is, moreover, permissible because we are certain that the instrument is within the stricture so that a false passage cannot be made. It is only when too much haste or force is used that the filiform can nick the urethra; if under such circumstances it be pushed onward great harm will naturally be done. Varnished silk- web catheters are now manufactured which corre- spond to Le Fort's instrument. The anterior part, about 30 cm. [12 inches] is filiform, while the remaining portion increases gradually into a thick large shaft [Rat-tail catheter]. (Fig. 137.) This instru- ment can often be passed when Le Fort's metal catheter fails. It may 148 DISEASES OF THE URETHRA AXD PENIS. be impossible, however, to overcome very indurated strictures; the softening produced by retention of the filiform is too slight to admit the passage of either the attached metal instrument or the gradually thickening soft catheter. Moreover, there are many circumstances under which it is not advisable to employ any of the above-named Fig. 136. — LeFort's instrument. Fig. 137. — Rat-tail catheter. methods, and which compel us to treat the stricture by operative measures. Of these we will first mention hypersensibility of the urethra, which manifests itself by derangement of the nervous system. There are patients who experience disturbances in various organs after every catheterization, no matter how carefully it may be performed. Apart TREATMENT OF STRICTURE. 1 49 from the intolerable pain caused by the passage of the instrument there remains for a considerable time an irritability of the urethra which inca- pacitates the patient for work, deprives him of appetite, and robs him of sleep. Slight attacks of syncope and symptoms of shock occur. If several soundings attest the permanency of this state of hypersen- sibility and the usual antagonistic measures such as preliminary cocainization of the urethra remain without effect, we must desist from attempts at dilatation. Urethral fever must not be confounded with this shock-like con- dition. It occurs in three forms : first as a single transitory attack of fever; second as a recurrent fever; third as a chronic continuous fever. Cases of this kind occurring after the passage of instruments are at present regarded exclusively as infectious; they indicate the presence of renal complications, but may occur independently thereof. In every such case we should use the utmost caution in employing dilata- tion, or even resort to some other procedure for removing the stricture. A second condition is the so-called resilient stricture, which shows a tendency to contract after every dilatation. The use of the bougies here amounts to nothing. The constriction occurs again, and even so rapidly as to demand the daily passage of an instrument to keep the urethra patulous. Some authors explain this condition by the supposition that the resorptive power of the tissue is no longer present, that the stricture is composed of an unalterable dry scar which always contracts. How- ever this may be, the fact remains that such strictures are not suitable for dilatation. In like manner experience has demonstrated that strictures near the external meatus are exceptionally obstinate. Dilatation is generally useless and also very painful. They are conquered much more easily and quickly by a free internal incision with a small blunt-pointed knife, or a concealed bistoury. The exceedingly rare valvular stric- tures should be cut (Fig. 138). In the very rarest instances they are due to consolidation of free masses of exudate projecting from the surface of the urethra, but generally result from congenital duplica- tion of the mucous membrane. Treatment consists in dividing the valve with a fine-pointed bistoury on a tunnelled sound. For the division of all strictures situated further back special instruments and procedures are required. We distinguish between internal and external urethrotomy. IS© DISEASES OF THE URETHRA AND PENIS. INTERNAL URETHROTOMY. Internal urethrotomy is performed by carrying a knife into the urethra and evenly dividing the constricted portion. The object aimed at is to cut through the callous or contracted scar-tissue in such a manner that _ a „.a mm \M Fig. 138. — Valve-stricture. Stricture en bride of Voillemier. a new layer of scar-tissue shall be interposed between the cut edges, with the result that the stricture becomes widened. Internal urethrotomy may be performed from behind forward or from before backward. A prototype of the first method is that of Maisonneuve, while Thompson's represents the second. Many other INTERNAL URETHROTOMY. 151 surgeons have devised urethrotomes, and each thinks his own is the best. The construction of Thompson's instrument, which cuts from behind forward, is shown in the illustration (Fig. 139). The blade D is concealed in the sheath C. The instrument is passed through the stricture, the blade is liberated by pressing upon B and the instrument is then drawn forward. This urethrotome, the caliber of which about corresponds to No. 12 of the French scale, can be used only for strictures large enough to admit of its passage. I am of the opinion that a stricture which admits a No. 12 instrument seldom requires bisection, and therefore do not employ the method. A much more useful procedure is that of Maisonneuve, in which the incision is made from before backward, the only prerequisite to its per- C B * A Fig. 139. — Thompson's urethrotome. formance being the passage of a filiform bougie. The instruments necessary are shown in the accompanying illustration. (Fig. 140.) The filiform bougie (F) is introduced into the bladder and allowed to remain twenty-four hours. Upon the end of this the urethrotome (U) is attached by means of a screw- tip and pushed through the urethra into the bladder, whereupon the filiform curls up in the bladder the same as in Le Fort's method. The knife (M) is now inserted into the groove of the shaft; it cuts only forward and backward, being blunt at the summit. In conse- quence of this procedure the urethra is stretched wherever it is dilatable, so that the knife does not cut when it is inserted and withdrawn. In the places where the urethra cannot expand it cuts through the tissue. There are three blades of different sizes, M, Mi, M2, to be used according to the extent of the incision it is desired to make. The knife is carried down to the internal sphincter and then withdrawn, cutting as it returns any contractions not previously divided. The shaft of the instrument is now withdrawn until the filiform attached to its end appears at the meatus; the staff (St.) is now fastened to the filiform, and over it the cath- eter (K) is slipped and passed into the bladder; finally the staff and filiform are withdrawn and the catheter fastened into the bladder 1^2 DISEASES OF THE URETHRA AND PENIS. =>3 Ftg. 140. — Maisonneuve's urethrotome. EXTERNAL URETHROTOMY. I 53 and kept there for three days. This method is an excellent one, suc- ceeding in nearly all cases, even in those in which the strictures are considerably indurated. It may happen, however, that the catheter cannot be slipped over the filiform if the calloused masses are very large. Moreover, the procedure is not entirely without danger, and therefore is to be resorted to only when urgently indicated and after the other and milder methods have failed. The danger lies first in the possibility of infection taking place through the incision, and secondly in the pro- pensity to violent haemorrhage, most difficult of control. I have seen both conditions. In the first instance chills occur; this is not of much import if only one takes place, but the condition responsible for their occurrence may develop into a true sepsis, especially if a purulent cystitis be present. It is well to give i.o [15 grains] of quinine before and after the operation. Copious haemorrhages are more frequent. The operation is done in the dark, as it were, and the size of the incision canot be measured. It may open the corpora cavernosa widely, so that a continuous and uncon- trollable oozing of blood will take place" from the urethra. These haem- orrhages are particularly malign because the source of the bleeding cannot be reached. Compression of the urethra upon the catheter, and injections of gelatine may be tried; if they do not succeed external urethrotomy must be performed and the bleeding spot tamponed through the opened urethra. Do not be deceived by the absence of haemorrhage from the meatus, as the blood often flows backward into the bladder. A flow of clear urine free from blood through the retained catheter is proof that haemorrhage is not occurring. Severe haemorrhages may even develop days after the operation and upon these likewise must great attention be bestowed. EXTERNAL URETHROTOMY. External urethrotomy is reserved for those rare cases in which the milder procedures already described have failed. The method of performing it varies according to whether the urethra will admit the passage of an instrument. In those cases in which the operation is done for urinary abscess caused by infiltration of urine, and in which a metal sound passes through, it is extremely simple, a tunnelled staff (Fig. 141) being passed into the bladder, the urethra 154 DISEASES OF THE URETHRA AND PENIS. opened in the groove of the staff and the stricture divided [Syme's operation]. Its performance is much more difficult when only a filiform can be passed; in this condition the incision must be made exactly in the median line in an endeavor to cut down upon the filiform. As the urethra is often distorted it may be difficult to find the bougie through the incision, although with care and patience the difficulty can always be overcome. On the other hand, when no instrument what- ever can be passed through the urethra the opera- tion may be exceedingly difficult. A metal sound is carried into the urethra as far as it will go, an incision made down to its tip and the urethra opened; the edges are then drawn apart with forceps, or retracted and fastened with a thread, and the further course of the urethra sought for with a fine bougie. The effort is generally suc- cessful and the operation is then carried out as before described; it is not completed, however, until a large Nelaton or French catheter is passed into the bladder through the perineal wound and the urine flows out freely. [A perineal drainage tube may be substituted for either of these instru- ments, or a catheter may be passed from the meatus (Fig. 142). The introduction of a gorget (Fig. 143) into the bladder through the perineal wound will facilitate the introduction of the catheter or drain- age tube. Pass the gorget in before removing the staff, then withdraw the staff and insert the catheter or drainage-tube.] If the course of the urethra cannot be determined after the distal end of the stricture has been exposed, suprapubic cystotomy may be performed as a last resort and retrograde catheterization practised. After the bladder has been opened a metal catheter or staff is inserted into the internal orifice of the urethra and carried outward until its tip appears in the perineal wound ; a catheter is now passed from the external meatus and fastened onto the tip of this instrument, which is then drawn backward so that the catheter Fig. 141. — Syme's staff. EXTERNAL URETHROTOMY. J 55 is carried into the bladder. The catheter is carefully fastened and the bladder closed. The best instrument for this purpose is Jacques's patent catheter, which must be left in for two or three weeks. [Orville Horwitz has devised an instrument which facilitates the per- formance of external urethrotomy for very tight strictures or rupture of the urethra. Fig. 142. — Perineal drainage tube; Fig. 143. — Teale's probe-gorget. Fig. 144. — Horwitz's dilator for whip-bougie; blades closed. & place before the fiftieth year; tumors cause more rapid enlargement of the gland than does hypertrophy, and produce cachexia sooner; rectal palpation reveals the irregularity of tumors, which are almost always asymmet- rical and give off processes to one side or the other. These projections are usually external, in the direction of the seminal vesicles, or lateral, along the wall of the pelvis. The consistency of tumors, too, is much harder. Finally, the occurrence of metastases offers a means of differentiation. They are invariably present in cases of malignant prostatic growths, occurring mostly in the inguinal region, where they are readily palpable. They give rise to neuralgic pains in the lower extremities, which are not experienced in prostatic hypertrophy. Cys- toscopically the two conditions can often not be distinguished one from the other. Urinary retention without prostatic hypertrophy, for example, 348 DISEASES OF THE PROSTATE GLAND. that due to paralysis of the bladder, or fibrous degeneration of the vesical wall resulting from arteriosclerosis, is readily differentiated from hypertrophy by rectal palpation, and especially by the shortness of the urethra. The history of the case and the clinical findings are also of help. The prognosis of prostatic hypertrophy as to cure is absolutely bad. Of more importance, however, is the prognosis as to life. In this latter respect it may be said that with proper care and treatment the subjects of prostatic hypertrophy may live comfortably for years or tens of years and attain an advanced age. On the other hand, frequent attacks of retention of urine, difficulty of catheterization, and complications, especially infection of the upper urinary passages, make the prognosis worse. Those patients do best whose bladder undergoes adequate com- pensatory dilatation. When this takes place the bladder is converted into a large reservoir which can receive and hold the urine for twelve to eighteen hours without causing the patient inconvenience and without exerting any deleterious influence on other organs of the body. The prognosis is much less favorable for those patients whose bladder is small or contracted (concentric hypertrophy). The uncon- trollable strangury reduces their strength and lessens their power of resistance. The most dangerous complication, urosepsis and uraemia, occurs 'much more readily in these patients than in those of the first-named group. Frequently recurring haemorrhages also make the prognosis more unfavorable. The worst cases of all are those in which there are great obstacles to catheterization, so that in case of retention of urine the danger of creating false passages and thereby causing infection becomes especially great. TREATMENT. The treatment of prostatic hypertrophy is a difficult task. It requires great knowledge and much patience on the part of the surgeon. In view of the fact that there are many men with an enlarged prostate who remain free from trouble as long as they five, our efforts must be directed to guarding the patient against those injurious influences which are known to produce such unfavorable conditions as congestion and engorgement of the prostate. Consequently exposure to cold, HYPERTROPHY OF THE PROSTATE. 349 especially of the feet, alcoholic excesses, protracted sitting, fatiguing walks, horseback riding, and holding the urine too long must be for- bidden. A light diet, attention to digestion, avoidance of spices, and regular exercise are to be enjoined. It is important that the bowels be kept regular. Apart from these prophylactic measures treatment may be instituted either for the relief of symptoms or for the purpose of decreasing the size of the prostate. Many prostatics can get along for years with- out any treatment, a careful regimen of living according to the principles above outlined preserving them from trouble and enabling them to attain a vigorous old age. If, in course of years, occasional attacks of severe strangury, pain, and difficult micturition occur, hot baths, especially sitz-baths at a temperature of 35 C. [95 F.] increased to 42 C. [107 F.], and hot applications to the hypogastric region and perineum, together with the use of morphine or heroin suppositories, or an injection containing these drugs with antipyrin 0.5 [7J grains] or pyramidon 0.3 [5 grains], may be employed with advantage. These measures in association with confinement of the patient to bed or to his room usually promptly ovecome the congestive attacks. The principal symptomatic treatment is catheterization. It is self-evident that it must be employed in cases of chronic or acute com- plete retention of urine. In incomplete retention, too, it is also our chief recourse. As catheterization is especially difficult in the subjects of prostatic hypertrophy, and as it is also not without danger, the greatest precaution is necessary in its performance; it should not be employed, moreover, unless it is strongly indicated. It scarcely need be mentioned that the strictest asepsis must be practised. First, in regard to the technic of catheterization, great stress must be placed upon the selection of proper instruments. In general nothing but soft instruments (Nekton's catheters) should be used. If these cannot be made to pass then Mercier's or Guyon's may be tried. If the introduction of these soft instruments cannot be effected the following expedient should be tried. Both anterior and posterior urethra are cocainized with about 6 cc. [i£ drachms] of 2 per cent cocain solution; it is injected with an ordinary male syringe and pressed backward into the deep urethra; or a 1 or ^ per cent solution may be instilled with Guyon's or Ultzmann's capillary catheter. Adrenalin is also worthy of trial, as it produces even greater anaemia 350 DISEASES OF THE PROSTATE GLAND. than cocain, and thus may cause shrinking of the tumescent prostatic urethra. The injection of 5 to 15 cc. [1 to 4 drachms] of warm sterile oil is also often useful, as it lubricates the parts and frequently permits the passage of a Nelaton catheter which previously could not be intro- duced. If all attempts with soft-rubber instruments fail silk-web cathe- ters, provided either with Mercier's or Guyon's curve, should be tried. In introducing these instruments care should be taken to have the angle at the junction of the shaft and beak point upwards. The object of this curve is to have the point glide along the superior [or anterior] wall of the urethra, which, as is well known, makes the least divergence. These silk-web catheters with Mercier's curve are the real prostatic catheters, by which name they are also known. As to semi-hard catheters only those of English make need be con- sidered. They are made of some material which becomes malleable when heated and remains firm when cold. They are dipped in hot water, bent to the desired curve, and allowed to cool. There is no uniformity of opinion in regard to which curve is the best. The various curves shown in the accompanying illustration, reproduced from Socin's work, represent those which have been found useful by different surgeons (Fig. 188 ). The English catheters are best bent to the curve shown in e. During its introduction the catheter becomes warmed somewhat and its excessive curvature yields and so adapts itself to the shape of the urethra that the bladder can be entered even in very diffi- cult cases. This procedure, devised by Sir Henry Thompson, requires much practice and great skill. Guyon practises a similar procedure with a catheter coude, which he partly but not entirely draws over a stylet in such a manner as to con- vert it into a bicoude, or double-elbowed instrument (see Fig. 188 /). If careful and not unduly protracted efforts with soft and semi- hard instruments result in failure, then metal catheters may be used, the rule being to employ one of large caliber having a free curve and a long beak. In moderate degrees of hypertrophy catheters bent almost to a right angle and having a moderately long beak will suffice. Where excessive enlargement with considerable lengthening of the urethra exists, Sir Benjamin Brodie's catheter (e), the curve of which corres- ponds to the arc of a circle, is very serviceable. In the illustration the catheter is overcurved. In reality the tip should end 2 cm. [j- of an inch] above the eye. HYPERTROPHY OF THE PROSTATE. 35 1 Fig. 188. — Catheters of different curves used in hypertrophy of the prostate. 35 2 DISEASES OF THE PROSTATE GLAND. Metal catheters should be slowly and cautiously passed. The buttocks should be elevated. A finger in the rectum will guide the point of the instrument into the prostatic urethra. Force must never be used, but the instrument must rather be made to grope its way into the bladder. Manifestly theoretical descriptions will not be of any service. Mastership here can be attained only by practice. A rule to be borne in mind, however, is that the employment of metal catheters having short beaks similar to that of the stone-sound is abso- lutely inadmissible. Fig. 189. — Two perforations of the middle lobe of a hypertrophied prostate. (Giiterbock.) With such short-beaked instruments there is great danger of per- forating the prostate instead of passing over it. Once a false passage is established the difficulty of catheterization becomes augmented, because the tip of the catheter will always have a tendency to enter the false passage. Figure 189 gives a good representation of how a catheter may perforate the middle lobe; it shows two perforations. The great danger of haemorrhage and infection occasioned by a false passage has already been described. HYPERTROPHY OF THE PROSTATE 353 Patients having false passages should not be catheterized unless some urgent indication exists. Such indications will be stated presently. If it becomes necessary to catheterize, if, for ex- ample, retention of urine develops, then a large metal catheter should be tried first, its beak, if possible, being carried along that wall of the urethra through which the perforation did not take place. If the retention is relieved by this procedure and does not recur it will not be necessary to catheterize again. If, on the contrary, the retention continues, the difficulty attending the introduction of the metal catheter will always be experienced anew. For this reason it is advisable to leave a permanent catheter in the bladder until the false passage has healed. Only soft instruments are adapted for permanent catheterization. A metal catheter should never be left in the bladder over night, as its point may perforate the wall if the patient moves unduly while half asleep. I know of a case in which this accident happened. A Nelaton or silk- web catheter with or without a curve should be tried first, and if it cannot be passed a stylet should be inserted and the instrument bent to the same curve possessed by the previously inserted metal catheter. After the wire has been removed the catheter is fastened with adhesive plaster or a bandage. The self- retaining catheters devised by Pezzer, Malecot, and myself are excellent for permanent catheterization (Fig. 190). Pezzer's instrument expands into a mushroom-like tip, Malecot's has two projections, and mine four, which, during the introduction of the instrument, lie even with the stylet, but expand after the latteris removed and come up against the sphincter. In this way it is prevented from slipping out. As to the indications for catheterization it is obviously indispensable in cases of acute and chronic complete retention. If the usual means employed in acute retention, such as hot baths, hot applications, and injections of morphine produce no result, the bladder must be emptied by catheterization. In chronic complete retention, too, the catheter cannot be dispensed with. The small quantity of urine which rises above the level of the sphincter and escapes spontaneously is not sufficient to afford relief. The patients have continuous strangury which can be relieved only by emptying the bladder. Similar to these are the cases of incomplete retention in which a large quantity of urine remains in the bladder. 2 3 354 DISEASES OF THE PROSTATE GLAND. In all these cases catheterization is necessary to empty the bladder. If it be very difficult it is better to introduce a permanent catheter and thus save the patient the suffering incident to repeated passages of an instrument. If the bladder is as yet uninfected and the urine obtained is clear, I would advise the use of the permanent catheter only in exceptional cases, because it is almost always sure to lead to the development of HYPERTROPHY OF THE PROSTATE. 355 cystitis. It gives rise to urethritis which extends to the bladder; therefore when the urine is clear the permanent catheter should be employed only when catheterization is very difficult and associated with haemorrhage. If the bladder is infected then no hesitancy need be felt as to its use. Care should be taken, however, to cleanse the bladder once daily with silver nitrate i-iooo and thrice daily with mercury oxycya- nate 1-5000. These irrigations also serve to keep the catheter from becoming encrusted. (Although it was formerly the custom to follow Bazy's recommenda- tion and keep the subjects of permanent catheterization in bed, and, moreover, to continue the procedure for only a few weeks at most, I have introduced a method of treatment by permanent catheter- ization which has proved to be very valuable in a number of cases. It consists in allowing the catheter to remain in for months, or indefi- nitely for that matter, and also allowing the patients to walk about and follow their usual vocation. I use my own self- retaining catheter, which has four arches, and which does not easily become encrusted. The bladder must be irrigated once or twice a day, and the catheter changed every month or at least every two months. At first a suppu- rative urethritis is produced, but it soon heals and the urethra becomes dry; thus the natural passage is converted into an artificial fistulous canal. If the patient experiences much difficulty at first he should be kept in bed and given morphine. This treatment possesses the great advantage of doing away with the necessity of confining the patients to bed, and thus abolishes the danger of hypostatic pulmonary congestion, so prone to develop in old, decrepit persons who are bed-ridden. They are free from the strangury and pain caused by each passage of an instrument, and urinate easily every hour or two, according to their needs, by simply removing the cork which closes the catheter. The question as to how much residual urine must remain in the bladder to necessitate this form of permanent catheterization, or ordinary catheterization, can be easily and accurately answered. It depends upon the size of the bladder and the properties of the urine. It may be said that the dilatation of the bladder, which increases as the quantity of residual urine becomes greater, represents a curative effort on the part of nature. Patients with well-marked chronic retention (2 or 3 liters of urine) are occasionally met with who suffer 356 DISEASES OF THE PROSTATE GLAND. no impairment of health, only they have to urinate more frequently than other men. The condition of patients having contracted bladder is much worse. While the urgency of micturition experienced by the first class sub- sides as soon as they are catheterized once or twice daily, the tenesmus suffered by patients with small bladders is uncontrollable. The in- dication for catheterization, therefore, depends upon the dispro- portion between the capacity of the bladder and the amount of residual urine. If cystitis complicates chronic retention catheterization almost always works favorably. It rarely does harm, although occasionally a single catheterization may prove fatal. I have had two deaths occur immediately after simple catheterization. It had hardly been begun before the patients became worse, while previously their general condition had been good. The tongue became dry and coated, anorexia and nausea developed, stupor supervened, and death took place within two days. As cystitis was already present in both cases, infection as the cause can be excluded; the temperature was not elevated; no hasmorrhage had been produced. It cannot be explained otherwise than by assuming that the difference in pressure between the emptied and previously filled bladder resulted in such a profound alteration of the organism as to cause the exitus of the feeble and atheromatous patients. Therefore it should be an established rule to draw off the urine cautiously and slowly from patients who have not been catheter- ized before and whose bladder is much distended, and afterwards to inject 100 cc. [3^ ounces] of sterile water into the bladder. In time we may come to empty the bladder completely and also to draw off the water used for irrigation. The severe complications, acute and chronic urosepsis, which may follow a simple catheterization even when it has been practised with the utmost precaution, have already been mentioned. They have nothing in common with the condition just described. While in robust persons infection is followed by chills and fever, the urine becoming turbid and purulent, in the old and decrepit either an acute sepsis develops, which soon ends in death, or chronic sepsis, the so- called urinary fever, occurs; this latter condition runs its course with only slight elevation of temperature. The patients are plainly on the decline; their nutrition becomes poorer and their aversion to food more and more noticeable. Intense thirst is the predominant HYPERTROPHY OF THE PROSTATE. 357 symptom. The urine is purulent and does not become clear in response to irrigations. The patients become gradually weaker until death occurs. This chronic urinary intoxication or urinary fever is difficult to combat. Naturally recourse will be had to the internal disinfectants, of which urotropin holds first rank, it being a drug, too, which should always be administered as a prophylactic to those who have entered upon catheter-life. Permanent relief for the bladder should be secured by regular catheterization or by the use of a self- retaining catheter, and the bladder should be cleansed by antiseptic irrigations, prefer- ably of silver nitrate. In extreme cases the establishment of a perineal fistula will be resorted to in order to afford exit for the urine at the deepest part of the bladder, and thus prevent further absorption of septic material by permitting the urine to drain away as soon as it is discharged from the ureters. Cardiac stimulants, nourishment supplied in every possible way, even in the form of nutritive enemata if necessary, a liberal quantity of alcohol, and periodic saline injections or hypo- dermoclysis are indicated. By these measures the patients can fre- quently be saved. Anorexia, thirst, fever and general weakness slowly disappear, and the patients recover to the extent of regaining the same degree of health which they possessed before the infection occurred. The treatment of acute complete retention requires special consider- ation. There are many obstacles to catheterization. It generally happens that the surgeon is called to a case in which several fruitless attempts to pass an instrument have already been made, and in which false passages are often present. In such cases it is best not to dilly- dally with soft catheters, but, after cocainizing the urethra, to try a large, long-beaked metal instrument having a pronounced curve, and if this will not pass to use one with Brodie's curve. No hesitancy need be felt about anesthetizing the patient, for he generally is in such a state of excitement and restlessness that the catheter cannot be passed with ease and caution. If catheterization does not succeed after a reasonable trial, it should be abandoned and puncture of the bladder with a capillary trocar at once made. The skin is incised a little above the symphysis and the trocar plunged quickly and forcibly downwards and backwards. Capillary puncture is entirely without danger, even when repeated. I have practised it six times on the same patient without doing him any harm. The fine puncture agglutinates at once. Injury of the peritoneum or 358 DISEASES OF THE PROSTATE GLAND. bowel is out of the question because of the high position of the peri- toneum. Moreover, I deem it more conservative to puncture the bladder than to persist in efforts at catheterization, especially if false passages be present. If puncture be performed a few days in suc- cession and the urethra left undisturbed, it will usually be found that the catheter can then be easily passed. It is only in cases of severe haemorrhage into the bladder that capil- lary puncture fails; the admixture of urine and blood is too thick to flow through the fine trocar, which may also be occluded by clots. In these cases of violent prostatic haemorrhage into the bladder, supra- pubic section must be contemplated as an operation of necessity. Severe haemorrhage with simultaneous retention of urine and dilata- tion of the bladder can frequently be relieved by catheterization. A large catheter is introduced and a small quantity of sterile water injected through it at high pressure as soon as the eye becomes clogged with clots; powerful contractions of the bladder result and the clots are generally expelled with the urine. This manoeuvre is repeated until as many clots as possible are removed. If need be suction may be made with a good syringe; the clots are thus drawn into the syringe and the urine can then escape. If these measures do not succeed after reasonable trial they should not be unduly pro- longed; the patients become weak and anaemic, particularly if further bleeding takes place. It is better to open the bladder suprapubically, clear out the clots, and tampon the bladder firmly with sterile gauze in the event of continued haemorrhage. In such cases the bladder has been punctured with Fleurant's large trocar and a catheter introduced through the wound for the purpose of emptying the bladder. This method of puncture is not suitable for these cases and should not be practised. In cases where the haemorrhage is severe it is uncertain, as the thick clots may not go through the trocar. The establishment of a permanent suprapubic fistula is not advisable. No appliance can be worn which will close it tightly; the patient is greatly annoyed by always being more or less wet. Moreover, the fistula is situated much too high, so that a residuum of urine remains in the bladder. The peritoneum has been injured in making the puncture, and Frisch mentions a case reported by Monod in which the prostate itself was injured to such an extent that abundant haemorrhage resulted. HYPERTROPHY OF THE PROSTATE. 359 This procedure is justifiable only in that condition which I have named prostatismus, a condition in which there is violent and uncon- trollable strangury, although little or no residual urine is present in the bladder. In most cases of this kind the bladder is somewhat diminished in size ; if its cavity be very much lessened the case is to be considered as one of contracted bladder. In both these classes of cases little is to be expected from ordinary measures. Contracted bladders cannot be influenced by any kind of treatment, and prostatismus shows obstinate resistance. Before an artificial canal is established an attempt should be made to institute permanent catheterization, a measure which possesses the additional advantage of draining the bladder at a lower level. Unfortunately the attempt often proves futile because the bladder is too irritable to tolerate a catheter. Nevertheless, it should always be tried. If it fails, another procedure may be selected for the prostatismus cases, namely, division of the vas deferens, or vasectomy, which will also be discussed later as an operation for the radical cure of hyper- trophy. This operation has no effect upon contraction of the bladder, although it acts very well in prostatismus. It is probable that the latter condition is due to irritation of certain nerves which is pro- duced by the enlargement of the prostate, and that this irritation is abolished by section of the vas deferens together with the nerve fila- ments which accompany it to the prostate. Only in exceptionally urgent cases, and after the last mentioned method has failed, would I advise the establishment of a suprapubic fistula, and even then I think cystotomy and the use of Witzel's canula preferable. In 1 90 1 Goldmann proposed the operation of cystopexy for reten- tion of urine in cases in which vesical distention and infection has not occurred. In this operation a portion of the anterior vesical wall not covered by peritoneum is attached as high up as possible to the anterior abdominal wall. The traction thus made upon the anterior wall of the bladder is said to bring the viscus upwards and forwards and prevent the formation of recesses in the posterior wall. It is also supposed to draw the lips of the internal meatus apart. Goldmann has obtained good results in several cases in which he did this oper- ation. He had the opportunity of making an autopsy on one patient who died of myocarditis a number of years, after the operation was performed. The following conditions were revealed: 360 DISEASES OF TELE PROSTATE GLAND. 1. A broad adhesion between the bladder and the anterior abdomi- nal wall. 2. Anteversion of the bladder. 3. Widening of the internal urethral orifice. 4. No signs of recesses in the posterior wall of the bladder. 5. No signs of dilatation of the ureters and pelvis of the kidneys. Unfortunately this operation is too new for its exact value to be stated. All the procedures which we have mentioned thus far come under the scope of symptomatic treatment. We now have to consider radical treatment, the object of which is to reduce the size of the prostate, or even remove it completely, and thus by radical means take away the hindrance to micturition. A series of procedures formerly recommended and practised need only be mentioned, because they have proved to be worthless, and therefore have merely historical interest. There are no internal remedies which can diminish the size of the prostate. Prostaden, which was recently recommended, proved to be merely a fashionable nostrum. Organotherapy also was in vogue at one time, and dried prostatic substance was fed to patients. The results were absolutely negative. Massage of the prostate for the purpose of reducing hypertrophy has been abandoned as ineffective. The same may be said of electric massage and electrolysis. The latter undoubtedly causes the gland to become slightly smaller, for it certainly destroys small portions of tissue ; the effect, however, is only slight, and the number of treatments necessary to bring about any considerable diminution in size so great that the method has never become established. Compression of the prostate by large sounds and catheters is without effect ; it does not cause atrophy and it is doubtful whether it enlarges the caliber of the urethra. I tried the X-ray treatment recommended by Moskowitz in 1905, in three cases, but as the results were entirely negative I made no further experiments with it. The injection into the prostate of fluids which cause destruction of tissue and subsequent contraction, such as solutions of iodine and arsenic (Iversen), has been abandoned as too dangerous. The danger of suppuration within the capsule of the prostate, with consequent thrombosis, is too great. HYPERTROPHY OF THE PROSTATE. 36 1 It thus came to pass that all operative procedures for the cure of hypertrophy of the prostate were discontinued until within the last few years, during which time a complete reversal of opinion has taken place, and three kinds of operations have been devised one after another, and each has been declared to possess superior merits. We will first mention Bier's operation, which consists in the ligation of both internal iliac arteries. Bier believes that the prostate can be made to atrophy by ligaturing these vessels, which supply it with- blood, just as myoma of the uterus atrophies after the uterine arteries have been tied. Aside from the fact that the cases reported by Bier do not prove the good results of the operation, for the reason that they were mostly cases of comparatively recent retention of urine, which not uncommonly undergo spontaneous relief and therefore cannot be taken as criteria, the procedure is much too formidable and dangerous to be practised on old and enfeebled persons. With few exceptions (Willy Meyer) it has found no supporters. Treatment took an entirely new course with the introduction of the so-called sexual operations, which were devised almost at the same time, in the years 1893 and 1894, by Ramm, of Christiana, and White, of Philadelphia. These surgeons recommended double castration, their theory being based on observations which had convinced them that the prostate ceased to grow in young animals which had been castrated, that in older ones it atrophied, and that the analogous condition of uterine myoma diminished in size after removal of the ovaries. The smallness of the gland in eunuchs and in the subjects of anor- chism and cryptorchidism was adduced as proof of the correctness of their theory. Except as to the comparison of prostatic hypertrophy with uterine myoma, which is not apposite to the subject, for the reason that the prostate is an organ which cannot be compared to the uterus, the result of the experiments is correct. I have myself conducted a large number of similar experiments upon dogs and rabbits, and have found that the glandular portion of the prostate of these animals atrophies after the performance of double castration. The accompanying illustrations fully elucidate the change which ensues (Figs. 191 and 192). Although shrinking actually takes place, the theoretical conclusion drawn from this fact is erroneous. It is the glandular elements of the enlarged prostate which shrivel; but it has been definitely deter- 362 DISEASES OF THE PROSTATE GLAND. mined that only the minority of cases of prostatic hypertrophy depend upon hyperplasia and hypertrophy of these elements. In the majority of cases there is a typical nodular myoma, and it cannot be affected by castration. Thus it is seen that castration will result in shrinkage Fig. 191. — Section from the prostate of an old rabbit, a gland-lobules, b cysts, c stroma. d stratified bodies, e prostatic vesicles, / seminal vesicle, g urethra, h musculature. of the gland in only the few cases which are of true adenomatous over- growth. The results of practical experience, both my own and that of others, is in accord with these deductions. I have performed castration for prostatic hypertrophy about twenty times. At first, influenced by the reports of others, there was a tendency to attribute some value to the procedure, but upon more candid judgment it has been found HYPERTROPHY OF THE PROSTATE. 363 to be without practical value; indeed, it may be declared to be injurious, as it exerts an unfavorable influence upon the patient's mind. It is an operation which has been abandoned. A little more favorable statements may be made in regard to division of the vasa deferentia. Theoretically its effect upon the prostate is even less valuable than that of castration, for it has been shown that neither the testicles nor the prostate regularly atrophy after its per- formance. (See Figs. 193 and 194.) In some instances shrinkage ' (3.) 2&. ^\ ( "vA._.„.-- Fig. 192. — Section from the prostate of an old rabbit 3J months after castration. a stratified body in an atrophied gland-tubule, b collapsed and contracted tubule, c fibrous stroma, d prostatic vesicle, e urethra, / seminal vesicle. took place; in others it did not occur. In order to prevent the vasa deferentia from growing together again Isnardi excised a portion; the result, however, remained the same. The results obtained in practice correspond to those given by exper- imentation. Vasectomy has no effect upon the size of the prostate. Notwithstanding this, however, it has acted beneficially in a few cases, and for this reason I would not exclude it from the treatment of pros- tatic hypertrophy. Primarily it is important to bear in mind that the procedure is entirely harmless, and that it can be done under 3 6 4 DISEASES OF THE PROSTATE GLAND. Schleich's local anaesthesia in a very short time. I have done the operation in this manner twenty times and allowed the patients to go home at once. They suffered no inconvenience and the wounds healed by first intention. The operation is of value in two kinds of cases, namely, those in which epididymitis develops as the result of repeated catheterization, and, secondly, in prostatismus, which has already been described. The frequently recurring and painful epididymitis is permanently cured. In prostatismus, in which increased desire to urinate is pre- sent without material contraction of the bladder and without residual urine, the favorable results have to be attributed to something else Connective tissue stroma. Musculature of the stroma. Large septum. Smooth glandu- lar wall. Small septa. Papillary excrescences. Fig. 193. — Prostate of a full-grown dog. (Glandular tubules. Highly magnified.) than diminution in the size of the prostate. We are led to this con- clusion by the fact that the benefit often ensues within a few days after the operation, a period of time, of course, in which the prostate could not have undergone contraction. It must, therefore, be taken for granted that the division of the nerves which accompany the vasa deferentia to their entrance into the prostate relieves the irritation. It is only for these two classes of cases that vasectomy can be recom- mended. Division of the entire spermatic cord, as well as the injection of zinc chloride into the parenchyma of the testes, both of which have HYPERTROPHY OF THE PROSTATE. 365 been advised, are to be condemned because they are liable to produce gangrene of the testicles. In recent times there has been a return to, and an attempt to improve, the more formidable operations which had formerly been tried in a few cases. These operations are complete and partial prostatec- tomy. Partial or total removal of the prostate has been attempted through a suprapubic cystotomy incision, through a perineal opening, and also by the prerectal route. Musculature of the stroma. Connective tissue stroma. \ ^c;s/« Contracted ducts ; lumen obliterated and recognizable only by the stained nuclei. Fig. 194. — Prostate of a full-grown dog 4J months after double vasectomy. (Highly magnified.) To trace the evolution of prostatic surgery would, indeed, be interest- ing, but in a work of this character space will not permit it to be followed from its origin to its present stage of development. Therefore only the most important epochs will be mentioned. In regard to suprapubic prostatectomy the first noteworthy pro- cedure was that practised by Belfield, of Chicago, and McGill, of Leeds. These surgeons did a partial prostatectomy through suprapubic and transvesical incisions, opening the bladder, incising 366 DISEASES OF THE PROSTATE GLAND. the mucous membrane over the prostate and then removing the ob- structing portions of the gland by cutting them away or enucleating them with the fingers. This operation, though generally known as McGill's, had been performed three times by Belfield before McGill operated on his first patient. I practised this procedure in several cases; in some the results were gratifying, in others the patients died, and so I came to consider it too severe for the majority of prostatics. As surgeons gained experience with this operation the idea of enu- cleating the prostate in its entirety was conceived and executed. Accord- ingly, in 1895, Dr. Eugene Fuller, of New York, did a complete enuclea- tion of the gland in one piece through a suprapubic and transvesical incision, and then drained the bladder through a perineal opening. A similar enucleation was also performed in 1897 by Dr. F. S. Watson, of Boston. In 1900, Mr. P. J. Freyer, of London, adopting and modifying the principle of Fuller's method, began the series of operations which have connected his name with suprapubic prostatectomy. He has found it possible to enucleate the prostate in its entirety in almost every instance, and has shown that perineal drainage is not necessary. The perineal operations as first practised were partial prostatec- tomies, the obstructing portions of the gland being removed through a median perineal incision. This method has been largely practised by Goodfellow, of San Francisco, who finally came to do a complete enucleation through this incision. In order to gain better access to the gland and facilitate its complete removal various other incisions have been devised. Chief among these may be mentioned the transverse curved incision advocated by Proust and Albarran and the inverted V incision of Young. These operations are to be welcomed as a decided advance in the therapy of prostatic hypertrophy, inasmuch as they afford relief in a class of cases not otherwise amenable to treatment. They are not without danger, however, and therefore should not be employed indiscriminately nor undertaken lightly, being reserved for those cases in which milder measures prove futile. When catheterization fails or has to be frequently repeated owing to smallness of the bladder produced by thickening of its walls, when it is very painful or is followed by haemorrhage, when severe cystitis is present or frequent attacks of retention occur, and when a case is not , HYPERTROPHY OF THE PROSTATE. 367 suitable for the Bottini operation, then a radical operation is to be considered. The one selected will depend upon the nature of the individual case. No doubt further experience will result in better knowledge of the exact indications for the two recognized procedures, namely, the suprapubic and perineal operations. At present the weight of evidence seems to be in favor of the former for the majority of cases. The functional results are better, the complications less frequent, and a decided decrease in mortality has occurred as improvements in opera- tive technic have taken place. In my clinic it has been the operation of choice. It is easier to perform than perineal prostatectomy, and as it affords a better view of the field of operation than the latter method, it enables the operator more surely to enucleate the gland in its entirety. Moreover, when operating through the suprapubic route the surgeon is not at all liable to leave calculi in the retroprostatic pouch. The great disadvantage of the operation is the poor drainage which it affords. In order to overcome this disadvantage external perineal urethrotomy has been performed and the bladder drained through the perineal wound. I have never done this myself, being satisfied to drain through the suprapubic wound by means of a large rubber tube. Among the unpleasant sequelae of the operation, the first to be mentioned is haemorrhage. As the field of operation is easily acces- sible, bleeding can almost always be controlled (see under Technic of the Operation). Infection must also be taken into account, as it is liable to occur owing to the action of the septic urine upon the wound. Fistulae sometimes persist, but they are not so frequent as after the perineal operation, in which injury to the rectum is very liable to lead to the formation of urethro -rectal and vesico-rectal fistulae. Incontinence of urine sometimes ihough rarely occurs. In my clinic it is exceedingly uncommon. Of twelve patents operated on in the Jewish Infirmary, however, two suffered from a slight degree of incontinence. The mortality of the suprapubic operation still remains higher than that of the perineal. Thus Tenney and Chase collected 396 cases of suprapubic prostatectomy, with a mortality of 9.8 per cent and 617 cases of perineal prostatectomy with a mortality of 7.6percent. These statis- tics are based upon the work of many operators and not upon series of cases reported by surgeons especially skillful in the performance of 368 DISEASES OF THE PROSTATE GLAND. the respective operations. Therefore they may be considered as repre- senting a fair average mortality-rate of the two procedures up to the year 1906. Freyer's last published statistics (1908), based upon 481 cases, give a mortality of 6.65 per cent for the suprapubic operation. Young's latest published statistics (1908), based upon 238 cases, give a mortality of 2.9 per cent for the perineal operation. These latter statistics are very significant, representing as they do the mortality- rate of two surgeons who have had unusual experience in the per- formance of the respective operations. Owing to improvements in technic there has been a constant decrease in mortality, and in all probability this decrease will continue. In 1900 Fuller stated that the mortality after suprapubic prostatectomy was from 15 per cent to 18 per cent; in 1904 Watson gave it as 11 per cent; in 1905 Freyer's statistics showed it to be 9 per cent, and, as already stated, in 1908 he had reduced it to 6.65 per cent. Notwithstanding its higher mortality, I consider it the preferable operation for the majority of cases. If the prostate is entirely removed and the patient recovers from the operation, he will be completely and permanently cured of his trouble. It would be difficult to define the exact contraindications to this operation because improvements in its technic will render it applicable to a greater and greater number of cases. It is very important that the patient's nutrition be not reduced too low. Ad- vanced atheroma, severe bilateral renal disease and other serious organic diseases must be looked upon as contraindications. Uni- lateral pyelitis and cystitis, however, are not contraindications. A large number of my patients had a very bad cystitis, which disap- peared after the operation. Even when these contraindications do not exist, the operation is by no means a trivial one. A patient of mine, aged fifty-nine years, who showed no signs of cardiac or arterial disease, succumbed to shock on the fourth day after the operation. The technic of the modern operation of suprapubic prostatectomy is as follows : After the bladder has been thoroughly washed out with hot saline or boric acid solution and about four ounces of the fluid left in the viscus, the soft rubber catheter through which the irriga- tion has been done is clamped and left in situ, the patient put into the Trendelenburg position, and the bladder exposed by a suprapubic incision from two to five inches in length, according as the patient is thin or very obese. The lower end of this incision should come directly PLATE II. 24 PLATE III. PLATE IV. a) c o § PLATE V. ,xl c HYPERTROPHY OF THE PROSTATE. 369 against the symphysis pubis. When the bladder is brought into view two retention sutures are passed through its outer coats, one on either side of the line through which it is to be opened; or the viscus may be steadied with a tenaculum while the incision is being made and also until the prostate is reached. (Plate II.) The catheter acts as a guide to the urethral orifice and lobes of the prostate. When the gland is located the mucous membrane covering one lobe is incised, the finger introduced and enucleation begun. (Plate III.) With one or two fingers of the other hand in the patient's rectum the prostate is pushed up toward the enucleating finger. (Plate IV.) In some instances the finger may be passed across to the second lobe and the latter re- moved through the original incision in the mucous membrane. In others the membrane over the second lobe will have to be incised. As a rule, the prostatic urethra and ejaculatory ducts will be divided. Deaver, from whom this description of the operation has chiefly been taken, states that he considers it impossible to preserve the attachments of the ducts. After the enucleation has been completed the cavity formed by removal of the prostate is irrigated with hot saline solution, and if haemorrhage persists, is packed with gauze and the vesical mucous membrane forming its roof sutured over the gauze. One end is left long and brought out through the suprapubic wound so as to facilitate its removal (Deaver) (Plate V). Drainage is provided by a long rubber tube passed into the bladder and connected with a bottle or jar containing an antiseptic fluid. A sterile gauze dressing is cut so as to fit around this tube, which is held in place by a stitch through the skin. It is left in the bladder from two to six days. The bladder should be irrigated regularly, at first through the supra- pubic wound, later through the urethra. In regard to the perineal operation it may be stated that in cases in which the gland is hard and fibrous, and does not project upward into the bladder for any distance, it may probably be better removed by this method than by the suprapubic. The technic of the operation is practised by Hugh Young, who is one of its strongest advocates, is as follows: The patient is placed in the exaggerated lithotomy position and an inverted V-shaped incision (Plate VI), each branch of which is about two inches long, is made through the superficial structures of the perineum. The deep tissues, except the central tendon and the recto-urethral muscle, 3/0 DISEASES OF THE PROSTATE GLAND. are divided by blunt dissection. The membranous urethra is then opened on a grooved staff, its edges drawn apart with forceps or sutures, and the prostatic tractor (Fig. 195) introduced and opened. (Plate VI.) By making traction with this instrument the gland is drawn into the wound. When it has been brought well into view an incision is made through each lateral lobe parallel with and as deep as the urethra. (Plate VII.) The capsule of the gland is then separated by blunt dissection and the urethra is also isolated in the same manner. Deep enucleation is accomplished with the finger. " If a medium lobe or bar is present, it can generally be removed by engaging it with one blade of the tractor, making traction and rotating at the same time. This will generally cause the lobe to pre- sent in the left lateral cavity (Plate VIII), where it can be engaged Fig. 195. — Young's prostatic tractor. with the small lobe-forceps, or, if it is too small for these, by some small toothed forceps, and enucleated or cut away with scissors. "If it is too small to be engaged with the blade of the tractor, this instrument may be removed and the index-finger of the left hand inserted through the dilated urethra and used as a tractor, as shown in Plate IX." In this operation a bridge of tissue containing the urethra and ejaculatory ducts is preserved. Occasionally, however, a fibrous median lobe is present which cannot be removed by forcing it into one of the lateral cavities with a blade of the tractor, and then it is neces- sary to cut through the capsule covering the ducts and destroy them in the removal of the obstruction. The lateral cavities are packed with gauze, a double catheter inserted into the bladder and fastened to the skin-wound by a suture and continuous irrigation begun. The divided ends of the levator ani muscles are united with a catgut suture. The drain is removed on the second day. PLATE VI. Fig. i. — The inverted V cutaneous incision. (Young.) Fig. 2. — Opening of urethra on sound, preparatory to intro- duction of tractor. (Young.) PLATE VII. Tractor introduced, blades separated, traction made exposing posterior surface of prostate. Incisions in capsule on each side of ejaculatory ducts. (Young.) PLATE VIII. m , . Bn . w, \l Showing technique of delivery of middle lobe into cavity of left lateral lobe. (Young.) PLATE IX Showing use of finger instead of tractor to draw down small median lobe into lateral cavity. (Young.) 25 HYPERTROPHY OF THE PROSTATE. 371 Dr. Young has had good results from this operation in a large number of cases, his last published report being based upon 238. In regard to the mortality of the perineal operation, the statistics of Proust, based upon a collection of 813 cases, show a mortality of 7.63 per cent, which is somewhat higher than that based upon smaller series of recent cases. For example, in 322 cases collected by Deaver the mortality was 6.83 per cent, and in 1192 cases collected by Tuffier, 6.6 per cent. Young's total mortality in 238 cases is only 2.9 per cent. Among the sequelae of the perineal operation may be mentioned perineal and rectal fistulae, incontinence of urine, epididymitis, impo- tence and contraction of the neck of the bladder. In 410 cases studied by Escat perineal or rectal fistulae were present in over 8 per cent and permanent incontinence in over 3 per cent. Young believes that urethro-rectal fistulae are due to a breaking down of the rectum resulting from the absence of support normally afforded by the levator ani muscles. It is for this reason that he unites the -divided ends of the muscles with a heavy catgut suture when the operation is completed. When this suture is tied it brings the muscles together in front of the rectum, thus affording support against pressure of gauze as well as the straining which takes place at stool. The prostate has also been attacked by the combined suprapubic and perineal routes. Thus Nicoll opens the bladder, incises the perineum down to the prostate, and then pushes the gland into the perineal wound by pressure exerted upon it through the bladder. He does not open the urethra. Samuel Alexander performs suprapubic cystotomy, opens the urethra on a grooved staff from the bulb to the apex of the prostate, pushes the gland down into the wound through the bladder, enucleates it, and then introduces both a suprapubic and perineal tube. The former is removed on the fourth day, the latter on the seventh. The bladder is irrigated daily. Finally we come to a consideration of the Bottini operation, with reports of which medical literature has been flooded during the last ten years. In 1874 Bottini published his method of galvano-caustic incision of the prostate, and later, at various medical congresses, reported and lauded the results he obtained, without, however, suc- ceeding in awakening any interest in the operation. 37 2 DISEASES OF THE PROSTATE GLAND. Freudenburg, who improved the instruments used in this procedure, was the first to attract serious attention to it, and since his time it has been tried and studied everywhere. The operation is really a modification of the old Merrier and Civiale operations, which consisted in cutting out a piece of the prostate. Bottini sought to accomplish the same result with the galvano- caustic incisor and at the same time lessen the danger of haemorrhage. The construction of the instrument is shown in Fig. 1 96. The platino-iridium blade, which is concealed in the shaft during the introduction of the instrument, is brought out of the beak by turning a screw at the handle, in a manner similar to that in which the male blade of a lithotrite is withdrawn from the female blade. The plati- num blade is heated by a strong battery; a current of cold water flows between the blade and the shaft to keep the latter from becoming hot. The technic of the operation is very simple. It can be done under local anaesthesia, but I advise the use of a general anaesthetic because I consider thorough burning advantageous, and this is poorly borne when only local anaesthesia is employed. The bladder is emptied and then partly distended with air [or fluid] ; the instrument is then passed into the bladder the same as a metal catheter, the beak turned downwards and laterally and brought firmly against the projecting prostate. The best place to make the incision has been previously deter- mined by cystoscopic examination. The knife should be white-hot. The tissues should be burned slowly, ten minutes being consumed for each cut; one incision is made downward and to the right, one downward and to the left, and one directly downward; an upward incision should never be made. The cut must not be too long. As a rule, 3 cm. [1 1 inches] will suffice. A finger should be placed in the rectum and the tip of the instrument sought for behind the prostate. The instrument must be held close against the prostate, which is best done by keeping the Fig. 196. Bottini's pros tatic incisor. HYPERTROPHY OF THE PROSTATE. 373 handle somewhat elevated ; it must also be kept fixed so that the beak will not slip into the urethra. A catheter is introduced and fastened in place after the operation if complete or serious incomplete retention has previously existed. The important questions which arise concerning this operation are, first, what results are obtained by it; second, what are its dangers; third, should it be employed, and if so in what cases. These questions have been answered differently by different surgeons. At first surgeons were generally enthusiastic over it. The results were apparently brilliant. Gradually, however, more and more bad results followed its employ- ment, so that its value finally came to be judged more calmly. I withheld my opinion six years so that I might be able to speak from experience. As I have now performed the operation thirty times, and as it is a comparatively new procedure, in regard to which personal experience counts for considerable, I will express solely my own personal views concerning it. If we adhere to the above mentioned classification of cases into those associated with retention and those of prostatismus without residual urine, it is plain that the operation is suitable only for those of the first class. Three cases of prostatismus which I operated on were made worse, the painful urgency of urination being increased instead of diminished. From the day of operation until six, nine, and eighteen months afterward, respectively, more severe pain was experienced than had ever been present before. It was felt in the penis and also in the rectum. These observations are entirely in accord with the theoretical considerations. Although the prostate is enlarged in prostatismus, no obstruction great enough to prevent the patient emptying his bladder is present. It is self-evident, moreover, that the burning of one or more grooves in the enlarged prostate will increase the nervous irritability upon which the condition largely depends. Therefore, in these cases the Bottini operation is contraindicated. As to its employment for cases of retention, either partial or com- plete, those which are chronic are the only ones which need be con- sidered. Acute retention of urine [due to hypertrophy of the prostate] never requires operative interference, because it can be made to yield to regular catheterization. If it has persisted longer than three months, then, according to my experience at least, the question of operation arises. 374 DISEASES OF THE PROSTATE GLAND. Some of these chronic cases were entirely cured by the Bottini operation. The residual urine and pain disappeared and micturition was reduced to normal frequency. These were all cases in which the urethra was lengthened, a circumstance which shows that the principal trouble lay in the urethra. Many patients also were improved. It is true that they did not empty the bladder completely after the operation, but they voided better than they could before. The stream of urine was more free and the pain disappeared or became considerably lessened. In a few instances the first operation was fruitless, although after the second, the patients, who had not voided a drop of water for years, began to urinate again, and were able to empty or nearly empty their bladder. In other cases absolutely no result was observed. This latter class included both complete and incomplete retention. Patients with complete retention could not void after the operation, and those with incomplete retention continued to have the same quantity of residual urine. In some cases, too, a second operation was likewise ineffective. I have four deaths to report. Only three of these were directly due to the operation, one patient having succumbed to heart failure. He was a decrepit man of seventy-five, with advanced arteriosclerosis, in whom catheterism produced intense suffering. On account of this pain I decided upon operation, which was performed in the usual manner. The patient became weaker day by day. His temperature remained normal; the pulse was small; nothing abnormal could be found in the abdomen and rectum. Four days after operation he died of heart failure. The second death resulted from haemorrhage. At first the oper- ation seemed to have been successful. No bleeding occurred. On the third day a sudden and inexplicable haemorrhage occurred, which was so violent that it occluded the catheter with clots. With difficulty the catheter was kept free. At the expiration of four days the bleeding ceased, but in the meantime the patient had become so weak and anaemic that he died on the eighth day after operation. The third patient was killed by sepsis resulting from phlegmonous inflammation of the cut surface in the prostate. He was old and feeble and suffered with complete retention of urine; catheterization was difficult. The prostate, especially the middle lobe, was of immense size (Fig. 197); the bladder was much inflamed and filled with HYPERTROPHY OF THE PROSTATE. 375 purulent ammoniacal urine, and the pelvis of both kidneys was filled with pus. The fourth death was also due to sepsis. In this case the bladder was punctured for the purpose of introducing the cystoscope so that the incision made by the Bottini knife could be seen and guided. This method was recommended by Hurry Fenwick, of London, and Kraskc, of Freiburg. Autopsy revealed an abscess in the pelvic connective Middle lobe. Beginning of in- cision in mid- dle lobe. Phlegmonous ulcer- ation extending into membranous urethra. Fig. 197. — Very large hypertrophied prostate operated on by Bottini's method. tissue. The Bottini incision was covered with a healthy eschar and there was no evidence of inflammation or suppuration around it. This fatality, therefore, is to be attributed to the vesical puncture rather than to the Bottini operation. If, after these statements, we come to define the indications for the Bottini operation, the following considerations are in place. When an operation is recommended for the relief of a condition in which vital indications for its performance are not present, it is 376 DISEASES OF THE PROSTATE GLAND. for the reason that non-operative measures are ineffectual, or because it is feared that the condition will become worse and more difficult of control if allowed to progress without interference. Such operative interference is, of course, justifiable only when it offers at least a reasonable chance of improvement, or when it does not entail too great danger to life. What relation, now, does this question bear to hypertrophy of the prostate, and particularly as concerns its treatment by the Bottini operation? First of all the fact must be borne in mind that many prostatics having chronic retention of urine enjoy the best of health and attain an advanced age. The state of their health depends upon the capacity of their bladder. Transitory exacerbations can always be overcome and thus do not enter the question. If the bladder is capacious, holding from \ to i liter [i to 2 pints], the patients usually do not need to be catheterized more than twice a day, or they may catheterize themselves. By this means the bladder is fully relieved, and the patients are disturbed neither during the day nor at night. Such patients naturally have no desire to submit to operation, and the surgeon surely cannot do otherwise than approve their, atti- tude, especially when they have enough spare time to practise catheter- ization with the utmost care and caution, thereby obviating the danger incident to this procedure. To recommend operation to them because there is a possibility of their condition becoming worse would be inadvisable for two reasons. In the first place many of my patients have reached or passed the age of eighty on catheterism with entire comfort so far as the urinary tract is concerned; it cannot be asserted that these case's of chronic retention will progress to the bad, and on the other hand, it cannot be affirmed that they may not become worse after a Bottini operation. It can no more be expected that partial cauterization of the prostate will arrest the formation of new tissue than it can be assumed that fibro-my- omatous or adenomatous overgrowth will not progress and cause enlargement of the gland when left undisturbed. Accordingly no change for the worse may take place when operation is not done, while it may occur after operation has been done. Therefore, in this class of cases, operation should not be advised. It is different when the bladder is small, or when catheterization is very difficult. In the first instance, because of the patient's inability to empty his bladder, the catheter has to be used from six to ten times HYPERTROPHY OF THE PROSTATE. 377 in twenty-four hours, or even oftener. This is a great discomfort, causing irritation of the urethra and increasing the danger of infection. If it is difficult to insert the catheter, or if exacerbations take place which make its insertion impossible without repeated trials, then life becomes wretched, and we are warranted in concurring with the patient's wish to be freed from catheter-life. Operation is also indicated in those patients who are subject to frequent attacks of acute retention of urine. The more frequently retention develops the more certain is the patient to acquire cystitis. As is well known, too, nothing predisposes to infection more than the reduction in pressure which takes place after the bladder is freed from complete retention. These attacks can often be lessened by careful living, attention to diet, keeping the bowels free, and avoiding excesses, but there are cases in which the congestion of the prostate is so great that the attacks of retention frequently recur. The more difficult catheter- ization is, the stronger is the indication for operation in these cases. The dangers of the operation constitute its chief contraindications. I learned from my own cases that haemorrhage and sepsis have to be taken into account.* If the patients are very feeble, affected with arteriosclerosis, and suffer from chronic urinary fever, they will not tolerate the slightest interference. The Bottini operation is too severe for them, they die after it, as I have had occasion to observe in my own and other cases. It is true that they do not live long even when no interference is prac- tised, but they last longer than when they are operated on. Pyelitis or pyonephrosis, if unilateral, constitutes no contraindication to the operation, for, as is well known, persons with these affections may live a long time. When both kidneys are involved, however, we should not operate. The danger of haemorrhage, which may occur either during or after operation, is not to be underestimated. It is of great consequence because it sometimes cannot be arrested, styptics and the permanent catheter often proving of no avail; even operative measures do not invariably control it. Neither by the suprapubic nor perineal oper- ation is it always possible to tampon the prostate sufficiently to control the bleeding. I have seen cases of prostatic haemorrhage which could not be stanched. These haemorrhages may occur during the operation, or afterwards, when the slough separates. The first *In 1907 Freudenberg reported 152 cases with a mortality of 7 per cent. 378 DISEASES OF THE PROSTATE GLAND. are preventable if proper cases are selected for operation and the cauterization be thorough and protracted. Proper cases are those which have shown no tendency to severe haemorrhage. Patients who show such a tendency I consider to be very poor subjects for the Bottini operation. As already stated, the manner of cauterization is important. With the knife at a white heat four minutes should be consumed in burning one centimeter, at which rate twelve minutes will be required for an incision three centimeters in length. The incisor should be heated to a white heat, because the moisture of the tissues will reduce it to a red heat; if it be heated only to a glow before it is introduced it will not remain red-hot, but will become considerably cooled, with the result that there is danger of tearing instead of cleanly dividing the tissues. Although haemorrhage during operation can be prevented by the means above mentioned, there is no way in which bleeding can be guarded against when the eschar separates; I have repeatedly seen it occur under this circumstance. Finally, sepsis constitutes a great danger. The instrument can, of course, be sterilized, but if the patient has a purulent cystitis, the surface of the wound is bound to be bathed with septic fluid. We should not be deceived in regard to this condition. In such cases it is imperative to previously cleanse the bladder, and if possible to institute continuous catheterization and employ irrigations of silver nitrate. If the cystitis cannot be bettered by these means — which seldom happens — then it is better not to operate. The direct dangers of- the operation, namely, burning the wall of the bladder or rectum, and injury to the membranous urethra, I con- sider of slight importance, as I also do the danger of dribbling of urine after the operation. Proper technic overcomes these dangers. In my cases none of them occurred. I managed my cases in accordance with these principles. I cannot say that the results are brilliant, but yet some patients were cured and many relieved. Therefore I am an advocate of the operation in selected cases. On the other hand, I do not fail to recognize its dan- gers, and, above all, to realize that its results are altogether uncertain. For these reasons I consider it unjustifiable to advise the operation in the early stages of the disease, at a time when the urine is clear and only a slight residuum is present, as in this stage the patient TUBERCULOSIS OF THE PROSTATE. 379 experiences little trouble; in the first place we do not know whether the operation will help him, and in the second, we cannot tell but what he may continue to the end of his days in an equally good condition without operation. Finally, even when the operation proves of benefit it does not guard against recurrence, as the gland may con- tinue to grow. I have seen several such cases. By a second operation, however, it will often be possible to afford the patient relief again. From the above account it will be seen that the treatment of hyper- trophy of the prostate is a very satisfactory undertaking for the sur- geon who is thoroughly conversant with the nature of the disease and understands how to individualize. Those prostatics who cannot be helped constitute the minority; the majority can be relieved, either by or without operation, according to their condition. My views on the various methods of treatment may be summarized as follows: i. For all patients whose social condition permits them to carry on a careful and prolonged palliative treatment, regular catheterization is at first to be considered the method of choice. 2. If catheterization is very difficult or very painful, if it has to be very frequently repeated, or if it produces haemorrhage, then supra- pubic vesical puncture or cystotomy is to be employed when a major operation is contraindicated or refused. 3. When a major operation is not contraindicated by advanced arteriosclerosis, cachexia, or any other serious organic disease, the choice of procedure lies between the Bottini operation and suprapubic prostatectomy. According to my experience the Bottini operation, as a rule, is only palliative. In a few specially selected cases, however, it affords permanent relief. 4. Suprapubic prostatectomy offers the best chance for complete cure. The relatively high mortality after this operation, however, militates against its universal employment. It is to be hoped that improvements in technic will constantly reduce the mortality rate. 5. Division of the vasa deferentia is to be considered only in the case of those patients who suffer from prostatism or recurring epidid- ymitis due to catheterization. TUBERCULOSIS OF THE PROSTATE. Tuberculosis of the prostate usually affects young adults, rarely children and old men. As in most other tuberculous diseases, hered- 380 DISEASES OF THE PROSTATE GLAND. itary predisposition has to be assumed in explanation of the develop- ment of this malady. Although we are as yet unable to explain the exact nature of this hereditary influence, the fact remains that many young persons in whom there is no apparent cause for the develop- ment of disease are taken ill with an affection the diagnosis of which is at first obscure, but which, as it progresses, proves to be tuberculosis of the prostate. If the history of such persons be investigated it will be found that they belong to tuberculous families. Weigert states explicitly that the prostate seems to afford a particularly favorable soil for the growth of infective microorganisms. It is easily conceivable that tuberculosis will break out more readily in those having the above mentioned hereditary predisposition when they have sustained some injury to the genital tract. A prominent cause, and one the importance of which was for a long time not suffi- ciently recognized, is gonorrhoea. I have seen numberless cases of urogenital tuberculosis involving the prostate, the soil for the develop- ment of which had been prepared by a long-standing gonorrhoea. Gonorrhoea, especially the chronic form — which might well be named eternal — is similar in effect to an injury, which in the predisposed favors the development of tuberculosis of the genital tract just as it does in other organs of the body. It has not been proved that excesses in venery or masturbation are causes of tuberculosis of the prostate in persons who have no hereditary tendency to tuberculous disease, and such a theory, moreover, is not confirmed by clinical experience. It is conceivable that tubercle bacilli may gain access to the urinary passages from without, either from cohabitation with a tuberculous person (Cornet) or through infected catheters, although such occur- rences are rare in comparison with infection through the blood or lymph-streams. This view is corroborated by the circumstance that prostatic tuber- culosis seldom occurs or remains as a distinct and isolated disease. There are almost always tuberculous lesions in other parts of the body. It is either preceded by phthisis, or else renal tuberculosis is the pri- mary disease; the morbid process is either carried to the prostate by the blood, or reaches it by direct descent from the kidneys to the bladder. In other cases tuberculous epididymitis appears as the first manifestation of disease, the prostate and seminal vesicles becoming involved afterwards. The latter organs are very often affected with the prostate. In short, few cases have been observed in which autopsy TUBERCULOSIS OF THE PROSTATE. 381 showed the prostate alone to be affected. The work of Jani, who found tubercle bacilli in the testes and undiseased prostate of the subjects of phthisis, is important in showing the readiness with which infective microorganisms take up their abode in the latter organ. Pathological Anatomy. The prostate is sometimes enlarged and sometimes decreased in size, according to the manner in which the pathic process manifests itself. In this respect it is well to discrim- inate between tuberculosis of the prostate and tuberculous pros- tatitis. In the first condition, which is rarely observed at autopsy, isolated nodules are found in the acini, there being no changes, or at most only slight alterations, in the surrounding tissue; whereas in prostatitis the alterations ordinarily observed in this condition are plainly discernible. These changes consist in an eruption of tubercles, at first isolated, later confluent, which pursue the same course as they always take in other parts of the body. In the early stages there are gray nodules in the tissue surrounding the acini, together with an infiltration of round cells and some giant and epithelioid cells; later the center undergoes caseous degeneration and the whole tubercle softens, the dead cellular elements becoming converted into a thick, greasy, caseous mass. These small caseous collections are surrounded by a zone of infiltration. The tubercle bacilli are particularly abundant between the epithelium and its underlying connective tissue. The tubercles are more common toward the periphery of the gland than they are near the urethra (the excentric form of Thompson and Guyon). The countless number of these small foci, which increase in size and communicate with one another, cause, in conjunction with the reactive inflammation to which they give rise, considerable enlargement of the gland. Its surface becomes uneven and tuberculated; as to consistency, hard and soft portions alternate with one another. In addition to caseation, the most common pathic process which occurs in tubercles, purulent disintegration may take place, as the result of which abscesses are formed. The number of abscesses de- pends upon the extent of the destruction which takes place. In the more advanced stages of the disease these purulent collections coalesce and form one large tuberculous abscess which destroys more or less of the substance of gland. Even when considerable alteration has been produced by caseation and suppuration of many tubercles a relative cure may yet take place. DISEASES OF THE PROSTATE GLAND. The contents of the suppurating and caseating cavities becomes resorbed, or slowly undergoes induration and calcification (Broca). Unfortunately, however, such an occurrence is very rare; generally the morbid process advances uninterruptedly toward the periphery, through which it torces its way; or the abscess may rupture externally or break into the urethra or bladder. Thus the abscess may empty itself completely at once, so that a cavity with tuberculous walls remains, or if rupture takes place by means of small and irregular passages, only a portion of the tuberculous mass may be evacuated. The fistulas thus formed, which open into the urethra, bladder, perineum, or anus show no tendency to heal. English calls attention to an especially virulent form, tuberculous periprostatitis, which may give rise to a general dissemination of tuberculosis. The tubercle bacilli are carried to the periprostatic plexus by the blood or lymph-current, and they may get out of the veins into the surrounding connective tissue. Their presence in the veins, too, may readily cause thrombosis and pyaemia. Symptoms, Course and Diagnosis. A clinical distinction also has to be made between tuberculosis of the prostate and tuberculous pros- tatitis. The first, that is, the development of one or more isolated tuberculous foci in the prostate, may take place unnoticed, and the lesion may remain latent for years without producing the slightest symptoms. It is only when the process extends to the adjacent parts, or the latter become infected through the blood, or when vesical or renal tuberculosis breaks forth that symptoms are produced, and the prostate, upon examination through the rectum, is found to be dis- eased with tubercles which must have existed for a long time. Thus it is seen that a beginning tuberculosis of the prostate confined to the parenchyma of the gland, and not affecting the urethra and bladder, is difficult or impossible to diagnosticate. As no symptoms are present there will be no occasion to palpate the prostate. As concerns the subjective symptoms which sooner or later manifest themselves, it may be said that they have little which is characteristic. They consist in disturbances of micturition, pain, hasmaturia, and hasmospermia. . The disturbances of micturition have no peculiarities. The patients urinate more frequently by day than by night, urination causing a burning sensation, which is more pronounced at the end of the act. It seems as though the urine is expelled with difficulty. This form of TUBERCULOSIS OF THE PROSTATE. 383 tenesmus is exactly the same as that which is observed in simple cystitis colli, except that it resists all treatment, whereas in the latter disease good results are obtained. Independent of micturition there is a feeling of pressure and heaviness in the perineum and around the anus, a painful sensation which becomes much intensified by activity, by sitting, and also at stool. Here, again, the difficulty with which this symptom can be overcome is characteristic. In regard to haemorrhage, it may be said that severe bleeding seldom occurs; on the contrary, usually only a few drops of blood are lost, this slight haemorrhage sometimes taking place at the beginning of micturition, although usually following the act. While the same phenomenon is observed in gonorrheal inflammation of the neck of the bladder (cystitis colli gonorrhoica), it must not be forgotten that one or two instillations of silver nitrate suffice to control the bleeding. In tuberculous prostatitis, however, this treatment has an exactly opposite effect: it increases haemorrhage and intensifies the pain. About the same thing may be said of haemospermia. The last drops of semen expelled during coitus, and occasionally also when pollutions occur, are blood-stained; this is a symptom, too, which is met with in simple inflammation of the seminal vesicles. While in the latter condition it is characterized by benignity, in tuberculosis it often cannot be overcome. On the other hand it must be remembered that occurrence of haemospermia in tuberculosis is not constant. Although these symptoms of prostatic tuberculosis present nothing specific, the diagnosis can, however, be confirmed by physical exam- ination, especially if the constitutional condition of the patient be thoroughly investigated and his history carefully elicited. In regard to urethral discharge little importance is to be attributed to it, as it is by no means always present. The disease must reach the urethra and produce ulcers or fistulous passages before it can give rise to a discharge manifesting itself at the external orifice, or produce filaments in the urine. In order to prove that the discharge is tuber- culous tubercle bacilli must be found in it, and this is a thing which seldom comes to pass ; moreover, it must be determined at least beyond probable doubt that the discharge comes from the prostate. In order to determine this the prostate may be massaged, the urethra being previously cleansed, and the secretion thus obtained stained and examined in the usual manner. 384 DISEASES OF THE PROSTATE GLAND. A much more certain method is careful palpation of the prostate through the rectum. The isolated nodules can be plainly felt. They occur in no other prostatic disease. The prostate is also excessively sensitive to pressure. If the finger be long enough, the thickened, nodular and tortuous seminal vesicles can be felt above the prostate. Examination with the cystoscope and sound is unnecessary. With the cystoscope nothing can be seen, for the changes in the prostate can at most manifest themselves at the sphincter, and similar changes are also produced there by ordinary prostatitis. The introduction of a sound gives rise to so much pain, and is of such varied significance, that it should not be made use of. The above depicted subjective and objective symptoms are suffi- cient to enable one to make a diagnosis, especially when considered conjointly with the general condition of the patient, knowledge of which can be obtained by an adequate examination of the entire body. If the suspicious symptoms are accompanied by a tuberculous infection, if the patient has a hereditary taint, if the disease is characterized by inveterateness and resistance to treatment, error of diagnosis will seldom be made. Prognosis. The prognosis is not altogether unfavorable unless there are associated tuberculous lesions which threaten life. If, for example, there is in addition to the prostatic disease a unilateral renal tuberculosis, cure is possible, and in the case of persons otherwise strong, and having good powers of resistance, it is even probable. Cases in which the disease ascends, and in which the bladder, epididy- mes and seminal vesicles are involved offer a much poorer prospect of cure. These cases usually tend to bilateral involvement of the ureters and kidneys, or there are so many associated tuberculous foci in the body that cure is impossible. But apart from remote localization of the tuberculous process the disease progresses more commonly than it retrogrades. Abscesses and fistula? are formed in the manner already described. The thing most to be feared is the development of the painful and uncontrollable vesical tuberculosis. Frequently a miliary tuberculosis brings an end to the patient's suffering. Treatment. There is very little to be done for prostatic tubercu- losis. In view of the above described predisposing causes, we should endeavor by every possible means to cure chronic gonorrhoea, so that tuberculosis may not be superimposed upon it. On the other hand, TUBERCULOSIS OF THE PROSTATE. 385 it must not be forgotten that heroic treatment so weakens the organ- ism, and particularly the sexual organs, that there is danger of any tubercle bacilli which may be in the blood taking up their abode in the prostate. For this reason too active treatment is to be avoided. Such diseases as urethritis, epididymitis, and prostatitis occurring in those predisposed to tuberculosis are to be treated with the utmost caution, and, if possible, without resort to active local measures. The medical treatment of tuberculosis of the prostate with creasote and similar drugs offers little hope of success. I have never seen any results from their use. Local applications of silver nitrate, iodoform, and corrosive subli- mate to the posterior urethra are to be considered only when the urethra is involved; under other circumstances their employment is irrational. But even in cases in which the urethra is affected I advise against their use. They do little good and cause the patient much suffering. They do not reach the source of the tuberculous process, but merely a portion of it which has developed secondarily. General hygienic measures, such as are useful in other forms of tuberculosis, as for example, sanatorium-treatment, mild hydrothera- peutic measures, the rest-cure, residence in a southern climate, over- feeding, and the avoidance of all injurious influences are of value. If micturition or defecation is very painful, the employment of morphine, heroin, or belladonna in the form of rectal injections or suppositories is to be recommended. If symptoms referable to the bladder pre- dominate, then the sublimate instillations used for vesical tuberculosis may be tried. Their effect is usually beneficial. Continuous catheterization for the relief of tenesmus is not to be advised, because in tuberculous cystitis, which is usually associated, the permanent catheter cannot be endured. If the pain and urgency of urination become intolerable, then the only measure which will bring relief is puncture of the bladder and establishment of a fistula. Surgical treatment consisting in removal of the entire prostate, together with the seminal vesicles, as practised by Young and others, has as yet been insufficiently tested to enable us to recommend it. Furthermore, it would be appropriate only for those cases in which no other tuberculous foci exist, or for those in which the associated lesions are of such a character as to permit such a formidable procedure and offer a prospect of cure. It is quite a different matter when we have to do with cold tuberculous 26 386 DISEASES OF THE PROSTATE GLAND. abscesses of the prostate, or with fistulse, which are exceedingly annoy- ing to the patient. Prostatic abscesses may be opened through the classical perineal incision or by means of the prerectal incision; they should then be curetted and injected with iodoform emulsion. Fis- tulae should be laid open and similarly treated. CONCRETIONS AND CALCULI OF THE PROSTATE. In the prostate gland of every adult there are small bodies called stratified corpuscles, or corpula amylacea, mention of which has already been made. Their development, according to Virchow, is due to thickening of the prostatic secretion and its cohesion with one or more degenerated cells to form a nucleus, around which successive layers are deposited. Recklinghausen considers them to be closely allied to starch-corpuscles, and Stilling believes them to be purely amyloid. Posner's investigations show that they are produced by coagulation of albuminous secretion or necrotic cells, the coagulum becoming infiltrated with lecithin. These become superimposed one upon another, with the result that concretions are formed, which may attain the size of a flax-seed; they occur in large numbers in the acini and ducts of the gland. Their color varies from light pearl- gray to amber, brown, or black. The dark color is due to pigmentation. The gray or brown granules are seen on the cut surfaces. These stratified bodies, aggregations of which form concretions, are not a product of disease, but are rather to be considered as the expression of disturbed glandular secretion. They may remain in the prostate for years or for a lifetime without causing any trouble. When they increase sufficiently in size, or become incrusted with lime salts to such an extent that they project above the level of the urethra, it is then that they are often first recognized. As a rule, they remain small; when deposits of carbonate or oxalate of lime, or triple phosphates, are added to them they become true calculi. Entirely different in origin from these are those stones which lie in the prostatic urethra; they are either true urethral calculi or frag- ments of vesical calculi. To the latter category belong the so-called pipe-stones, which lie partly in the bladder and partly in the urethra, being bent at an angle after the manner of a pipe-head. Those which have received the name of hour-glass calculi because the expanded ends are united by a slender median portion may be urethral, vesical, or prostatic. These stones result from the deposition CONCRETIONS AND CALCULI OF THE PROSTATE. 387 of urinary salts upon the primary calculus. True prostatic calculi are seldom singular, generally being present in large numbers. Gold- ing-Bird describes a case in which there were one hundred and thirty calculi in the prostate. Calculi in the prostatic urethra, on the con- trary, are usually single. The larger their number the smaller they are, and vice versa. Stones weighing as much as 120 grammes [1800 grains] have been found. If the prostate undergoes calcareous degeneration in the manner thus described, the calculi generally lie in cavities which are irregularly distributed throughout the entire gland, although they may be confined to certain portions, or perhaps to one side, of the gland. If there is a single stone of considerable size, the substance of the gland around it atrophies, and the cavity in which it is then contained will be surrounded by a zone of atrophied tissue. Incrustations must also be included with prostatic calculi, although in origin they differ from the latter, originating as they do from small circumscribed collections of pus which undergo inspissation and calcification, They are extremely rare. The same is true of venous calculi, or phleboliths, which occur in the dilated veins of the periprostatic plexus. They seldom attain a size larger than a pea. Their development is favored by dilatation of the veins and also by venous stasis. Phleboliths also are very rare. In general it may be said that prostatic concretions and calculi pro- duce no symptoms, and therefore that their existence cannot be deter- mined. They are only discovered during operation or found post- mortem. Sometimes, however, especially if they protrude into the urethra, they give rise to trouble, producing difficult and painful micturition. The patient has to urinate oftener than usual and there is perceptible resistance to the outflow of urine; it is noteworthy that this resistance is not constant, being present at times and absent at others. The condition is analogous to that which obtains when small vesical calculi are carried to the neck of the bladder and occlude it. Complete retention of urine may result. Urination is painful, the pain radiating to the tip of the penis. Defecation likewise causes pain. The patient also experiences a sense of heaviness and pressure in the perineum existing independently of micturition. Haemorrhages due to prostatic calculi are not frequent, although they sometimes occur. When the stone projects into the urethra 388 DISEASES OF THE PROSTATE GLAND. blood- cells are almost always found in the urine. In one case I saw a severe and almost fatal haemorrhage produced by a calculus a little larger than a pea, the sharp edge of which jutted out into the urethra. The patient died a few weeks later and the above described condition was revealed at autopsy. Other inflammatory processes also not uncommonly make their appearance in the posterior urethra and bladder without causing the urine to show the characteristics of cystitis. The calculi have eroded the urethral mucosa and produced small areas of necrosis. If the stone is expelled, the urethral inflammation usually subsides, although it sometimes resists all treatment. The expulsion of the calculi occurs in one of two ways: either they escape from the prostatic ducts into the urethra, or they ulcerate their way through the substance of the prostate and thus reach the canal, from which they are then washed away by the urine. They may also be carried backward into the bladder, and become vesical calculi. If they lie further away from the periphery, more toward the center of the gland, they lead to inflammatory phenomena, as the result of which atrophy takes place. Such an occurrence renders diagnosis more easy for the reason that the stone can then be detected by palpation through the rectum. It is this circumstance which first leads to certainty of diagnosis, for the above described subjective symptoms of difficult, painful and interrupted micturition are too ambiguous to permit the nature of the trouble to be determined. With the finger in the rectum the uneven, hard and enlarged prostate can be palpated, and at times the grating of one calculus upon another can be felt. If a metal sound be introduced into the urethra, those stones, and only those, of course, which project into its lumen can be felt. The sensation imparted cannot be mistaken ; it consists in a distinct grating or crepitation. Naturally this is not characteristic of prostatic calculi alone, for urethral calculi give the same results. If simultaneous palpa- tion with a sound in the urethra and a finger in the rectum be practised, it may happen that a hard body will be detected between the two. Radioscopy is to be considered as a further means of diagnosis; the bladder and rectum must be empty when the examination is made. Golding-Bird has succeeded in obtaining very good X-ray pictures of prostatic calculi. Proof is obtained only when the picture is positive. NEW GROWTHS OF THE PROSTATE. 389 Prostatic calculi may be present even though no shadow appears on the plate, for the X-rays are not absorbed by all varieties. Owing to the rarity of prostatic calculi it is evident that this method is yet in its formative stage. Treatment. In those cases in which the calculi, which perhaps have been discovered accidentally, produce no trouble, treatment is unnecessary. Even when pain and difficulty of micturition are occa- sionally experienced the surgeon may wait to see whether the stone will not be spontaneously expelled before resorting to treatment, which, because of the nature of the condition, can only be surgical. If the trouble increases, if inflammation and suppuration ensue, and if there are grounds for believing that the calculus or calculi are becoming larger, then, of course, operation is necessary. Crushing and evacuation through the natural passages, the lateral prostatic incision, similar to that made in lateral lithotomy (Dupuytren), and opening the prostate through the rectum (Mazzoni), have been aban- doned. The only choice to be made is between the perineal and the prerectal incision (Demarquay, Dittel, Zuckerkandl, Socin). The latter is constantly winning more supporters, because the prostate can be reached more surely and safely by it. If the calculi are firmly imbedded in the substance of the gland, it may be necessary to use a stone-spoon, or some instrument which affords leverage, to get them out. The prognosis of the operation, as of the disease itself, is favorable, and cure usually takes place without any difficulty. NEW GROWTHS OF THE PROSTATE. The only new growths of the prostate which we shall consider here are the malignant ones, carcinoma and sarcoma; the benign growths, fibromyoma and adenoma, were designated as hypertrophy of the prostate and described as such. The malignant tumors are almost always primary; it is very rare for them to be secondary. The latter form may be due to direct extension from a neighboring growth, as for example, intestinal carcinoma; or it may be caused by metas- tasis from a growth more remotely situated, such as cancer of the stomach, dura mater, or penis. It is worthy of notice that malignant vesical tumors have no tendency to invade the prostate, although prostatic growths often extend to the bladder. That an ordinary prostatic hypertrophy may be transformed into a 390 DISEASES OF THE PROSTATE GLAND. carcinoma, as Albarran and Halle have stated, does not seem to me to have been proved. The theory that the seeming hypertrophy was a slowly progressive malignant neoplasm is irrefutable. The causes are entirely unknown, as is the case with malignant disease of other organs. That heredity or gonorrhoea plays a role has not been proved, and it is particularly improbable that the latter has any causative influence in their evolution. Carcinoma shows a predilection for old people. In children and young men it is very Tare. Sarcoma, on the contrary, has often been observed in early childhood. Klebs attributes the latter circumstance to intrauterine influences. PATHOLOGICAL ANATOMY. Carcinoma of the prostate occurs in two principle forms, the soft, medullary, or adeno- carcinoma, also called epithelioma, and the hard or schirrus form. Macroscopically the diffuse and circum- scribed forms require differentiation. Medullary or adeno-carcinoma is characterized by its softness and succulency. The small mononuclear cells are imbedded in a delicate fibrillary stroma. Orth describes them as follows: "Micro- scopically the cancer is a cylindric cell new growth, the cells often being arranged in gland-like ducts or tubes, so that adeno-carcinoma must be diagnosticated. The stroma may either be normal or show small- celled infiltration, being in the latter case involved in the neoplasm." It is upon this condition that Albarran and Halle base their theory of the transformation of simple prostatic hypertrophy into carcinoma. As already stated, the growth may be diffuse or circumscribed. In the latter case only one, or at most a few portions, of the gland are affected and show the characteristic signs of the disease, the remaining part showing typical prostatic tissue. These more rare forms are of slow growth. The prostate usually does not attain a large size. In sharp contradistinction to these tumors are those which affect more or less of the entire gland, and advance rapidly to the surrounding tissue. They soon break through the capsule of the prostate and extend to the small pelvis, filling it with tumor-masses, and go on to the seminal vesicles, the ureters, the perineum, and the innominate bones. Guyon has named these forms, which are characterized by enor- mous size, diffuse prostato-pelvic carcinoma. This large tumor may NEW GROWTHS OF THE PROSTATE. 391 either be of homogeneous consistency, or present alternating hard and soft portions. The surface is lobulated, uneven, and hard, and the mucous membrane of the rectum is adherent to it. These tumors grow through the bladder, proliferating freely, so that when viewed through the cystoscope they simulate typical vesical neoplasms ; or they may push the vesical mucosa in front of them, so that the convexity shown in the cystoscopic picture appears to be covered with hyperaemic, though otherwise normal, membrane. The rectal mucosa is simultaneously affected; the carcinomatous masses ulcerate and give rise to a malodorous discharge. Later, or perhaps at the same time, the lymph-glands situated near the Fig. -Extension of carcinoma through the lymph-glands. (Musee Guyon.) prostate become infiltrated; the mesenteric, inguinal and retroper- itoneal glands are affected (Fig. 198). Secondary nodules are found in the liver, the pleura, the lungs, the corpora cavernosa, the kidneys and spleen. Different from these in form, structure, and evolution, as well as in the manner in which they produce metastases, are the osteoplastic carcinomata of the prostate, which have been studied by Reck- linghausen. The remarkable thing about them is that the primary lesion in the prostate is small and insignificant in comparison with the abundant and widely disseminated bone-metastases. 39 2 DISEASES OF THE PROSTATE GLAND. While the primary focus is often so small that it is not demonstrable clinically, and is even hard to find at autopsy, numerous diffuse carci- nomatous infiltrations of bone are always present. They affect the pelvis, the lower portion of the vertebral column, the joints of the lower extremity, the ribs, the sternum, the scapula, the humerus, and the bones 01 the skull, showing a special predilection for the lower end of the femur and humerus. The internal organs are usually not involved. Von Recklinghausen describes the changes in the bones as follows: "there is wide spread sclerosis and eburnation of parts which are normally spongy, or in which cavities are present, such as the epi- physes and diaphyses of the long bones, the vertebra?, etc.; extensive resorption and atrophy of compact bone tissue alternate irregularly with one another. In addition to these changes marked thickening of the diseased parts is produced by deposition of new bone tissue in the form of spicules resembling stalactites, the spaces between them and the canaliculi being filled with cancer cells." The cancer proliferates more rapidly than it disintegrates, so that its nature is not markedly destructive (Von Frisch). The metastases are of mye- logenous origin. "The seed of these growths is disseminated in the bone-marrow, and the growth takes place outward and perforates the bone." Osseous cancer extends along the course of the blood-vessels, and breaks through the vessels at the surface of the bone. These osseous metastases show the same structure as the primary prostatic focus of disease, consisting of connective tissue alveoli filled with cuboid and cylindric cells. Just as cancer of the mammary gland is the most common cause of carcinomatosis in woman, so likewise is prostatic carcinoma often responsible for general diffusion of cancer in man, It has already been stated that sarcoma is considerably rarer than carcinoma, and that it occurs particularly in the earliest years of childhood and in old age. This disease is almost exclusively primary. A few exceptional cases of secondary sarcoma which has extended from other structures, such as the seminal vesicles or bones, for instance, have been reported. The tumor is almost always composed of round or spindle-shaped cells, and in the beginning of its development its limits are sharply defined; it looks like a fibroma embedded in the substance of the gland. NEW GROWTHS OF THE PROSTATE. 393 As proliferation advances first a portion and finally the entire gland becomes transformed into a malignant growth. Proliferation does not stop here. Sarcomata are characterized by their large size and rapid growth. It is less common for sarcoma of the prostate to be diagnosticated when it has merely grown sufficiently to cause the middle lobe to protrude into the bladder as a pedunculated fungous mass, than it is for it to be found extending in various directions and involving many different structures. It fills the true pelvis, com- presses the ureters, grows around the bladder, pushes outwards and forwards ; occasionally, too, it grows through the bladder and narrows the broad expansion of the rectum. The metastases, in contradistinction to those of carcinoma, are characterized by the fact that they appear late in the disease and that they affect in comparatively small measure the inguinal and other neighboring glands, which are extensively involved in carcinoma. Generally there are metastases of remote organs, such as the liver, pancreas and lungs, before the lymph-glands of the pelvis become affected. SYMPTOMS, COURSE AND DIAGNOSIS. We will first consider prostatic sarcoma as it occurs in childhood, and which is first discovered when retention of urine develops suddenly and without apparent cause. If these little patients be examined a tumor of considerable size will be found. In some cases difficult and painful micturition, pain upon defecation, and sometimes, though rarely, the occurrence of urinary haemorrhage, will first attract notice and bring the case to the surgeon's attention. When palpation is practised, especially bimanual, a tumor will be felt through the rectum where the prostate would lie later in life. This growth is hard, and often presents projections which reach to the symphysis and bladder. The tumor develops rapidly and death invariably ensues in from one to two years after the beginning of the disease. The symptoms of carcinoma and sarcoma in adults are so near alike that they may be considered conjointly. A few minor differences will be pointed out. The symptoms consist in disturbances of mic- turition — of pain occurring both in association and independently thereof — and in disturbances of defecation; objectively the general cachexia, the presence of blood and pus in the urine, and perhaps 394 DISEASES OF THE PROSTATE GLAND. of fragments of tissue, the results obtained by sounding, cystoscopy, and rectal palpation, together with the demonstration of metastases, confirm the diagnosis. The disturbances of micturition are essentially the same as those of prostatic hypertrophy. According to the size of the growth, and the interference with the normal relation of the part which it produces, the patient is compelled to strain more or less in order to void his urine; the stream loses its former projectile power. The frequency of micturition is increased in varying degree, the bladder gradually comes to empty itself with more and more difficulty, and chronic incomplete retention, which may become converted into complete retention, soon ensues. The latter, however, is less frequent than in hypertrophy of the prostate. In such cases involuntary voiding of urine may, of course, take place ; in other words overflow of the blad- der occurs. Incontinence of urine, which also occasionally occurs, is different from this, coming on, as a rule, toward the end of the disease, and being due to interference with the sphincter by the new growth. Pain upon urination is a typical symptom; it is characterized by the fact that it can be relieved only slightly and for short periods at a time. If the use of narcotics be discontinued it returns at once. A more characteristic point of difference between the pain of malig- nant disease and that of prostatic hypertrophy, is that the former is not only present during micturition, but that it remains constantly with the patient. It is located in the glans and root of the penis, in the rectum, in the perineum, in the hypogastrium, and also in the sacral region. Severe exacerbations may occur. As the pain is unremitting, it may seriously impair the patient's strength. It extends along the ischiatic and crural nerves; the whole region supplied by the sacral and lumbar plexus may be affected. There is no doubt that these pains are evoked through compression of nerve- trunks by the tumor and its metastatic glandular swellings. This view is corroborated by the persistence and obstinacy of the pain, which cannot be overcome; the circumstance that the prostate is as yet relatively small at the time these pains occur does not militate against it, for we know that small tumors of the lymphatic glands may be accompanied by metastatic processes of considerable size. As regards the last class of subjective symptoms, namely, the dis- turbances referable to the rectum, it may be stated that they are the same as those occurring in simple hypertrophy. Evacuation of the NEW GROWTHS OF THE PROSTATE. 395 bowels is difficult, and chronic constipation, which may become so severe as to constitute complete obstruction, results. A circumstance worthy of attention, too, is that defecation is often attended by pain, a symptom winch is absent in prostatic hypertrophy. If the tumor attacks the rectal mucosa itself and causes ulceration, a severe catarrh is produced, the secretion being thick and bloody and containing particles of decayed tissue. Of the objective symptoms, cachexia will at once attract notice. The face is sallow and the body emaciated; the patient cannot be made to gain weight even under the most careful nourishment. It is true that prostatics occasionally show the same picture of bodily decline, especially when they are suffering from urinary infection, but it is possible to distinguish between the two. The cachexia of prostatics, evoked by exacerbations and compli- cations, proves to be transitory. If the complications are subdued, the patient usually improves and his general condition becomes better; the symptoms of urinary infection subside. The absorption of intensely purulent and decomposing urine is recognized as the cause of the decline in these cases. In the cachexia of malignant disease, on the contrary, the urine may be perfectly clear, or show only the most trivial departures from the normal. Loss of weight and progres- sive weakness are incessant. As just stated marked changes in the urine are, as a rule, not present. There is usually some pus and occasionally some blood, and when the tumor pushes its way into the bladder fragments of tumor may be voided. The last phenomenon is so rare, however, that it cannot be reckoned upon as a help in making a diagnosis. Admixture of pus with the urine is much more common. The circulatory disturbances which are produced in the bladder by the tumor naturally prepare a favorable field for the reception of infective microorganisms. It is rare, though, for the cystitis to assume any great degree of severity. Urinary haemorrhage due to prostatic tumors has nothing character- istic about it. The bleeding may be either initial or terminal, or the blood may come out of the bladder thoroughly mixed with the urine. Haemorrhage occurs not only when the tumor has broken into the bladder, but may also take place as the result of venous stasis produced by the prostatic tumor growing around the bladder. In common with all haemorrhages due to tumors of the bladder the bleeding occurs without apparent cause, resists all treatment, and disappears spon- 396 DISEASES OF THE PROSTATE GLAND. taneously; it is neither excited by activity nor can it be subdued by rest. It differs from ordinary vesical haemorrhage in being less profuse; very copious bleeding from prostatic tumors is exceptional. In regard to examination with sounds and the cystoscope we should be forewarned that it usually proves deleterious. The sound generally shows that the urethra is displaced, the same as in hypertrophy of the prostate. There are deviations which fender the passage of an inflexible instrument into the bladder very difficult. I have seen cases in which it was absolutely impossible to get a metal sound into the bladder, whereas a flexible bougie went in with ease. For this reason soft instruments are to be preferred for examination as well as for treatment. Slight haemorrhage generally follows the use of instru- ments. Examination with the short-beaked cystoscope may also be very difficult and impracticable. If the cystoscope can be introduced into the bladder without producing haemorrhage, or if the bladder can be freed from blood which has escaped as the result of instrumenta- tion, it will be seen that the tumor of the prostate has either pushed its way into the bladder, carrying the vesical mucous membrane before it, or that it has broken through the vesical wall. When the tumor is covered by mucous membrane the latter appears entirely normal except that it is somewhat injected; when the tumor has ruptured the bladder- wall the cystoscopic picture is not different from the one generally presented by vesical tumors. In such cases rectal palpation will clear up all doubt, as in vesical tumors the prostate is normal. Oftentimes the results of rectal palpation are so precise that from them alone the diagnosis of prostatic tumor can be made. One must take the precaution to examine when the bladder is empty, for if the examination be made when it is full, errors are likely to result. When- ever possible bimanual palpation should be employed. The prostate is almost always considerably enlarged. The initial elements of disease which have not yet led to enlargement can of course not be felt, but such a condition of affairs is very unusual. The surface of the prostate usually presents marked irregularities, and is exceptionally firm and dense; occasionally it is as hard as wood, a condition which does not obtain in simple hypertrophy. The rectal mucous membrane covering the tumor is not movable. If, in addition, there is irregularity in the extension of the tumor, for instance if hard NEW GROWTHS OF THE PROSTATE. 397 conical projections grow out into the surrounding tissue upwards or laterally, so that the gland cannot be outlined, there will be no doubt that we are dealing with a tumor, and not with hypertrophy of the prostate. These hom-like offshoots extending in different directions — now toward the seminal vesicles, now laterally to the wall of the pelvis — are typical of tumors both as to form and hardness. In order to feel anything by bimanual palpation the patient must be thin and the abdominal walls compressible. Finally, if metastases can be felt, for example, in the inguinal region; or if there is probability of their existence in the viscera; or if incessant pain in the legs, in the region of the sacrum, or in the shoulders make it seem likely that metastases are pressing upon nerve-trunks and invading the bones ; and if the lower extremities show signs of oedema, which point to the presence of venous thrombi, the diagnosis becomes less and less doubtful. The course of the disease usually proves to be most painful. In some cases vesical symptoms predominate, in others rectal, and in still others neuralgic. The duration of the disease does not exceed five years. The malady begins with symptoms similar to those of prostatic hypertrophy, but haemorrhage soon manifests itself, and it is not long before painful micturition, together with pain in the bones and sharp, shooting pains along the course of the nerves are superadded to the other symptoms. Cachexia comes more and more to the front, but, as a rule, before the patient succumbs to it, complications ensue which cause a more speedy termination of the disease than would result from this gradually progressive decline. Retention of urine, intestinal obstruc- tion, compression of the ureters with consequent hydro- and pyo- nephrosis, anuria, infection of the bladder, erosion of the vertebrae resulting in total haemiplegia (which I have twice seen), thrombosis of the pelvic veins, and finally hypostatic pneumonia, constitute the direct and indirect causes of death. TREATMENT. The treatment of malignant tumors of the prostate is entirely symptomatic. We must be satisfied with lessening the patient's pain and trying to sustain his strength. For the control of pain narcotics in the most varied forms cannot be dispensed with. Morphine, belladonna, heroin, and dionin by mouth, and by rectum in the form 398 DISEASES OF THE PROSTATE GLAND. of injections, are useful; when given per rectum pyramidon or anti- pyrin may be combined with them. Hot sitz-baths, hot applications, the thermophore — in fact heat in all its forms — are useful. Catheter- ization should be employed both for complete and incomplete re- tention of urine. I will again call attention to the fact that only soft instruments are to be used. The condition of the bowels must be looked after; evacuations are best secured by means of high enemata. A generous diet should be provided. Local treatment is not to be made use of except when it is specially indicated, for instance, when retention of urine takes place, or when suppuration cannot be controlled by other measures. Formidable methods of examination, such as cystoscopy, should not be resorted to unless absolutely necessary for making a diagnosis. Radical treatment of prostatic tumors, having in view the removal of the entire neoplasm, is to be advised against, because, judging from the results thus far obtained, it shortens life. Partial removal of the gland is irrational, because it is impossible to say whether diseased areas are not contained in the portion which remains behind. Nothing short of complete extirpation is to be considered, and even this can offer hope of results only when it is undertaken before metas- tases have occurred. The prospects of success are exceedingly small, because the tumor has usually existed a long time before its real nature is learned. These considerations are in accord with the following results obtained by operation. Billroth's patient, the first ever operated on, recovered from the operation, but died fourteen months later of a recurrence; Stein's first patient died at the end of nine months; his second patient, and also Leisrink's and Depages's did not survive the operation. In Verhoogen's case death due to recurrence of the disease took place in nine months, and in Fuller's in eleven months. Socin's patient, how- ever, was still living four years after operation without any return of the disease. While it must be admitted that these statistics are the worst con- ceivable, and that the prospects of success are very slight, it must not be forgotten that even without operation the patient is sure to die. In view of our improved technic in operation for hypertrophy of the prostate, such as the introduction of the prerectal incision, and such procedures as Fritz Koenig's operation for removal of carcinoma of PLATE X. A. Prostate separated from surrounding structures except posteriorly 1 yi^N^ fe\ Dk r ^ *£■ — | mB \ B. Prostate completely freed and drawn well out into the wound (Young.) PLATE XI. C. Bladder incised at prostato-vesical junction. D. Vesical incision continued. Trigone exposed. The dotted line marks the incision across it. (Young.) 27 PLATE Xll. E. Base of bladder pushed upwards exposing anterior surface of seminal vesicles and vasa deferentia. F. Showing anastomosis between the membranous urethra and bladder, and the sutures passed through the margins of the vesical wound. (Young.) NEW GROWTHS OF THE PROSTATE. 399 the rectum, hope should not be entirely abandoned, but further efforts should be made to completely remove the neoplasm. [Young, of Baltimore, has recently reported four cases in which he removed the entire prostate, the seminal vesicles, the vasa deferentia and most of the trigonum. Dr. Young describes his operation practically as follows: The prostate is exposed as in the operation of perineal prostatec- tomy. The handle of the retractor is then depressed so as to expose the membranous urethra, -which is then divided transversely. By further depressing the handle of the tractor the pubo-prostatic liga- ment is exposed, and is divided with scissors, thus completely sever- ing the prostate from all important attachments except posteriorly, as shown in Plate X, A. The lateral attachments are then separated by the fingers. The posterior surface of the seminal vesicles is then freed by blunt dissection, the now mobile prostate being well out of the wound, as shown in Plate X, B. In exposing the posterior surface of the vesicles care must be taken not to break through the fascia of Denon- villiers, which covers the posterior surface of the prostate and seminal vesicles, and which undoubtedly forms an important barrier to the backward growth of the disease. The next step is to expose the anterior surface of the bladder by still further depressing the tractor and making strong traction. The bladder is then incised at a point in the middle line about i cm. be- hind the prostato- vesical junction (Plate XI, C). The dissection is then continued on each side with scissors until the trigone is exposed. The trigone is then incised transversely about i cm. in front of the ureteral orifices. (Plate XI, D.) While still making traction upon the prostate, the base of the bladder is pushed upward so as to expose the anterior surface of the seminal vesicles and the adjacent vasa deferentia (Plate XII, E), all of which are carefully freed by blunt dissection with the finger as high up as possible, so as to remove with the vesicles the circumjacent fat and areolar tissues on account of the lymphatics which they con- tain. The vasa deferentia are divided as high up as possible, care being taken to see that the ureters are not cut with them. An anastomosis is then made between the bladder and membranous urethra and the remainder of the vesical wound closed. (Plate XII, F.) The first suture is placed by inserting the needle into the tri- 400 DISEASES OF THE PROSTATE GLAND. angular ligament above the urethra and out through the anterior wall of the bladder in the median line, from within out, care being taken to include only the submucosa and muscle. When this suture is tied, the median line of the anterior wall of the bladder is drawn to meet the urethra, the knot outside, and the thread left long. Lateral sutures, similarly placed (including the periurethral muscu- lar structures below), and two posterior sutures complete the anas- tomosis of the membranous urethra with a small ring into w r hich the anterior portion of the margin of the vesical wound has been fash- ioned by the tying of the sutures. It is most interesting to note that the functional results after this extensive operation were good. One patient died at the end of six weeks, death being attributed to the removal of the valvular ends of the ureters, owing to the belief that they were involved in the malignant process; one patient died at the end of a year as the result of a stone-crushing operation ; the other cases were too recent for consideration, six and two months respectively having elapsed between the date of operation and the time the report was made.*] SYPHILIS OF THE PROSTATE. From the circumstance that I have not met with a single positive case of syphilis among a large number of diseases affecting the prostate I am led to conclude that its occurrence is exceedingly rare. More- over, only a few cases are mentioned in literature which may possibly have been true cases of lues of the prostate. These have been reported by Reliquet, Rochon, Wroszynski, and Grosligk. Grosligk's case is the one in which there is the greatest probability that the lesion in question was a gumma. This case was that of a man aged forty-five who complained of painful and urgent urination and tenderness in the perineum. He had had gonorrhoea a long time before, but had been cured of it and had remained perfectly well. There was a scanty brownish urethral discharge containing pus-cells and erythrocytes, but no gonococci. A t 9 French sound was passed without difficulty. Upon rectal exami. * Since the publication of the first edition of this book two other patients have been operated on. Of six, the total number upon whom the operation was per- formed, two were well and apparently free from recurrence January i, 1908, nearly three years after they were operated upon. PARASITES OF THE PROSTATE. 401. nation the prostate was found to be as large as a man's fist, uneven, of the consistency of cartilage, and sensitive to pressure. These findings naturally aroused the suspicion of carcinoma, and this sus- picion was strengthened by the patient's denial of syphilis. Later, however, he admitted having had the disease, and energetic antisyph- ilitic treatment was begun, with the result that in four weeks all signs of the tumor and all subjective symptoms had disappeared. In course of time the prostate enlarged again simultaneously with the occurrence of a syphilitic affection of the neck; both lesions subsided under anti- luetic treatment. This carefully observed case must be taken into account, and in cases of prostatic inflammation in which there is no determinable cause it should direct our attention to the possibility of syphilitic disease. Above all this case teaches us to be careful in making a diagnosis of cancer. In dealing with cases of prostatic tumor in which the origin, nature, rapid growth, and findings upon palpation are in any- wise suspicious, and especially if other known signs of syphilis are demonstrable, antisyphilitic treatment may be tried after all the other means of diagnosis have been exhausted. PARASITES OF THE PROSTATE. The echinococcus is the only parasite requiring consideration, and it is doubtful if the cases reported as such were cases of true echinococcus disease, or whether they were cases in which the echinococcus had taken up its abode in the tissues and grown into the prostate. In the space between the bladder and rectum echinococcus cysts have been repeatedly found. Of cases which have been carefully observed, and some of which have been studied postmortem, we will mention three which best illustrate the development and symptoms of the affection. In one case, that of Maunder, and which I take from Englisch's description, a man twenty-four years old was attacked with retention of urine, which lasted four days. The region above the symphysis, up as high as the umbilicus, was much distended by a spherical tumor, which upon pressure was sensitive and plainly showed signs of fluctu- ation. This fluctuating mass could be plainly felt through the rectum, through which it was punctured, and a liter of clear serous fluid obtain- 4 20 3 .-The cord has been ligated in two o o portions and divided below the ligature. 1 he to pursue their COUrse to the stump is seen at the upper angle of the wound. 1 1 • , i-i (Veau.) juxta-aortic glands, into which they empty. Although it is impossible to reach them at their termi- nation, every portion of them which is accessible should be removed. This is the only rational surgical procedure. Following the method of Cumston and Rolfe, an incision is made parallel to, and about one-half or three-quarters of an inch above, Poupart's ligament, the inguinal canal laid open, the cord freed and lifted out. The iliac fossa is then entered by an opening made through the posterior wall of the canal. The vas is followed downward into the pelvis as far as possible, tied, cut, and the stump touched with pure carbolic acid. The spermatic vessels are then traced upward as far as possible, ligated in two places and divided between the ligatures. The cord is separated from its coverings from above downward to a point below the external ring. The testicle, if not too much enlarged, may be pressed upward and forced out through the opening above Poupart's ligament, where it is removed together with the cord. 428 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. If the growth be very large it will be necessary to make a longitu- dinal incision down the scrotum in order to remove it. Whenever a malignant tumor is adherent to the scrotum the skin must be freely excised, and the inguinal glands also dissected out, as the lymphatics of the scrotum empty into them. SYPHILIS OF THE TESTICLE AND EPIDIDYMIS. Syphilis occurs in the testicle and epididymis in two different forms: gummata, and diffuse overgrowth of the connective tissue in which the seminal tubules are destroyed and extensive indurations formed. Both forms may be present simultaneously. Concerning the development of this affection I shall ignore the rare instances in which the testicle and epididymis are involved at the outbreak of lues and consider only those in which it occurs as a late manifestation of the infection. As is often the case with localized syphilitic lesions, injury or inflammation, as for example, a gonorrhceal epididymitis, may act as exciting causes. Although orchitis and epididymitis are among the most frequent localized syphilitic lesions, it is well-known that the syphilitic virus may be present in the semen of persons in whose genital organs no signs of lues can be found. The clinical picture of syphilitic orchitis is not very distinctly delin- eated. The disease develops insidiously, the testicle gradually becom- ing larger, but yet not attaining an excessive size. An important point of differential diagnosis is that, in contradistinction to tubercu- losis, in syphilis the testicle is almost always affected before the epididy- mis, and that the vas deferens, as a rule, remains uninvolved. The swelling may be diffuse, or hard nodules of varying size may be detected; the former condition is the more common. The testicle is firm and elastic, and apparently fluctuates, so that the condition is not uncommonly confounded with hydrocele. In isolated cases the diffuse swelling may gradually subside and a small indurated testicle remain. When, as more frequently happens, owing to mistaken diagnosis, antisyphilitic treatment is not given, the nodules soften and perforate through the skin of the scrotum, thus forming ulcers. The testicle may prolapse, but the opening is generally diminished in size by the proliferation of granulation tissue which forms the so-called fungus syphiliticus. The disease is painless; sensitiveness is neither present nor can it be elicited by pressure. SYPHILIS OF THE TESTICLE AND EPIDIDYMIS. 429 Other manifestations of syphilis may be found, their nature depend- ing upon the stage of the disease during which they occur. As little as the disease annoys the patient or affects the general health its results may nevertheless be most serious. When bilateral it may produce sterility. This does not usually happen, however, unless the diagnosis has been made very late and treatment delayed until destruction of the glands has become most extensive. As a rule, some functionally active tissue will remain. In regard to diagnosis, which cannot always be easily made, the following points are to be observed: the history of the case; other signs of recent or tardy syphilis; gradual development of the swelling without pain; involvement of the testicle first; non-involvement of the vas deferens in contradistinction to its participation in tuberculosis; freedom of the lymph-glands in contradistinction to their implication in malignant growths. In cases in which diagnosis remains obscure despite the consideration of these data, the therapeutic test may be applied. A course of mercury followed by large doses of potassium iodide, will, if benefit follows its employment, enable one to conclude that the tumor in question was of syphilitic origin. Prognosis as to life is good ; prognosis as to recovery is also favorable provided that treatment be not too long delayed. It is only when the lesion is congenital that complete destruction of the testicle is wont to take place. Treatment consists primarily in the energetic employment of mer- cury or potassium iodide, or of both. In recent cases mercury is the drug of preference, in the older ones potassium iodide. Mercurial plaster should also be applied to the testicle. As in constitutional syphilis these measures may be supplemented by bathing cures. If perforation has taken place the resulting ulcer should be treated in accordance with the established principles of surgery, and an energetic antisyphilitic treatment instituted. Local applications of sublimate solution 1 : 3000, the dressing being renewed every two hours, act excellently. Under this treatment the necrotic portion of the testicle will usually slough away, the wound become healthy and healing take place, so that the greater part of the gland will be preserved. It is only in exceptional cases, where extensive destruction of the paren- chyma of the testicle is rapidly taking place despite energetic treat- ment, that the surgeon will be compelled to perform castration. It is not unusual to see recurrences of the disease after healing has 430 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. once taken place; they are to be treated in exactly the same way as was the previous manifestation of the disease. ORCHITIS. Acute inflammation of the testicle is exceedingly less common than inflammation of the epididymis. Both are produced by the same causes; sometimes it is an injury, sometimes extension of an infective process from neighboring parts, as for instance gonorrhoea, prostatic disease, or vesical catarrh, which gives rise to the inflammation. Orchitis of urethral origin may be accompanied by inflammation of the epididymis and vas deferens, but these structures may also escape, the inflammatory process being confined entirely to the testicle. Rarely both forms may be of metastatic origin. In mumps acute orchitis may occur, and it is noteworthy that the complication may ensue after the inflammation of the parotid has sub- sided, and that the disease may affect the testicle first. Kocher found the typhoid bacillus in the testicle in a case of orchitis which occurred as a complication of typhoid fever. Finally there remain to be mentioned orchitis of rheumatic and malarial origin, the latter of which reacts to quinine. The symptoms consist of pain, tenderness upon chitis 2 °Testide P ressure > enlargement of the testicle, and constitutional swollen, epididy- disturbance. mis lengthened. . . . . , . . ram may be severe. It is characterized by the fact that it persists while the patient remains in the dorsal position, and that it either may be confined to the testicle alone or radiate to the loins and back. These pains in the back are to be considered either as reflex neuralgia or as peripheral neuritis. Upon palpation the testicle is found to be swollen and very sensitive to pressure. The epididymis lies behind the testicle and is lengthened by the swelling of the former, so that it feels like a thick cylindrical tumor. (Fig 204.) The testicle may swell very rapidly, sometimes becoming as large as a goose's egg within twenty-four hours. ,The general health is considerably disturbed; fever is present and the evening temperature may rise as high as 40°C. [104 F.]. The metastatic forms are the mildest. [In Sumatra, Martin observed an intense fulminating inflammation of the testicle occurring as a com- plication of malaria.] The majority of cases due to traumatism also ORCHITIS. 43I pursue a favorable course. Those due to urethral disease are of longer duration, owing, no doubt, to the fact that the urethral trouble often persists. Orchitis is to be differentiated from epididymitis and hydrocele. Palpation furnishes a sure means of distinguishing it from the former, and, as a rule, will also serve to separate it from hydrocele. If doubt exists, it should be remembered that hydrocele is usually transparent, that the epididymis retains its normal form in hydrocele, but is length- ened in orchitis. Fluctuation is a sign of little worth, because in orchi- tis the swollen testicle may apparently fluctuate. The intense swelling is due to serous infiltration and intense hyper- emia of the substance of the testicle. If the process advances further, the testicular tissue is seen to be of a yellow color when the gland is sectioned. Along the septa and albuginea, and in the substance of the gland as well, small circumscribed areas of suppuration are found which later coalesce. The albuginea is thickened, the septa are broadened. Under the microscope the connective-tissue stroma is seen to be infiltrated with small cells. Wall and seminiferous tubule and interstitial connective tissue are all infiltrated with leuco- cytes. In regard to the course and termination of the disease, it may be stated that, as a rule, it lasts from two to three weeks. After the swelling has reached its height and the pain consequently attained its maximum intensity, the fever begins to subside and the temperature soon reaches its normal level. The further course of the disease is unattended by material disturbance of the organism. In the majority of cases complete restitutio ad integrum results; nodular infiltrates do not remain behind as in epididymitis. A somewhat less favorable termination is in atrophy of the testicle, which is caused by the excessive overgrowth of interstitial connective tissue. The most unfavorable ending of all is suppuration, which may either extend toward the periphery and rupture externally, or lead to gangrene before rupture occurs. The greatest danger, how- ever, is extension of the suppurative process to the spermatic cord, with resulting peritonitis and pyaemia. Fortunately this occurrence is exceedingly rare. Treatment consists in absolute rest, elevation of the testicle, applica- tions of an ice-cold 2 per cent solution of acetate of aluminum, together with the internal use of antipyrin or salicylic acid. 432 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. This antiphlogistic therapy will suffice in the vast majority of cases. It may be necessary, however, to employ narcotics if the pain is very severe. Although incision of the inflamed testicle causes relaxation of the distended tissues, and thereby lessens pain, it should not be resorted to for the reason that cure almost always follows without its employ- ment, and, furthermore, because there is danger of prolapse and con- sequent gangrene occurring. It is quite different when there is reason to believe that suppuration is present and that resorption will not take place. When high fever, chills, pain, and swelling persist beyond the usual time, and fluctuation makes it plain that pus is present, then no delay should be entertained in making a free incision. The danger of prolapse of the seminiferous tubules and consequent gangrene is the only one to be feared, but it is of such moment that incision should be resorted to only when marked indications exist. Small non-confluent foci of suppuration may be present and give rise to the severe symptoms above mentioned. When this is the case incision will afford relief by lessening tension, but it should not be employed for the reason that the suppurating foci may undergo resorption. Therefore, as a prerequisite to operation, pus should be obtained by puncture, unless the symptoms are so violent as to demand surgical intervention even though pus cannot thus be obtained nor fluctuation detected. Chronic orchitis is a very rare disease, for the two affections in which chronic inflammation of the testicular substance occurs, namely, tuberculosis and syphilis, are considered by themselves as maladies due to specific causes. The term chronic orchitis is therefore reserved for a very few cases in which acute orchitis terminates in a manner different than any of those just described. Instead of complete resolution, atrophy, or suppuration, chronic inflammation of the parenchyma of the testicle may result. Such an occurrence is so rare, however, that I am inclined to believe it represents exacerbations of latent inflammation which has remained after the subsidence of an acute orchitis. Treatment consists in the long- continued application of tincture of iodine, or inunctions of iodine vasogen or compound iodine ointment, together with the use of Priessnitz's compresses and the wearing of a suspensory bandage. EPIDIDYMITIS. 433 EPIDIDYMITIS. Inflammation of the epididymis is one of the most frequent affections of the genital glands. Although it does not endanger life its results may be of far-reaching consequence to the person who is affected. The disease is characterized by acute swelling of the epididymis. Chronic inflammation is always the result of a previous acute process. As concerns the causes of the disease it may be stated that injuries, such as kicks, blows, or bruises are occasionally, though rarely, respon- sible for its development. It may also occur as a metastatic process in the course of infectious diseases, such as variola and pyaemia, for instance. These are of minor importance, however, in comparison with its most frequent cause, namely, urethral infection, be it due to gonor- rhoea, stricture, catheterism or litholapaxy. When caused by any of these conditions it is evident that the process is infective. In one case it may be the gonococci which give rise to the infection, in another the microorganisms which reach the urethra as the result of catheterism, or others which normally inhabit the urethra, but become virulent owing to the disturbed conditions produced by the mechanical inter- ference incident to catheterization. It may happen that the suppura- tive inflammatory process extends to the epididymis by way of the ejaculatory ducts and vas deferens, and that it also involves these structures; it may, however, leave the vas unscathed and establish itself in the epididymis; and, finally, the agents of infection may be carried to the epididymis by the lymphatics. Epididymitis is such a common complication of gonorrhoea that about 20 per cent of all men affected with the latter disease are attacked by it. Although it may occur in any stage of the disease, it is uncom- mon before the second week; from this period, however, there is no limitation to its incidence. I have seen cases of chronic urethritis which had existed for years, and in which no gonococci had been demonstrable for years, become exacerbated and suddenly give rise to an epididymitis. Strictly speaking it is not the gonococcus which leads to the development of the complication in this class of cases, but a post-gonorrhceal urethritis. Symptoms and Course. The onset of the disease is announced by slight pain, or a dragging sensation extending from the region of the testicle to the groin. This pain gradually becomes more intense and extends to the region of the loins and pelvis. Very soon it becomes 434 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. exceedingly severe in the testicle, so that the patient can scarcely move without experiencing the most intense agony; he seeks instinctively to support the scrotum. In view of the extreme painfulness of the testicle and epididymis it is not surprising that the general health becomes considerably affected. The patient is feverish, although the temperature may not be high, feels weak, and often experiences a sense of fainting; indeed, it is commonly stated that diseases of the testicle predispose to attacks of syncope. The health is also disturbed in other ways, anorexia being present and the patient looking pale and generally miserable. Upon palpation it is at once noticed that the epididymis is considerably enlarged. The testicle appears to be imbedded in the epididymis, whereas in health the epididy- Fig.^-EpididymMsT The mis HeS U P 0n the testicle ( F1 §- 20 5)- At first testicle is imbedded in the epi- either the head or tail may be affected, but didymis. . . m a short time, generally in the course of a few days, the entire organ becomes very much swollen, so that the testicle forms the smallest part of the scrotum. The skin over the swelling is usually somewhat cedematous and may also be reddened. Pressure upon the inflamed epididymis, or even attempt to palpate it, gives rise to violent pain, which may cause the patient to swoon. For this reason examination should be made with the patient in the horizontal position. Palpation will also disclose the fact that the epi- didymis is much harder than normal; it feels hard, uneven and rough. If the scrotum be lifted up, the patient experiences a sense of relief; the severe tugging pain extending well up toward the back is usually considerably diminished. This pain is probably produced by the increased weight of the inflamed epididymis. The connective-tissue bands between the seminiferous tubules, the connective tissue of the tunica albuginea, and the fasciculus of fibers which fasten the vas deferens to the epididymis are all affected with serous infiltration, and it is owing to this condition that the size and weight of the organ become increased, with the result that painful traction is exerted upon the spermatic cord, which is also usually inflamed. In the cord, muscle, connective tissue, and especially the vessels, are all inflamed and swollen, so that it is as thick as one's finger, and can easily be followed up to the external abdominal ring. EPIDIDYMITIS. 435 Owing to the narrowness of the ring pressure is exerted upon the swollen plexus of the cord, and this, in conjunction with the traction, gives rise to peritoneal irritation and causes an inclination to vomit. The pain in the loins, as has already been stated, may be explained by assuming that it is caused by traction upon the cord. It seems not improbable, however, that von Leyden is right in assuming it to be due to peripheral inflammation which extends along the nerves to the spermatic and renal plexuses. This view is corroborated by the circumstance, that in many cases the lumbar pain is not relieved by elevation of the scrotum and the consequent reduction of traction upon the cord, although the pain in the epididymis ceases. The duration of the disease may be stated to be from ten to twelve days. At about the tenth day it is at its height, pain and swelling being then most intense; a gradual retrogression of the inflammation then begins, the thickening and induration of the epididymis subsides, so that at the end of two weeks more it has assumed its normal shape, with the exception of presenting small nodules which represent the remains of the previous inflammation. As resolution takes place pain and fever disappear, and by the third week, as a rule, the general health ceases to be disturbed. This, the most frequent termination, is seldom reached without the incurrence of structural changes which may be most deleterious to the patient. In the vast majority of cases the thickening of the epidid- ymis which remains is sufficient to lessen or even occlude the lumen of the vas deferens, so that the spermatozoa cannot pass through it, or if they do succeed in getting through, they have their vitality much impaired. If the affection has been bilateral complete sterility will usually result. I can state that the majority of childless marriages in which the husband is at fault are dependent upon a double epididymitis. The nodular indurations which remain may also become acutely in- flamed and thus give rise to relapses. Almost never is complete restitu- tio ad integrum obtained so that the disease disappears without leaving any nodules behind. Among other complications acute hydrocele and involvement of the testicle may be mentioned: The former is not very rare; the latter, fortunately, is less frequently met with. The serous exudation into the cavity of the tunica vaginalis usually persists after the epididymitis subsides; as a rule, it does not undergo resorption. The inflammation 3° 436 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. of the testicle, however, subsides simultaneously with that of the epididymis. A more important matter is, that in feeble persons and those having hereditary predisposition, tuberculosis maybe superimposed upon the original simple epididymitis. Therefore special precautions must be taken when such persons are affected. In regard to the pathological anatomy, we find, according to Malas- sez and Terillon, that during the height of the process, the epithelium of the seminiferous tubules is swollen and deprived of its cilia, and that their walls are cedematous and infiltrated with small cells. As the morbid process advances swelling and small-cell infiltration of the connective tissue which surrounds and fastens the tubules together occurs, and the tubules themselves are filled with greenish yellow fluid consisting of an intermixture of pus and semen. The nodules remaining after epididymitis consist of hard, cicatricial, contracting masses of connective-tissue infiltrate which surround the seminiferous tubules. Treatment. The treatment of epididymitis is satisfactory. The aim of treatment should be to secure complete cure if possible, or at least obtain entire resolution except for the nodular infiltrate pre- viously mentioned, and, above all things, to prevent termination in suppuration or tuberculosis. Not enough attention has been paid to the supervention of tubercu- losis in this disease ; it is a matter, however, which requires the greatest precautions. In view of its likelihood all methods which interfere with the nutrition of the testicle and epididymis should be prohibited. For this reason I have completely rejected the Fricke dressing, which was formerly so much in vogue. A patient with acute epididymitis should be put to bed, especially as he usually has slight elevation of temperature. The testicle should be elevated and an application of a 2 per cent solution of aluminum acetate, cooled with ice, kept on four hours every day, two hours in the forenoon and two hours in the afternoon. Ice should not be applied directly to the testicle because it might cause gangrene. In weakly persons this antiphlogistic treatment should be continued until the swelling has completely subsided. The diet should be light and the bowels kept regular. Twice a day 0.75 [10 grains] of salicylic acid may be given, or small doses of antipyrin may be used instead, 1.0 [15 grains] being taken during twenty-four hours. Both of these EPIDIDYMITIS. 437 drugs exert a favorable effect upon the patient's constitutional condi- tion. At night the testicles should be elevated by means of a bandage. In other cases, especially in strong, robust persons, treatment by compression may be tried. For this purpose a properly fitting suspen- sory bandage gives the best results. There are many of these bandages on the market, but the Zeissl-Langlebert has proved best in my experi- ence. I have had small hooks and eyes attached to it so that the testicle can be better elevated. [Martin's epididymitis bag, which is made by Lentz and Sons, of Philadelphia, is a very satisfactory American appliance.] Compression is not so useful as suspension, which secures both elevation and rest for the testicle. After the skin has been lightly annointed with lanolin, the sus- pensory bandage is lined with soft cotton of good quality and so adjusted as to raise the scrotum slightly toward the abdomen. It is kept on for four or five days and then changed. As the swelling subsides the degree of suspension may be lessened; this is accomplished by adjusting the bandage more loosely and placing less cotton in it. The results obtained by this method are excellent. Pain soon sub- sides, and in course of a few days, after the acute inflammation and swelling have abated and the slight fever disappeared, the patient may be allowed to walk around and fulfill the ordinary duties of his vocation. Fricke's adhesive-plaster dressing, as well as Gerson's bandage, are heroic appliances which it is better not to employ; moreover, they are rendered needless by the method of suspension which has just been described. During an attack of epididymitis local treatment of the urethra must be discontinued. Neither the use of instruments nor the employ- ment of injections is permissible. If the urethral discharge is florid, balsamics and diluent drinks may be given. Not until all inflamma- tion of the epididymis has completely subsided should anti-gonorrhceal treatment be resumed. The later stages of epididymitis, in which pain and swelling are no longer present, must not be allowed to go untreated, but an attempt be made to secure resolution of the nodules which have remained behind. Applications of iodine-vasogen — which acts better than tincture of iodine — or a lanolin ointment containing 2 per cent of iodine and 10 per cent of potassium iodide should be kept up for months. [I have obtained good results with oleate of mercury.] Warm moist Priess- nitz's compresses applied under the suspensory bandage also have a good effect. I have never seen any good effects from the use of 438 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. electricity, which has been employed for the purpose of causing absorp- tion of the remaining infiltrate. DEFERENITIS OR FUNICULITIS. Inflammation of the vas deferens seldom occurs as an isolated lesion, but is generally associated with gonorrhceal epididymitis or sperma- tocystitis. The vas can be felt as a hard cord resembling a quill; it can be rolled between the fingers and traced to the swollen epidid- ymis. In this case the inflammation from the urethra extends by continuity into the ejaculatory duct and thence upwards into the vas deferens. In case of traumatic epididymitis complicated with defer- enitis the reverse of this process obtains, the inflammation extending downwards from the epididymis into the vas. It has often been observed that epididymitis may complicate gon- orrhoea without the vas deferens being involved. In reality this freedom of the latter structure is, as a rule, merely apparent. A per- ceptible and palpable swelling does not always occur, but notwith- standing this the vas deferens is nevertheless involved, as is proved by the fact, that in those affections in which no symptoms of deferenitis are manifest objective changes are found in the vas. Deferenitis requires no special consideration, because it almost always ends with the epididymitis, which with very few exceptions is an entirely benign disease. Swelling and induration subside simul- taneously with the pain. It is only when symptoms of peritoneal irritation, such as colic and vomiting, develop that the disease becomes serious. Such symptoms are due to the compression to which the cord is subjected owing to its swollen condition. As the swelling subsides spontaneously we may rest at ease, and not be prevailed upon to operate by the fear that the condition is strangulated hernia, which, as is known, gives rise to similar symptoms. Only when there is reason to believe that suppuration in the region of the peritoneum will follow, is there any ground for interference. Such an occurrence is to be feared when high fever, chills, and fluctu- ation of the cord are present, when pus is obtained by puncture, and when the symptoms do not yield to antiphlogistic treatment. Under these circumstances intervention must be practised, because peri- tonitis may result if the suppuration is allowed to extend. The focus of suppuration must be sought out, and if it is necessary to open the inguinal canal to reveal it, no hesitancy should be felt in so doing. ACUTE HYDROCELE. 439 After the abscess has been emptied and an antiseptic dressing applied, the danger will be overcome. ACUTE HYDROCELE. Acute inflammation of the tunica vaginalis propria is generally caused by trauma ; less frequently extension of inflammation from the urethra or bladder — usually gonorrhoea — is responsible, and in ex- ceptional cases it is metastatic in origin. According to the character of the exudate, we distinguish serous, fibrinous or plastic, and purulent acute hydrocele. The first is usually a complication of gonorrhoea; the last often follows injury, as for example, puncture of a hydrocele, but it also may develop in an old hydrocele without any apparent cause. Owing to the rapid effusion of fluid between the layers of the tunic, swelling of the scrotum rapidly develops, so that a transparent fluctuat- ing tumor is formed; considerable constitutional disturbance, such as fever, depression and pain, is present. The testicle lies behind the tumor. In the very rare fibrinous form, in which flakes and granules of fibrin are precipitated, crepitation can be plainly felt. The purulent form is characterized by severe pain, absence of translucency, and severe constitutional symptoms. All these forms are benign. The serous form subsides in one or two weeks, the exudate being absorbed. Occasionally it becomes chronic. The fibrinous form leads to agglutination and adhesion of the two layers within a short time. The termination of the purulent form is less favorable. The tunica vaginalis almost always becomes adherent to the superficial layers of the scrotum, which become inflamed and suppurate, with the result tat the pus breaks through the skin. The treatment of the first two forms consists in rest, elevation of the penis, cool applications, and, as soon as the most acute symptoms have passed, the employment of slight compression. Great care must be taken, however, in using compression. Fricke's plaster dressing is to be avoided for the reason that it may produce excoria- tion and eczema, and perhaps even gangrene of the scrotum. Pres- sure is best made by means of good soft cotton placed in a large suspensory bandage. For this purpose the well-known Zeissl-Langle- bert suspensory, to which I have added hooks and eyes, is very satis- factory. Before it is applied the skin of the entire scrotum is greased with lanolin cream. 44Q TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. Puncture is seldom necessary in the serous form; the above mentioned measures are nearly always successful. If the exudate is not entirely absorbed then the hydrocele may be punctured and from i to 3 cm. [1 5 to 45 minims] of a mixture of equal parts of carbolic acid and glycerine injected. In the purulent form incision is to be preferred to puncture. If any of the above named causes result in an effusion of fluid Fig. 206. — Hydrocele. along the vas deferens, the condition is known as acute hydrocele of the cord. It is very rare, and when it does occur is usually due to acute inflammation of an already existing hydrocele of the cord. The exudate may be serous, fibrinous, or purulent. CHRONIC HYDROCELE. Hydrocele, also called periorchitis and vaginalitis, is the most frequent affection of the scrotum. It is a collection of fluid in the CHRONIC HYDROCELE. 441 cavity of the tunica vaginalis propria. As a cause we have already recognized the transition of acute into chronic hydrocele; we know, furthermore, that various injuries of the testicle are followed by a gradual outpouring of fluid into the tunica vaginalis; next to these causes gonorrhoea is the most common cause, agonorrhceal epididymitis representing the connecting link between the two diseases. Other diseases of the testicle, for example, syphilis and new growths, act as predisposing causes, and, finally, it must be stated that there are cases in which no cause can be determined. Hydrocele is characterized by its pear-shaped form. The stem of the pear lies at the inguinal ring and its body is directed downwards (Fig. 206). The tumor generally ends abruptly at the inguinal ring, only exceptionally entering the canal. In size it may be as large as a man's head, and reach below the knee. It is said that as much as twenty liters [5 gallons] of fluid have been obtained from one hydrocele. As the tumor is composed of fluid it is relatively lighter than solid tumors of the same size. The position of the testicle is determined by the collection of fluid. If it were not previously adherent to surrounding parts, it will lie in the lower and posterior portion of the scrotum (Fig. 207), the tunic rising above owing to its distention by the fluids. Other important characteristics of the tumor are its fluctuation and translucency. Fluctuation, how- ever, may be indistinct if the tunic is filled very full or its walls thickened. At first the serous wall Fig. 207.— The tes- r .-, . . . 1 1 t , • Till i •. tide lies below and of the tunic is not changed, but m old hydroceles it behind. becomes thickened and indurated, resembling a rind, and may be partly calcified or ossified. The translucency is due to the fact that the contents of the tumor is ordinary serum, such as is found in ascites and hydrothorax. In this serum shining crystalline plates of cholesterin may usually be found; they contain a high percentage of albumen. Owing to discoloration of this fluid, as well as to thickening of the walls of the hydrocele, translucency may entirely disappear, a fact which it is important to know as regards diagnosis. Discoloration of hydrocele fluid is often observed in cases of long standing. It then becomes dark yellow or brown, and loses its limpid- 442 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. ity. This change is particularly favored by repeated puncture of the sac, which allows the coloring matter of the blood to mix with the serum. Other non-translucent collections of fluid in the tunica vaginalis, namely, spermatocele and hematocele, will be considered later. A process in which both discoloration of the serous fluid and changes in the wall of the sac occur, has been described under the name of fibrinous hydrocele. As the result of a peculiar inflammatory process a fibrinous exudation takes place, some of the fibrin being deposited upon the internal walls of the hydrocele and some being taken up by the fluid. When the connection between the wall and the fibrinous deposit becomes thinner, owing to shrinkage and contraction, a pedun- culated tumor is gradually formed. The peduncle may become separated from the wall and thickening of the latter occur, so that upon palpation it may seem as though a solid tumor were present, but crepitation of the detached mass of fibrin will lead to a correct differ- ential diagnosis. As a rule, hydrocele does not produce any symptoms other than those due to its size. Thus it happens that as long as the tumor remains small it is generally not noticed by the patient, attention being attracted to it only when it becomes large and heavy enough to cause traction on the cord and so produce discomfort. As the tumor grows the difficulty increases. The sac encroaches upon surrounding tissues, the space for the other testicle becomes too small, the skin of the penis is trespassed upon, so that the organ shrivels and is pushed to one side, with the result that cohabitation is often rendered impossible. During micturition wetting of the skin is unavoidable, and frequently gives rise to very troublesome eczema. Other ill effects are gradual atrophy of the testicle owing to pres- sure of the fluid upon it, and the development of hernia. The latter occurrence is explained by the traction which the hydrocele exerts upon the peritoneum, with which the tunica vaginalis is adherent. In regard to the course of hydrocele, it may be stated that the tumor seldom remains of the same size, but generally becomes larger and larger, attaining dimensions which cause it to become unendurable. In many cases, however, its progress is interrupted by periods of quiescence. Unless the greatly distended sac bursts, an occurrence which has been observed only a few times, the patient is forced to seek relief from the surgeon. CHRONIC HYDROCELE. 443 Occasionally, instead of being pear-shaped, a hydrocele may resemble an hour-glass, being constricted at the inguinal canal. Two sacs are then present, communicating with one another through a fine opening; both may be in the scrotum, or one may be in the scrotum and one in the abdomen. When the latter condition obtains we have a bilocular hydrocele. The fluid can be pressed out of one sac into the other. Both sacs are translucent. Less frequently there are several divisions of the tumor, constituting a multilocular hydrocele. Hydro- cele may also be associated with cystoma of the testicle. The most important complication is hernia. Serous effusion into a hernial sac may occur as well as hernia in association with true hydrocele (Konig). If the hernia reaches far down it usually lies behind the hydrocele. In regard to diagnosis, it may be stated that while some cases are very easy to recognize others may be most difficult. Great care must be given to differentiating between hydrocele and scrotal hernia, a correct diagnosis being of the utmost importance. If tympany be elicited upon percussion of the tumor, hydrocele is out of the question. Epiplocele as well as enterocele which does not contain gas may, however, emit a dull note. Palpation of a hydrocele reveals it to be a fluctuating tumor having a smooth regular surface, such as is never presented by a scrotal hernia. Hydrocele is usually translucent, hernia never. Cough has no effect upon the size of a hydrocele; when the patient is in the horizontal position its size is not altered; pressure is not painful, and the tumor cannot be reduced. Between the highest part of a hydrocele and the inguinal ring is a space into which the finger can be inserted and its tip carried into the inguinal ring, where nothing but the cord will be felt; no protrusion will occur when the patient coughs. There are exceptional cases, as has already been stated, in which the hydrocele extends into the inguinal canal, but, as a rule, this is not the case; moreover, hydrocele, in contradistinction to hernia, develops from below upwards. Hydrocele differs from tumors of the testicle and epididymis in that it has a fairly regular pyriform shape, whereas tumors form an irregular mass in the scrotum. With the exception of cysts tumors are also not transparent, nor are they so tense as hydrocele; moreover, they are sensitive to pressure, while hydrocele , as is well-known, may be pressed upon without any pain being caused. 444 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. The last characteristic is a valuable diagnostic point in distinguishing hydrocele from inflammatory diseases of the testicle and epididymis. The consideration of all these circumstances will in most cases lead to the determination of a correct diagnosis. As a last resort puncture with a fine needle is permissible, and may be considered safe. As concerns treatment, it is first of all important to understand that hydrocele will not undergo spontaneous cure, but, on the contrary, will be almost certain to become larger. It is only when the hydrocele remains unchanged in size — which is rare — and is not large enough to annoy the patient, that it may be allowed to remain untreated. Fig. 208. — Tapping a hydrocele according to Kocher's method. a. Direction of the trocar when the puncture is made. b. Direction when the fluid is withdrawn, c. Hydrocele, d. Epididymis, e. Testis. (Konig.) Internal medication and local applications of liniments and oint- ments are without result ; therefore they may be dismissed from consider- ation without further mention. Treatment must be entirely surgical. The simplest way is to tap the sac with a fine trocar. After being carefully disinfected, the scrotum is so held in the left hand that its posterior surface, together with the testicle, lies in the hollow of the palm. The trocar is then plunged in perpendicularly to the long axis of the scrotum. This manner of making the puncture is important, for CHRONIC HYDROCELE. 445 if it be practised otherwise the needle may be carried between the tissues of the scrotum. After withdrawal of the stilet the canula is lowered (Fig. 208) and the serum begins to flow out. Tapping can be performed repeatedly without any damage. I have punctured a hydrocele twenty times for a patient who was unwilling to have a radical operation performed, tapping it once or twice every year. From what has already been stated it will be understood that tapping is solely a palliative measure, and that the tunica vaginalis will slowly fill up again after its contents have been withdrawn. It is only in children — and exceptionally in adults — that the irritation of the punc- ture results in sufficient inflammation to cause adhesion of the layers of the tunica and thus obliterate the cavity so that the hydrocele cannot recur. A procedure which may be combined with tapping is the injection of irritating substances through the canula after the fluid has been withdrawn. Among those which have been employed are alcohol, chloroform, ether, and tincture of iodine; recently a mixture of equal parts of glycerine and concentrated carbolic acid has been more com- monly used than these other substances. The procedure is very simple and in many cases results in cure, but it is not absolutely certain nor entirely without danger. A day or two after the injection the inflammatory process begins to manifest itself. The patient complains of more or less pain in the testicle, and the tissues around the gland begin to swell ; elevation of temperature is not uncommon. All these phenomena, however, usually subside within a few days, and within a week or two recovery is complete. There may, however, be a different termination. Severe suppurative inflammation with liberation of the pus externally may occur, or the suppuration may invade the testicle. I have also seen recurrence of the hydrocele follow this method. Therefore I favor the radical operation by means of open incision, and of the various methods, I prefer that of Volkmann. Skin and hydrocele-sac are incised, the tunica vaginalis sewed to the skin on each side with catgut, and then the edges of the wound, with the exception of a small cleft which is left open at the lower angle, are closed with a few interrupted silk ligatures, care being taken to bring the serous surfaces of the hydrocele walls into close apposition. When the tissues are cut through all haemorrhage must be arrested, because otherwise a haematoma may form which may suppurate and retard 446 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. healing. This is the only danger of the operation. I never saw any accident happen except this one. Cure is effected by adhesion of the two layers of the tunica vaginalis which are brought closely together. Recurrence is thus practically impossible, although now and then one may happen. In my own experience none have occurred. Von Bergmann recommended the extirpation of the tunica vaginalis, either in its entirety or up to the cord, with suture of the cut edges over the testicle. I consider this method unnecessary; if the tunica vaginalis is very thick and large it may be well to cut off a piece. Winkelmann's method [also known as Doyen's and Jaboulay's], in which the tunica vaginalis is incised, turned inside out and the edges united by suture, I have abandoned as being an unnecessary procedure. GALACTOCELE, HEMATOCELE ANDTSPERMATOCELE. Galactocele differs from hydrocele in that the fluid contained in the cavity of the tunica vaginalis is milky instead of clear and yellow. It is such a rare affection that it merely requires to be mentioned. Vidal saw one case in a soldier who came to him from Africa. The essen- tial feature of this case was the excessively fatty character of the fluid, which, when viewed under the microscope, looked like an emulsion. Accordingly we may consider galactocele as a fatty hydrocele. In haematocele the fluid which is poured out into the tunica vaginalis is sanguinolent. In regard to the origin of this affection, it is known that a large number of cases result from injury; thus, for example, it not uncom- monly happens that haematocele follows repeated puncture of a hydro- cele. Often, however, the causative injury passes unnoticed. Slight traction upon or bruising of the hydrocele, which may not produce pain, and therefore passes unobserved, causes slight haemorrhage and inflammation of the tunic. Thickening of its walls and alterations in its blood-vessels may also give rise to bleeding. Thus, haematocele may merely represent a metamorphosed hydrocele. Diagnosis is not difficult. It may be learned from the history of the case, or from a previous observation, that a translucent, fluctuating tumor was present in the scrotum. In the absence of such knowledge information must be obtained in regard to the development of the tumor— whether it was sudden, rapid, or gradual. Slow evolution is by far the most common. The smooth and sometimes tense tumor GALACTOCELE, HEMATOCELE AND SPERMATOCELE. 447 lies anterior to the testicle exactly the same as a hydrocele. Trans- lucency, however, is absent. On account of the thickening of the wall fluctuation is seldom demonstrable. Subjective symptoms may be absent, but in some cases dragging pain is present. The affection is entirely devoid of danger, although the testicle may gradually atrophy. For the latter reason removal of the tumor is indicated. This can be effected only by operation. Compression by means of a suspensory bandage lined with cotton will seldom accomplish any- thing, and I do not advise the use of Fricke's plaster dressing. The hematocele cannot be entirely emptied by puncturing it. Volkmann's operation for hydrocele is the appropriate measure. Precaution must be taken to empty the sac completely, and to this end the walls of the hydrocele must be most carefully examined. Spermatocele is to be considered in a somewhat different light than galactocele and haematocele. It is a cyst-like tumor of the scrotum containing semen. Its development is to be attributed to the occur- rence of any inflammatory process which leads to the partial or total occlusion of the seminiferous tubules, so that any semen which may continue to be secreted is retained, and thus gives rise to disten- tion of the constricted tubules. The tumor is thus a typical reten- tion-cyst. These spermatoceles generally take origin at the site where the vasa efferentia empty into the epididymis, that is, at the point of union between the testicle and epididymis. The form and growth of the tumor is thus explained by its manner of development. It may be either extravaginal or intravaginal, according as it extends backwards and forwards or grows downwards into the tunica vaginalis. If growth occurs in an upward direction the tunica vaginalis is not dis- turbed, so that when the spermatocele is incised the former is not injured. If growth occurs downwards and forwards the tunica is carried before it, and in this case must be cut before the wall of the cyst can be reached. The extravaginal form of spermatocele is more common than intravaginal. The fluid in the sac somewhat resembles soap-suds; it contains albumen and spermatozoa. It may be impossible to diagnosticate the intravaginal form from hydrocele unless puncture be made; the testicle lies behind as is the case in hydrocele; fluctuation is present; translucency is wanting, but 448 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. as it may also be absent in hydrocele when the walls of the sac are thickened, this is a sign of minor value. Extravaginal spermatocele is very likely to be confused with hydrocele of the cord. It forms a pyriform fluctuating tumor above the testicle, along the course of the cord. It may be distinguished from hydrocele of the cord by the fact, that the apex of the latter tumor is above and the broad base below, whereas in hydrocele the opposite condition obtains. Translucency of the hydrocele, or, if this be absent, puncture of the tumor, will assure diagnosis. As concerns treatment, tapping followed by the injection of carbolic acid and glycerine in equal parts may be practised, or the cyst may be opened and the edges sutured to the superficial structures as in the radical operation for hydrocele. HYDROCELE OF THE SPERMATIC CORD, OR CYSTIC HYDROCELE. Hydrocele of the spermatic cord occurs if a portion of the vaginal process remains patent instead of becoming obliterated and a serous effusion takes place into its cavity. If the vaginal process be closed only above at the internal ring and below at the upper part of the testicle, the tumor will extend along the cord as far as the internal ring ; in other cases when the vaginal process is partly obliterated smaller cysts are formed along the course of the cord. If non-union exists at several places multiple cysts are formed, and the condition is known as multilocular hydrocele of the spermatic cord ; if the cyst is divided into two parts it is termed bilocular. Hydrocele of the cord is characterized by the fact that it forms a pear-shaped tumor the limits of which may be defined at the internal abdominal ring above and the testicle below. It is not reducible, undergoes no alteration when the patient changes position, is not forced out by coughing, sneezing, or vomiting, thus differing in all these respects from hernia, from which it will be readily distinguished. Fluctuation cannot always be detected, because the sac may be so full that the tumor is tense and distended; its walls may also be too thick for the wave of fluid to be transmitted. For the same reason translucency is less marked than in congenital hydrocele. Occasionally hydrocele of the cord descends behind the testicle, and in this case may easily be mistaken for an ordinary hydrocele with abnormal position of the testis. These relations are important VARICOCELE. 449 in regard to tapping; if the puncture should be made in the ordinary manner from before backwards the testicle would be pierced. The cause of this affection is, in some cases at least, to be sought for in trauma, which may have been slight and therefore have passed unnoticed. More frequently, however, it is due to a congenital con- dition in which faulty coalescence of the vaginal process is present and is followed by traumatic or inflammatory effusion. It causes little trouble, and one or more tappings will suffice to effect a cure. As an auxiliary measure a small quantity of Lugol's solution or the carbolic-glycerine mixture may be injected. Incidentally we wish to mention the cysts which develop from the pedunculated and sessile hydatids of Morgagni. These small vesicles occasionally undergo cystic dilatation, becoming as large as cherries or perhaps even attaining the size of plums. According to Konig, these intravaginal cysts occasionally rupture, and being in communi- cation with the tubules of the epididymis the result is an outpouring of semen into the cavity of the tunica vaginalis. Different from these are the very rare cysts which develop in the connective tissue of the cord. They occur as single or multiple circum- scribed cystic dilatations of the lymph vessels of the testicle and epidid- ymis. VARICOCELE. Varicocele is a term applied to varicosities of the spermatic cord and testicle. Usually the distention is confined to the veins of the cord; more rarely those of the testicle are involved. The affection develops in adult life and is essentially dependent upon anatomical conditions. The spermatic vein is formed by the conflu- ence of the different branches of the pampiniform plexus, and ascends directly upwards as far as the second lumbar vertebra, so that when the body is in the upright position the pressure of a moderately high column of blood is brought to bear upon the plexus (Bardeleben). The greater frequency of varicocele on the left side may be explained by the fact that the left spermatic vein empties into the renal vein at a right angle, whereas the right spermatic vein empties directly into the inferior vena cava at an acute angle. Owing to these conditions there is more resistance to the emptying of the blood from the left spermatic vein than from the right. The pressure exerted upon the left vein by the distended sigmoid 450 TESTICLES, EPIDIDYMIS AND SPERMATIC CORD. flexure has also been designated as a causative factor. If, in addition to these conditions, it be remembered that the left testicle generally hangs lower than the right, as a result of which its vessels are longer, and that owing to sexual excitement there is a frequent afflux of blood to the veins of the cord, the origin of the affection will be understood without further explanation. Symptoms may be entirely wanting or again may be of considerable severity. In the majority of cases I have not seen any great disturbance. The traction exerted upon the testicle is uncomfortable, and upon exertion the discomfort may amount to a dull, dragging pain. Rarely very severe pain may be present. The patient is usually at ease when he is lying down or sitting, the pain coming on after violent exertion or walking. The disease may remain stationary for years, the patient experienc- ing no trouble except an occasional uncomfortable dragging sensation. The varicosity, however, does not become any larger. Distention of the vessels varies according as the upright or recumbent posture is assumed; they become filled when the patient stands and empty themselves when he lies down. They can also be filled by rubbing them in a downward direction and emptied by stroking them in an upward direction. Inspection alone is usually sufficient for a diagnosis and palpation renders it certain in every case. There is diffuse swelling of the affected half of the scrotum and it is lengthened and thickened; the veins are tortuous and dilated, and when rolled between the fingers feel like a mass of earthworms. Periphlebitic areas with thickening of the vessel- walls may also be detected. The course of the disease is entirely benign and does not endanger life. The condition sometimes requires to be remedied, however, as the pressure to which the testicle is subjected may cause it to atrophy. Interference is indicated particularly when the affection is bilateral. Otherwise it is only exceptional cases, in which unbearable pain annoys the patient, that will demand intervention. In mild cases treatment consists in removing the traction which the testicle exerts upon the cord by having the patient wear a well-fitting suspensory bandage. In numerous cases of mine this has succeeded in entirely removing all the discomfort which my patients experienced. I do not consider it advisable to employ compression, and, moreover, deem it useless. There is, of course, no objection to padding the VARICOCELE. 451 suspensory lightly. The scrotum may also be frequently washed with cool water, which at all events can do no harm. The bowels should be regulated and the rectum kept free from scybalae, so that pressure will not be exerted upon the veins. Cure is to be expected only by a radical operation. Many procedures which were formerly practised, such as galvano-puncture, compression even to the point of gangrene, removal of a portion of the scrotum with the idea that the resulting contraction would shorten the veins, and subcutaneous uncoiling and ligation of single veins have been entirely abandoned. If operation is indicated at all the only thing to be considered is to lay bare the veins and ligate them under the guidance of the eye. The pampiniform plexus is exposed — and to this end it is better to operate with the patient in the sitting posture so that the veins may be well distended — and the arteries and vas deferens carefully and cautiously separated; the spermatic artery must be handled cautiously for the reason that even the slightest injury to it may result in gangrene of the testicle. The veins thus isolated are tied above and below and the portion between the ligatures cut out. At first reactive inflam- mation sets in, but it soon subsides. Healing of the wound always follows. I have never seen any complications ensue. As already stated, it is only in exceptional cases that operation is necessary. Usually the wearing of a suspensory bandage will suffice. [In operating for varicocele it is my practice to cover the divided ends of the veins with fascia, using the finest catgut for suturing, and then to bring them into apposition by tying the ligatures together. Varicocele may also be operated upon by making an incision over the external abdominal ring, drawing up the cord and then excising the veins in the usual manner. This method was introduced by Bloodgood.] 31 452 DISEASES OF THE SEMINAL VESICLES. DISEASES OF THE SEMINAL VESICLES. ANATOMY AND PHYSIOLOGY. The seminal vesicles, which develop from the Wolfian bodies, are two sausage-shaped expansions of the vasa deferentia, placed symmet- rically upon the floor of the pelvis. From the vasa deferentia they extend lateralwards and upwards on each side, forming an angle of about 45 . They are about 5 cm. [2 inches] long, 2 cm. [f of an inch] wide and 1 cm. [f of an inch] thick. They are enclosed in a sort of a capsule made up of strong connective tissue, and have a rough surface. The seminal vesicles lie with their posterior surface placed against the rectum and their anterior against the bladder. Internally they are in relation with the vasa deferentia and below with the prostate. The peritoneum covers only their upper surface. It passes from the bladder to the upper part of the seminal vesicles, descends between the rectum and bladder and again proceeds upwards from the rectum. That portion of the bladder lying between the seminal vesicles and not covered by peritoneum, sometimes called the trigonum inter dej- erentiale, varies in size: the fuller the bladder the higher the perito- neum will rise, and consequently the greater the free surface will become. The secretion of the seminal vesicles is golden-yellow in color, contains albumen and almost without exception spermatozoa. For a long time no uniformity of opinion has prevailed concerning the nature of this secretion and the function of the seminal vesicles. A few investigators have maintained that the semen is fully elaborated in the testicles and that it is merely stored up in the seminal vesicles, from which it is expelled when ejaculation occurs. Others have held to the opinion that the seminal vesicles are not only receptacles for the semen, but that they also produce a specific secretion, which comes from certain sinus-like depressions in the mucosa, known as glands, although Waldeyer and Kolliker do not consider them to be such. This latter difference of opinion is not of importance, for, as is well known, the epithelium of the mucous membrane can produce a secre- tion. The seminal vesicles, then, may be said to elaborate a specific EXAMINATION OF THE SEMINAL VESICLES. 453 secretion, which, according to Virchow, is a proteid compound; it is insoluble in water, but dissolves readily in acetic acid and a solution of potassium f errocyanide ; when warm it is liquid, but when cold it becomes gelatinous in consistency. That this secretion is derived from the seminal vesicles is attested by the fact, that it can be sepa- rated from the testicular secretion and its differences from the latter proved by chemical analysis. Adopting the results of Rehfisch's diligent investigations it may be stated that the seminal vesicles produce a specific secretion; that the spermatozoa bear a definite though as yet unknown relation to this secretion; that a sufficiently large quantity of semen for an ejaculation is stored up in them, and that the musculature of their walls plays an important role in the production of ejaculation. The arteries of the seminal vesicles are derived from the middle hemorrhoidal, internal pudic, deferential, inferior vesical and internal iliac. The veins empty into the internal iliac vein. The lymphatic vessels discharge into the glands of the rectum and those at the inlet of the pelvis. EXAMINATION OF THE SEMINAL VESICLES AND THEIR SECRETION. Examination of the seminal vesicles is difficult because of their concealed position. If the surgeon's finger is long and the patient not too fat, rectal examination may reveal the presence of a gut-like, soft, doughy body about the size and length of a finger on either side of the prostate. They diverge upwards and may be distinguished from the prostate by their uneven surface. In numerous cases, however, they cannot be felt under ordinary circumstances, it being necessary to induce ansesthesia before the finger can be carried sufficiently high in the rectum to palpate them. To obtain their secretion the seminal vesicles must be massaged. This can be done properly only when they can be palpated in their entirety, for if only the lower portion, just above the prostate, can be reached, they are not accustomed to empty themselves. Their contents may appear at the external meatus or flow back into the bladder. In the latter case the patient is told to urinate and the product is then recovered from the urine; or, if this does not suc- ceed, the bladder may be filled with sterile water and the contents then 4.54 DISEASES OF THE SEMINAL VESICLES. withdrawn. The semen will appear in the water as sausage-shaped, translucent masses. Microscopically many motionless spermatozoa may be perceived in a pellucid filamentous stroma. If the contents cannot be expressed in this manner, there is nothing to do but anaesthetize the patient and then introduce the finger into the rectum, or better still to use Felecki's metal instrument, which is a pyriform bulb placed at a right angle upon a long handle. With this instrument pressure can be made upon the seminal vesicles without difficulty, so that their contents will be expelled. Because of the inaccessibility of the seminal vesicles diseases affecting them are rarely diagnosticated. They are subject to malformation, injury, acute and chronic inflammation, tuberculosis, abscess, cysts and hydrocele, concretions, and, finally, sarcoma and carcinoma. MALFORMATIONS OF THE SEMINAL VESICLES. Absence of both seminal vesicles is due to an arrest of develop- ment. The testicles may also be absent or atrophied; in case they are well developed there are other defects in the urogenital apparatus. Thus, the bladder or prostate may be absent, a kidney may be wanting, the anus be imperforate, exstrophy of the bladder may be present, or the entire sexual apparatus may be absent. Absence of one seminal vesicle is more common than absence of both. In such cases there are usually other defects in the same side of the genital apparatus, the corresponding testicle, kidney, ureter, or vas deferens being absent. Fusion of both seminal vesicles has also been observed; when this happens the single vesicle lies in the median line. The most remarkable anomaly of the seminal vesicles is their union with the ureters. It is explained by the fact that the ureter and vas deferens, of which the seminal vesicle is a diverticulum, in the beginning of their development empty into an opening in the uro-gen- ital sinus. INJURIES OF THE SEMINAL VESICLES. Injuries to the seminal vesicles are inflicted almost exclusively dur- ing operations. Formerly it was rectal puncture and lateral lithotomy which brought the surgeon into conflict with them; at present, how- ACUTE INFLAMMATION OF THE SEMINAL VESICLES. 455 ever, these operative methods have become antiquated. It is only in the operation for perineal prostatectomy that any question of their injury can arise. They occupy such a well protected position that they are seldom affected by traumatism. A few remarkable cases, however, have been reported. Velpeau saw one in which the seminal vesicles were injured by a fracture of the ischium, and Demarquay reports an in- stance in which a rifle-bullet perforated the bladder and seminal vesicle. ACUTE INFLAMMATION OF THE SEMINAL VESICLES. (ACUTE SPERMATOCYSTITIS.) Spermatocystitis occurs almost exclusively as a complication of gonorrhoea. The anatomical relation of the seminal vesicles and their ducts with the urethra sufficiently explains its occurrence. Rocher also believes in the existence of a traumatic form, having seen one case develop as the result of a kick in the perineum. Rapin considers sexual abuse to be a cause. The symptoms of the acute form so closely resemble those of pros- tatitis that the two diseases can frequently not be distinguished from one another. Confusion occurs the more readily because both affec- tions usually exist together. The patient complains of a dull though shooting pain in the rectum, which may increase in severity. It radiates toward the perineum and testicles and becomes more intense during micturition and def- ecation, especially if the feces are hard. Coitus is also painful, although the desire to copulate may be in- creased owing to frequent erections. Upon ejaculation the sensation of discomfort is increased to sharp pain. The urine contains pus and sometimes blood. In a case as well-marked as that just described diagnosis is not difficult, and if the clinical picture is at all obscure, palpation through the rectum will clear it up. The probability that an inflammatory infection of the seminal vesicles is present is increased if epididymitis or deferenitis can be discovered. The course of acute spermatocystitis varies. Frequently complete resolution takes place; more rarely the inflammation advances to sup- puration, the pus either perforating neighboring organs, or, what is more favorable, rupturing into the urethra. Fortunately the latter termination is the more common. Peritonitis resulting from rupture 456 DISEASES OF THE SEMINAL VESICLES. of the abscess has been very rarely observed. Most frequently acute spermatocystitis passes into the chronic stage. Chronic spermatocystitis is much more difficult to diagnosticate, as the symptoms are not so well pronounced as in the acute form. The history or existence of gonorrhoea or stricture; simultaneous involve- ment of the prostate (which is more easily recognized) ; an uncomfort- able sensation in the region of the perineum, between the bladder and rectum; increased sensitiveness upon difficult defecation; occasional tenesmus; frequent erections and pollutions; and, finally, the presence of pus in the semen, and the findings upon rectal palpation; — these are the symptoms and signs which will serve to strengthen the diag- nosis. Occasionally colicky pains confined mostly to the lower segment of the rectum occur. They are due to narrowing of the ejaculatory duct caused by the inflammatory process, as a result of which the accumulated semen cannot gain free exit. The colicky pains, then, are similar in origin to those experienced in renal and rectal colic, all being due to occlusion. Finger and others state that they have been able to feel pear-shaped bodies, of the consistency of an air- cushion, on the posterior surface of the bladder above the prostate. I have seldom, been able to do this without an anaesthetic. Chronic spermatocystitis may be cured. It may also persist for a great many years without causing any serious difficulty or interfering in any way with the functional capacity of the individual. Apart from the unpleasant sensations just described, and which are usually experienced only at intervals, neither the general health nor the sexual activity is disturbed. I have fully convinced myself that the semen of men affected with this disease retains its power of procreation. In regard to the pathological anatomy, hypertrophy of the walls may take place, or atrophy and chondrification may result. The therapy of the acute form consists in treating the underlying causative affection (gonorrhoea), enjoining rest, regulating the diet, increasing the flow of urine, administering urinary antiseptics such as urotropin, and also laxatives, so that the feces will not become hard and produce new irritation. If abscess can be positively demon- strated it should be opened in order to prevent rupture at an undesirable site. Under complete anaesthesia a speculum may be introduced into the rectum and the vesicle incised. Proper disinfection of the rectum should be secured before the operation and the bowels should TUBERCULOSIS OF THE SEMINAL VESICLES. 457 be confined afterwards. The abscess may also be reached by a method practised in operations upon the prostate, namely, by freeing the rectum so that a space is made between it and the bladder, through which the vesicles may be reached. Treatment of chronic spermatocystitis is not very satisfactory. It is practically the same as that of chronic prostatitis. I recommend massage of the seminal vesicles, which is best performed with Felecki's instrument, at intervals of two or three days, in conjunction with the use of the rectal thermophore on the other days. The latter instru- ment should be kept in the rectum for half an hour and should be as hot as the patient can endure. In addition, mild laxatives, diuretics and urinary antiseptics may be given, hot sitz-baths employed, the diet regulated, sexual excesses forbidden, and, if possible, the causative gonorrhoea or prostatitis cured. As many patients become neurasthenic overtreatment must be guarded against; a too protracted course of treatment is particularly undesirable. Suggestive treatment, and perhaps eventually residence in a sanitarium where mild hydrotherapeutic measures can be employed, have an excellent effect. [Belfield, of Chicago, has obtained good results in these cases by irrigating and draining the seminal vesicle through an opening made into the vas deferens. He exposes the vas by a half-inch incision through the skin and other coverings of the spermatic cord, incises it by a transverse or longitudinal cut, and injects the desired solu- tion with a hypodermatic syringe. The point of the needle used is blunted, so that it may be inserted well into the lumen of the vas without producing injury. At first not more than thirty minims of fluid should be injected, as a larger amount is apt to produce spermatic colic. As the inflammation subsides the quantity of fluid may be gradually increased. The vas deferens may be stitched to the skin with a piece of fine silkworm gut, the suture being passed through each cut edge. By this procedure the opening is maintained and treatment can be applied daily if desired. The operation is done under local anaesthesia. A solution of one of the organic silver salts is generally employed in gonorrhceal infection.] TUBERCULOSIS OF THE SEMINAL VESICLES. This is a more common affection than it was formerly thought to be. It almost always occurs in association with tuberculosis of some other 458 DISEASES OF THE SEMINAL VESICLES. portion of the genito- urinary organs. It is generally combined with tuberculosis of the testicle, epididymis, vas deferens, prostate, bladder, or kidney, or occurs simultaneously with tuberculous affections of other organs, especially the lungs. Primary tuberculosis of the seminal vesicles is very rare, or, more correctly speaking, it is very rarely diagnosticated; many cases of tuberculosis of the prostate or epididymis may have been preceded by a tuberculosis of the seminal vesicle, the existence of which was unknown owing to the difficulty with which diagnosis can be made. Children are very seldom affected, the disease occurring during the period of active sexual life. Trauma and gonorrhoea constitute the predisposing causes. The frequent congestion of the generative organs induced by sexual excesses may also supply the cause for the development of the disease, if the individual be predisposed to tuber- culosis. In regard to the morbid changes which occur, it is found that the mucous membrane is first covered with tubercles, which gradually penetrate into the deeper structures, coalesce, and thereby become in- creased in size. As a result of the simultaneous inflammation the walls become infiltrated and thickened, the tubercles undergo caseous changes, and ulcerations develop which may either cause rupture into various surrounding structures or result in cicatricial contraction of the entire organ together with its excretory ducts. Diagnosis is difficult. The patient may be entirely free from subjective symptoms. There may be merely a sensation of pressure around the anus or a feeling of heaviness in the perineum. At first sexual desire is increased, but with the destruction of the vesicles and the onset of constitutional disturbances depending upon the involvement of other organs it becomes diminished, and the power of copulation may be lost. If the vesicles can be palpated through the rectum, isolated, small, hard nodules may be felt above the prostate, similar to those which are detected in tuberculosis of the latter organ. Symptoms depending upon tuberculosis of neighboring organs gradually come to the fore. If the prostate and ejaculatory ducts are involved, a yellowish- white discharge takes place from the urethra; this is of great diagnostic importance, for if such a secretion appears at the external urethral orifice of a man in whom gonorrhoea can be excluded and no other cause be determined, the suspicion that it is due to tuberculosis of the seminal vesicles will be well founded. CYSTS AND HYDROCELE OF THE SEMINAL VESICLES. 459 As the morbid process becomes further developed fistulse may be formed; they may open into the rectum or perineum, or into the large veins of the pudic plexus, the latter occurrence being one which has resulted in death. Diagnosis depends essentially on the findings upon palpation and the discovery of other tuberculous lesions. In regard to treatment, results are to be expected only from surgical intervention, that is, from total extirpation of the seminal vesicles. It is not known whether tuberculosis of the seminal vesicles ever undergoes spontaneous cure; in view of the fact that localized tuberculous lesions of other organs become healed, it may be reasoned by analogy that the same thing may take place in these organs. In consideration of this assumption the question as to whether a tuberculous seminal vesicle should be removed must be decided by the circumstances of the individual case. In general the principle should be adhered to that a tuberculous focus ought to be destroyed whenever it is possible to destroy it without greatly endangering the patient, pro- vided, of course, that its destruction offers a prospect of protecting him from a dissemination of the disease. This is often the case in tuber- culosis confined to the genital tract. Tuberculosis affecting the semi- nal vesicles alone, or associated with tuberculosis of the testicles or pros- tate, is therefore operable, whereas a simultaneous tuberculosis of the lungs, kidneys, or bladder renders it inoperable. The seminal vesicles may be removed either through the prerectal incision of Dittel and Zuckerkandl or by the method of Fritz Konig, or, as Young has shown, they may be freed from the posterior surface of the bladder through a suprapubic incision. In the light of our present experience the perineal operations are to be considered the less formidable. CYSTS AND HYDROCELE OF THE SEMINAL VESICLES. The case of hydrocele of the seminal vesicles which is recorded in literature was cured by two tappings. If for any reason dilatation of the seminal vesicles and consequent stagnation of their secretion occurs, they become converted into cyst-like bodies. This condition may be caused by occlusion or narrowing of the ejaculatory duct, resulting from inflammation, or it may be due to mechanical interference with the outflow of semen depending upon hypertrophy of the prostate. It is to be separated from true cysts such as Englisch has described 460 DISEASES OF THE SEMINAL VESICLES. in his work on "Cysts on the Posterior Wall 0} the Bladder in Man." A case has been reported by Smith in which a cyst of the seminal vesicle holding five liters [quarts] produced retention of urine. Small unilocular and multilocular cysts develop as the result of isolation and occlusion of one or more alveoli. They are connected to the seminal vesicle only by a peduncle (Maisonneuve, Englisch). CONCRETIONS OF THE SEMINAL VESICLES. A distinction is made between concretions and true calculi. The first are small and produce no symptoms, so that they are not diag- nosticated during life. Some of them correspond to the bodies formerly described by Trousseau and L'Allemand, consisting of round-cells and polyhedral cuboid epithelium which become infiltrated with inorganic salts. They are about a millimeter in length. According to Meckel, they are cadaveric products, although Fiirbringer believes that they are formed during life. Other concretions are composed of mucus, spermatozoa, and inorganic matter. Robin has described this variety under the name of sympexions. They are insoluble in acetic acid. Their occurrence is not very rare, large numbers com- monly being found. Seminal calculi are different, being composed of 90% of phosphate and carbonate of lime and 10% of organic matter in which sperma- tozoa are frequently found. They grow as large as a cherry-stone, so that they may completely occlude the ejaculatory duct. Their number may also be considerable. It is supposed that their formation is due to stagnation of the secretion in the seminal vesicles. Stagnation occurs especially in advanced age, though it may also take place at an early period of life when inflammatory processes have narrowed the caliber of the ejaculatory duct so that there is an impediment to the outflow of semen. If one or more calculi completely occlude the ejaculatory duct, severe spasmodic pain is experienced when orgasm occurs, to which the name colique spermatique has been given by the French. The semen may be completely retained, so that ejaculation fails to take place, or it may flow out slowly in small quantities. It is not positively known whether complete absence of ejaculation in cases in which one ejac- ulatory duct is occluded is due to reflex contractions of the other, or whether the congestive swelling produced by the stone causes simulta- neous occlusion of the other duct. TUMORS OF THE SEMINAL VESICLES. 46 1 Seminal calculi not infrequently give rise to pain upon micturition and defecation. In such a case where there is suspicion of seminal calculi an attempt should be made to palpate the seminal vesicles. Occasionally a stone can be felt, especially if a metal sound is introduced into the bladder and used as a guide in palpating through the rectum. The pain is to be controlled by hot sitz-baths, and narcotics if neces- sary. An attempt may be made to crush the calculi through the rectum by pressing it against a sound introduced into the bladder. TUMORS OF THE SEMINAL VESICLES. Tumors are rare and are not often diagnosticated when they do occur. Zahn has reported a case of sarcoma which was not diagnos- ticated during life. The seminal vesicle was the primary seat of the disease and from it metastases to the lung, heart, and kidney had taken place. Carcinoma of the seminal vesicles, which is somewhat more common, may be either primary, occur as a metastasis from a remote organ, or grow into the seminal vesicle from a neighboring structure. Usually it is found in association with carcinoma of the rectum, bladder, or prostate, and more rarely the testicle. Owing to the inaccessibility of the seminal vesicles it will be readily understood that carcinoma affecting these organs is not easily diag- nosticated. As a rule, the diagnosis is first made when severe disturbance of micturition leads to the making of a thorough examination. Fre- quent urination, lessened capacity of the bladder owing to infiltration of its walls, and even complete retention of urine have been observed. I once had occasion to observe a case in which a hard nodular tumor was distinctly palpable above the prostate, from which it was separated by a furrow; this tumor destroyed the seminal vesicle and broke through into the rectum and bladder. Diagnosis was first made when fibers and fecal elements were discovered in the urine. Because of the lateness with which diagnosis is made, it usually being at a time when metastases have occurred, there is not much to be expected from radi- cal treatment, so that we have to confine ourselves to a purely sympto- matic therapy. 462 DISEASES OF THE KIDNEYS. DISEASES OF THE KIDNEYS. [ANATOMY AND PHYSIOLOGY.] The kidneys are two bean-shaped glandular organs deeply placed behind the posterior parietal peritoneum, one lying on either side of the spinal column, approximately on a level with the last dorsal and first two lumbar vertebrae. Their position with reference to the vertebras, however, is variable. Thus one or both kidneys may extend up as high as the summit of the eleventh dorsal vertebra and as low down as the fourth lumbar. The latter level is rare, although it is not unusual to find a kidney, especially the right one, extending as low as the third lumbar vertebra. The long axis of each kidney is directed downwards, outwards, and somewhat forwards, so that there is a greater space between their lower than between their upper extremities. Each kidney has an anterior and a posterior surface, a superior and an inferior extremity, and an internal and an external border. The anterior surface is convex, directed slightly outwards and forwards, and is covered by peritoneum. The posterior surface is flattened, and is intimately surrounded by areolar tissue and fat. The extremities, or poles, are rounded, the superior ones being surmounted by the suprarenal glands. The external border is narrow and convex. The internal border is wider and straighter than the external, and at its middle third presents a deep longitudinal fissure, known as the hilum, through which the renal artery and nerves enter and the veins, lymphatics and ureter emerge. These structures form the surgical pedicle of the kidney, and consequently it is important for the surgeon to be familiar with their relative position and the variations from the normal which some of them often present. The relative position of these structures is as follows: the vein lies in front, the ureter behind and the artery in the middle. The arterial blood-supply of the kidneys may be derived from single or multiple main arterial trunks. When there is but a single renal artery it divides into an anterior and a posterior branch, of which the anterior is much the larger. Consequently the anterior portion of the kidney is more vascular than the posterior. PLATE XIX BLOOD SUPPLY OF THE KIDNEY AND RELATIONS OH THE STRUCTURES SITUATED IN THE HILUM OF THE KIDNEY. AS SHOWN BY A CORROSION PREPARATION MADE BY PROF. E. A. SPITZKA. i COLLECTION OF DEPARTMENT OF GENERAL ANATOMY, JEFFERSON MEDICAL COLLEGE ANATOMY AND PHYSIOLOGY. 463 This circumstance may be utilized to lessen hemorrhage in the operation of nephrotomy. Thus an incision made six millimeters behind the external border of the organ will open into its less vascular segment, whereas one made in front of this border will wound the highly developed plexus formed by the subdivision of the anterior branch of the renal artery. Before the renal artery passes into the hilum it generally gives off a branch which ascends to the upper pole of the kidney to enter the suprarenal gland. Hence in ligating the artery in the operation of nephrectomy, care should be taken to place the ligature internal to this branch. Multiple renal arteries are present in a considerable proportion of all subjects — according to my observations in the dissecting rooms of Jefferson Medical College, in about twenty-nine per cent. In some instances three, four, or more vessels are given off from the aorta; in others a short thick trunk derived from the aorta divides into several branches. In either case it is noteworthy that only a portion of these vessels enter the kidney at the hilum. Some may go to the extremi- ties, others penetrate the gland on its internal border a short distance above or below the hilum, and occasionally one may be seen passing to the external border. It is exceedingly important that the possible existence of such anomalous blood-vessels be borne in mind during the operation of nephrectomy, and that any which are present be secured. Patients have bled to death from such vessels which were not ligatured. Of the multiple arteries entering the hilum some pass in front of the ureter and some behind it. In general the veins correspond to the arteries. The right one is much shorter than the left, however, so that in removing the right kidney greater care must be taken not to injure the vena cava. Frequently two or three small veins lie behind the ureter. The blood-supply of the kidney and the relations of the structures in the hilum are shown in Plate XIX. The nerves are derived from the renal plexus. They enter the hilum upon the arteries. They communicate with branches of the spermatic plexus, a circumstance which may account for the pain which is referred to the testicle in certain diseases of the kidney. There are two sets of lymphatics, superficial and deep. The superficial set consists of two systems, one which perforates the 464 DISEASES OF THE KIDNEYS. fibrous capsule and empties into the perirenal lymphatics in the fatty capsule, and one which enters the substance of the gland to unite with the deep set. The channels thus formed emerge at the hilum and empty into the lumbar glands. The kidneys are covered by a fibrous capsule intimately adherent to the glandular substance. In addition thereto they are invested by the renal fascia and the fatty capsule. The renal fascia is a special portion of the retro-peritoneal con- nective tissue, which descending from the lower part of the dia- phragm, splits into two layers above the superior pole of the kidney, one passing anterior to the organ and the other posterior. The anterior layers of this fascia blend with one another over the lumbar vertebrae. The posterior layer on each side becomes attached to the vertebrae along the inner border of the psoas magnus muscle. By its attachment to the diaphragm above and the spine below, the renal fascia contributes materially to the fixation of the kidney. This fascia is stronger on the left side than on the right, being fortified by some fibrous bands remaining from the union of the descending mesocolon with the parietal peritoneum. Thus the left kidney is more intimately connected with the descending colon than the right kidney is with the ascending colon, a circumstance which perhaps may account for the less frequent displacement of the left kidney than of the right. (Fig. 209.) The fatty capsule is composed of lobulated adipose tissue, which is more abundant around the posterior surface of the kidney than it is in front, where it is almost always scanty and sometimes absent, so that the true fibrous capsule of the organ may be separated from the peritoneum only by the renal fascia. Posteriorly some of this fat is found on either side of the renal fascia. Although the fatty capsule may contribute somewhat to the fixation of the kidney, it is probably of less importance in this respect than it was formerly thought to be. The abdominal walls, the peritoneum and surrounding organs also afford some support, but it is the renal fascia which acts most power- fully in keeping the kidneys in position. The anterior relations of the two kidneys are different. The left one is in relation with the spleen, stomach, pancreas, descending colon and a portion of the small intestine. The right one is in relation with the liver, the duodenum, the ascending colon and also a portion of the small intestine. ANATOMY AND PHYSIOLOGY. 465 Posteriorly the kidneys are in relation with the internal and external arcuate ligaments of the diaphragm, the psoas, quadratus lumborum and transversales muscles. The relation with the diaphragm brings the kidneys into close proximity to the pleura. The twelfth rib Pleura phrenica. Diaphragma Capsula'adiposa renis. Glandula suprarenalis. Peritoneum. Capsula fibrosa renis. Fascia renalis. Colon descendens. Fascia iliaca. Musculus iliacus. Fig. 209. — Longitudinal section through the kidney, suprarenal gland and renal fascia. (Gerota.) crosses the posterior surface of the kidney, dividing it into a superior and an inferior segment, of which the latter is the larger. It is the upper segment which is in relation with the pleura, lying behind it and being overlapped by the costo-diaphragmatic sinus. These relations explain why a perinephric abscess may discharge itself into the pleural cavity, and also why an empyema is sometimes com- plicated by a perinephric abscess. In resecting the twelfth rib in operations upon the kidney care should be taken not to open the pleura. The experience of W. J. Mayo, A. J. Ochsner and others, however, show that this accident is not as serious as it was formerly thought to be. 466 DISEASES OF THE KIDNEYS. Behind the inferior segment the twelfth dorsal, ilio-hypogastric and ilio-inguinal nerves pass outwards and downwards. They are to be avoided when exposing the kidney through a lumbar incision. If the kidney be cut through from one border to the other its interior will be found to vary in appearance. Just within the hilum a cavity, known as the sinus, will be seen. The larger blood-vessels and the dilated extremity of the ureter, the pelvis of the kidney, as it is called, are contained in it. The pelvis is divided into two or three tubular portions, which subdivide into a number of branches known as calices. The sinus is surrounded by the substance of the kidney, which consists of two parts. The outer third of the organ, the cortex, is dark in color and is made up of two distinct structures, the medullary rays and the labyrinth, the latter separating the former from one another, and giving the cortical substance its striated appearance. The medulla is lighter in color than the cortex, and is made up of the Malpighian pyramids, separated at their bases for a variable dis- tance by the columns of Bertini, which are prolongations of the cortical substance. The apices of these pyramids project into the calices of the ureter, their openings being known as the papillary ducts. The cortex of the kidney contains the following structures: Within the labyrinth, the Malpighian corpuscles and the convoluted tubules; within the medullary rays, the upper ends of the descending and ascending limbs of Henle's loop and straight collecting tubules, and the arched collecting tubules. The Malpighian corpuscles are formed by a little cluster of arte- rioles, the glomerulus, surrounded by a delicate double membrane, called Bowman's capsule. The medulla of the kidney contains the lower ends of the descending and ascending limbs and the loop of Henle, the straight connecting tubules and the papillary ducts. Thus it is seen that the uriniferous tubules, beginning in the Malpig- hian corpuscles, have a very irregular course, passing from cortex to medulla, then back to the cortex only to return to the medulla and finally terminate in the papillary ducts at the apices of the calices. There are two principal theories of urinary secretion, namely, Ludwig's theory and Bowman's theory. EXAMINATION OF THE KIDNEYS. 467 Ludwig maintained that the urine is produced solely by the physical processes of filtration and diffusion. He believed that all the constituents of the urine — water, inorganic salts, and organic substances — -were filtered from the blood in the glomeruli, passing through them into the uriniferous tubules. Bowman assumed that the water and inorganic salts are produced in the glomeruli by a process of secretion, and that the organic con- stituents are produced by a special secretory power in the epthelium lining the convoluted tubules. Without entering into a discussion of the various experiments which have been performed to verify each of these theories, or the arguments which have been made in support of each of them, it may be stated that the weight of evidence seems to be in favor of Bowman's theory. That it does not entirely explain the process of urinary secretion will probably be admitted by all who are familiar with the literature of the subject. The chemistry of living tissues is yet obscure, and much remains to be demonstrated in reference to the vital processes by which secretions so complex as the urine are elaborated. For further reference to this subject the reader is referred to modern text-books and journals on physiology. GENERAL CONSIDERATIONS CONCERNING EXAMINA- TION OF THE KIDNEYS. The successful diagnosis and treatment of diseases of the kidneys must rest on an adequate determination of their structural and func- tional condition, and for this reason the most important points concern- ing the methods of examination will first be considered. The questions which arise in regard to diagnosis are: (i) What is the nature of the renal disease? (2) Is it bilateral or unilateral? (3) Which kidney is affected? (4) If one kidney only is diseased, is the function of the other sufficiently good to permit an operation, be it nephrotomy or nephrectomy, upon the diseased organ? Inspection is of little value; it does not enable the examiner to determine whether a second kidney is present, much less whether it is diseased. Percussion is equally unreliable. According to my experience nothing can be learned from it regarding the absence or condition of the kidney. Palpation is of greater value. It is practised in many ways. Bimanual palpation is employed with the patient in the dorsal posi- 32 468 DISEASES OF THE KIDNEYS. tion, the legs being slightly flexed and a deep breath being exhaled just as the examiner palpates (Turner, Litten). If the patient makes his abdomen tense palpation is of no use. Under these circumstances relaxation must be secured either by placing the patient in a warm bath or anaesthetizing him (Lennhof). In conjunction with palpation Guyon employs ballotement renal, a procedure in which the kidney is carried forward by means of short sharp blows upon the lumbar region, so that it can be more readily felt by the other hand laid flat upon the abdominal wall. Morris has the patient lie upon the sound side with the legs drawn up and the body slightly inclined to the front. In this position the intestines fall for- ward, the lumbar region sinks in, and the kidneys are more easily felt. Israel's method of examination is similar. Finally there is the procede de pouce recommended by Glenard. If the right side is to be examined the. fingers of the left hand are placed behind, over the loin, and the thumb in front, over the region of the kidney; then the loin is pressed upon by the fingers so that the kidney is pushed forwards where it can be felt through the abdominal wall by the other hand. These methods are all serviceable. It is well to combine them, using first one and then another. It must not be forgotten, however, that in many cases of diseased and enlarged kidney due to stone, tumor, tuberculosis, or other causes nothing can be felt. It is the same with very fat persons and also thin persons in whom the kidney lies under the arch of the ribs and cannot be forced down by deep inspiration. Moreover, a kidney of normal or increased size may be palpated and the examiner yet be unable to determine whether it is healthy or diseased. Finally there is great difficulty in deciding whether a palpable tumor is the kidney. It is sometimes impossible to differentiate an enlarged gall- bladder from the right kidney. On the left side the spleen may feel exactly like the kidney. So, too, when the colon is distended it often happens that little can be accomplished, for although this portion of the bowel usually lies over the kidney and behind the lower portion of the gall-bladder, when it is distended it may become adherent to neighboring structures, and the normal relations be so distorted that it may not lie over the kidney but be placed anteriorly to the gall- bladder. The modern method of examination with the Roentgen rays has not PLATE XX. Kidney, Renal Vessels, and Ureters. (Dea'ver.) EXAMINATION OF THE KIDNEYS. 469 added much to the diagnosis of renal disease. The only positive fact which has been learned from it is, that certain renal calculi, namely, those composed of oxalates and phosphates, and occasionally those formed of urates, make a visible shadow on the plate {see the chapter on renal calculi). Cystoscopy has afforded great advantages. It enables us to see the ureteral orifices, and in many cases to recognize that disease of one kidney is present; moreover, pus or blood may be seen issuing direct from the kidney. Of course, in those cases in which hematuria or pyuria is slight, the method cannot be relied upon, for slight turbidity of the urine from the kidney does not differ materially from that of the fluid present in the bladder. This defect has been supplied by ureteral catheterization. By introducing the catheter into the ureter it can be accurately determined whence the pus or blood has its source; it can be learned where the seat of the disease is, and whether one or both kidneys are affected. The exact nature of the disease will then be determined by the sum total of the clinical findings, which must be critically considered. One question will still arise: what can be stated concerning the functional capacity of the second kidney, when one has been found so diseased as to necessitate operation ? The anatomical diagnosis alone will not suffice to decide this question. For instance, let us assume that we are dealing with a tuberculous right kidney and that the urine coming from the left kidney is albuminous — now, then, is removal of the right kidney contraindicated ? Not at all, for the albuminuria may be merely the expression of a remediable toxic disturbance depending upon a very restricted amyloid degeneration. This degeneration becomes arrested and the remainder of the kidney will be preserved if the other tuberculous kidney is removed. On the other hand, clear urine free from albumen may be obtained from a contracted kidney. . If the tuberculous kidney should be removed in such a case, death would certainly follow the operation, whereas without operation the patient might live for years. In view of these circumstances we are led to conclude that it is equally important to determine the functional capacity of the second kidney. Will it alone suffice to maintain the vital functions ? Is it anatomically diseased? Some light has been thrown on these questions by the methods of functional examination introduced by myself and P. Fr. Richter. 47© DISEASES OF THE KIDNEYS. If a catheter be introduced into each ureter and the urine from each kidney simultaneously collected for a short time, it will be found that the quantity of urine secreted by the two kidneys is not always equal, but that the nitrogen content (N), the salt content, the molecular concentration ( ), and, if phloridzin (o.oi) has been injected hypo- dermatically, the quantity of sugar excreted from the two sides, will be approximately the same. As the last two are the most certain it is sufficient to measure their value. A = the freezing point, which represents the totality of molecules (without reference to their quality) contained in the urine, and the sugar artificially produced by the phloridzin and temporarily excreted by the kidneys. Phloridzin-diabetes lasts about three hours. The two following examples will serve as illustrations. Normal Case R. L. Quantity 36 cm. 3 35 cm. 3 A 0.50 0.50 Sugar 1.4% 1.4% N 0.213 0.206 Or Normal Case Quantity 22 cm. 3 20 cm. 3 A 0.9 1.0 Sugar 2.0% 2.0% It is seen that the figures of the two sides are approximately equal. It is important to know that the absolute figures do not express anything. A kidney which secretes water abundantly, for example after free drinking, may excrete 0.2% of sugar at one time and 2% at another after exactly the same amount of phloridzin has been injected. Only the comparative values have any significance. If, now, the function of one kidney be disturbed, less nitrogen will be excreted, fewer molecules will be elaborated from the blood, and less sugar will be produced than by the healthy kidney; therefore the figures representing the output of the diseased side are always lower than those of the healthy side. In cases of grave disturbance in which a considerable portion of the parenchyma of the kidney is destroyed, the freezing point of the urine from the diseased side is very low and sugar is entirely absent. A few examples may serve to illustrate this: EXAMINATION OF THE KIDNEYS. 471 1. Right Pyonephrosis R. L. Quantity 33.0 cm. 3 25.0 cm. 3 A 0.48 1.18 Sugar o 1.0 N 0.322% 0.782% 2. Left Renal Tuberculosis R. L. Quantity 16 cm. 3 10 cm. 3 A 1.5 °- QI Sugar 2.0 0.05 N 0.63 0.385 In this manner we obtain a picture of the functional power of the second kidney, and are in a position to decide, after carefully weigh- ing all the circumstances and results obtained by other methods of examination, whether an operation is permissible. If several examinations after phloridzin injections show that sugar is not excreted, and the undiluted urine is found to have a low freezing point, the kidney is functionally incapacitated. Removal of the other kidney might be followed by uraemia and death. On the other hand, the presence of pus in the urine from the kidney which is not to be operated on does not contraindicate operation if it has a high freezing point and shows a considerable quantity of sugar after the injection of phloridzin. Such a finding would show that, although the kidney or its pelvis is diseased, its functional power continues to be good. It is obvious that it may sometimes be difficult to fix exact limits, and that there is no absolute protection afforded against failure of the remaining kidney. Experience has already shown and will show further that deaths from renal diseases are becoming less frequent. Our aim will be to ascertain to what extent the condition of the remaining kidney as shown at autopsy corresponds to the previously made diagnosis and prognosis. It would exceed the scope of this book to enter into this matter in detail. It will suffice to state that the results have been accepted as correct by the best clinicians and recognized as the foundation of a precise method of renal diagnosis. The exception taken to them by a few authors cannot alter their value at all, since our experience is derived from hundreds of cases, while theirs is based upon only a few exceptional instances. Exceptions always occur, and, as is well known, prove the rule. 472 DISEASES OF THE KIDNEYS. For more detailed information concerning this question the reader is referred to the monograph on Functional Diagnosis of Kidney Diseases by the author and P. F. Richter, and also to various articles which have appeared in the medical journals and archives during the last few years. [Among other tests devised for determining the functional capacity of EXAMINATION OF THE KIDNEYS. 473 the kidney may be mentioned cryoscopy of the blood and chromo- cystoscopy. In regard to the former it is probable that the freezing point of the blood is influenced by many other and undeterminable causes aside from the action of the kidney. Chromocystoscopy is of no value in showing the functional capacity of the kidney. It is useful, however, for finding the orifices of the ureters when they cannot be plainly seen. Various urine segregators have been devised for the purpose of obtaining the urine separately from each kidney without invading the ureters. They are of two kinds, one attempting to form a water-tight Fig. 211. — Segregator attached to its support. (Hartmann.) septum between the two ureteral orifices which shall completely divide the bladder, and the other designed to elevate the posterior vesical wall, by means of an instrument introduced into the rectum, so as to convert it into a longitudinal fold which shall separate the bladder between the ureteral orifices. Of the former kind are the instruments of Luys (Figs. 210, 211, and 212) and Cathelin, of the latter those of Neumann and Harris (Fig. 213). That these instruments afford the accurate results offered by catheter- ization of the ureters is greatly to be doubted. In a paper read at the surgical congress in Berlin, in 1905, Prof. Casper showed that the mortality of renal operations has fallen from 474 DISEASES OF THE KIDNEYS. Fig. 212. — Section of the pelvis showing the segregator in position. (Hartmann.) Fig. 213. — Harris's segregator. MALFORMATIONS AND DISPLACEMENTS OF THE KIDNEYS. 475 26.9% to 17.4% in the last ten years. He attributes this decrease largely to improved methods of diagnosis.] CONGENITAL MALFORMATIONS AND DISPLACEMENTS OF THE KIDNEYS. Congenital absence of a kidney is a rare condition, but nevertheless it is one which has to be considered from a practical point of view. Another malformation comparable to this one is the rudimentary kidney, which is due to an arrest of development of the organ; such a kidney is entirely devoid of functional activity. Absence or arrest Fig. 214. — Horseshoe kidney with broad isthmus. (Anterior view.) Fig. 215. — Horseshoe kidney with broad isthmus. (Posterior view.) of development of one kidney may be the only malformation, but frequently others are present. They particularly affect the genitalia, atrophy of the testicle and atrophy or absence of the seminal vesicle on the same side often being found. The occurrence of supernumerary kidneys is not fully recog- nized by Kiister. He is of the opinion that the condition is generally one in which there are two kidneys with multiple pelves and ureters. If the condition of fcetal lobulation persists in later life the term foetal kidney is applied to it. The fcetal kidney is characterized by its special predisposition to tuberculosis. If the poles of both kidneys are grown together the organ thus consti- tuted is known as horseshoe kidney (Figs. 214 and 215). Most fre- 476 DISEASES OF THE KIDNEYS. A Fig. 216.— Displacement of the left kidney into the hollow of the sacrum A. Aorta. A.r.d. Right renal artery (double). R.d. Right kidney u.r. Right ureter. V.r.s. Left renal vein. A.s.r. Right suprarenal artery A.r.s. Left renal artery. R.s. Left kidnev. u.s. Left ureter. (Rayer.) MALFORMATIONS AND DISPLACEMENTS OF THE KIDNEYS. quently it is the lower poles which are grown together, so that the concavity is above. The upper poles may be united, with the result that the concavity is directed downwards. The kidney is usually deeply placed. The bridge of union consists either of a fibrous cord or of kidney tissue. It is interesting to note that in this condition the number of ureters and renal vessels are much in- creased. Again, both kidneys may be fused into a single disc-like mass having indentations on the border and lying in the median line and at a much lower level than the normal organ. To this malformation the Germans have given the name Kuchenniere. The term dystopia is applied to con- genital displacement of the organ. Dis- placements occur principally in association with the previously mentioned malforma- tions, but a normal kidney may also be displaced. They are more common on the left side. The kidney may lie upon the lower lumbar vertebrae (pelvic kidney) ; once I found it on the sacrum. The ureters are shortened (Mullerheim). By establishing this fact by means of ureteral catheteriza- tion and the other considerations apposite to the case, Mullerheim was able in several instances to diagnosticate this condition during life. The renal arteries arise from the common iliac, the external iliac and the femoral (Fig. 216). Displacement of the pelvis of the kidney may occur in an organ otherwise normally placed, the pelvis being at the anterior sur- face instead of at the mesial border. Very interesting and of practical import- ance as well is the occurrence of two renal Fig. 217. — Double kidney and ureter. Kidney has been sectioned. (Rayer.) 478 DISEASES OF THE KIDNEYS. pelves. The ureters issuing from them may unite at a greater or less distance below their origin or empty into the bladder separately (Figs. 217 and 218). A good specimen of a kidney having two ureters and affected with pyonephrosis is shown in Fig. 219. The ureter may be wanting in cases in which the kidney is absent. In rudimentary kidney it is more common for the ureter of the cor- responding side to end as a blind sac extending either above or below. Fig. 218. — Kidney of a new-born child with two ureters and four ureteral orifices. (Rayer.) It is not very unusual for the ureters to open in an abnormal place. In the bladder they may lie either toward the midline or lateralwards, or be displaced posteriorly. In rare cases the orifice has been known to open into the posterior urethra near the caput gallinaginis. The most unusual condition of all is union of the ureter with one of the seminal vesicles, the vas deferens, or the ejaculatory duct. Finally MALFORMATIONS AND DISPLACEMENTS OF THE KIDNEYS. 479 the ureter may present variations in respect to length and width. The last is the most important. There are points of predilection for ureteral strictures ; one such is the line of transition between the pelvis of the kidney and the ureter, a place where kinking of the ureter also frequently occurs; the other point is where the ureter enters the bladder. In addition to narrowing Fig. 219. — Pyonephrosis of a kidney having two ureters. of the ureter, duplicature of the mucous membrane may take place and simulate stricture, and also give rise to the same symptoms. These duplicatures may have their seat in any portion of the ureter. 480 DISEASES OF THE KIDNEYS. CIRCULATORY DISTURBANCES OF THE KIDNEYS. HYPEREMIA. Hyperemia of the kidneys may be active or passive. Active hyper aemia occurs as a result of increased cardiac action or because of distention of the renal vessels due either to beginning inflamma- tion or to faulty innervation. Therefore it is merely a sequel of other disorders. Passive hyperaemia (engorged kidney) develops as the result of general or local circulatory obstruction. In valvular disease of the heart, myocarditis and endocarditis the propulsive power of the heart becomes diminished after compensation fails, so that the distention of the arteries is lessened, while that of the veins is increased. Any condition which increases intra-abdominal pressure, thus hindering the outflow of blood from the abdominal organs and thereby giving rise to localized engorgement of the kidneys, may be considered as another cause of this disease. Among the causes which act in this way may be mentioned pregnancy, abdominal tumors and severe meteorism. A high degree of local venous stasis also occurs when- ever the inferior vena cava becomes obstructed at any point above the renal veins, or when the veins themselves are partly or entirely occluded. Such an occurrence may be due to thrombi or inflam- mation of the vessels, or to tumors which encroach upon them from without. The anatomical changes which take place in the kidney of passive hyperaemia are fairly well pronounced. The interstitial veins and capillaries, which are swollen and turgid, press upon the uriniferous tubules and crowd them together, while in Bowman's capsule and the intertubular spaces small haemorrhages take place; some of the glom- eruli are also much distended. Hyaline casts are observed in the uriniferous tubules and albuminous exudate in Bowman's capsule. If the stasis continues cyanotic induration of the kidney results. The capsule is thickened and adherent and strips off with difficulty; the epithelium is granular and fatty, the glomeruli are contracted or obliterated, and the interstitial tissue between the uriniferous tubules and vessels is increased. Symptoms. Passive congestion of the kidney when caused by general venous stasis presents the signs and symptoms of general circulatory engorgement; namely, cyanosis, dyspnoea, cardiac and HEMORRHAGIC INFARCT OF THE KIDNEY. 48 1 respiratory disturbances, pleural or mediastinal disorder, gastric catarrh, and enlargement of the liver. When the engorgement is merely local these phenomena do not occur. In either case, however, the urine shows characteristic changes, which are as follows. The total amount voided in twenty-four hours is less than normal; the specific gravity is increased, for the reason that the elimination of solid elements is not decreased in the same degree as is the excretion of fluid; the reaction is strongly acid and turbidity due to precipitation of urates is not uncommon. With increasing stasis albuminuria develops and hyaline casts are found, although both red and white corpuscles are absent, or present only in very small numbers. Dropsy supervenes, or if it were already present increases in severity. During the period of transition from the stage of engorgement to the stage of contraction the urine becomes cleared, although the other symptoms of obstruction remain the same. From chronic nephritis passive hyperemia may be easily differentiated by the mode of devel- opment, by the character of the urine (absence of blood), and especially by the fact that passive hyperemia may almost always be traced to heart disease, while heart disease resulting from chronic nephritis is very rare. The treatment should be directed, if possible, to the removal of the underlying cause. An endeavor should be made to restore the broken cardiac compensation, and for this purpose the administration of such drugs as digitalis, strophanthus, squill, camphor and caffeine is in- dicated. Dropsy is to be treated in accordance with established principles. HEMORRHAGIC INFARCT OF THE KIDNEY; THROM- BOSIS AND EMBOLISM OF THE RENAL ARTERIES. If the flow of arterial blood in the kidney is checked, a condition results to which the name of hcemorrhagic infarct has been given. This arrest of circulation may be caused by spasm of the vessels, which narrows or occludes the main branches of the renal artery, or it may be produced by thrombi or emboli which occlude these vessels. An arterial thrombosis resulting from disease of the vessel- wall, such as endarteritis or arteriosclerosis, is very rare. It usually results from displacement of clots or inflammatory products from the left side of the heart or aorta, or from particles of tumor which gain access to 3.3 482 DISEASES OF THE KIDNEYS. the renal blood-current and are carried to the vessels of the glomeruli or other capillaries. The infarct forms a gray or whitish wedge which is surrounded by a haemorrhagic area. In the center of the wedge coagulation necrosis develops, the epithelium of the glomeruli losing its nuclei and being destroyed. This results from the cutting off of the blood supply, which is due to occlusion of the terminal renal vessels by emboli; the accessory vessels, those of the ureter and capsule of the kidney, are. not sufficient to maintain the nutrition. The reddened border contains vessels filled with blood. The infarct finally becomes con- verted into scar-tissue. The diagnosis of haemorrhagic infarct cannot often be made. In order to make even a probable diagnosis a cause for emboli must be demonstrated after the occurrence of sudden pain in the lumbar region and the finding of albumen, blood and other morphotic ele- ments in the urine. DIFFUSED HEMATOGENOUS NON-SUPPURATIVE INFLAM- MATION OF THE KIDNEYS (BRIGHT'S DISEASE). As numerous terms are met with in the literature on Bright's disease, such as acute, chronic, parenchymatous, interstitial and desquamative nephritis, glomerulo-nephritis, genuine and secondary contracted kidney, it is necessary first of all to obtain an adequate conception of the conditions to which the term Bright's disease itself should be applied. It is applicable only to those affections in which the primary morbid process, caused by irritation of the altered blood, expresses itself as an inflammation involving all the tissues of both kidneys. There is not, as was formerly supposed, a purely parenchymatous form in which the epithelial elements only are affected, nor a strictly interstitial variety in which nothing but the interstitial tissue is the seat of disease. In all forms, in both the acute and chronic, but particularly in the latter there is a diffuse process which has its origin in the parenchyma and extends to the interstitial tissue, or, conversely, one which begins in the interstitial structure and later encroaches upon the epithelial portion of the organ. The most that can be said in regard to this matter, is that according to the nature of the irritating substance producing the inflammation, the parenchyma will be affected in one case and the interstitial struc- ACUTE DIFFUSE NEPHRITIS. 483 ture containing the blood-vessels in another. So likewise from the clinical standpoint it can only be said that this or that tissue is pre- ponderantly affected, and not that one is exclusively involved. Weigert's investigations have abolished this artificial classification of inflamma- tions of the kidney and proved that the process is always diffuse. This does not mean, however, that every diffuse process affecting both kidneys is a nephritis. Thus, those affections resulting from circulatory disturbances and degeneration of the vessels, such as passive hyperemia and amyloid degeneration, for example, are not to be considered as nephritis. It is self-evident, however, that those processes which are localized instead of diffuse cannot be included under the term. The diseases of the kidneys in which there are foci of suppuration, and which constitute the so-called suppurative met- astatic nephritis, rightly belong in this category. Accordingly, it is the object of this chapter to describe acute and chronic nephritis, and as a subdivision of the latter the special form known as contracted kidney. ACUTE DIFFUSE NEPHRITIS. Etiology. Inflammatory processes of the kidney depend upon a morbid condition of the blood, which in turn may be due to morbific agents of various kinds. These substances are carried to the kidneys by the blood, are excreted, and in their progress through the blood- vessels and epithelium exert an injurious or destructive influence. This toxic-hasmatogenous origin explains the circumstance that both kidneys are diseased and that the disease is diffused throughout the entire organ. Unilateral nephritis in the sense that the term nephritis is used here, and, moreover, as it is generally accepted, is a condition which I have never seen, and did it exist I naturally would have soon encountered it in the numerous examinations which I have made of both kidneys by means of ureteral catheterization. Furthermore I do not believe in inflammations of this type which affect only one pole of the kidney. It is true, however, that there are differences in degree, character and extent of the inflammatory processes. These are no doubt due to the circumstance that healing takes place more rapidly in some parts than it does in others, and that the involve- ment of the blood-vessels is not uniform throughout the kidney. In regard to the nature of these toxic substances, it must be admitted 484 DISEASES OF THE KIDNEYS. that we have not yet succeeded in finding out enough about them to state that the development of all the forms of nephritis is explained. The acute forms in which well-defined chemical poisons reach the body and are excreted by the kidneys are the ones which are best understood. To this class belong the cases of acute poisoning by the mineral acids, corrosive sublimate, carbolic acid, cantharides, potassium chlorate, the aniline preparations externally employed, extensive burns, etc. In like manner it must be assumed that in the acute infectious diseases certain toxins are formed in the blood which produce disease in the kidneys. It is well known that scarlet- fever, septicaemia and diphtheria may give rise to severe nephritis; the same is true in lesser degree of pneumonia and erysipelas and even more rarely of typhoid fever. It is worthy of note that these sequelae may first manifest themselves at a very late period. Thus may be explained the many cases of nephritis in which no previous malign influence can be demonstrated. It is only too probable that in many of these cases there has been an undetected infection, for example, a slight inflammation of the throat, which although producing only trivial local disturbance nevertheless gave rise to the formation of toxins with consequent serious sequelae. There- fore it need not be denied that exposure to cold and wet, as was formerly supposed to be the case, may cause nephritis, provided that we are inclined to consider it as a factor contributing to the development of inflammation insofar as it favors increase in the number of microorganisms circulating in the blood and impels them to assume unwonted activity. Pathological Anatomy. The macroscopic appearance of the kidney varies. It may be of normal size although it is more often enlarged; in consistency it is soft, flabby and fragile; the surface is smooth; the color varies from pale red to dark red, the tissue here and there showing punctate or striate areas of deeper hue, which are due to haemorrhages ; the cortex is broadened and the glomeruli stand out as red or pale granules. Microscopically haemorrhages into the capsule of the glomeruli and uriniferous tubules are detected. Cloudiness and swelling of the epithelium of the uriniferous tubules and glomeruli, small-celled infil- tration of the connective tissue, thickening of the walls of the vascular loops, swelling of the nuclei of the epithelial cells, together with a ACUTE DIFFUSE NEPHRITIS. 485 crescent-shaped rim of coagulative albumen containing the detritus of the glomerular and capsular epithelium, will also be observed around the vascular loops. Although these changes affect the entire substance of the kidneys, any one portion may be particularly involved. When the parenchyma is chiefly affected the condition is spoken of as parenchymatous neph- ritis, or to be more exact, as tubular nephritis when the tubules bear the brunt of the disease, and as glomerulo-nephritis when the glomeruli are principally involved; if the morbid changes in the interstitial tissue are also conspicuous, then the process is known as diffuse nephritis. Symptoms. It is of the utmost importance for the physician to know that acute nephritis often begins without fever. When a patient complains of general weakness, gastro-intestinal disturbances such as constipation, loss of appetite, nausea and vomiting, suspicion should be aroused that renal disease may be threatening or already be developed, especially if there is a history of a malady or circum- stances which are known to be capable of affecting the kidneys. Alterations of micturition, changes in the urine, and signs of dropsy make an established nephritis manifest. The urine is voided more frequently, is diminished in quantity, and is of higher specific gravity. In color it is dark or red, resembling the juice of raw meat. It contains albumen in quantities varying from o.i to i.%. Under the microscope it shows red blood-corpuscles, mononuclear and polynuclear leucocytes, casts of all kinds — hyaline, epithelial, blood, bacterial — cylinders composed of inorganic salts, and renal epithelium which is often filled with fat-globules. The signs of dropsy usually show first in the face, beginning in the eyelids, then extending downwards and finally involving other parts of the body; it is characterized by its diverse character (oedema of the feet and legs, oedema of the scrotum, hydrothorax and hydropericardium). Gastric disturbances, especially vomiting, are often the precursors of uraemia. Inflammations of parenchymatous organs and their serous coverings are frequent and dangerous complications of acute nephritis. Thus pneumonia, pleuritis, pericarditis, and peritonitis may occur. Most cases of acute nephritis pursue a favorable course and one which is quite independent of the underlying causative affection. In cases of severe poisoning in which there is serious involvement of other organs the prognosis is of course less favorable. A fatal termina- 486 DISEASES OF THE KIDNEYS. tion, however, is rare. The duration of the disease may extend over months. If after three, or at the latest six months, the symptoms have not disappeared chronic nephritis almost invariably results. It is only in exceptional cases that complete cure is obtained when the disease is prolonged beyond this period. Treatment. Prophylaxis is of the utmost importance. Acute nephritis can often be prevented by avoiding the use of such drugs as are known to exert a toxic influence upon the kidneys. Patients suf- fering from an acute infectious disease may also be saved from renal complications by careful attention. They should not be allowed to get out of bed too soon, for the bodily effort which they then are forced to make, together with the possible exposure to cold, are injurious factors in their cases. Free elimination of toxins should be secured by the administration of diluents and the use of large quantities of carbonated waters. In a disease which cannot be cured by drugs the indicatio causalis plays a great role. Rest in bed, a bland diet, large quantities of milk, and warm baths are the chief measures to be employed. For severe pain over the lumbar and sacral region the withdrawal of blood, dry cups, or Priessnitz's compresses are advantageous. If severe bleeding occurs a styptic such as ergot, tannic acid, or the solution of sesqui- chloride of iron may be prescribed. CHRONIC NEPHRITIS. As the duration of acute nephritis is indefinite a sharp boundary- line cannot be drawn between it and chronic nephritis. Therefore transition forms, subacute and subchronic nephritis, are sometimes spoken of. The same malign influences which are recognized as the causes of acute nephritis, if long continued, may lead to the chronic form. As in the former, so in the latter, the noxious substance is always carried to the kidneys by the blood-stream, whether it be a drug introduced from without or a toxin generated within the body. The most common of these substances are alcohol and lead. Alcohol may act directly by its irritating influence, or it may lessen the resisting power of the tissues, as a result of which the kidneys can no longer perform the work which they were wont to do without injury; or finally alcohol may produce disturbance of the vessels (arterio- sclerosis) and thus lead to renal disease. CHRONIC NEPHRITIS. 487 Lead acts in the same way. The form most frequently met with in saturnine intoxication is chronic contracted kidney. In many cases both of these poisons, alcohol and lead, are responsible for the develop- ment of the disease. Owing to the gradual evolution of the malady it may, and in fact often does happen, that no cause can be determined. In such cases it must be assumed that many slight infections, such as sore throat for instance, which are scarcely noticed and at all events are forgot- ten, are the causative factors, although the resulting nephritis does not manifest itself until a time when a cause for its presence can no longer be found. Furthermore there are two diseases of metabolism in which chronic nephritis occurs either as a sequel or as an associated phenomenon, namely, gout and diabetes mellitus. So, too, arteriosclerosis may be recognized as a frequent cause of contracted kidney. Besides these exogenous forms of nephritis, cases of genuine contracted kidney occur in comparatively young persons which we must assume with Striimpell to be due to congenital constitutional weakness of the renal tissues, as the result of which the process of metabolism cannot be maintained. This hypothesis of renal weakness finds support in the well-known cyclic albuminuria, which occurs only when the patient is up and about or after severe exertion (Leube). Symptoms. That which is most characteristic of this form of nephritis is the presence of albumen and casts in the urine. It must be borne in mind, however," that there are renal inflammations (con- tracted kidney and amyloid disease) in which both of these pathogno- monic elements are absent. Without albumen and casts a diagnosis of nephritis cannot, as a rule, be made. Whilst in health the renal epithelium excretes only the products of destructive metabolism, in nephritis it is so injured that it allows albumen, a substance useful to constructive metabolism, to escape. The excretion of albumen has also been considered as an inflam- matory exudation from the renal tissues, the exudate being composed of blood-serum, and leucocytes which have migrated through the walls of the blood-vessels, and which become mixed with the urine. The casts are either exudation products, being formed by coagula- tion of the albumen exuded from the blood-vessels, or they develop from the union, fusion and degeneration of epithelial cells cast off from the uriniferous tubules. 488 DISEASES OF THE KIDNEYS. In addition to casts white and red blood-cells are also encountered. The former migrate from the blood-vessels, the latter reach the urin- iferous tubules either by diapedesis or as the result of capillary haem- orrhage. Furthermore, renal epithelium is found, the cells being somewhat larger than leucocytes, having large nuclei, and often showing fatty granules. Leucocytes may also take up granules of fat. If the kidneys fail to excrete the products of retrograde metabolism, the retention of these substances in the blood soon makes itself apparent in the condition of the general health. The diminution in the excretive power of the kidney cells, in other words, the accumulation Of injurious substances in the blood, puts more work upon the heart, since it functionates more actively in an endeavor to flush the kidneys and thereby purify the blood. The expression of this increased work of the heart is a rise in arterial blood-pressure, increased tension of pulse, accentuation of the aortic second sound, hypertrophy of the left ventricle, and occasionally of the right as well. These cardiac changes are plainly shown by increase in the area of cardiac dullness toward the left (and also occasionally to the right) and abnormal accentuation and resist- ance of the apex-beat. As long as this augmentation in cardiac activity can prevent the accumulation of the toxic material in the blood, the term compensated renal disease, introduced by Strumpell, may be correctly used. Among the general symptoms uraemia may be first mentioned ; it is due to the accumulation of urinary elements, but what the exact nature of the poison is we do not know. The intoxication manifests itself by uremic hemiplegia, epileptiform convulsions, amaurosis, headache, vomiting, dyspnoea, stupor, convulsions and coma; coma generally supervenes gradually, but it may develop suddenly. Another expression of the toxic substances circulating in the blood is the occurrence of degenerative changes in the mucous membrane of the stomach, intestines and respiratory organs, and in the pleura, pericardium and retina. Thus gastritis, enteritis, bronchitis, pneu- monia, pleuritis, pericarditis and retinitis are not uncommon affec- tions in those afflicted with nephritis. It has not been positively determined whether dropsy is a result of nephritis, or whether the same poisons which produce the nephritis also give rise to changes in the blood-vessels leading to the development PLATE XXI / V* 1 'vS/ y 4 V LARGE WHITE KIDNEY, NATURAL SIZE. (DRAWING MADE FROM SPECIMEN IN THE MUSEUM OF THE JEFFERSON MEDICAL COLLEGE i CHRONIC NEPHRITIS. 489 of dropsy. It is characteristic for the subjects of nephritis to have localized oedema (for instance that affecting the face, eyelids, wall of the thorax and pleural cavities) in contradistinction to general dropsy such as occurs in cardiac disease, and which first manifests itself in the dependant portions of the body, for instance, the ankle-joints. The disturbances in the blood-vessels may also give rise to haemorrhages from the most diverse parts of the body — the nose, the intestines, the brain. If it seems from what has already been stated that the clinical picture of chronic nephritis is so characteristic that a diagnosis can be made without difficulty, the question will yet arise as to whether we are in a position to decide which form of nephritis predominates, a question which is of importance from the standpoint of prognosis and expectation of life. As the various causes of nephritis produce the same structural changes it is not desirable to classify the disease according to its eti- ology, but rather according to its pathological anatomy, especially since the clinical phenomena are essentially dependent upon the anatomical changes. Weigert has established the unity of the different forms of nephritis and shown that the differences in the anatomical picture, as in the clinical, are merely in the magnitude, rapidity of development and extent of the morbid process. For example, if the poison works with great intensity in equal degree upon all parts of the parenchyma, chronic diffuse nephritis develops; if the malady progresses slowly and the destruction of the parenchyma consequently takes place gradually, and in patches, genuine contracted kidney results. In diffuse nephritis, owing to the swelling of the epithelium and the serous infiltration of the tissues, the kidney is enlarged and swollen; it looks red when the blood-vessels are equally distended, pale and yellow if the epithelium is fatty, variegated if infarcts are interspersed among the fatty portions. In accordance with these changes a haemorrhagic, a large white fatty, and a large variegated kidney are spoken of. There is never a genuine chronic parenchymatous nephritis, for wherever there is extensive destruction of renal epithelium there is likewise an increase of interstitial connective tissue, and this can be demonstrated early in the course of the malady. If the process advances slowly the kidney remains large for a certain length of time, perhaps 4QO DISEASES OF THE KIDNEYS. for years; the contraction which the newly formed connective tissue produces ensues very gradually, but results in the secondary con- tracted kidney with its granular surface. This kidney becomes con- stantly smaller and smaller. If the disease comes on very insidiously the parenchymatous changes do not occasion any enlargement of the organ, but the genuine con- tracted kidney with its granular, nodulated surface is slowly produced * "•'•*• * 1_1„ • • * » 1 \.>v. 1,1 ' -tfS-« Sf Fig. 220. — Chronic parenchymatous nephritis, a. Malpighian tuft containing an unusually large number of nuclei, b. b. b. Points at which there is slight in- crease in the interstitial tissue, c. Tubule containing granular, degenerating, epi- thelial cells, which have coalesced, d. Tubule from which all the epithelium has desquamated and been discharged, e. Blood-vessel. (Coplin.) without any intervening symptoms' of severe disease of the epithelium being present. It may be either hyperaemic, the red contracted kidney, or anaemic, the white contracted kidney. The presently accepted opinion as to the unity of the pathic process makes it seem desirable to me to differentiate, in common with Strumpell, the following forms of chronic nephritis. 1. The diffuse subchronic and chronic forms, which generally cause PLATE XXII CHRONIC INTERSTITIAL NEPHRITIS. (DRAWING MADE FROM SPECIMEN IN THE MUSEUM OF THE JEFFERSON MEDICAL COLLI CHRONIC NEPHRITIS. 491 enlargement of the organ; their subdivisions are: (a) simple diffuse parenchymatous nephritis: large red kidney; (b) parenchymatous nephritis with pronounced fatty degeneration of the epithelium: large white kidney; (c) diffuse parenchymatous nephritis with haem- orrhages: large variegated kidney. 2. The later stages of diffuse parenchymatous nephritis with beginning contraction; the kidney is of normal size, or already some- what smaller than in health; this is the secondary contracted kidney. 3. The genuine contracted kidney. 4. The arteriosclerotic contracted kidney. Examination of the urine affords the best means of distinguishing these forms clinically. In diffuse chronic parenchymatous nephritis Fig. 221. — Chronic interstitial nephritis. A. Part of capsule. B. Malpighian body showing advancing granular and hyaline changes with marked thickening of the capsule. C. C. C. Tubules in the midst of newly formed connective tissue; epi- thelium wasted or absent and tubular wall notably thickened. The larger tubes on the left and below are somewhat dilated. (Coplin.) there is a diminution in the excretion of urine, the same as there is in the acute form; the quantity may fall to8ooc.c. [about 26 fluid ounces] or even less; the specific gravity is high, ranging from 1015 to 1020; there is a considerable quantity of albumen, casts of all kinds, and an abun- dance of whitejand red blood-cells and epithelium. Numerous blood- 492 DISEASES OF THE KIDNEYS. casts indicate capillary haemorrhages; fatty casts and fatty granular cells are signs of marked fatty degeneration of the epithelium of the uriniferous tubules. This condition of the Urine is nearly identical with that which obtains in acute nephritis, because the morbid process, though differing in its duration, is essentially the same in character. A further dif- ferentiation is afforded by the general manifestations of the disease, the associated conditions, and the sequelae. These consist in oedema of the subcutaneous connective tissue, collections of fluid in the serous cavities, uraemic symptoms such as headache and vomiting, retinitis, and hypertrophy of the heart, particularly of the left ventricle. The duration of the disease may extend over years. The patient may succumb at the end of a year or two, or the intense phenomena due to inflammatory and degenerative changes subside, and secondary contracted kidney develop. Such a remission may be mistaken for cure, although in reality the disease is slowly progressing. Cure may occur during the first months and perhaps even after a year. If the albumen still persists at the expiration of this period, the development of contracted kidney must surely be expected. The clinical picture of genuine contracted kidney is also different. The slowly progressive process is such that the organism's power of resistance has time to establish compensation, and as a result of this there is neither marked diminution in the quantity of urine nor a marked excretion of albumen. On the contrary, polyuria is usually present, two or three liters of urine of low specific gravity (1005 -ioio), containing but little albumen and few formed elements, being voided in twenty-four hours. The increase in the quantity of urine will be un- derstood if it is assumed that arterial pressure is already raised before any considerable injury to the secretive structures in the parenchyma occurs. The general symptoms and sequelae are quite in accord with the urinary findings, being very slight, in fact often so trivial that the disease may remain unnoticed for years. Headache and disturbances of vision not uncommonly lead to its discovery; later in its course dyspnoea due to cardiac insufficiency, weakness, loss of appetite, emaciation and pallor manifest themselves. (Edema is often wanting or occurs late in the disease. It is an expression of cardiac rather than renal insufficiency. Therefore it affects the dependant portions of the body, the legs and ankles. CHRONIC NEPHRITIS. 493 In case the circulatory disturbances gain ascendancy over the renal, the clinical picture is converted into one of uncompensated cardiac disease; the urine is modified by the circulatory engorgement, being small in quantity, of a deep color, a high specific gravity, and contain- ing much albumen; dyspnoea is also present. Signs of uraemia may be entirely absent, may come on suddenly, or may develop gradually. In the advanced stages of the disease complications affecting other organs are very common. Among them may be mentioned cardiac disease, hypertrophy and cirrhosis of the liver, arteriosclerosis, bron- chitis, and gout. The arteriosclerotic contracted kidney presents the same clinical picture as the genuine contracted kidney. The urine is pale and of low specific gravity, and polyuria and hypertrophy of the heart are present; the symptoms referable to the heart and vessels are more pronounced than those produced by the renal lesions. Arteriosclerotic nephritis may be co- existent with general arterio- sclerosis, the toxins simultaneously causing disease of the kidneys and blood-vessels; it may be a result of renal disease, the vessels being injured by changes in the blood depending upon faulty action of the kidneys; and conversely, the arteriosclerosis and obliteration of the smaller renal vessels may interfere with the blood-supply of the par- enchyma and bring about necrosis. This condition is typical in old age. The prognosis of chronic nephritis is unfavorable. The more diffuse the morbid process the sooner will dropsy, uraemia and other compli- cations ensue and produce death. The transition into secondary contracted kidney is relatively favorable, as it leads to an apparent arrest of the disease, the general condition and functional capacity of the body often being such that they leave little to be desired. The anatomical changes may progress so slowly that complete destruction of the organ does not take place for years. Therefore, although every contracted kidney shortens life, the patients may live from ten to twenty years. The therapeutic measures at our command have already been men- tioned under acute nephritis. Prophylaxis is important. Everything known to injure the kidneys, for instance, certain drugs and alcoholic beverages, should be avoided. Care should be taken to prevent contraction of the infectious diseases, and exposure to cold should be guarded against. Furthermore regulation of the diet is important. 494 DISEASES OF THE KIDNEYS. It should be unirritating, consisting of milk, vegetables, farinaceous articles and little meat; highly seasoned food, spices and alcohol are to be interdicted. The patient should be warmly clad and obtain as much fresh air as possible; it is also desirable that he should reside in a warm climate. The skin should be kept active by two or three warm baths every week and brisk rubbing with cool water or spirits. I know of no drugs which influence the process favorably. For dropsy diuretics such as potassium acetate and diuretin, together with sweating [the hot pack] may be employed; for cardiac insufficiency digitalis, strophanthus, and small doses of morphine; for chronic uraemia antipyrin and phenacetin; for acute attacks chloral, chloroform, and venesection. [In cases of chronic contracted kidney associated with high arterial tension and a greater or lesser degree of general arterio- sclerosis, I get good results from the use of nitroglycerine in ascending doses. It is my practice to begin with y^- of a grain four times a day and increase gradually as the patient becomes accustomed to the drug and the latter begins to lose its effect. For the anaemia of chronic nephritis Basham's mixture, in the dose of two or three drachms three times a day, will be found useful. It acts both as a tonic and a diuretic. In uraemia the hot pack and free purgation with calomel may be employed in addition to the measures already mentioned ; and hypodermoclysis or venous infusion of normal saline solution may be used in conjunction with blood-letting.] THE NEPHRITIS OF PREGNANCY. By the term "nephritis of pregnancy" is understood an affection of the kidneys caused by the gravid state, but which is not generally recognized as being inflammatory in character. It does not manifest itself before the third month of pregnancy, and its development is to be explained by assuming that there is an accumulation of toxic products in the blood ; owing to the disturbed condition of the circulation these substances are not properly excreted. Thus there is a faulty elimina- tion and the resulting toxaemia causes the inflammation. The nature of these toxins has not yet been determined. The kidney of pregnancy is pale. There is extensive fatty degen- eration of the epithelium and the convoluted tubules. The clinical symptoms usually consist in cedema, dropsy, and changes in the urine similar to those occurring in acute nephritis. The quantity is dimin- ished, the specific gravity high, and the amount of albumen considerable, AMYLOID DEGENERATION OF THE KIDNEY. 495 although, as a rule, organized elements are not so abundant as in acute nephritis. There are cases in which casts are entirely absent through- out the course of the disease. The disease occasionally has a rapidly fatal termination, but more commonly recovery takes place, the patient regaining health soon after delivery. Convulsions occurring before or during labor seriously threaten life; they constitute the condition known as eclampsia of pregnant or parturient women [commonly called eclampsia of preg- nancy]. It is a condition concerning the causes of which no uni- formity of opinion has yet been reached. The number of deaths from eclampsia is fairly large, although the affection often terminates in recovery. It is exceptional for the nephritis of pregnancy to lead to chronic nephritis. The treatment is the same as that recommended for the other forms of nephritis. Above all things, the prevention of eclampsia is to be sought. If the symptoms are so menacing that its supervention is feared labor may be induced. Eclampsia itself is to be combated by chloral hydrate, inhalations of chloroform, venesec- tion, infusion and transfusion. AMYLOID DEGENERATION OF THE KIDNEY. Amyloid degeneration of the kidney does not of itself represent an inflammatory process. It depends much more upon the presence in the blood of some toxic substance which causes a disturbance of the protoplasm, particularly of the connective tissue. The causes of this degeneration are known to be long- continued suppuration in any part of the body, bone-fistulas, empyema, bron- chiectasis, tuberculosis of the lungs, suppurative disease of the kidney itself, and tertiary syphilis. As a result of the disease, the tissue, especially the walls of the blood-vessels in the glomeruli, sustain such injury that they become highly permeable to albumen. Accordingly there is a severe albuminuria and also an increase in the quantity of urine, the renal capillaries allowing more fluid to filter through. The urine is bright yellow, but has a relatively higher specific gravity than that of contracted kidney, for the reason that it contains much more albumen than the latter. Organized elements are rare and generally are not met with at all. Owing to the increased permeability of the kidneys there is no reten- tion of urinary elements in the blood, so that symptoms depending upon such retention, namely, hypertrophy of the heart, secondary 496 DISEASES OF THE KIDNEYS. inflammations and uraemia are absent. The severe oedema frequently met with is to be explained by the occurrence of alterations in the blood- vessels, it being probable that the toxins affect the vessels of the skin in the same deleterious manner as they affect deeper structures. It is typical for amyloid changes to occur simultaneously in other organs. Thus the liver and spleen are enlarged, and amyloid degeneration of the intestines takes place, giving rise to diarrhoea. The skin also has a striking yellow, waxy appearance. Amyloid tissue gives a characteristic reaction with Lugol's iodine solution, turning reddish, mahogany, or nut-brown when brought in contact with this fluid, whereas the other tissues are colored yellow. It is colored red by the anilin dyes, methyl violet, gentian violet and methyl green, and blue by thionin. Although the diagnosis is generally not difficult, it may become so when genuine nephritic changes are superimposed upon the amyloid degeneration, as the former affect particularly the epithelium. Under these circumstances there is first a combination of amyloid kidney and diffuse nephritis and later an amyloid contracting kidney, or if the nephritic process is very insidious in its evolution, a combination of genuine contracted kidney and amyloid kidney may be found. The clinical symptoms and the character of the urine then correspond to a combination of these two conditions. The prognosis of amyloid disease is not absolutely unfavorable. Of course those portions of tissue which have been destroyed cannot be regenerated, but if the causative factors can be eliminated the tissue which is yet undamaged will remain healthy, so that there is only a partial ultimate defect. Therefore the first object of treatment is the removal of the source of suppuration, or perhaps the subjuga- tion of syphilis. FATTY KIDNEY. The term fatty kidney is applied to a condition in which a collection of fat is found in the epithelium of the uriniferous tubules without the presence of an associated inflammatory process in the kidney. The condition is one of fatty degeneration in the sense that this term is used by Virchow, that isj the fatty destruction of renal epithelium is only a manifestation of a general fatty degeneration affecting the liver, the heart, the muscles, etc. It is usually the result of an intoxication. Among the poisons best known to produce this condition are phos- PYELITIS AND PYELONEPHRITIS. 497 phorous, arsenic and sulphuric acid. In rare instances it occurs in pernicious anaemia. PYELITIS AND PYELONEPHRITIS, SUPPURATIVE NE- PHRITIS, ABSCESS OF THE KIDNEY. These four affections have much in common and are partly stages of one and the same morbid process. They all result from infection and are associated with suppuration in the kidney, be it macroscopic or microscopic in extent. There is, however, an essential struct- ural and clinical difference between them. Whilst pyelitis is exclusively a disease of the pelvis of the kidney, in pyelonephritis the tissues of the cortex are also involved. The term suppurative nephritis is used as long as miliary foci of suppuration are present in the kidney, but when these become confluent and form a focus large enough to be seen with the naked eye, the term kidney- abscess is applied. Etiology. The form of suppuration which develops in the kidney and its pelvis depends, apart from the circumstances to be mentioned later, upon the kind of infection which takes place. Microorganisms may gain access to the kidney through the blood-stream or through the urinary tract. When infection occurs in the former way it is called haematogenous, when in the latter urogenous. The type of haematogenous metastatic renal suppuration is such as occasionally develops in pyaemia, septicaemia, ulcerative endocarditis, pneumonia, measles, scarlet-fever, small-pox, typhoid fever and dysentery. The urogenous or ascending infection almost always follows a cys- titis with or without concomitant retention of urine. The cystitis of old persons, especially prostatics, is almost invariably associated with retention; in such persons long- continued disease very often leads to involvement of the renal pelvis. Young men suffering from gonor- rhceal cystitis may also be attacked by unilateral or bilateral pyelitis, owing to extension of the infective process upwards. A third way in which it is possible for infection to take place is directly from without, as in wounds of the kidneys. Finally the infective microorganisms may wander to the kidney from neighboring organs, as for example, in inflammation of the liver, intestines and psoas muscle. The numerous cases of infection with the bacillus coli communis which have been observed must be considered 34 498 DISEASES OF THE KIDNEYS. as haematogenous ; for some unknown reason the system becomes flooded with these organisms and they are occasionally deposited in the kidney or its pelvis. In like manner are to be understood those suppurative processes of the kidney which develop as the result of infection in other parts of the body, as for example, from a carbuncle. In this in- stance the microorganisms in the carbuncle are transmitted to the kidneys through the blood-stream. Among the bacteria found in the secretion from the kidney are the colon bacillus (already mentioned), streptococcus, gonococcus, and proteus vulgaris. In one case the actinomyces was demonstrated to be the exciter of suppuration. The diplococcus pneumonias of Fraenkel and the typhoid bacillus are also, though rarely, found. It is yet undecided whether the diplococcus ureas of Rovsing, the streptococcus ureas, sarcina alba and flava, coccobacillus ureas, bacillus longus liquefaciens, and bacillus crassus have any causative relation with renal suppuration; at all events they are of no great importance. It is evident that circulatory disturbances of the kidney such as occur in pregnancy, and even in greater degree in certain diseases of the kidney, favor the development of infection. Pathological Anatomy. The pelvis of the kidney shows a most variable condition according to the character, intensity and duration of the infectious process. It is slightly or not at all dilated, contains urine which may be merely a little cloudy, or purulent, malodorous, and swarming with microorganisms. The mucous membrane is swollen, varies in color from light gray to red, and is traversed by dilated vessels. If ecchymoses are present the condition is called hasmorrhagic pyelitis. The existence of large shreds composed of fibrin and bacteria, which during life are sometimes discharged in the urine, has led Rovsing to speak, of a pseudomembranous pyelitis. If there is a coating similar to that found in the throat in diphtheria (fine granular masses containing bacteria and pus-corpuscles), the term croupous or diphtheritic pyelitis is used; if the coating is com- posed of gangrenous mucous membrane, the condition then might be called gangrenous pyelitis. If in addition to these phenomena obstruction occurs, the pelvis and calices become dilated. In consequence of the pressure to which they are subjected the papillae gradually become flattened, atrophy, and finally are destroyed. The pelvis becomes more and more dilated PYELITIS AND PYELONEPHRITIS. 499 at the expense of the renal tissue; the cortex becomes narrower and narrower, the sac wider and wider. This form of extension of the process is, as a rule, peculiar to ascend- ing pyelitis, in which the ureter is also involved. The latter structure is dilated in some places and constricted in others without there being any material thickening of the wall {ureteritis interna). The morbid process chiefly affects the inner layer of the ureter. If superficial cavities are present, which represent dilated mucous glands, the con- dition is known as cystic ureteritis. In external ureteritis or periureter- itis, which is also associated with constrictions, the outer layers of the ureter, the musculature and its surrounding connective and fatty tissue are chiefly affected. The ureter becomes very much, thickened, is adherent to its surrounding structures, and its lumen may become entirely occluded. The morbid process may not pursue the course above described, leaving the kidney unimpaired except for the damage it sustains in consequence of compression, but it may early invade the kidney itself, giving rise to a true infectious renal inflammation. We then have to do with pyelonephritis. In recent cases the kidney is generally swollen, soft, and fragile. Upon section the swelling is also plainly marked. If the disease progresses slowly, radiating gray striations, which can sometimes be traced to the cortex, are seen when the kidney is sectioned, and accom- panying them red streaks or specks may be found; they are collec- tions of leucocytes derived from the surrounding inflamed tissues and in later stages appear as minute abscesses. Microscopically the epithelium of the uriniferous tubules, especi- ally in the medullary portion, either undergoes proliferation leading to dilatation of the tubules, or else it undergoes retrograde changes. The cells are granular and some are replaced by fat-corpuscles. Areas infiltrated with leucocytes are seen here and there in the con- nective tissue, especially in the medullary portion, but also around the glomeruli. In the center of these areas the microorganisms are located and force their way out into neighboring parts. Softening of these areas leads to formation of the miliary abscesses already mentioned. It is somewhat different with descending hematogenous pyelitis and pyelonephritis. In the course of an acute infectious disease, or a suppurative process in a remote portion of the body, genuine pyelitis may naturally occur as the result of metastasis, and present the same 500 DISEASES OF THE KIDNEYS. structural picture as urogenous pyelitis. This, however, is exceptional. As a rule, pelvis and cortex are simultaneously involved, so that every metastatic pyelitis is also a pyelonephritis. In the acute forms, in addition to haemorrhage into the parenchyma of the kidney, changes in the epithelium in the cortex are especially prominent. In the con- voluted tubules the epithelial cells are granular or fatty and the nuclei stain poorly or not at all. Interstitial collections of leucocytes are present, particularly in the region of the blood-vessels. They contain microorganisms of all kinds. If the process becomes chronic, these masses of leucocytes are slowly changed into circumscribed abscesses, which in contradistinction to those occurring in the ascending form, are located more in the cortex, so that the surface of the kidney has a rough, irregular appearance. Small foci of suppuration also occur in the medullary substance, but their arrangement is not so regular as that which characterizes those in the cortex. Microorganisms are found in the blood-vessels, espe- cially when the latter contain emboli. In the previously described ascending form the microbes are contained mostly in the uriniferous tubules. The longer the process lasts the more diverse are the anatomical changes, until finally alterations of the most different character are found side by side; thus a pyelitis of increasing severity may be associated with interstitial and parenchymatous nephritis and simultaneous pressure-atrophy of the renal tissue, or haematogenous infection may lead to severe suppuration in the pelvis of the kidney and consequent distention of the same, in addition to the interstitial and other parenchymatous changes already present. Symptoms and Course. The clinical picture is different in the acute and chronic forms. Both, however, are generally preceded by some other disease of the kidneys or other organs. Acute pyelitis usually begins with chills and high fever, which may reach 40 or 41 C. [io4°-io5.8° F.]. The ordinary phenomena accompanying high temperature are present; the tongue is dry, thirst is experienced, and there is some hebetude. The urine contains pus, bacteria and albumen, according to the degree of the nephritic process. Death sometimes occurs within a short period; in other cases the fever subsides suddenly or assumes the remittent type; in still others it gradually becomes normal, and the acute process passes into the chronic. PYELITIS AND PYELONEPHRITIS. 50I The renal region is frequently sensitive. If this sensibility becomes pronounced, lasts for a long time, and if the chills and fever recur, it may be assumed that an abscess is forming in the kidney or that one is already present. It is not uncommon for the acute form to become chronic. More frequently, however, the latter form develops insidiously without being preceded by an acute process. It must be borne in mind that pyelitis and also pyelonephritis may be entirely unaccompanied by fever. When of the secondary form, it is preceded by diseases of the lower genito-urinary tract, such as gonorrhoea, stricture, prostatic affections, tumors of the bladder, puerperal diseases, and vesical paralyses (tabes, myelitis, etc.). The excretion of pus, tenderness over the affected kidney, the development of a small swelling in the lumbar region, and constitutional disturbances are the most impor- tant symptoms. In regard to the general condition, it may be stated that pyelitis may exist for many years without producing the slightest constitu- tional disturbances. Just as there are persons having chronic cystitis for years without impairment of the general health, so, too, there are others with pyelitis who suffer no constitutional trouble. Suppuration may be confined entirely to the pelvis of the kidney for a very long period of time without the kidney itself becoming involved. More frequently, however, nephritis is superimposed upon the pye- litis. Pyelonephritis may also pursue so slow a course and the destruc- tion of renal tissue which it leads to be so gradual that years elapse before the patient notices any trouble. This, however, is excep- tional, considerable disturbance usually ensuing within a short time. The patients gradually lose flesh, the appetite becomes impaired, the tongue is coated, nausea and vomiting are present; in short, they show signs of being seriously ill, presenting a clinical picture similar to that of a protracted and advanced diffuse haematogenous nephritis. This applies to unilateral as well as bilateral ascending pyeloneph- ritis. Accordingly this condition of decline is to be attributed to a poisoning of the blood, a toxaemia, rather than to renal insufficiency. The more frequently attacks of fever occur during the malady the earlier is the supervention of the decline. Tenderness in the region of the affected kidney is a totally untrust- worthy symptom. It is occasionally present, and is then of some value, but it is as often absent, and its absence does not afford proof 502 DISEASES OF THE KIDNEYS. that the kidney is healthy. Patients often complain of an annoying feeling of pressure in the region of the kidneys, which becomes intensi- fied upon severe exertion. The same statement may be made in regard to swelling. It may be present or absent. A pyelitis may exist without the pelvis of the kidney being markedly dilated; a pyelonephritis may be present in which the destruction of renal tissue leads to diminution in the size of the kidney. When there is a copious secretion of pus it is not unusual for the ureter to become partly or entirely obstructed. This leads to obstruc- tion in the pelvis of the kidney; the kidney itself becomes swollen and tender. During this time the urine may lose some of its turbidity or even become perfectly clear. The signs of retention are usually accompanied by fever and also occasionally by attacks of typical renal colic. These are conditions which resemble those encountered in intermittent hydronephrosis and pyonephrosis, concerning which more will be said later. In consequence of this uncertainty in the symptoms, we are forced to depend upon the changes in the urine for the establishment of a diagnosis. The history of a previous malady is also of some value. Several peculiar characteristics have been attributed to pyelitic urine. It has been said that the quantity voided, its reaction, its albumen- content and the kind of epithelium it contains will supply sufficient data for the establishment of a diagnosis. This statement, however, is incorrect. The only constant and trustworthy characteristic of pyelitic urine is the presence of pus. It is true that the urine of pyelitis and pyelonephritis is usually acid, but in the majority of cases of cystitis the urine is also acid. On the other hand, if ammoniacal decomposition of the urine in the pelvis of the kidney takes place, an alkaline reaction may be obtained in pyelitis. That club-shaped or tile-shaped epithelial cells placed one upon another must be derived from the pelvis of the kidney is an idea which formerly met with general, acceptation, but at present it is gen- erally agreed that the same forms may be derived from the deeper strata of the lower urinary tract; consequently their presence does not constitute a means of differential diagnosis. Furthermore, as concerns the albumen-content, it is entirely wanting in true pyelitis. Only as much albumen is found as is contained in the pus which is excreted. Even when the latter is present in large PYELITIS AND PYELONEPHRITIS. 503 quantity the amount of albumen will scarcely exceed 0.1%. In pyelo- nephritis the albumen-content is naturally higher, as it corresponds to the amount of pus secreted and therefore increases gradatim with the in- volvement of the kidney. Pyelonephritis, therefore, may be differen- tiated from cystitis by means of the albumen-content, but simple pyelitis cannot thus be distinguished. Casts are not present in true pyelitis, nor do they occur in pyelo- nephritis as a rule, being absent just as they often are in contracting kidney. Their constant presence points towards pyelonephritis, but their absence does not exclude the possibility of this disease. The presence of pus in the urine is the only positive sign. As admixture of pus occurs in other diseases, for example, in certain affections of the bladder and prostate, the task of determining whether the pus originates in the kidney may be reserved for those cases in which its presence cannot be traced to some other source. Moreover, if the diagnosis of pyelitis or pyelonephritis be accepted, it still remains to be determined whether the disease is unilateral or bilateral. In most cases careful observation of the course of the dis- ease will enable one to make a differential diagnosis, or at least to determine whether cystitis alone is present, or whether there is an as- sociated pyelitis. For this purpose the effect of treatment is of assistance. All forms of cystitis except those due to malignant tumors and tuberculosis improve under proper local treatment. The subjective symptoms abate and the urine becomes clear. If the amount of pus fails to decrease despite careful treatment, and tuberculosis and malignant disease of the bladder can be excluded, one will seldom go wrong in assuming that the pus comes from the kidney or pelvis of the kidney. The positive determination of the source of the pus, as well as knowledge relative to which kidney is affected, is afforded only by cystoscopy and catheterization of the ureters. The ori- fices of the ureters are revealed by the cystoscope, and the turbid, pur- ulent urine can often be seen issuing from them. If the turbidity is so slight that it cannot be determined whether the fluid spurting from the ureters is cloudy or not, a ureteral catheter is introduced and the urine thus collected. If pyelitis is not present the urine will contain only epithelium, or perhaps only a few red blood-corpuscles, their presence being due to diapedesis resulting from hyperaemia. Otherwise it con- tains pus-corpuscles. 504 DISEASES OF THE KIDNEYS. To determine whether the kidney itself is affected its functional capacity should be tested (see page 469). In simple pyelitis or chronic interstitial nephritis each kidney will give approximately the same value for A and sugar, whilst in pyelonephritis the diseased kidney will give a value less than that of the healthy one. The prognosis of suppuration in the kidney is variable. Simple pyelitis may exist for years without the kidney itself becoming involved and without producing any disturbance whatever. Pyelonephritis, as a rule, gradually leads to destruction of the kidney, and therefore must be considered as a serious malady. Pyelitis also not uncommonly invades the kidney and its importance is not to be underrated. Uni- lateral affections naturally offer a more favorable prognosis than bilateral. Treatment. The treatment of acute pyelitis consists in the employ- ment of antiphlogistic measures, the local abstraction of blood, the application of ice, narcotics for the relief of severe pain, quinine, salicylic acid and antipyrin for fever, urotropin for disinfection of the renal pelvis, and the use of moist warm cataplasms in the subacute forms. A bland diet and regular evacuation of the bow T els are of course necessary. The patient should drink freely; Fachingen, Wildungen and similar waters are well suited to these cases. In the majority of cases these measures will overcome the disease, or at least allay its most violent manifestations, so that it passes into the chronic stage. If threatening symptoms persist, such as high fever and chills, and if an exact diagnosis has been made as to which kidney is diseased, or at least as to which one is the more diseased, a brilliant curative effect can sometimes be obtained by splitting the kidney. This applies to pyelitis as well as to pyelonephritis. This procedure will naturally be of use only in the ascending forms, or in metastatic suppurative processes in which the primary disease with its localiza- tion in other organs has already or is about to become extinct. In regard to the treatment of chronic pyelitis and pyelonephritis, the measures already mentioned for the acute form should be tried first. These consist in drinking- cures, rest, baths, diet, and the administration of urotropin. The chances of cure by these means, however, are slight. For pyelitis of benign nature, or in other words one due to the gonococcus or bacillus coli communis, irrigation of the pelvis of the HYDRONEPHROSIS. 505 kidney with silver nitrate solution i : iooo is wonderfully effective. I have tried it in twelve cases (nine due to the gonococcus and three to the bacillus coli communis) which had resisted all other treatment and have obtained a perfect cure in every case. It is contraindicated in pyelonephritis, and when tuberculosis or renal calculi affect the pelvis of the kidney. If the tubercle bacillus cannot be found, it can be learned whether the suppuration is dependent upon tuberculosis by inoculating a guinea-pig with the secretion. The diagnosis of pyelonephritis can be accepted when the functional renal examination shows a considerable diminution in the value of A and sugar in com- parison with the urine from the opposite kidney. In suppuration due to calculi irrigation of the renal pelvis has a transitory, but not permanent, beneficial effect. The suppuration becomes less but does not cease. t In unilateral pyelonephritis good results may be obtained by neph- rotomy, provided that the disease is not too far advanced. The kid- ney is laid open, washed out with i : iooo silver nitrate solution, and the wound left unclosed. If the kidney has been destroyed by multi- ple foci of suppuration, nephrectomy is indicated, provided of course that the functional capacity of the other kidney permits it. It has not been positively determined whether cure can be obtained in bi- lateral pyelonephritis by operating first on one kidney and then later on the other. Before the question is decided information must be col- lected in regard to the degree of danger incident to such a procedure. HYDRONEPHROSIS. Etiology. Various names have been applied to those affections of the kidney in which fluid accumulates in the renal pelvis and causes it to become distended. Among these may be mentioned cystineph- rosis, sacciform kidney, and hydronephrosis. I prefer the term hydronephrosis, which was first used by Rayer, and shall designate as such those dilatations of the pelvis of the kidney which are caused by obstruction to the outflow of urine. There is a congenital and an acquired form of hydronephrosis. In the former either the condition itself or the causes leading to it may be congenital. Generally there is a partial obliteration or stenosis of the ureter; the points of predilection are the outlet of the ureter from the renal pelvis, and that portion which traverses the bladder. Reduplications and valves, kinking and torsion, or abnormal inser- 506 DISEASES OF THE KIDNEYS. tion of the ureter into the renal pelvis may have the same effect. If the ureter at its outlet forms an acute angle with the pelvis of the kidney, its opening will become closed much like a valve when the pelvis becomes very full ; if its opening is high instead of low the urine will not have a proper outflow. In connection with the development of hydronephrosis those cases in which there is a double renal pelvis and double ureters are of special interest. When such conditions exist the renal pelvis whose ureter opens abnormally in the bladder and thus constitutes an obstruction to the outflow of urine is the one in which hydronephrosis develops. Among the acquired causes of hydroneph- rosis are inflammatory affections of the urinary organs and concre- tions which interfere with the outflow of urine. The first class is constituted principally by ulcerative ureteritis leading to stricture- formation, and peri- and para-metritic exudates which compress the ureters; furthermore tumors of the bladder, uterus, and ovaries, new growths of the pelvic bones, enlargement of the prostate, uterine re- flexes occurring during pregnancy or independently thereof, kinking and torsion of the ureter resulting from displacement of the kidney, may all produce obstruction and thus give rise to hydronephrosis. Floating kidney particularly predisposes to the so-called intermittent hydronephrosis (Landau), which is characterized by the fact that the distended renal pelvis is filled with fluid at one time and is empty at another. In consequence of the descent of the kidney, the origin of the ureter, which is normally situated at the lowest portion, reaches a higher or perhaps the highest level. If no cause for the development of hydronephrosis can be found at operation or autopsy, it must be assumed that the cause has been overlooked or rendered unrecogniz- able by the manipulations which have been practised. Hydronephrosis is more often unilateral than bilateral, and the right side is more often affected than the left. The female sex is specially predisposed in consequence of the numerous diseases of their genital organs which produce compression of the ureters. Pathological Anatomy. Total hydronephrosis, that is, one in which the entire kidney is converted into a sac, so that no renal tissue is left, is very rare, occurring mostly in kidneys with double ureters. If the obstruction in the ureter is high up near the pelvis of the kid- ney, the pelvis only is dilated, whilst the lower the impediment to the outflow of urine, the greater is the liability of the ureter also becom- ing dilated. HYDRONEPHROSIS. 507 If the obstruction develops suddenly and the ureter is completely occluded, the renal pelvis will be only moderately distended, whereas if the obstruction develops more gradually, as is the case when a por- tion of the lumen of the ureter remains open, an enormous sac, which may attain the size of a man's head, is formed. In the first instance it is not unusual for the functional power of the kidney to be lost, but when slow and only partial obstruction of the ureter occurs the kidney still continues to secrete urine, which stagnates and distends its pelvis. When there is permanent complete occlusion the term closed hydronephrosis is used to designate the condition, and when complete obstruction does not exist, so that some of the urine can escape, we employ the term open hydronephrosis. It is upon these conditions that the reaction upon the kidney itself depends. Closed hydronephrosis rapidly leads to flattening of the papillae and causes pressure atrophy of the medullary and cortical substance, so that finally nothing but dilated calices remain, forming, together with the pelvis, a large thin- walled sac in which a few ridges, the remnants of the calices, may be seen. Such complete destruction, however, is exceptional. As a rule, normal renal tissue or tissue showing interstitial changes will be found; in the latter case the epithelium of the uriniferous tubules will show degenerative changes due to pressure. The contents of the sac is watery fluid having a uriniferous odor; in recent accumulations, or in the intermittent form of hydroneph- rosis, it possesses the properties of urine, whereas in older cases w th complete occlusion of the sac only a little urea is found. Symptoms and Course. Small hydronephrotic sacs may not cause any symptoms. Larger ones are characterized by a swelling which may assume enormous dimensions. This swelling may be oblong or round, its surface is smooth, and occasionally a soft portion (the sac) and a hard portion (indurated kidney tissue) can be distinguished upon palpation. It shows more respiratory displacement on the right side than on the left. Fluctuation may or may not be detected. Percussion supplies information concerning many of the conditions present. There is generally a zone of tympanitic resonance between the area of liver dullness and that over the hydronephrotic sac. By inflating the colon it will often be found that the kidney lies behind this portion of the bowel, although this sign often fails owing to the fact that the intestine is pushed to one side by the tumor. 508 DISEASES OF THE KIDNEYS. Another symptom is a feeling of pressure over the affected side. This may, however, be entirely wanting, but as a rule it is present, and may occasionally amount to severe pain, or even be increased to violent colic. Intermittent hydronephrosis, during the period of complete retention of urine, sometimes produces symptoms identical with those of nephrolithiasis. The urine may be perfectly normal. Occasionally a remarkable variation in its quantity and properties is observed, which gives rise to the suspicion that there is a variation in the quantity contained in the pelvis of the kidney. Even when a tumor is present it may be difficult to recognize it, as a hydronephrotic sac may be mistaken for other pelvic tumors, and other diseases of the kidneys may give rise to a similar tumefaction. Among such conditions may be mentioned cysts of the ovaries and spleen, echinococcus-cysts of the liver and kidney, and simple cysts or polycystic degeneration of the kidney. For the purpose of differential diagnosis an exploratory puncture may be made, if possible, by the extraperitoneal route; the result of this procedure, however, is by no means positive, for hydronephrotic fluid usually does not contain urea, and, on the other hand, urea has been found in the fluid of ovarian cysts. In doubtful cases recourse should be had to catheterization of the ureters, although this method naturally cannot always lead to a certain diagnosis. If the hydronephrosis is closed nothing comes out of the ureteral catheter, and if this condition obtains upon a second trial diagnosis will be plain. If fluid flows out, pressure should be made upon the tumor after the catheter has been brought near to the pelvis of the kidney, whereupon the outflow may be seen to increase, although in some cases the opposite condition is observed, the stream stopping suddenly, the passage through which it flows being occluded by the pressure which is exerted. The course of hydronephrosis is usually very slow, particularly when the affection is unilateral. The disease may last for decades. It is only when the outflow of urine is completely shut off and the kidney continues to secrete urine, that the distention becomes so great as to cause pain or possibly give rise to attacks of colic. If infection of the sac takes place pyonephrosis develops, although in such a case it would be more correct to use the term infected hydro- nephrosis. When this condition supervenes it may cause violent HYDRONEPHROSIS. 509 disturbances and thus transform the clinical picture into one of great severity. The prognosis of hydronephrosis is bad as to cure, as it is seldom possible to remove the cause of the obstruction; as to life it is favorable, because, as has already been stated, the condition may go on for years, until so much of the renal substance is destroyed that the system begins to be affected. The other kidney then performs a vicarious function. Treatment. As obstruction to the outflow of urine is the cause of hydronephrosis, the chief object of treatment is to secure the removal of the obstruction. This is a task, however, which cannot always be performed. Congenital hydronephrosis offers especial difficulties in this respect, since the nature of the obstruction is hard to diagnosticate. In intermittent hydronephrosis caused by displacement of the kidney the prospects of cure are good, as in many cases nephropexy perma- nently removes the obstruction. The kidney should be fastened as high up as possible, so that the ureter may be stretched. Instead of passing sutures through the substance of the kidney, as was formerly the custom, I now practise decapsulation of the kidney exclusively and find that it gives excellent results. A question will naturally arise as to whether milder measures will not afford relief. Occasionally the kidney can be retained in place by bandages so that kinking of the ureter will not occur, although this is exceptional. Too much must not be expected from catheterization of the ureters. It has been attempted to stretch the ureter by leaving the ureteral catheter in situ, and in a few cases the undertaking has proved suc- cessful. I do not, however, favor the procedure, as it is very difficult to prevent infection of the hydronephrotic sac when a catheter remains in the ureter for a considerable lime. Although there is little danger of infection when ureteral catheterization is quickly performed and completed, it is almost sure to take place when the catheter is allowed to remain in the ureter for a long time. Whether frequently repeated irrigation of the pelvis of the kidney will prevent infection, as is the case with irrigation of the bladder when continuous catheterization is being practised, can be learned only by experience. In those cases in which an operable condition in the pelvis, for in- stance, retroflexion of the uterus, is causing compression of the ureter, the obstruction can be readily removed. In most other cases operation upon the kidney itself must be resorted to, as simple puncture of the 510 DISEASES OF THE KIDNEYS. sac will not do any good. The injection into the punctured sac of irritating substances such as iodine, arsenic and alcohol is too danger- ous to be used; it can easily lead to suppuration. Before deciding upon operation the question as to whether operative interference is actually indicated must be carefully weighed. Many cases of hydronephrosis cause no trouble; they increase so slowly that the general health remains good for many years. Therefore such cases should not be operated upon, particularly if they are unilateral. When bilateral hydronephrosis is present the fact that the kidneys are being slowly subjected to pressure-atrophy must be taken into account. In regard to the operation itself, it has been found that simply anchor- ing the kidney, as was formerly practised, will not produce a cure; we have to do with a large sac caused by distention of the renal pelvis and consequent destruction of renal tissue, and for this reason nephrot- omy, combined perhaps with plastic operations on the kidney, is the rational procedure. Simple pyelotomy and pyelostomy should be entirely abandoned because they are too frequently followed by fistulse, which are more annoying to the patient than the hydronephrosis for which the operation was performed. Nephrectomy is usually not permissible; at present the tendency is not to sacrifice portions of renal tissue which are functionally active and therefore useful to the economy. The plastic operations on the pelvis of the kidney — pyeloplication, uretero-pyelostomy, resection of the ureter and anastomosis of the cut end into the pelvis of the kidney — are still in the stage of development, but they offer prospects of success and should usually be tried. Nephrectomy should be performed only when operation shows that very little renal tissue remains, or that the remaining portion is much diseased. It must, of course, be posi- tively determined that the functional capacity of the other kidney is good. In such cases nephrectomy gives good results. PYONEPHROSIS. Owing to the multiplicity of terms applied to suppuration in the kidney it is necessary to have a clear conception of what is meant by pyonephrosis. In accordance with the mode of development, two forms may be distinguished, one of which has already been spoken of as infected hydronephrosis. If the urine in a distended renal pelvis, PYONEPHROSIS. 511 which has been formed principally at the expense of the renal tissues, becomes infected, suppuration develops in the sac and slowly invades the parenchyma of the kidney. In the second group an ascending suppurative process involves the parenchyma of the kidney, which was previously healthy, and causes its destruction, without, however, pro- ducing distention of the renal pelvis; it is these cases which the French call pyelonephritis without distention (pyelonephrite sans distention) and which Israel terms primary pyonephrosis (originare pyonephrose). Finally, belonging to the second group are those cases in which primary infection of the parenchyma of the kidney takes place without involving the pelvis, and therefore without producing distention. Thus it is seen that infection is the result of haematogenous pyelonephritis. Primary pyelonephrosis is generally a sequel of cystitis. The latter disease extends to the ureter and produces ureteritis with thickening of the walls, which causes loss or diminution of their contractility. As a result of these changes the caliber of the ureter becomes lessened, and consequently there is a tendency for the secretion in the pelvis of the kidney to become stagnant. If the ascending infection produces a pyelitis or pyelonephritis, pyonephrosis will develop in consequence of the changes in the ureter. These ascending forms of urinary infection are met with very fre- quently in pregnant and puerperal women and may occur quite inde- pendently of catheter-infection; they also occur as the result of ascending gonorrhoea, although it has not yet been determined whether they are due to the gonococcus alone or to mixed infection. This form frequently affects only one kidney. The form due to infection of retained fluid in the renal pelvis has been described in connection with hydronephrosis. These dilated aseptic sacs may become infected either by an ascending or a hsema- togenous infection. The first usually follows some obstructive con- dition in the urinary system, such as stricture of the urethra, hyper- trophy of the prostate, paralysis or tumors of the bladder; the latter occurs in association with general infections such as pyaemia, typhoid fever, small pox, osteomyelitis, etc. As has already been stated, haematogenous infection may also give rise to primary suppura- tion in the parenchyma of the kidney without previously involving the pelvis. Pathological Anatomy. Although the origin of pyonephrosis is most diverse and the appearance of the different forms about to be 512 DISEASES OF THE KIDNEYS. described is very different, the presence of foci of suppuration within the substance of the kidney is common to them all ; moreover, a greater or less degree of inflammation in the renal parenchyma not yet destroyed by the suppurative process is also invariably present. Fig. 222. — Pyonephrotic kidney weighing forty-five pounds. (N. T. Brewis.) The size of pyonephrotic kidneys is most variable (Fig. 222) . Infected hydro-nephroses are usually larger than the primary variety, and as a PYONEPHROSIS. 513 rule are so deeply situated that they are not accessible to palpation; the latter variety also often lies concealed beneath the thorax. The mucous membrane of the renal pelvis shows the changes of pyelitis. It is maculated or reddened, may be smooth or rough, and also cedematous, and is sometimes covered with fine miliary nodules which at first glance may appear to be tubercles, but which in reality are either collections of leucocytes or minute areas of fatty degenera- tion. The kidney tissue itself is pale, cloudy and friable. It contains small yellow foci, which may attain the size of the head of a pin, and which represent either collections of leucocytes or minute abscesses. The latter may coalesce and form larger abscesses, containing creamy or perhaps sanious pus, in which are found sand, gravel, fragments of calculi, masses composed of pus, blood and epithelium, and others formed of triple phosphate; the latter may attain a considerable size. According to the manner in which the disease develops, the pelvis of the kidney and the calices are dilated, or the cavity may encroach upon the substance of the kidney. The calices are often as large as apples, and their opening into the pelvis is frequently narrow, in contradistinction to hydronephrosis, in which the dilated calices are usually drawn into the pelvis. Around the hilus there often develops pari passu with the destruction of the substance of the kidney a thick accumulation of fat, which often is so extensive that it converts the entire kidney into one large fatty mass, in which remnants of the parenchyma and a few cavities filled with pus may be seen here and there. If the process of granulation extends through the kidney to the fibrous capsule, perinephric adhesions are formed and suppuration may finally occur. The suppurative process may even invade the fatty capsule of the kidney and partly destroy it. The condition which then obtains is one of paranephric suppuration. The condition of the ureters depends upon whether the disease ascended from below or began in the kidney. In the ascending form ureteritis is always present, and if it develops simultaneously with obstructive conditions leads to thickening of the walls, particularly the outer layers, and converts the ureter into a thick tough cord which becomes adherent to the peritoneum. If no obstruction exists, an ascending ureteritis having produced pyelonephritis, extensive thickening of the ureter does not take place, 35 514 DISEASES OF THE KIDNEYS. although circumscribed areas of stenosis due to plastic exudate are present. In infected hydronephrosis the ureter is usually dilated and may be as large as a coil of intestine. It is of practical importance to remember that the vessels in the pedicle of large pyonephroses often have an abnormally narrow lumen. This is partly due to functional adjustment — the vessels having less tissue to nourish — and partly to endarteritis. Symptoms, Course and Diagnosis. The clinical picture of pyo- nephrosis is most variable, thus corresponding to the heterogeneous - ness of the underlying morbid anatomical process. Purulent urine is common to all open pyonephroses. This pyuria exists as long as there is an open channel from the suppurating renal pelvis. It may cease temporarily or permanently — temporarily if an obstruction develops in the kidney or ureter, permanently if this obstruction persists, or if the kidney has been destroyed by suppuration, so that nothing but a fatty and fibrous mass remains. Sudden occlusion of a pyonephrosis almost always produces a con- stitutional reaction. Although the patient may feel perfectly well as long as the pus has a free exit, fever, weakness and anorexia develop as soon as its outflow is impeded. Fever, however, may be present in open pyonephrosis, although I have found it absent as often as present. It evidently depends upon the acuteness of the inflammatory and suppurative process going on in the parenchyma of the kidney. On the other hand, occlusion of a pyonephrosis may occur without pro- ducing fever. The urine clears up and remains clear as long as the pyonephrosis is closed, provided that the second kidney is not secret- ing pus. Even an open pyonephrosis, however, may occasionally fail to produce purulent urine. This is especially true of infected hydro- nephrosis. Owing to copious discharge of pus there are periods in which the sac becomes so well cleansed that clear urine is secreted for some time ; then after another obstruction (twisting of the ureter, etc.) occurs, accompanied by symptoms of colic, pus appears again. These cases have been rightly called pyohydronephrosis. A further symptom of pyonephrosis is pain in the renal region. This pain may develop spontaneously or first manifest itself upon pressure. Spontaneous renal pain is absent as often as it is present. There are persons having a large suppurating kidney-sac who are not at all troubled by it. Less often pressure over the kidney fails to cause PYONEPHROSIS. 515 pain. Usually an uncomfortable feeling is experienced which is transformed into pain when pressure is made. Palpation is not to be relied upon. A greatly distended renal sac can usually be felt when it lies below the arch of the ribs, or when it is brought out under the arch by a deep inspiration. But all pyoneph- roses are not very large and all do not lie under the costal arch. I have often seen cases in which the kidney lay concealed under the thorax and was absolutely inaccessible to palpation. If all the symptoms are taken together, namely, the pyuria which persists despite all internal and local treatment, the absence of vesical symptoms, the pain upon pressure, the development, perhaps, of a tumor, the constitutional reaction, and in addition to these the evolu- tion of the malady, diagnosis can usually be made: under such cir- cumstances there is suppuration in the kidney. Further examination must then be made to determine, which kidney is suppurating and to ascertain if the other kidney is in a condition to permit operation. Ofttimes the cystoscopic picture will show which kidney is secreting clear and which purulent urine. If it cannot be determined in this manner ureteral catheterization should be tried. A catheter should be introduced into the ureter on the presumably diseased side and an ordinary urethral catheter passed into the blad- der so as to collect the urine from the other kidney. This method of examination shows precisely which kidney secretes clear and which cloudy urine. It also shows whether the second kidney is healthy and how it is working. The question as to how healthy it is and whether it is working with sufficient activity can be determined by the functional examination {quod vide). A typical example of unilateral pyonephrosis with well preserved functional activity of the other kidney is the following: Ureteral Catheterization. Phloridzin o.oi. R. L. Urine: Cloudy with thick flocculi. Cloudy; acid. Sediment: Pus. None Albumen: Corresponding to the Pus. None A -0.48 0.96 Sugar: o 0.8 Finally, as concerns the differential diagnosis of pyonephrosis from other tumors in the ■ abdominal cavity, it may be stated that the great 516 DISEASES OF THE KIDNEYS. difficulties which formerly prevailed have been overcome by ureteral catheterization. The ureteral catheter shows the source of the pus to be directly from the kidney. The prognosis and course of the disease usually depend upon the rapidity with which the suppuration advances and whether it is bilat- eral or unilateral. In the latter instance the prognosis is much better than in the former. Such cases may last for years without affecting the general health. It happens more often, however, that some dis- turbance is produced; the principal one is toxic nephritis of the other kidney, caused by the resorption of pus. It has already been stated that cure may occur without intervention, the whole kidney suppurating and being converted into a fatty, fibrous mass; such a termination, however, is exceptional, and is not to be expected. It is much more common for the suppuration, if left to itself, to invade the tissues around the kidney and cause perinephritis or paranephritis {quod vide). The treatment of pyonephrosis differs with the nature of the morbid process present, its extent, and whether it affects one or both kidneys. Internal treatment is not to be thought of unless both kidneys are so diseased that operative treatment cannot be employed. In cases suitable for operation internal treatment should be entirely discarded, for it will never succeed in rendering an infected renal sac aseptic. The exceptional cases of spontaneous cure above mentioned are ex- cluded from this rule. Accordingly the focus of suppuration must be attacked. This can be done in two ways, either by irrigating through a ureteral catheter introduced into the pelvis of the kidney, or by incising, or perhaps removing, the kidney. In regard to the irrigation method its usefulness is very limited, and it is applicable only in cases of infected hydronephrosis. I have cured two such cases in which the renal pelvis was converted into a large pus-sac by irrigating with nitrate of silver solution (i-iooo). In these cases' the method may be tried. In cases in which the substance of the kidney is involved and per- meated with abscess cavities, which perhaps do not communicate with the pelvis of the kidney, or at most open into it by very narrow outlets, irrigation is useless. Hence before the irrigation method is employed it is necessary to make an exact diagnosis, so that one may be sure that he is dealing with an infected hydronephrosis and not a primary or TUBERCULOSIS OF THE KIDNEY. 517 secondary pyonephrosis; this can usually be done by functional renal examination. If irrigation fails to give prompt results no time should be wasted with it. It can soon be learned whether a case is suitable for this treatment, as the pus begins to dimmish after a few irrigations. In case no benefit is derived nothing but operation (nephrotomy or neph- rectomy) will suffice. The former is particularly indicated in infected hydronephrosis in which a great deal of renal tissue is still preserved, whereas when typical abscesses are present in the parenchyma, nephrectomy is to be preferred on account of the danger of fistulae incident to nephrotomy, provided always that the condition of the second kidney warrants intervention. If the second kidney is seriously diseased and its function poor I also consider nephrotomy contraindicated, for it is also a serious opera- tion; in addition to the danger it involves it offers little advantage, because very annoying fistulae are apt to remain after its performance. Such cases, therefore, are to be considered inoperable. TUBERCULOSIS OF THE KIDNEY (NEPHROPHTHISIS). Tuberculosis of the kidney may be one of many localizations of general tuberculosis. As such it is naturally not subject to special treatment. The disease may also affect the kidney only, or be confined to it and a few other organs. It was formerly believed that most cases of renal tuberculosis were due to ascending infection, but this is not the case, such a manner of development being decidedly exceptional. The rule is primary hematogenous nephrophthisis. In simultaneous localization in the genital system, for example, in the epididymis, tuberculosis may ascend from the bladder, but it is important to know that both epididymis and kidney are favorite sites for the localization of hasmatogenous tuberculous infection. In this case the bladder is not involved. In women the ascending form has rarely been observed; in men it is more common, but it occurs much less frequently than the hasmatog- enous form. In men it is not unusual to find associated tuberculous disease of the sexual and urinary organs. Renal tuberculosis is most common between the twentieth and fortieth years; before twenty and after forty it is rare. 51 8 DISEASES OF THE KIDNEYS. Pathological Anatomy. In primary renal tuberculosis cavities are generally found, which are formed by softening and liquefaction of masses of caseated tubercles. Occasionally a kidney is found at oper- ation presenting numerous isolated nodules that have not yet under- gone liquefaction. The cavities are characterized by their ragged walls and irregular size. Surrounding them is an area of granulation tissue. In the columns of kidney tissue which separate the cavities there are many fresh or perhaps already caseated tubercles; they are also present on the surface, both above and beneath the true capsule, where they appear as fine nodules. It is worthy of notice that the disease is sometimes distinctly isolated, being confined to one pole of the kidney. Zondeck thinks this is due to the fact that the pole of the organ receives a separate blood supply. As time elapses the tubercles in the kidney encroach upon contiguous structures. Both true and fatty capsules are converted into thick connective and lardaceous tissue, or else a suppurative perinephritis is produced owing to extension by continuity of the liquefactive tuber- culous process to the capsule; in some cases the connective tissue between the kidney and its capsule may escape, the infection being carried to the capsule through the lymphatics. More rarely the parenchyma of the kidney remains free, tuberculous ulceration of the surface of the papillae being the only lesion present. In primary tuberculosis of long duration the ureters invariably be- come diseased. Simple or tuberculous inflammation is produced, with the result that the walls become thickened, the canal stenotic, and converted into a firm cord which is adherent to the surrounding tissue. This condition is known as sclerosing periureteritis (Fig. 223). If the process is tuberculous lenticular ulcers and nodules are frequently seen on the ureteral mucosa. In like manner the bladder may also be affected with tuberculous or simple inflammation. Unfortunately the latter form is rare. When the bladder is tuberculous, swelling, redness, displacement and ulcer- ation of the ureteral orifices are seen. The surrounding tissue is also inflamed. Occasionally disseminated tubercles are found in this region, whereas in simple inflammatory cystitis the changes are more diffuse, extending over the whole bladder. Of great importance is the circumstance that renal tuberculosis is often unilateral, and that when it is bilateral it has frequently been transmitted to the second kidney from the first. In addition to tuber- TUBERCULOSIS OF THE KIDNEY. 519 culosis other pathic processes are even more frequently met with, par- ticularly amyloid degeneration, chronic nephritis, or granular atrophy. It is evident that in primary renal tuberculosis other organs, such as -e Fig. 223.— Tuberculosis of the kidney and ureter, a. Cicatricial narrowing of the ureter, b. Lower end of the divided ureter, c.c. Dilated calices with tubercles. the epididymis, prostate, seminal vesicles, lungs, joints, and vertebrae may also be diseased. It must not, therefore, be assumed that an associated genital tuberculosis signifies an ascending renal tuberculosis. 520 DISEASES OF THE KIDNEYS. In the latter case genuine tuberculous disease of the bladder and ureter will always be found. Symptoms and Diagnosis. As in other localizations of tubercu- losis, so in the renal form, every symptom may be wanting in the beginning stages of the disease. It does not betray its presence in any way whatsoever, not even by a phthisical habit. Soon, however, it makes itself plainly evident; constitutional disturbances, a palpable renal tumor, and unmistakable alterations in the urine make the na- ture of the affection plain. The general health becomes considerably impaired; the patient may either be free from fever or suffer with the intermittent hectic fever typical of tuberculous infection. In the first instance emaciation and the livid sallow appearance characteristic of these patients comes on gradually, whereas in the latter their development is more rapid. The enlargement of the kidney seldom escapes detection upon palpation, although it usually is not so great as in non-tuberculous pyonephrosis. In cases in which no distinct swelling was present I have often found the renal region on the affected side to be more resistant and distended than in health. This evidently is due to the fact, that the kidney and its capsule are surrounded by adhesions, in consequence of which it becomes increased in size. For the same reason the tuberculous kidney is frequently found to be less movable than the healthy kidney and other renal tumors. The enlarged kidney either gives rise to pain spontaneously, the patients experiencing a dull, heavy feeling in the lumbar region, or distinct pain is produced upon pressure. The urine contains pus in varying quantities, and also occasionally crumbling caseous masses in which many tubercle bacilli are sometimes found, although they may be entirely absent. The albumen-content depends upon the ofttimes simultaneous nephritic process which is present in those portions of the kidney which have not yet become tuberculous. Blood-corpuscles are seldom absent; macroscopic haemorrhages, however, are of rare occurrence. If the tuberculous foci have not broken through into the pelvis of the kidney, or if the ureter is obliterated or obstructed, the urine may be perfectly clear and thus cause errors in diagnosis. If the bladder is involved typical symptoms, dysuria, strangury and tenesmus, are present, although it is noteworthy that these vesical manifestations may also be caused by the renal disease, particularly TUBERCULOSIS OF THE KIDNEY. 52 1 when the pelvis is affected, the bladder being neither tuberculous nor highly inflamed. Thus it is seen that the diagnosis of renal tuberculosis may present great difficulties. In order to make it clear auxiliary measures may have to be employed. A very careful history should be obtained, and evidences of tuber- culosis sought for in other parts of the body, in the glands, lungs, joints, epididymes, seminal vesicles, etc. It must be remembered that tuberculosis may be superimposed upon an old, uncured gonorrhoea. I have seen many cases of gonorrhceal pyelitis develop into tuberculosis of the kidney. On the other hand renal suppuration for which no cause can be found represents one type of renal tuberculosis. Pyuria which fails to improve under appropriate treatment should arouse suspicion that the trouble is not in the bladder but in the kidney. The determination of the seat of suppuration is a step in advance. Whether it is tuber- culous naturally has to be learned by other methods of examination. Tubercle bacilli are found in 70% to 80% of all cases in which thorough examination is made. If they are not found and suspicion that the disease is tuberculous still remains, guinea-pigs should be inoculated in the peritoneal cavity with some of the purulent urinary sediment. After five or six weeks postmortem examination of the guinea pigs will reveal in positive cases the presence of an acute miliary tubercu- losis. Of material assistance in diagnosis are cystoscopy and catheterization of the ureters. If there is purulent urine which fails to become clear under proper treatment, and if cystoscopic examination reveals a com- paratively healthy bladder, it may be concluded that the pus comes from the kidney. If the orifices of the ureters are then observed, tur- bid fluid will often be seen issuing from one or both of them. Occasionally characteristic changes are present in the ureteral pap- illae. It is highly vascular and its edges are distorted, being either in- verted or everted, and covered with minute ulcers or areas of capillary haemorrhage. In order to remove all doubt and to determine whether the affection is unilateral or bilateral, the ureteral catheter may be employed; this will clear up the situation at once, though it naturally will not reveal the nature of the suppurative process unless tubercle bacilli are found in the urine obtained by its use. The following are characteristic examples of the urine obtained by 522 DISEASES OF THE KIDNEYS. catheterization of the ureters in unilateral and bilateral renal tuber- culosis. 1. TUBERCULOSIS OF THE RIGHT KIDNEY. CATHETERIZATION OF THE URETERS. (o.OI PHLORIDZLN.) Right. Left. Urine turbid. Clear. Albumen: A heavy ring upon addition of nitric acid to the filtered urine. None Sediment: Pus and tubercle bacilli. None A 0.94 1.44 Sugar: 2.4 4.0 This is a case of beginning tuberculosis, as is shown by the relatively good functional power of the right kidney. 2. BILATERAL RENAL TUBERCULOSIS. CATHETERIZATION OF THE URETERS. (O.I PHLORIDZLN.) Right. Left. Urine turbid. Urine turbid Albumen: 0.01% 0.15 Sediment: Pus and tubercle Pus and tubercle bacilli. bacilli A 0.5 0.43 Sugar: A trace. o This was a case of advanced and inoperable bilateral renal tubercu- losis. In general the prognosis of tuberculosis of the kidney is unfavorable. It depends materially upon the stage in which the patient comes under treatment. If the affection is bilateral and other tuberculous foci are present in the body, the prognosis is considerably worse than it other- wise would be. On the contrary, unilateral cases which come under observation early offer a good prognosis, the patients usually regaining their health after the diseased kidney has been removed. The course of inoperable cases is rather slow. They last a long time, often for many years, before the parenchyma of the kidney is so destroyed that signs of renal insufficiency manifest themselves. As a rule, metastases and general dissemination of tuberculosis occur and cause death. Extension of the tuberculous process to the perinephric and para- nephric tissues is not uncommon. It extends along the fibrous and TUBERCULOSIS OF THE KIDNEY. 523 fatty capsule, perforates these structures and advances toward the exterior, producing suppuration limited only by the superficial tissues. This course usually produces acute symptoms, consisting of painful swelling in the region of the kidney, high fever, and general constitu- tional disturbance. In severe cases in which both kidneys are tuberculous or in which one is tuberculous and one nephritic or amyloid, or in those cases in which numerous other tuberculous foci exist, treatment may be merely symptomatic, and confined to the relief of the patient's suffering. Nutritious food, avoidance of all injurious influences, occasional irrigation of the bladder, and the administration of urotropin and narcotics are the proper measures. If tuberculosis of one kidney is detected early enough I recommend removal of the diseased organ in its entirety. Operation has been advised against in cases in which the disease was recognized and in which signs of tuberculosis could not be detected in any other organ, for the reason that spontaneous cures occasionally occur; they are so unusual, however, that they should not be relied upon. In the great majority of all cases it is rather to be expected that the disease will advance, that the kidney will become more and more destroyed, and that other organs, particularly the opposite kidney, will become involved. It is inflammation or amyloid degeneration of the second kidney which renders prognosis unfavorable. Therefore operation should be done before these complications become established. More- over, I have obtained very gratifying results from early extirpation of the kidney. Moderate involvement of the bladder or lungs is not a contraindica- tion to operation; experience has taught that the bladder will heal, or at least improve, if the source of the tuberculous material, which in this case is the kidney, be removed. I advise against partial resection of the kidney. Our knowledge of the results obtained by this procedure is insufficient. Furthermore, it is often impossible to determine whether a destroyed tuberculous focus is the only one present in the kidney. Section of the kidney will not solve the question, for although it may appear healthy, multiple concealed tuberculous foci may be contained within the parenchyma. Perinephric suppuration originating from a tuberculous kidney always requires surgical intervention, which, however, must often be confined to opening the abscess. 524 DISEASES OF THE KIDNEYS. RENAL AND URETERAL CALCULI (NEPHROLITHIASIS). We know as little about the causes of renal calculi as we do concerning those of stone in the bladder. If normal or abnormal constituents of the urine fail to remain soluble, but are precipitated upon an organ- ized stroma, the prerequisites for the development of a calculus are supplied (Ebstein, Posner). If the precipitate is very fine and meal-like it is spoken of as renal sand, while if it is larger, like wheat or millet-seed, it is known as gravel. If it occurs in the form of large masses it is called renal stone. In size these stones vary from that of a lentil to a pigeon's egg. If tooth-like prolongations project into the calices, the so-called coral stones are formed. As a rule, the larger the calculi the fewer their number. Small calculi from the size of a lentil to that of a bean occur in large numbers in the pelvis of the kidney. The stones may be either primary or secondary. To the first class belong those composed of uric acid, urates, or a combination of the two, which are characterized by their red color; those made up of oxalate of lime, which vary in color from gray to blackish-brown and have rough spiny surfaces; and finally the rare soft cystin calculi and the even rarer hard xanthin stones. The secondary calculi are composed of phosphate and carbonate of lime and phosphate of magnesia, these salts being deposited upon a foreign body (mucus, pus, blood). In exceptional cases these stones may also be primary. Mixed stones are those which contain several of these substances. Thus there are some having a deposit of oxalates around a nucleus of urates, and others with a layer of phosphates superimposed upon a nucleus of oxalates. Nephrolithiasis is most common in advanced age and early child- hood. Persons in middle life are comparatively free from it. Men are affected more often than women. Heredity and diet have some influence, but exactly what it is has not yet been determined. Thus in many respects the disease rests upon an unknown foundation. {Compare with the remarks on the causes of vesical calculi.) Pathological Anatomy. In a few exceptional cases renal calculi do not produce any changes in the kidney and its pelvis. They lie as aseptic foreign bodies in the pelvis of the kidney, and if they occlude the opening of the ureter give rise to an aseptic retention of urine, which upon long duration or frequent repetition may produce hydro- RENAL AND URETERAL CALCULI. 525 nephrosis. In the majority of cases, however, they lead to chronic inflammation of the interstitial tissue of the kidney and to hyperplastic changes in the capsule and hilus. Israel recognizes the large firm calculous kidney, in which hyper- plastic fibrinous overgrowth of the capsule, periglomerulitis and peri- vascular thickening are responsible for the enlargement of the organ; and the contracted calculous kidney, in which the epithelium atrophies c t ,-*-•_ f-^ r ^L Fig. 224. — Calculi in a kidney which has undergone com- plete fatty-fibroid degeneration. and connective-tissue formation predominates (Fig. 224); the hydro- nephrotic calculous kidney, which seldom attains a large size and is exceptionally associated with diminution in size; and finally the lipoma - tous calculous kidney, in which the atrophy and contraction of the parenchyma is accompanied by proliferation of the fatty tissue pro- ceeding from the hilus. Entirely different from any of these forms is the infected calculous kidney, in which there is a suppurative and often ulcerative inflam- 526 DISEASES OF THE KIDNEYS. mation of the renal pelvis and calices, which may extend to the medullary and later to the cortical portion of the kidney and give rise to small foci of suppuration. In the early stages of this condition the kidney is usually enlarged, but later in its course, owing to cicatricial con- traction in the suppurating tissue, a reduction in the size takes place. (Fig. 225). If in consequence of obliteration of the ureteral opening, obstruc- tion is superimposed upon pyelitis and pyelonephritis, a pyonephrosis develops, the contents of which are pus, blood, and primary, secondary and mixed calculi. The pelvis of the kidney becomes more and more distended and the renal parenchyma is destroyed partly by liquefaction Fig. 225. — Pyonephrotic kidney containing calculi, in cavities, b. Spaces filled with pus. a. Calculi and partly by pressure. It is not unusual for the morbid process to break through the kidney and invade the neighboring tissues. If this occurs gradually, adhesions form between the fatty and fibrous capsule and the superjacent soft parts, producing a chronic perineph- RENAL AND URETERAL CALCULI. 527 ritis and paranephritis, whereas if the extension is rapid and an area of suppuration is quickly formed, a perinephric or paranephric abscess is the result. In regard to the nature of the infection, it may be stated that aseptic calculi are usually infected through the blood, in which case it is rare for the source of infection to be determined. It may also occur from below. This does not depend alone upon the transmission of infection by instrumentation, but may be due to extension of gonorrhoea or cystitis. Symptoms and Diagnosis. Stone in the kidney presents such a variable clinical picture, to which are added the manifestations of disease in other organs, that the establishment of a positive diagnosis may be attained with the greatest difficulty, or may even be impossible. Moreover, there are cases in which calculi may be present in the kidney for a long time without causing any symptoms, although this is exceptional. The passage of gravel or sand usually gives rise to a burning or pricking sensation in the urethra, which is due to the irritation pro- duced by the sharp crystals of the salts. On the other hand, I have frequently seen cases in which large bean-shaped calculi passed along the urinary tract to the external urethral orifice without causing any pain whatever. The majority of cases, however, are characterized by pain, changes in the urine, and a palpable renal tumor. The pain in nephrolithiasis may be either constant or periodical. When constant it occurs as a feeling of pressure in the region of the kidney, which annoys the patient but little or not at all, although it is prone to become worse upon motion, and particularly upon certain kinds of movement, such as bending or stooping, for instance. Pres- sure upon the kidney or upon the lumbar region below the last rib also increases it. The periodical pain occurs in the form of renal colic. It is caused by incarceration of a stone in the ureter which hinders the outflow of urine, and also by the contractions which the ureteral walls make in an endeavor to expel the urine in the pelvis of the kidney or first por- tion of the ureter. This colic is usually typical. The patient writhes with pain, becomes pale, is nauseated or vomits, and is covered with sweat. A chill may usher in the attack. The pain radiates along the inguinal region down 528 DISEASES OF THE KIDNEYS. to the testicle or glans penis ; it may also extend upwards to the thorax as far as the shoulder-blades. In regard to the urinary changes, deposits of the salts of which the calculi are composed are often found; if pyelitis is present pus and epithelium are also found. All of these, however, may be absent. Only one substance is invariably present, and that is blood. Some- times it can be plainly seen with the naked eye, and with the microscope fresh or old blood-corpuscles never fail to be revealed. There is only one exception to this rule, namely, when the passage of the calculus is completely arrested so that no urine can escape. It must be borne in mind, however, that blood may appear in the urine in other renal diseases, or, indeed, as the result of congestion in some portion of the urinary tract other than the kidney, the latter being perfectly healthy. A total occlusion of the ureter results in excretion of urine from the sound kidney only. A normal urine, therefore, does not mean that both kidneys are healthy. Occasionally it happens that both kidneys are stopped up with calculi at the same time, or that when one is obstructed the other becomes closed through reflex spasm. We then have to do with anuria, which, unless it subsides or is overcome by artificial means, will certainly lead to uraemia and death. The third symptom enumerated, namely, the presence of a palpable tumor, is very untrustworthy; in many cases the kidney is not enlarged, in others the abdominal wall is too thick to permit accurate palpation, and finally there are numerous cases in which the kidney is placed so deeply under the ribs that it itself, much less a calculus within it, cannot be felt. If a hydronephrotic or pyonephrotic calculous kidney has developed, palpation yields the results mentioned in the discussion of those maladies. In addition to this uncertainty and variability of symptoms there is another circumstance which is liable to increase the difficulty of diagnosis, namely, that the affection may be easily confounded with many other diseases. First in regard to renal colic, it must be remembered that attacks having exactly the same characteristics may occur in the absence of calculi. Gall stones, appendicitis and intestinal obstruction may cause very similar attacks of pain. A floating kidney or an intermit- tent hydronephrosis by suddenly causing occlusion of the ureter may produce a true colic. Thick blood-clots in renal tumors, plugs of pus RENAL AND URETERAL CALCULI. 5 2 9 in pyonephrosis and tuberculosis, and parasites may all occasionally give rise to colic if they occlude the ureter. Moreover, cases have been observed in which there was absolutely no disease of the kidney. These have been designated as nephralgia. There are also cases of chronic nephritis in which exacerbations suddenly occur and cause typical unilateral renal colic. Finally it must not be forgotten that certain gynecological affections (distorsion, adhesions and kinking of the ureters after gynecological operations) may also be responsible for attacks of renal colic. All these conditions must be carefully weighed in the making of a diagnosis, and all the diagnostic measures which we possess must be employed. The history of the case, palpation, and examination of the urine must be made use of. Radiography will often though not always be of help. Catheterization of the ureters has proved itself to be the most valuable aid in diagnosis. From cystoscopy alone not much can be learned. Inspection of the ureteral orifices will not show whether there is a stone in the ureter unless, as very rarely happens, it is revealed in consequence of prolapse of the mucosa or a large gaping ostium. On the contrary, ureteral catheterization combined with functional examination of the kidney enables us to differentiate renal colic from gall stones, appendicitis and intestinal obstruction. In these affec- tions the functional capacity of both kidneys will be good and the value of A and sugar approximately the same. I have been able to diagnosticate with certainty cases of this kind in which all other methods had failed. In nephrolithiasis, particularly in cases of long duration, these values will also be lower in the urine from the diseased kidney than in that from the healthy one. If the kidney is otherwise healthy, however, the differences will be slight. Examples: I. LARGE CALCULUS WITH PYONEPHROTIC EIGHT KIDNEY. CATHETERIZATION OF THE URETERS (PHLORIDZIN O.Ol). Right Left Urine: Cloudy, pus moderate, Clear, no Albumen. albumen. A 0.57 0.92 Sugar: 0.3% 1.1 36 530 DISEASES OF THE KIDNEYS. 2. ASEPTIC CALCULOUS KIDNEY WITH MEDIUM SIZED CALCULUS. CATHETERIZATION OF THE URETERS (PHLORIDZIN O.Ol). Right Left Urine: Cloudy, red blood Clear, no corpuscles, no pus, sediment, albumen correspond- no albumen ing to the amount of blood. A 0.95 1.06 Sugar: 0.8% 1.2% N. : 0.24 0.38 In large hydronephroses and pyonephroses the difference in these values is much greater (see under these diseases). In chronic nephritis unequivocally low values will be obtained from both sides, and in nephralgia the functional activity of both kidneys will be equally good. The certainty of diagnosis under these difficult conditions has been materially advanced by ureteral catheterization and functional exam- ination of the kidneys. The mistake of relying solely upon these methods must not be made, for errors may occur. Thus, for example, a chronic nephritis associated with attacks of colic may be so mild that fairly good func- tional results may be obtained from both kidneys. The totality of symptoms must be considered in connection with the findings of ure- teral catheterization and the functional examination, in order for trustworthy diagnostic results to be obtained. The course of nephrolithiasis is chronic. In common with the prognosis it depends largely upon treatment. If a calculus is allowed to remain undisturbed, it may in exceptional cases be expelled spon- taneously through the natural channels. It is very rare for a stone to break through the kidney and give rise to fatal peritonitis. Furth- ermore, spontaneous cure, in the sense that the stone permanently occludes the kidney and causes gradual pressure atrophy of the pa- renchyma to the point of complete obliteration without producing infection, is also rare. The supervention of complete anuria, which in the majority of cases results in death unless intervention is prac- tised, is also unusual. Most frequently the kidney becomes infected in the course of time, with the result that pyonephrosis develops. The RENAL AND URETERAL CALCULI. 53 1 earlier nephrolithiasis is recognized and interference practised the bet- ter will be the prognosis. Treatment. The same measures recommended for the prevention of vesical calculi are appropriate in the prophylaxis of renal stone. There are no remedies which dissolve calculi. I have tested those reputed to do so, namely, lysidin, urezidin, lysetol, urotropin, urosin, chinotropin, sidonal, and others and have found that none of them possess their reputed action. The most that can be done, there- fore, is to guard against the formation of new calculi. In this respect the manner of living is first to be considered. The diet of persons having the uric-acid diathesis should not be rich. An excess of meat and the use of beer are to be avoided ; foods containing a high percentage of nuclein, such as thymus, spleen, liver, brains and kidney are to be strictly interdicted, as are also strong tea and coffee. A mixed diet consisting of a moderate amount of meat, eggs, and an abundance of fruit and fresh vegetables is to be recommended. Suf- ficient exercise and warm baths should be taken for the purpose of securing assimilation and elimination of the food ingested. In order to increase the solvency of the urine for uric acid it is well to administer alkalies in the form of carbonates and vegetable acid compounds, alkaline earths, and mineral waters. Lithium citrate and acetate in doses of 0.1-0.2 [15-30 grains] several times a day, carbonate of lime, borocitrate of magnesia in teaspoonful doses, or a mixture of all of these drugs, may be used, as may also the alka- line earthy mineral waters, such as Wildungen, Contrexeville, Vichy, Offenbach, Assmannshaus, Bilin, and Neuenahr, as well as the simple carbonated waters like Apollinaris, Harzer Sauerbrunnen, Elster, and Franzensbad. They are useful not only because of their alkaline action, but also because they increase diuresis, with the result that a larger quantity of uric acid can be held in solution. For patients of less means the artificial Sandow Salts may be pre- scribed instead of the natural mineral waters. The diet in oxalate calculi is practically the same, although food rich in lime salts, as well as tea and a few vegetables such as spinach and sorrel, which are rich in oxalic acid, must be avoided. Some caution must be employed in the use of fruits. Apples are contraindicated. The simple carbonated waters are better than the strongly alkaline. Apollinaris, Harzer Sauerbrunn, Krondorf, and Wernarz in Briick- enau may be used. 532 DISEASES OF THE KIDNEYS. For the pressure-pains of nephrolithiasis I have found that glycerine is the only drug except the narcotics which does any good. It was recommended by Hermann in doses of 50 to 100 cc. [approximately i£ to 3 fl. ounces]. I have given as much as 150 cc. [5 fl. ounces] twice a week and have been well pleased with the results. It is best given with 20 cc. [5 fl. drachms] of syrup of orange peel, because other- wise it may produce nausea. I have never seen any ill effects, par- ticularly hsematuria, follow its use, although slight diarrhoea is some- times produced. Renal colic must be combated by means of hot applications to the lumbar region, free use of drinking water to increase diuresis, and especially by the administration of narcotics. The surest remedy to arrest contractions of the ureter is a hypodermatic injection of morphine. The dose must be full and commensurate with the degree of tolerance which the patient has established. If vomiting ensues the drug may be given per rectum -with a small glycerine syringe. By all these remedies and procedures it will only be possible to cause the expulsion of relatively small stones in fragments or in their entirety. Once a calculus attains a size larger than the lumen of the ureter its spontaneous expulsion is not to be expected. Operative treatment then has to be considered. Three operations are practised, namely, nephrolithotomy, nephrotomy, and nephrectomy. In nephrolithotomy the kidney is freed, incised, the calculi removed and the kidney then sutured. In nephrotomy, after the stone is removed, the kidney-wound is packed with gauze and left open. The first operation is suitable for aseptic calculous kidneys, the second for those in which suppuration is present in the pelvis or parenchyma of the kidney. After the stone has been removed suppuration of the open wound continues until healing and cicatrization gradually occur. If the kidney is mostly destroyed, if a large pyonephrotic sac is present, or if the remaining kidney-tissue is highly inflamed, then nephrec- tomy is indicated. It might justly be asked if it is necessary to operate on every calculous kidney. Cases in which an indication is manifestly present cannot enter the question. If the attacks of colic recur, if a persistent unbearable sensation of pressure which interferes with motion exists, if the haem- orrhage is uncontrollable, and if suppuration is present, there is no doubt that an operation is required. Which one is indicated has to TUMORS OF THE KIDNEY. 533 be determined by the nature of the case and the condition of the other kidney. Anuria, unless it can be relieved by catheterizing the ureters, also necessitates immediate surgical intervention, because if it persists it will lead to uraemia and death. Ureteral catheterization should always be attempted before operating. I once succeeded in freeing an incar- cerated stone by injecting oil into the ureter. In another case due to reflex spasm the anuria was relieved by introducing a catheter into the unobstructed ureter, with the result that the spasm was overcome and the flow of urine established. If the anuria can be relieved the prognosis after the removal of the stone by operation is much better. Even in cases in which none of these urgent indications are present I believe in operating whenever the presence of a calculus can be positively determined. In aseptic calculous kidney the danger of operation is slight, although it may well be said that the sword of Damocles hangs over the patient's head if his malady is allowed to take its course. Anuria develops in consequence of incarceration of a calculus, or the renal substance is destroyed by pressure, or, what is more frequent than either of these conditions, the kidney becomes infected, pyelonephritis or pyonephrosis develops and necessitates operation later, when the chances of cure are not so good as they are in uncomplicated aseptic nephrolithiasis. TUMORS OF THE KIDNEY. The most common as well as the most interesting of renal tumors are hypernephroma, carcinoma and sarcoma. Concerning the causes of carcinoma and sarcoma nothing is known. Hypernephroma, also called epinephroid, struma suprarenalis, and Grawitz's tumor, originates from misplaced elements of renal tissue. (Plate XXIII.) Primary tumors only will be considered here, as those of metastatic origin are not subject to treatment. In contradistinction to metas- tatic growths, which usually affect both kidneys, primary cancer and sarcoma are almost always unilateral. Cancer is more common than sarcoma. Both may occur at any time of life, although they are most common after fifty. Pathological Anatomy. [The hypernephromata are sharply defined from the surrounding tissue, being enclosed in a capsule derived originally from the renal tissue itself, which undergoes atrophy. The tumor substance is usually yellow in color, owing to its abundant 534 DISEASES OF THE KIDNEYS. fat content, although Steorck believes it to be due to the presence of protagon instead of fat. Microscopic examination shows that these tumors have a glandular structure. Muscle fibers and giant-cells have been found in them. Hypernephromata may undergo cystic, carcinomatous or sarcom- atous degeneration.] The majority of renal carcinomata are of the soft medullary variety, which may attain a considerable size. The rarer hard scirrhus cancer is nodular and is not so large (Fig. 226). The tumor is usually kidney-shaped, has either a smooth or rough surface, and sometimes extends into the pelvis of the kidney or even into the ureter. Thrombosis of the renal vein or inferior vena cava may occur. In the substance- of the tumor areas of softening and haemor- rhage are found. Metastases are com- paratively rare. Cancer may extend to the neighboring parts, to the perito- neum, intestine or liver. The retro- peritoneal lymph glands are involved the earliest. While carcinoma originates from the epithelium of the uriniferous tubules, sarcoma, both spindle and round-cell, develops from the capsule of the kidney or the perirenal connective tissue. Small round-cell sarcoma is more malignant than the large-cell variety, although even in the former metastases occur comparatively late in the disease. Symptoms and Diagnosis. The symptoms of tumor of the kidney are pain over the affected side, changes in the urine, cachexia, the formation of a mass, and pain in other parts of the body when metastases occur. Unfortunately these symptoms are seldom present together. As a rule, the majority of them are absent, or they are first noticed when it has become too late for operative interference. First, as regards the pain in the lumbar region, no reliance whatever is to be placed upon it. Although it is sometimes present I have more often found that it was absent, the patient even not having experienced the slightest sensation of discomfort in the diseased part. Fig. 226. — Scirrhus carcinoma of the kidney. PLATK XXIII \ LARGE HYPERNEPHROMA, (DRAWING FROM A SPECIMEN REMO\ I MR. C. H. GOLDING-B1RD, OF LONDON.) TUMORS OF THE KIDNEY. 535 The only change in the urine which is of any importance is the presence of blood. Pus-corpuscles are of no significance, as their presence always depends upon secondary changes. There is a double reason why the possible presence of tumor-cells is not to be depended upon. In the first place the normal epithelium of the urinary tract may closely resemble these cells and, secondly, the latter are very rarely found in the urine. Albumen is of no importance as it is due to second- ary causes. Casts are merely the expression of a coexistent nephritis. Haematuria may be very severe or so slight as to be detected only by the microscope. It must of course be determined that the source of the blood is from the kidney. This is nearly always possible by means of cystoscopy and catheterization of the ureters. It is no longer necessary to depend upon the highly untrustworthy means of differ- entiation formerly in vogue, namely, whether the blood is red or brown, whether the corpuscles are old or fresh, and whether the blood occurs in the form of worm-like masses. These phenomena are of value when present, but they are frequently absent. It must be remembered, however, that the bleeding kidney might not be the one in which the tumor is situated, as the other one might bleed owing to congestion or the presence of calculi. Such a condition must of course be exceed- ingly rare. Much has been written concerning the kind of haemorrhage character- istic of renal tumors. It is true that the haemorrhage is usually profuse and of long duration, that it occurs suddenly and ceases in the same manner, and that it is not influenced by treatment. All this, however, may occur in vesical tumors without producing tenesmus. Therefore such bleeding cannot be considered a means of differential diagnosis. There is yet a greater difficulty than this. A tumor may exist for years before it causes haemorrhage even though in many cases bleeding is an early symptom. So, too, years may elapse between the first and second haemorrhage. A more constant symptom is cachexia. I have observed that nearly all patients having renal tumor enter upon a decline, become markedly emaciated, and upon first sight give one the impression that they are seriously ill. It would be more important, of course, to recognize the disease before cachexia developed. Its presence may well cause fear that the disease is 'far advanced. The most positive sign, the presence of a tumor, is one of the most importance, as it is less commonly absent than the others. Upon 536 DISEASES OF THE KIDNEYS. palpation a mass may be felt under the costal arch when the patient breathes deeply; it can often be learned whether the growth is smooth or rough, how large it is, and whether it is distinct from the kidney. Of course it is not always easy to tell whether a tumor thus palpated is in the kidney; confusion with other organs, such as the liver, gall- bladder, intestines, spleen, ovaries, uterus and enlarged retroperi- toneal lymph-glands, has occurred. Moreover, there are tumors which produce only small nodules, are placed deep in the kidney, and there- fore cannot be felt, and others which together with the kidney are so concealed under the costal arch that they are not accessible to palpation. Finally it must be stated that the disease is usually well advanced before the tumor can be plainly felt. It is the same with the " rheumatoid pains" which are felt in different parts of the body and which are to be attributed to metastases in the bones. If they prove to be caused by metastases diagnosis is then of no practical value. Other metastases, for example, glandular involve- ment, make it difficult, particularly at first, to establish a diagnosis. From this sketch of the symptom-complex it is seen that malignant tumors of the kidney are not difficult to diagnosticate at a certain period of their evolution, and, moreover, that an early diagnosis is of the utmost importance. Therefore the greatest attention must be given to ever}' urinary haemorrhage. Reliance must not be placed on the fact that haemor- rhage may occur from a healthy kidney, but every renal haemorrhage must be most carefully investigated. Every patient should be imme- diately subjected to catheterization of the ureters and functional examination of the kidneys. The functional capacity of a kidney in which the normal tissue has been replaced by the elements of a new growth is always lower than that of the other kidney, and this is true in a stage of the disease when all other symptoms and signs may be absent. An example may illustrate this fact. Case L (operation). CATHETERIZATION OF THE URETER (o.OI PHLORIDZIN). Right. Left. Urine: Clear, only a Clear, free from few erythrocytes, all abnormal no albumen. elements. A 0.21 0.45 Sugar: 0.4 1.0 TUMORS OF THE KIDNEY. 537 In this case the examination was made in the interval of freedom from haemorrhage and other symptoms. The patient had a haem- orrhage weeks before. A diagnosis of tumor of the right kidney was at once made, and it was confirmed by the operation. This case shows the importance of the examination. Without the functional test one would have been obliged to wait until another haemorrhage had occurred in order to determine the source of the bleeding, as there was no palpable tumor, and other symptoms, such as marked emaciation, were entirely absent. Therefore, in the early diagnosis of malignant tumors of the kidney, the functional renal examination is very valuable, although it must be remembered that care is necessary in forming a conclusion, inasmuch as in tumors of the renal capsule and suprarenal gland, which may give rise to the same symptoms as renal tumors, although the substance of the kidney is only slightly or not at all attacked, the functional examination may yield the same or approximate results. From this the following conclusion is to be drawn: if a mass can be felt on one side or a haemorrhage from the kidney on this side be deter- mined, and if the values for A and sugar in the urine from this kidney are considerably lower than in that from the opposite one, then a tumor of the kidney certainly exists, provided that the symptoms present are such as occur in tumor and not in other affections, as tuberculosis, for instance; if a mass can be felt and the values are high, tumor cannot be excluded, for one of the above mentioned forms may be present. In comparison with the great advantages which this examination offers, the other signs, although they should never be disregarded, are of minor importance. According to Guyon the sudden development of a varicocele upon the diseased side should arouse suspicion of a renal tumor. This may be true, but there are tumors enough in which varicocele is absent. Concerning benign tumors of the kidney, which are very rare, and of which adenoma, fibroma and lipoma are by far the most common, it may be said that they are considerably smaller than malignant growths, that they increase in size less rapidly, and that cachexia does not occur. It is very difficult to diagnosticate them during life. The prognosis of malignant tumors is bad — bad without operation and bad with operation. In the minority of cases death results directly from the operation; in the majority, however, it is due to metastases. 53^ DISEASES OF THE KIDNEYS. The earlier the diagnosis the better the prognosis as regards both immediate and remote results. As to treatment, nephrectomy is the only procedure to be considered. Operation is indicated when the functional capacity of the other kidney is good and the general condition, particular^ the cardiac action, leads one to believe that metastases have not occurred. Stress should be laid upon the fact that the previously mentioned capsular tumors (of which the fibroma and sarcoma generally origi- nate in the fibrous, and lipoma and myxosarcoma in the fatty capsule), may attain large dimensions, and that they are characterized by their retroperitoneal location, displacement of the colon, slight mobility, and absence of urinary haemorrhage. Great caution must be employed in basing a diagnosis upon displace- ment of the colon, because the colon may push a renal tumor upwards, or a tumor may displace the colon lateralwards. I have often seen both these conditions. These tumors of the capsule are therefore very difficult to diagnosticate. Treatment consists in their removal, which necessitates the sacrifice of the kidney. TUMORS OF THE PELVIS OF THE KIDNEY AND URETER. Tumors of the renal pelvis and ureter are exceedingly rare. There are two kinds, both of which have a papillary structure; one is true papillary carcinoma, the other simple papilloma, such as often occurs in the bladder. The latter form cannot be considered as strictly benign because it often extends into the ureter and bladder. Although its structure may appear benign under the microscope its multiplicity makes it of a severe and serious nature. The recognition of this affection is beset with great difficulties. Little can be learned by palpation, for the tumors are small and do not cause enlargement of the kidney. If the kidney becomes enlarged it is generally owing to obstruction of the renal pelvis by the tumor. The mass then has the characteristics of hydronephrosis. From the latter, however, the affection may be distinguished by a marked tendency to haemorrhage, which does not exist in hydroneph- rosis. James Israel has called attention to an important symptom. He has noticed that in consequence of the great vascularity of the tumor, its size varies with the degree of distention of its blood vessels. If CYSTS OF THE KIDNEY. 539 haemorrhage occurs the tumor becomes smaller, as does also the engorged, enlarged kidney, which remains small until another attack of congestion and interference with the outflow of urine causes it to enlarge again. As Israel has aptly said, the clinical picture is one of intermittent haematonephrosis. Rarely fragments of the tumor may be found in the urine; their source can be determined by cystoscopy. Up to the present time, owing to the rarity of the disease, functional examination has been made in only one case. In this one there was a great difference in the urine of the two kidneys, a circumstance which was due to the fact that the kidney was also affected with interstitial inflammation. In absence of such inflammation there is no reason why the function of the kidney should be materially impaired. The values for both sides should be good and practically the same- Treatment consists in complete extirpation of the kidney, together with removal of as much of the ureter as is possible, because, as has already been stated, the tumor frequently invades the ureter. CYSTS OF THE KIDNEY (BENIGN CYSTS AND POLYCYSTIC DEGENERATION). Small multiple cysts are found in perfectly healthy kidneys, especially in the cortex. They are of no practical importance, being due, no doubt, to constriction of the uriniferous tubules. Small and large cysts are also found in genuine contracted and arteriosclerotic contracted kidney, in which the constricting, contracting connective tissue has caused occlusion of the uriniferous tubules. Unless they attain considerable size they are likewise of no practical importance. In contradistinction to these, that rare condition known as cystic degeneration of the kidney, which develops in both organs simultaneously, is fraught with special interest. Either massive cysts or a number of sacs separated by remnants of parenchyma are found in the kidney, which is much enlarged owing to their presence. (Rein gros polycystique of the French). (Fig. 227.) Their surface is bosselated, their contents composed of serum, mucus and blood. The congenital forms will not be considered here as they are of no importance except that they constitute a hindrance to birth. They are due to constriction of the uriniferous tubules, to atresia of the 54o DISEASES OF THE KIDNEYS. papillae occurring in intrauterine life, and to dilatation of Miiller's capsule following haemorrhage. Of practical importance is polycystic degeneration occurring at a later age, which is due to abnormalities that originate during fcetal life, although they manifest themselves at a later period of existence. (Victor Steiner believes that the condition is hereditary.) The diagnosis of this condition is uncommonly difficult. The cysts often remain entirely latent, are frequently not palpable, and when Fig. 227. — Cystoma of the kidney. Removed from an adult. (Kiister.) they can be felt are very difficult to distinguish from other renal tumors. Their bosselated surface may cause them to be mistaken for malignant tumors, although this attribute serves to distinguish them from the hydronephrotic kidney, which has a smooth surface. The most impor- tant characteristic is that they occur bilaterally. If a mass which is apparently cystic is felt on both sides this disease must be thought of. Naturally, under certain conditions, a palpable mass may be found on one side only, and then this sign fails. MOVABLE KIDNEY. 541 Another important diagnostic sign is the frequent simultaneous occurrence of hepatic cysts. The latter also often escape detection. Changes in the urine are likewise unconstant ; they may be present or absent. The urine is similar to that of contracted kidney, being very pale, of low specific gravity and very copious in quantity. In both affec- tions there is destruction of renal tissue. Israel also found the circu- latory changes characteristic of contracted kidney, namely, increase in arterial tension and hypertrophy and dilatation of the left ventricle. Functional examination of the kidney will afford the best means of diagnosis, for the reason that diminution in the functional power of the organ is bound to be expressed by figures, although as yet the examination has not been made. It is remarkable how long persons affected with the malady may live without experiencing any difficulty. It shows with how little renal tissue a patient may live, as long as the transient equilibrium of the organism remains and is not disturbed by surgical interference. Therefore, the diagnosis of this condition is most important, because it will prevent interference which will destroy the patient. As the affec- tion is bilateral operative treatment is out of the question. MOVABLE KIDNEY (REN MOBILIS SEU MIGRANS). A movable kidney is one which is abnormally situated and unduly mobile. The degree of mobility is variable; in some cases the kidney may be displaced only a short distance, while in others it may be freely moved upward under the costal arch or downward apparently as far as the small pelvis. A kidney which is deeply situated and easily palpable, but not mobile, is not to be considered as a movable kidney. Movable kidney may be congenital, although it is more frequently acquired. It is more common on the right side than on the left, and affects women oftener than men. Its development is due to loosening of the attachments of the kidney (Landau), which may be caused by pressure of tumors in neighboring organs or by growths in the kidney itself which make traction upon the attachments; by traumatisms sustained during violent fits of coughing, severe straining at stool, heavy lifting, etc. ; by severe diseases which lead to rapid shrinking of the paranephric fatty tissue ; by relaxation of the pelvic organs, such as occurs in the puerperium when involution of the genital organs takes place; by tight lacing which produces dislocation of the liver and consequent pressure upon the right kidney; and possibly also by 54 2 DISEASES OF THE KIDNEYS. frequently repeated congestion of the renal plexus produced by the afflux of blood to the communicating ovarian plexus during menstrua- tion. Occasionally movable kidney is only a part of a general enterop- tosis. In consequence of inflammatory adhesions a movable kidney may become firmly fixed in an abnormal position. As a rule, the paren- chyma of the organ is perfectly healthy, although other affections such as cystic degeneration and pyonephrosis may occur. An associated hydronephrosis is exceedingly common, the mobility of the kidney causing the ureter or outlet of the renal pelvis to become compressed, thus producing a retention of fluid. Symptoms and Diagnosis. In a large number of cases movable kidney does not give rise to any symptoms. In a minority of cases symptoms are present, although it is doubtful whether they all depend upon the movable kidney or whether they are not due rather to the condition produced by general enteroptosis. The most pronounced symptoms are a series of severe nervous disturbances caused by pressure and traction upon the nerves of the kidney. Neuralgic pains radiate to the sacrum, back and groin. They are more acute during menstruation and are also increased by bodily exertion and violent exercise. Digestive disturbances are also marked ; they consist in anorexia, nausea, vomiting, constipation, and distention of the abdomen. Nervous palpitation of the heart has also often been observed. Disturbances of micturition may be present, although in the majority of cases the urine is normal as to quantity and quality. When altera- tions occur they are the same as those of intermittent hydronephrosis. The occasional occurrence of renal colic in hydronephrosis has already been mentioned. Even without the supervention of hydro- nephrosis, movable kidney may sometimes give rise to typical colic owing to a sort of strangulation and closure of the kidney produced by its abnormal position, torsion and kinking of the vessels, and occlusion of the ureter. The attacks of colic thus produced differ in no wise from those previously described as occurring in nephrolithiasis. The diagnosis of movable kidney can be positively made by pal- pation, which is easily performed by the bimanual method, and which reveals an abnormally mobile and dislocated kidney and enables the examiner to recognize its typical form and consistency. Pressure over the kidney usually fails to elicit pain. Percussion gives MOVABLE KIDNEY. 543 forth a dull note, but upon inflation of the colon the dullness gener- ally disappears. The prognosis of movable kidney is favorable. As a rule, the condition persists for years unless intervention is practised; in a few cases infection of the kidney takes place in consequence of the circula- tory disturbances and intermittent distention of the renal pelvis with urine. Cases of spontaneous cure have been observed, particu- larly in persons who have taken on flesh rapidly, and it has been endeav- ored to produce this condition artificially by means of Weir Mitchell's rest-cure. Treatment. First of all our attention must be directed to the prevention of movable kidney. For this purpose a strict veto must be placed upon tight lacing and great care employed in the hygiene of the puerperium. Puerperal women should not be allowed to get up too soon, and should wear a wide abdominal binder, which acts as a support to the pelvic organs during involution. If a movable kidney causes trouble it should first be treated by means of bandages, of which there are many serviceable kinds. Good results are sometimes obtained in the case of emaciated persons by a rest-cure, from which it may be assumed that absorption of fat caused the development of the movable kidney. If these measures do not afford relief and severe symptoms arise which make the patient's life miserable, nephropexy should be resorted to; as it is now performed it is without danger and offers a certain cure. I have completely abandoned suture of the kidney, fixation to the ribs, etc., and now do merely a decapsulation. The capsule of the kidney is split on the convex border of the organ from one pole to the other, stripped off on each side, and then cut completely away near the pelvis. The kidney thus bared is replaced upon the fatty capsule, which is fastened as high as possible to the underlying muscle with a few strong catgut sutures. Firm adhesions then form between the fatty capsule and the muscle on one side and the kidney and fatty capsule on the other. This operation is devoid of the dangers incident to the earlier operations in which sutures were passed through the substance of the kidney, and I have found it thoroughly reliable in a series of cases. If there is a complicating hydronephrosis, together with frequent attacks of renal colic, treatment is to be conducted in accordance with the rules prescribed for the management of that affection. 544 DISEASES OF THE KIDNEYS. PARASITES IN THE KIDNEY. The Echinococcus. The echinococcus, the embryo of tania echinococcus, which inhabits the intestine of the dog, is found in the kidney, as in other organs, in the form of a large round or ovoid gelatinous cyst containing a clear watery fluid in which numbers of daughter- cysts are floating. On the inner wall of the smallest cyst scolices are found having a rostellum provided with hooklets, which are important, as they also float free in the fluid and thus contribute to the recognition of the disease. If the ovum of the taenia echinococcus gains access to the stomach of man, it is freed from its investing membrane and enters the blood- vessels of the intestine, whence it passes into the portal vein and thence direct, or perhaps through the lymph-channels, into the right side of the heart. From the heart it is carried by the arterial blood- current to different organs of the body, particularly the liver and kidneys. The kidneys are attacked much more frequently than the liver, and, as a rule, only one kidney is affected. The echinococcus works its way from the cortex to the pelvis of the kidney. The cyst becomes adherent to other organs (spleen, liver) and may rupture into them; simultaneous rupture into the bronchi and renal pelvis has been observed. The disease first becomes recognizable when it leads to the forma- tion of a renal tumor. This mass occupies the position of the kidney, may be very large and even reach to the brim of the pelvis. It has the characteristics of a renal tumor, fluctuates, and occasionally gives forth the so-called hydatid thrill, although the latter sign is not of much value because it may occur in simple hydronephrosis. It may be very difficult to elicit fluctuation, and also to determine whether the tumor is in relation with the kidney. The difficulties which obtain in the diagnosis of renal tumors have been repeatedly described. The affection becomes easily recognizable if the contents of the cyst rupture into the pelvis of the kidney. Before this happens the urine may be absolutely normal. If blood or pus are present they are due to secondary changes. When rupture occurs, however, the vesicles reach the pelvis of the kidney and bladder and are voided with the urine. Diagnosis is then readily made by finding the vesicles and characteristic hooklets. The urine then also usually contains pus and albumen. PARASITES IN THE KIDNEY. 545 The discharge of the cyst through the ureter may be accompanied by colicky pains owing to temporary though complete occlusion of the ureter by the large vesicles. Vesical tenesmus and strangury have also been observed when a large number of cysts were passed or when they occluded the outlet of the bladder. As a rule, however, their passage causes no trouble. It is important to remember that the presence of cchinococcus cysts in the urine does not mean that they come from the kidney, for the location of the primary cyst may have been the liver, from which it perforated the renal pelvis, or a cyst between the rectum and bladder may have broken into the latter vise us. The prognosis is generally favorable. The disease may last for years without giving rise to any trouble. Rupture of an echinococcus cyst into the lung may prove fatal; its rupture into the pelvis of the kidney, however, constitutes a natural method of cure. It is evident that the parenchyma of the kidney will suffer pressure-atrophy, and that it may be completely destroyed if sufficient distention of the sac takes place. Treatment. As soon as the disease has been positively recognized operation is indicated. Exploratory puncture and the finding of vesicles and hooklets will make diagnosis positive. The kidney should then be laid freely open, its contents evacuated, and the sac cleansed and drained. Nephrectomy is permissible only when practically no renal tissue remains. Kiimmel succeeded in resecting the diseased portion of the kidney and leaving the healthy part intact. Of the remaining animal parasites found in the kidney the eustrongylus gigas, the distoma haematobium and filaria sanguinis are of some importance. The eustrongylus gigas, a nematode worm, is often found in the kidney of the horse, ox and dog, but is very rare in man. Its site of predilection in the human kidney is the pelvis. The symptoms which it causes are dysuria, haematuria, chyluria and pyuria. A patient from the tropics whom I had the opportunity of examining, arid in whose urine ova were found, was operated upon after I had determined by ureteral catheterization that the milky, purulent masses came from one kidney. The urine from the other kidney was clear. At operation the worm was not found in the kidney. It must have been in the lymph -vessels near the kidney The distoma haematobium (Bilharzii) is a trematode parasite 37 546 DISEASES OF THE KIDNEYS. which is common in Egypt. It gets into the intestine by means of contaminated drinking water or food (dates, fish and other food) and thence passes into the kidney, its pelvis, and the bladder. It causes occlusion of the blood-vessels, inflammation and haematuria. The diagnosis can be made only by finding the ova in the urine. Treatment must be preventive, the use of contaminated food being prohibited. The filaria sanguinis is a nematode worm indigenous in the tropics — in Brazil, the East and West Indies and Egypt. It gets into the intestines and occludes the lymph-vessels, as a result of which they become dilated and the lymph from the accessory channels is poured into the bladder or kidney. As proof that this explanation of the development of chyluria is correct, it has been cited that the thoracic duct is found dilated at autopsy. Incidentally it may be mentioned that Israel once diagnosticated a case of primary actinomycosis of the kidney. The diagnosis was made by finding actinomyces in the granulations of the scar of a previous exploratory puncture and in the urine. With the exception of this case actinomycosis has been observed only as a secondary process. SYPHILIS OF THE KIDNEY. Renal syphilis is still an obscure subject. Until within a short time syphilitic disease of the kidney was considered exclusively as a mani- festation of general syphilis, which occasionally affected both kidneys and produced a diffuse parenchymatous and interstitial nephritis. All the cases which I have seen were of this form. Israel also describes such a case in which the fatty capsule was thickened and very fibrous and the fibrous capsule was converted into a lardaceous rind. Upon section the kidney showed yellow wedge-shaped areas and marked interstitial and parenchymatous changes (small- celled infiltration of the interstitial tissue, degeneration and complete destruction of the epithe- lium). Thus far his observations are fully in accord with my opinion, that diffuse nephritis may develop in syphilis, but Israel believes that his case was one of unilateral syphilitic nephritis, for the reason that after extirpation of the kidney the patient recovered and gained forty pounds. I question the correctness of his opinion. According to my experience there is no such a thing as unilateral nephritis. I have never seen a SYPHILIS OF THE KIDNEY. 547 single case, and this alleged one of Israel's only strengthens my belief that it does not exist. Five years after the operation the patient still had albumen in his urine, so it is much more probable that he had a bilateral nephritis, which perhaps was more severe in the kidney extirpated and became arrested in the other kidney after he was oper- ated on. The second case, one in which a kidney which was extirpated chiefly on account of a fistula was found to have shiny yellow nodules on its surface and to be much contracted, seems to me to be consid- erably more important. Upon section map-like yellow areas were found. The adjoining tissue was yellow in color and not at all like normal kidney substance; it proved to be composed of connective- tissue cells having spindle-shaped nuclei, and was not sharply demar- cated from the yellow necrotic tissue. This case was one of diffuse gummata. The kidney was removed and the patient recovered. The case offers striking proof that gummata may affect one kidney. The diagnosis will always require evidence of syphilis or a history of this disease. It may be confirmed by treatment ex juvantibus. It has long been known that mercury has an unfavorable influence upon diffuse nephritis occurring in syphilis and that potassium iodide has scarcely any effect. Occasionally the albumen is somewhat diminished. It may be expected, however, that gummata will even- tually undergo complete absorption under the use of mercury and the iodides, just as they do in other organs. These drugs should always be tried. Extirpation of the kidney is permissible only when these remedies have failed, and then only after the functional capacity of the other kidney has been tested and found to be adequate. In diffuse nephritis, which can be diagnosticated by catheterization of the ureters, operation is contraindicated. [The existence of a genuine syphilitic diffuse nephritis was formerly denied, but so many cases of undoubted authenticity have been reported that its existence is now generally recognized. Cases occur in which no etiological factors other than syphilitic infection can be determined, the renal involvement manifesting itself suddenly early in the course of the disease, even before mercurial treatment has lnvn instituted. I have observed two cases of this kind in young and previously healthy persons who had neglected to take treatment owing to the beni X X LU < cu NEURALGIA OF THE KIDNEY. 553 of injury, in seven no injury had been sustained, and in three no history was obtainable. It is interesting to note that recovery took place in the three cases in which operation was performed. Those due to injury naturally offer the most favorable prognosis.] NEURALGIA OF THE KIDNEY (NEPHRALGIA, NEPHRALGIE HjEMATURIQUE, ANGIONEUROSIS RENIS, ESSEN- TIAL HEMATURIA, HAEMORRHAGE FROM HEALTHY KIDNEYS). In preceding sections mention has been made of a series of affections which are associated with pain, especially with proxysmal attacks of colic. It is known that any obstruction in the ureter may cause renal colic. Thus it may be due to renal and ureteral calculi, kinking of the ureter owing to low position of the kidney, movable kidney, hydronephrosis, occlusion due to blood-clots or pus resulting from new growth, parasites, tuberculosis and pyonephrosis. For many years, however, cases of typical renal colic have been recognized in which none of these affections were demonstrable nor could be found upon operation or at autopsy. The complaint under discussion is characterized either by violent pain in the region of the kidney, resembling true renal colic and recur- ring at variable intervals, or by colic associated with more or less severe haemorrhage, which is also of variable duration. In a third class of cases the only symptom observed is renal haemorrhage, which at times is of long duration. It is self-evident that affections in which other symptoms are present, for example, pus and blood in the urine, cannot be placed in this category. How are these cases to be explained ? In view of the fact that haem- orrhage of great severity and long duration has been observed inde- pendently of any of the recognized causes of renal bleeding, and par- ticularly for the reason that persons thus affected have enjoyed good health for years afterwards without the supervention of other haem- orrhages, it has been assumed that the trouble is due to disturbances of the vasomotor and sensory nerves, or in other words that the haem- orrhages are angioneurotic (Klemperer). Senator explained one case by the hypothesis of renal haemophilia. Israel is of the opinion that this case depended upon the structural changes in the kidney. He believes that in such cases there is a pre- 554 DISEASES OF THE KIDNEYS. existent circumscribed or diffuse inflammation, which produces no changes in the urine, but gives rise to paroxysmal attacks of conges- tion. Naunyn has also reported violent haemorrhages in contract- ing kidney. Harrison, Guyon, Albarran and Legueu are likewise of the opinion that the condition is due to congestive swelling of the kidney resulting from old inflammatory foci and leading to tension of the capsule. They also believe that the condition can be cured by splitting the capsule of the kidney. Senator and Rovsing think that there are always adhesions between the kidney and fibrous capsule and the fibrous and fatty capsule, and that the pain is caused by traction. They believe the curative effect produced by splitting the kidney to be due to the fact that the adhesions are broken up when the organ is freed from its investing layers. Therefore, Rovsing advises against incising the kidney and recommends that it be merely freed from its surrounding membranes, to which operation he applies the term nephrolysis. As concerns my own experience, I have seen cases of typical renal colic which differed in no wise from those due to calculi except that no red blood-cells were present in the urine, cases in which no discernible lesions were found upon operation and in which microscopic exam- ination of sections of renal tissue removed at the time of operation showed no abnormalities. In these cases, moreover, the patients recovered and experienced no return of their disease. In one of these cases just before each attack the kidney became so swollen that it could be easily palpated under the costal arch; after the attack the swelling disappeared. At operation (nephrotomy) neither hydronephrosis nor dilatation of the pelvis was found. In this case there could have been nothing but congestion and increase in the volume of the kidney. No cause for this condition was ascertainable; one is forced to accept the hypothesis of spasm of the ureter. This theory is corroborated by another observation. In two other cases I merely decapsulated the kidney and in both perfect and permanent cure was obtained. I have never seen a nephritis cause typical renal colic unless some other condition was also present. I have often seen cases in which there was severe pain in the back, but it was not sufficiently violent to constitute renal colic. I have yet to see a case of unilateral nephritis. It is true that profuse haemorrhages may occur in nephritis and that NEURALGIA OF THE KIDNEY. 555 the resulting blood-clots may occlude the ureter and thus give rise to colic, but this is quite another thing than the one now under consider- ation. Stenosing ureteritis, which also occasionally gives rise to colic, must likewise be excluded. I have seen three cases of severe haemorrhage from both kidneys in apparently healthy persons. In the beginning these cases were puzzling, as the patients presented no symptoms after the bleeding subsided. Upon continued careful examination, however, I found intermittent albuminuria and casts in all three. These, then, were cases of chronic nephritis with paroxysmal attacks of profuse haemorrhage. The following case is also important. I once relieved a patient suffering from complete anuria and violent renal colic by passing a catheter into the ureter on the affected side. The anuria was imme- diately overcome and the colic disappeared. No stone was passed nor was any seen upon subsequent cystoscopic examination. Having thus reviewed this somewhat obscure subject I will now express my own views in regard to it. There are cases of renal colic without any obstruction in the ureter which are caused by firm adhesions between the true capsule of the kidney and the surrounding fatty capsule. For these decapsulation is the proper treatment. Splitting the kidney should be abandoned. It has not yet been determined whether there is a local renal haem- ophilia or bleeding from healthy kidneys, nor whether circumscribed nephritic areas may produce renal colic. It is well-known, though, that severe haemorrhage may occur in chronic nephritis. There are spasms of the ureter for which no cause can be found. They are comparable to the cramps occurring in hysteria and to the gastric crises of tabes, for which reason they have been called crises nephretiques. They may lead to typical renal colic. As a rule, they are cured by simple catheterization of the ureter. If the attacks of colic are associated with severe haemorrhage, there is in the majority of cases an underlying structural change acting as the cause. The circumstance that no bleeding occurs for years after does not prove the contrary, for we know that haemorrhage from malignant tumors may cease for years at a time. Whether there is an underlying structural cause or whether the bleeding is angioneurotic (the existence of which form I do not consider proved) would be determined by catheterization of the ureters, together 556 DISEASES OF THE KIDNEYS. with functional examination of the kidney. It is natural to suppose that a kidney with structural lesions will not work as well as its fellow. Unfortunately I have had the opportunity of examining only one such case. Experience must teach whether the differences in the functional values of both kidneys are so great that positive conclusions can be drawn from them. [THE OPERATIONS OF NEPHROTOMY AND NEPH- RECTOMY.] To expose the kidney through the lumbar route, the patient is placed on the sound side with a sand-pillow or an inflated cylindrical rubber pad beneath the loin, and an incision commencing half an inch below the twelfth rib, close to the outer border of the erector spinas muscle, is carried obliquely downwards and outwards towards the crest of the ilium for a distance of three inches or more, perhaps being made to curve slightly forward at its lower extremity toward the abdomen, parallel with and about a half inch above the crest of the ilium. The latter modification will be found serviceable in the case of obese persons. The first cut divides skin, superficial fascia and fat, thus exposing the muscular layer formed by the latissimus dorsi behind and the external oblique in front. This layer is then cut through and the internal oblique, the lumbar fascia, and perhaps also some muscular fibers of the serratus posticus inferior, are brought into view. The divided tissues are now drawn back with retractors so as to give a good exposure of the field of operation. The twelfth dorsal nerve, which emerges from beneath the quad- ratus lumborum muscle, pierces the aponeurosis of origin of the transversalis abdominis, and then passes onwards between this latter muscle and the internal oblique, should now be sought for and drawn away from the line of incision through the lumbar fascia. The ilio-hypogastric, which lies below the twelfth dorsal, must be avoided. Occasionally a portion of the ilio-inguinal may be ex- posed. It will usually be necessary to prolong this incision into the substance of the internal oblique. The incision should be begun a little anterior to the erector spinae mass so as to avoid opening the sheath of this muscle. Care must be taken, however, not to begin it too far anteriorly lest the peritoneum be divided. Haemorrhage from the branches of the THE OPERATIONS OF NEPHROTOMY AND NEPHRECTOMY. 557 subcostal and lumbar arteries, if of any moment, should be arrested by tying the vessels. The perirenal fat bulges through the incision in the lumbar fascia, and is to be divided with the knife or separated by blunt dissection, whereupon the kidney can be forced out of its position into the wound by making pressure upon the abdominal wall. There are two points concerning the fatty capsule of the kidney which it is well not to forget ; one is anatomical, the other pathological. As regards the first, bear in mind that there is a distinct layer of fascia embedded in the substance of the fatty capsule which may be mistaken for peritoneum unless its existence be thought of when it is exposed. (See also under anatomy of the kidney.) The second has reference to the changes produced in the capsule by inflammation, as the result of which it becomes converted into a dense, firm mass difficult to break through and adherent to the true fibrous capsule. The separation or removal of such a mass is tedious, and considerably prolongs the time required for operation. If sufficient room is not secured by this method to bring the kidney into full view, various modifications may be employed according to the exigencies of the individual case. Thus, the quadratus lumborum muscle may be divided at right angles to its fibers, the original incision prolonged further downwards, or the twelfth rib may be divided or resected. Instead of the oblique incision a longitudinal one may be made along the border of the erector spinas mass from the twelfth rib down to the crest of the ilium. Edebohls, who employs this incision, places the patient in the prone position with an inflated cylindrical rubber bag beneath his abdomen. When the cutaneous and muscular layers have been divided, the patient is pulled by the legs toward the foot of the table, the pad thus being brought under the thorax. The abdominal breathing which results from this manipulation serves to force the kidney out of the wound. After the kidney has been exposed the method of treating it will depend entirely upon the morbid condition present. When operating for the removal of calculi (nephrolithotomy) an effort may be made to detect the stone by palpating the kidney with the finger or exploring it with a needle. If calculi are detected they are to be cut down upon and removed with the fingers, forceps or scoop. There is always a possibility, however, of leaving small calculi 558 DISEASES OF THE KIDNEYS. behind unless the interior of the kidney — the calices, pelvis and origin of the ureter — be thoroughly explored. Therefore it is better to lay the kidney freely open and explore the depths with a probe. In doing this the manner of making the incision is of some moment. Brodel's study of the blood-supply of the kidney has taught us that the anterior half is much more vascular than the posterior. Hence the first-named portion is to be avoided when the organ is incised. An incision made six millimeters behind the convex border of the kidney will pass between the anterior, highly developed plexus and the posterior plexus, thus considerably lessening division of blood-vessels (Kelly). (See also under anatomy of the kidney. ) The renal artery must be compressed before the kidney is cut into, and the compression must be maintained until the renal wound is closed. For suturing this wound two or three rows of catgut are to be used, so that both its deep and superficial portions may be brought into good apposition. If suppuration exists to any degree, the wound should be drained, and not closed. Under such circumstances the respective indications for nephrotomy and nephrectomy have already been stated {see Nephrolithiasis, Pyonephrosis, etc.). In operating for pyonephrosis the surrounding tissues must be pro- tected from contamination. It often happens that adhesions have firmly fixed the kidney to the superficial structures, thus obviating the necessity of packing off with gauze or suturing the fatty capsule to the external wound before evacuating the pus. After the abscess cavity is opened and the contents evacuated, the finger should be passed into it and any bands or partitions of tissue which divide it into separate compartments, or project from its walls, broken down so as to make a single large cavity. When this has been done the cavity is irrigated with hot normal salt-solution, a large drain properly surrounded by gauze introduced, and a few sutures put in at either end of the external incision. It is often advisable to suture the walls of the renal wound to the opening in the muscular layer. This effectually fixes the kidney. Irrigation of the abscess cavity should be frequently employed. The tube is gradually withdrawn as healing takes place. Nephrectomy, or the removal of a kidney, may be performed either through a lumbar or an abdominal incision. THE OPERATIONS OF NEPHROTOMY AND NEPHRECTOMY. 559 For lumbar nephrectomy either of the incisions already described will usually suffice, although various others have been devised. For the removal of very large growths that of Konig may be employed. This incision is carried along the border of the erector spinas mass nearly down to the crest of the ilium and then curved forwards and upwards towards the umbilicus, stopping at the border of the rectus. After the kidney has been exposed and separated from the perito- neum, it is lifted out of the wound, the structures forming the pedicle are isolated and ligated separately with strong silk, and the pedicle then divided close to the hilum of the kidney. If it is difficult or impossible to isolate the constituent structures of the pedicle, a clamp is placed upon it close to the kidney and it is then cut through, after which the divided vessels and ureter are ligatured in the stump. Care must be taken to arrest all haemorrhage. If the bleeding vessels cannot be caught with haemostatic forceps and tied, the wound must be firmly packed with gauze. More than one patient has died of haemorrhage from an anomalous artery which was not included in the primary ligatures. When the ureter is much diseased, as for instance when a suppurative process has extended to it from the kidney, it should be fastened into the edges of the wound instead of being ligated. In some cases it will be possible to remove a portion of the ureter and draw the end into the wound. This procedure permits the ablation of an additional amount of diseased tissue. In operating for malignant growths any remnants of the fatty capsule must be scrupulously removed, as it has been shown that this tissue often contains neoplastic cells (Israel, Lecene). The wound is closed in the usual manner, space being left, however, for a drainage tube. Abdominal nephrectomy is suitable for the removal of very large growths. The incision is made through the linea semilunaris, being four inches long, with its center corresponding to the umbilicus. The opening thus made may be enlarged above or below if necessary. After the abdominal cavity has been opened the hand is introduced and the opposite kidney felt for; if it be present and not grossly diseased the operation is continued. The intestines are pushed toward the median line and the field of 560 DISEASES OF THE KIDNEYS. operation surrounded with gauze. The peritoneum covering the kidney is then incised, dissected up, and drawn away from the kidney on either side by means of haemostatic forceps applied to either edge. It is important that the peritoneum be incised external to the colon, so that the blood-supply of the latter may not be interfered with. After the kidney is exposed it is freed mostly by blunt dissection with the fingers, scissors being used only to liberate confining bands of fibrous tissue; the structures forming the pedicle are then isolated and tied separately, the pedicle divided and the kidney removed. All bleeding is arrested, the wound in the peritoneum closed with catgut, all gauze removed from the abdominal cavity, and the opening in the parietes closed in the usual manner. In partial nephrectomy, which is permissible only for the removal of benign growths, cysts, strictly circumscribed areas of suppuration, fistulas, and portions of tissue destroyed by injury (Hartman), ablation of the diseased tissue is practised and the margins of the resulting wound approximated with catgut. EXAMINATION AND DISEASES OF THE URETERS. The ureters connect the kidneys with the bladder. It is very seldom that we have to do with isolated diseases of these organs, there gen- erally being an associated lesion of the kidney or bladder and perhaps of both. The ureters he concealed in the true pelvis and abdomen and under normal conditions cannot be felt through the abdominal walls. When diseased they can sometimes be palpated through the abdomen and rectum, and in the female through the vagina. Palpation of the upper portion of the ureter through the abdom- inal wall, however, is most uncertain. It is only in thin persons, and when the rectum is empty and the ureter much thickened, that they can be accurately palpated. Favorable conditions are also necessary for palpation of the lower segment through the rectum. The patient must not be fat, the examiner's fingers must be of good length and the ureter somewhat thickened. It can then be felt internal to and above the seminal vesicle as a cord which rolls under the finger. In the female this examination is comparatively easy through the vagina. All in all, however, these methods of examination remain difficult, untrustworthy, EXAMINATION AND DISEASES OF THE URETERS. 56 1 and mostly without result, as one can seldom reach a definite conclusion which will permit operation. For this reason other methods of examination have long been sought for. Their object is to secure the urine from each kidney separately and thus determine which side is diseased. It is unnecessary to describe all of these methods, for although some of them are very ingenious none are of practical value. This problem remained unsolved until I succeeded in placing catheterization of the ureters upon a practical basis. It has already been stated that there are few isolated diseases of the ureters. Catheterization of the ureters, therefore, affords an adequate means of diagnosticating diseases of the kidney as well as offering material assistance in the recognition of affections of the ureter. It is indicated, however, only when the simpler methods fail. The principal affections of the ureters are injuries, fistulae, inflam- mation, stricture, calculi and tuberculosis. Injuries may be simple contusions, ruptures or wounds. The first two are very rare. The most common are wounds inflicted during an operation, for example, during vaginal and also abdominal hys- terectomy. The diagnosis is generally easy, but occasionally there is some doubt as to which ureter is injured or in what portion the injury is located. The passage of a catheter will at once clear up the difficulty. [If the ureter is divided close to the bladder the proximal end may be implanted into the bladder. If the division has occurred higher up, the distal end may be ligated and an anastomosis made between the proximal end and a longitudinal slit in the distal end below the point of ligation (Van Hook).] It is the same with ureteral fistulae, nearly all of which are of traumatic origin. An ulcerating tumor or tubercle in the ureter may rarely lead to the spontaneous formation of a fistula. Inflammation of the ureters, ureteritis and periureteritis, occur only in association with an ascending process from the bladder or a descending one from the kidney. The symptoms, therefore, are identical with those of the respective renal and vesical affections. A distinction of more practical importance exists between the isolated forms, as some are associated with dilatation of the ureter and others with narrowing and kinking. The last two conditions can be positively diagnosticated by catheterizing the ureters. If the 38 562 DISEASES OF THE KIDNEYS. catheter repeatedly becomes arrested at the same place, the existence of one or the other of these conditions may be assumed unless symp- toms of obstruction due to some other cause, such as tumor or stone, are present. [The late Christian Fenger, of Chicago, applied the principle of the Heineke-Mikulicz operation of pyloroplasty to the treatment of stricture of the ureter, making a longitudinal incision over the stric- tured portion and then uniting the wound transversely.] Ureteral calculi are caused by the descent of a calculus from the pelvis of the kidney. They have three points of predilection, namely, at the junction of the renal pelvis and ureter, in the lower third of the ureter where the sacrum bends forward, and in the intravesical portion of the ureter. The symptoms vary according as the stone partly or completely obstructs the flow of urine. In the latter instance typical renal colic and anuria are not uncommon, whereas in the former no symptoms whatever may be produced. A calculus may remain impacted for years. If the history, and symptoms of the case be carefully studied and the results of palpation and catheterization of the ureters be considered, diagnosis will not be difficult. If the symptoms persist extraperito- neal ureterectomy is the proper procedure. [The upper portion of the ureter may be exposed by either of the two principal incisions described for exposing the kidney. If the oblique incision be prolonged around the iliac crest, parallel with Poupart's ligament, to a point corresponding to the external abdominal ring (Henry Morris), nearly the whole length of the ureter can be brought into view. The abdominal portion of this incision is carried down to the peritoneum, which is then separated and displaced inwards so as to expose the ureter. A longitudinal incision is then made in the ureter, the calculus extracted, and the wound closed with catgut. In cases where the ureter is greatly distended with foul decomposed urine and pus drainage is to be employed.] Tuberculosis, according to my experience, does not occur as an isolated disease. The process either descends from the kidney or ascends from the bladder, the former being its more common mode of propagation. The diseased ureter is usually markedly thickened, and the appearance of its vesical orifice generally betrays its condition. EXAMINATION AND DISEASES OF THE URETERS. 563 The orifice is either irregular, as though ulcerated, or it is cedematous and swollen; in some cases it is surrounded, or perhaps occluded, by an area of bullous oedema. Attempts at catheterization sometimes fail in consequence of the changes which have taken place in the ureter. These consist in thickening of the mucous membrane (cedema), stric- ture and kinking. The complete clinical picture, the inemcacy of treatment directed to the bladder, and the finding of tubercle bacilli in the urine make diagnosis certain. For further details concerning these affections the reader is referred to the articles on the diseases with which they are associated. 564 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. PHYSIOLOGY. In the male puberty begins at about the fifteenth year. The first signs of its development are changes of voice, growth of hair on certain parts of the body (pubes and face), and awakening of the sexual im- pulse. At the same time, or occasionally before, erections of the penis begin to occur; they constitute the most essential attribute of masculine potency. ERECTION. Erection is under control of the nervous system and it may be evoked by stimuli affecting the brain, certain peripheral nerves, and the spinal cord. These nerve-tracts influencing erection have been demonstrated on dogs by Eckhard. There is no reason to believe that the conditions in man are any different than in the higher animals. According to Eckhard the nerves controlling erection originate in the spinal cord; he succeeded in exciting erections with electrical stimulation of the cervical as well as the lumbar portion of the cord. Irritation of the pons at the point of entrance of the crura cerebri into the cerebrum likewise produced rigidity of the penis. From these experiments he concluded that the impulses necessary for the production of an erection originate in the cerebrum and are transmitted through the pons and crura cerebri to the cord. Furthermore, Goltz found that after separation of the lumbar portion from the remainder of the cord, erections could be produced by irritating the glans penis. This led to the conclusion that there is an inde- pendent center of erection in the lumbar cord. Goltz also showed that this lumbar center may be inhibited by impulses from the medulla and brain. He found that reflex stiffening of the penis occurred much more quickly when the cord was divided between the thoracic and lumbar portions, that is, when the putative inhibitory influence of the rest of the cord and brain is eliminated. Clinical observations in man are in accord with these statements. The influence of the brain upon erection is shown by the circumstance that certain sights and mental impressions are quite sufficient to ANATOMY AND PHYSIOLOGY. 565 produce an erection; indeed, this is the most frequent mode of origin; the sight of certain women, a lewd conversation, obscene pictures, or even the mere thought of such things, will cause rigidity of the penis. That erections may be generated in the spinal cord is also proved by clinical observations. It is known that in the primary hypersemic stage of certain chronic diseases of the spinal cord, frequent erections or even priapism are among the usual symptoms. So, too, erection and ejaculation have been observed in certain forms of irritation and concussion of the cord, particularly in the upper cervical portion (Oliver), and in fractures and dislocations of the vertebrae; they are often the first sign of a beginning ataxia (Erb). In regard to reflex stiffening of the penis, it is well-known that friction or even touching the organ may cause it to become turgid. In acute gonorrhoea, prostatitis, and vesical calculi frequent painful erections are one of the most constant symptoms. They are reflex and are due to irritation of the peripheral nerves resulting from inflam- mation in the urethra, prostate, or bladder. The usual morning erection is due to irritation of the peripheral nervi erigentes by a distended bladder. In regard to the phenomenon of erection itself, it must be admitted that its mechanism is not perfectly clear, although the works of Kolliker, Kohlrausch, Eckhard, Goltz, Loven and Frey have materially advanced our knowledge of it. The existence of an erection is dependent upon an increased afflux of blood to the corpora cavernosa and a lessened outflow from the same, so that they contain more blood when the penis is rigid than at other times. It is not entirely clear, however, in exactly what manner this change in the circulation is effected. That it is entirely dependent upon interference with the outflow of venous blood is doubtless false, for a good erection can- not be produced by simply tying the veins of the penis. There is a simultaneous increase in the flow of arterial blood; in animals the manometer shows a fall in blood-pressure in the arteries near the penis during erection, and Eckhard proved that it extended to the femoral artery. How does this increased afflux of blood occur? It is practically certain that it is not due to increased cardiac action; at least this is a very subordinate factor in the production of the necessary afflux of arterial blood. It is much more probable that the arteries of the penis are dilated during erection so that more blood enters the organ. 566 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. In answer to the question as to whether the vessels become dilated by direct action of the muscle fibers in their walls, or whether the walls become relaxed and the caliber of the vessels thus increased, Goltz made the following statement: "I am of the opinion that the relation of the nervi erigentes to the penis is the same as that of the vagus to the heart or the chorda tympani to the submaxillary gland. When the penis is flaccid its small arteries, and perhaps other vascular spaces as well, are in a state of moderate contraction, in consequence of which the blood-current in the penis is subjected to considerable pressure. It is probable that this tonicity of the vessels is maintained by the small ganglia which Loven discovered on the penis. Now when the nervi erigentes are stimulated to activity, the contracted arteries of the penis relax and forthwith become dilated under the pressure of the blood, which is copiously poured into the retiform spaces of the corpora cavernosa, distending them to the utmost. I am inclined to agree with Loven that the peripheral ganglia in the penis are the center of vascular tonicity and believe that they may be inhibited by the nervi erigentes, just as it is supposed that the vagus inhibits the ganglia of the heart." Whether this explanation is true or whether direct muscular action is the cause, or whether both relaxation and muscular action are responsible, has not yet been determined. There is less difficulty in explaining how the venous reflux is preven- ted. Part of the veins which carry the blood from the corpora caver- nosa empty into the dorsal vein of the penis and the remainder pass to the under surface of the organ through interstices in the cortical plexus. If the corpora cavernosa are filled with blood, pressure of the cortical plexus upon the veins will hinder the outflow of blood from these bodies. In addition to this there is the action of a muscular apparatus by which the reflux of blood is completed. The bulbo-cavernosus [accelerator urinae] arises from a tendinous raphe, from which the transversus perinei and sphincter ani externus also take origin. Its fibers extend along both sides of the bulb to bifurcate above and be inserted into the fibrous sheath of the corpora cavernosa. When this muscle contracts the penis is constricted in the region of the sym- physis and the return of blood from the corpora cavernosa thereby impeded. At the same time the penis is elevated and pressed against the symphysis by the ischio-cavernosus, which also assists in prevent- ing the reflux of blood from the corpora cavernosa. ANATOMY AND PHYSIOLOGY. 567 COHABITATION AND ORGASM. Cohabitation is a term applied to the act of copulation, through which the sperm is implanted in the ovum. For the fulfillment of this act rigidity of the penis is necessary, so that it can be introduced into the vagina of the female. By friction upon the vaginal walls it is so stimulated that orgasm and ejaculation occur, the latter being reflex. Orgasm is the crisis of voluptuous sensation which is experi- enced when the semen escapes through the urethra, or to be more exact, when it is expelled from the ejaculatory duct into the urethra. LIBIDO SEXUALIS. The sexual impulse peculiar to the healthy adult male, and compar- able to the sexual instinct of certain animals, is excited by those causes which we have recognized in the production of erection, only they are so intensified that they impel the individual to the performance of the sexual act. It is very difficult to draw the line between normal and abnormal sexual impulse; it must be remembered that the sexual feeling is not so highly developed per se, but that it is rather aroused by occasional causes. It is generally greater in men than in women. It is also influenced by individual disposition, regimen of living, food and occupation. Persons who work little and eat heartily of stimulating food are much disposed to eruptions of the sexual feeling, while those who are engaged in mental or physical work find that their passions are kept subdued. EJACULATION. Ejaculation is the term applied to the reflex process by which semen is discharged into the urethra and carried out of the body. When the crisis of sexual excitement is reached the musculature of the seminal vesicles and ejaculatory ducts force the semen into the urethra, whence it is forcibly ejected by a spasmodic contraction of the bulbo-cavernosus and the sphincteric portion of the prostate [sphincter vesicae]. Ejacu- lation is under the influence of reflex excitation of the ejaculatory center (genito-spinal center of Budge), which lies in the cord on the level of the fourth lumbar vertebra. This center sends fibers to the bulbo-cavernosus, which accordingly is the true muscle of ejaculation. 568 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. THE SEMEN. By semen or sperm is meant the fluid which under normal conditions flows out of the male urethra at the termination of coition. This fluid is not a simple product, but is composed of the secretion of the testicles, vasa deferentia, seminal vesicles, prostate and mucous glands of the urethra. The testicular secretion as it is found in the seminiferous tubules is a thick, white, viscid mass, consisting principally of spermatoblasts, the mother-cells of spermatozoa. The spermatozoa are first seen in the rete Halleri. Here and in the following segment of the seminal passage, in the epididymis and vas deferens, they are non-motile, in consequence, no doubt, of the density of the surrounding medium, which is a tenacious fluid containing nucleated epithelial cells of various shapes, and irregular, highly refractive granular cells. In the vasa deferentia the spermatozoa become thoroughly mixed with this fluid and are carried to the seminal vesicles with it. The secretion of the seminal vesicles which is now added to the mix- ture is tenacious, odorless and colorless, of a higher specific gravity than water, neutral in reaction and non-coagulable. It contains nucleated polyhedral epithelium, isolated leucocytes and shiny bodies resembling grains of sago. The secretion of the prostate is also added to the semen. It is alkaline or neutral and of a milky, opalescent color; it contains very fine granular cells, droplets of lecithin and hyaline flakes, to which isolated epithelial cells are almost always added when the prostatic secretion is expressed by pressure through the rectum. It is this secretion which gives the semen its white, half translucent, opalescent property, which differentiates it from the secretion found in the seminal vesicles. If several ejaculations occur in succession, the opalescence of the semen becomes less and less; it becomes thinner and more like the contents of the seminal vesicles. This is due to the absence of prostatic fluid. Occasionally the so-called prostatic corpuscles, stratified bodies having an amber or brown center usually surrounded by light concen- tric layers, are found in the prostatic fluid. These corpuscles vary in size from minute specks to masses as large as a hemp-seed. They are colored blue by iodine and green by substances rich in albumen. The next ingredient added to the seminal fluid is the secretion from Cowper's glands, a tenacious, ropy, hyaline mass which is alkaline ANATOMY AND PHYSIOLOGY. 569 in reaction and serves to lubricate the parts with which it comes in contact. It is secreted during erection, at the moment of ejaculation, and is analogous to the secretion of Bartholin's glands in the female. Let us now consider the semen as a whole, as it appears after an emission. It is a tenacious, grayish, opalescent fluid of alkaline reac- tion having a higher specific gravity than water and a peculiar odor resembling that of boiled starch. The quantity discharged at a single emission varies in different men from 5 to 20 g. [i 1 to 5 fl. drachms]. Fig. 228. — Normal Semen, a. Spermatozoa, b. Molecular detritus, c. Sper- matoblasts, d. Leucocytes, e. Epithelium. /. Specks of pigment. If coitus is repeated at frequent intervals, the quantity decreases with each ejaculation until finally only a few drops are expelled. Immediately after it is voided the seminal fluid becomes converted into a gelatinous mass, although the air soon causes it to liquefy again. According to Vauquelin it is composed of 10% of solids and 90% of water. One-half of the solids are organic elements. An albuminoid substance called spermatin can be extracted from the semen; it is probably formed in the seminal vesicles. About 3% of the solid 570 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. elements is phosphate of lime, and i% sodium salts; traces of ammonio- magnesium phosphate are also found. If a drop of seminal fluid is examined under the microscope all these elements are found (Fig. 228). The most important and most striking are the actively motile, undulating spermatozoa. Not always, though occasionally, leucocytes, the concentric stratified prostatic corpuscles, and the sago-like particles known as Lallemand-Trousseau corpuscles are found. The fecundat- ing power of the semen depends upon the life of the spermatozoa. The only sure sign of their vitality that we yet possess is their motility. If semen is allowed to stand in a reagent glass for a few hours, it separates into two layers, the upper of which is thin, white and trans- lucent, somewhat resembling whey, while the lower is a thick, white, opalescent mass. If a drop of the upper layer be examined micro- scopically, it will be found to contain epithelium and molecular detritus (the seminal granules) ; the under stratum is composed of spermatozoa. From the thickness of this layer and the rapidity with which it forms an idea as to the quantity of spermatozoa in a given specimen of semen can be obtained (Ultzmann). In normal semen their number is very great, many thousands being contained in one drop. Under the microscope they are seen to be actively motile. They consist of a flattened pyriform head, a neck and a long thread-like tapering tail. The tail is from ten to twelve times as long as the head and makes incessant undulating, lashing move- ments, by which the head is pushed forward between other sperma- tozoa and cells. This vivacity of movement caused the spermatozoa to be called seminal animalcules. The semen soon dries under a cover glass and the most active spermatozoa lose their power of motion after a few hours; if the semen be guarded from light and cold, however, living spermatozoa may be found at the expiration of thirty-six or forty-eight hours. Dead spermatozoa differ in no wise from the living except that their tail is extended or its extremity perhaps coiled up in spiral form. Water destroys spermatozoa immediately, whereas normal saline solution prolongs their power of motility for some time ; alkalies, such as solutions of potassium and sodium, also favor their motility, whereas acids, metal salts, and acid secretions, as urine, for example, at once kill them. ANATOMY AND PHYSIOLOGY. 57 1 This leads us to consider the significance and importance of the differ- ent components of the semen. As some urine remains in the urethra after each act of micturition, and as the semen passes through this canal, its contact with the acid urethral walls would impair the vitality of the spermatozoa had not nature provided a means to prevent this evil. The remedy is provided by the secretion of the prostate, Cowper's glands, the urethral mucous glands and the sinus pocularis. During erection and at the moment of ejaculation the last three secrete an alkaline fluid which greases, lubricates, and makes the urethral wall alkaline. It has already been stated that the secretion of the seminal vesicles acts chiefly as a diluent of the testicular product and thereby causes the spermatozoa, which are previously motionless, to become motile. The prostatic fluid is of equal importance. Marris Wilson long since showed that the secretion of the prostate is necessary to maintain the vitality of the spermatozoa. He believed that it was the neutral phosphate of lime in this fluid which preserved them from the destruc- tion to which they would be subjected by contact with the acid secre- tions of the urethra. Percy proved that spermatozoa soon perish in the uterine secretions unless the latter are mixed with prostatic fluid; when prostatic fluid is present, however, they remain active for three, four or even eight days. More recent investigations have confirmed this view. Fiir- bringer, who by the way believes the prostatic fluid to be acid, added fresh prostatic secretion to the semen of a man affected with spermator- rhoea and found that previously sluggish spermatozoa became active; he therefore concluded that the prostatic secretion exerts a specific vitalizing action upon the spermatozoa which are dormant while in the seminal vesicles and spermatic ducts. The relation of the prostatic secretion to the power of impregnation is shown by another observation, if not with certainty at least with probability. If semen is dried on a glass slide and examined after a certain time, varying from a few hours to three days, peculiar crystals having the form of rhombic prisms and ending in fine points or rhomboid margins, are found lying alone or arranged in layers. If one of these plates lies upon another a cross is formed, and if several are placed across each other a rosette is produced (Fig. 229). The composition and significance of these crystals, which were described by Van Deen and 572 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Bottcher, and named after the latter Bottcher's spermatic crystals, is still a subject of dispute. Bottcher thinks that they are albuminoid bodies, Schreiner consid- ers them to be phosphatic salts having an organic base, Ultzmann be- lieves that they are composed of phosphate of magnesium, and Gross that they are made up of ammonio-magnesium phosphate. Others believe them to be identical with Charcot's crystals, which are said to occur wherever profuse mucous secretion exists. Fiirbringer proved Fig. 229. — Spermatic crystals. by examination of the contents of the seminal vesicles and the pros- tatic secretion of a large number of corpses, and also the prostatic fluid of the living, that these crystals are found only in the prostatic fluid. He attributes the peculiar smell of the semen to these bodies. It is certain that they do not originate in the testicular secretion, for they are found most abundantly and best developed in azoospermia, a condition in which spermatozoa, the characteristic element of the testicular secretion, are absent. It may be said that the relation of the spermatozoa to the spermatic crystals is one of inverse proportion; the more numerous the latter and the more quickly they are formed, the fewer the spermatozoa THE ABNORMAL LOSS OF SEMEN. 573 or the less their activity. Therefore they are almost always found in azoospermia. The thinner and poorer in spermatozoa the semen, the earlier the appearance of these crystals and the greater their number. While they are found in normal semen only when it has been dried, and then perhaps only after several days, in the semen* of azoospermia they are seen a few hours after ejaculation. A drop of i% solution of ammonium phosphate renders them more distinct (Fiirb ringer). Ultzmann explains the late occurrence of these crystals in normal semen by assuming that crystallization cannot take place in a fluid so full of motion. It is only after the spermatozoa die and the semen becomes still that crystallization can begin. According to these statements the presence of spermatic crystals is of value in determining the impregnating power of the semen. The time at which semen is produced varies in different persons. Generally speaking it begins to be secreted at puberty and may continue until an advanced age. Liegeois found spermatozoa in the semen of two boys of fourteen, four of sixteen and two of eighteen years. In respect to the age limit, it may be stated that Wagner found them in the semen of men sixty and seventy years old, Curling in that of a man aged eighty-seven, and Casper (the medico-legal expert) in that of one aged ninety-six. Out of twenty-three cases in which death resulted from the weakness of old age or from affections common to this period of life, and in which no serious organic lesions were present, Dieu found them six times. Therefore it is seen that semen capable of causing impregnation may be produced under normal physiological conditions until an advanced age, but that its fecundating power dies out under the influence of severe diseases and a high degree of cachexia. FUNCTIONAL DISEASES OF THE SEXUAL ORGANS. Having discussed the physiology of the sexual apparatus we will now consider its functional disturbances. We will first study the so-called abnormal loss of semen, secondly impotence, and thirdly sterility. THE ABNORMAL LOSS OF SEMEN. Under normal conditions the adult male loses semen only upon cohabitation, or if this is not indulged in for a long time, it escapes spontaneously at intervals, this loss constituting what is known as pollutions. The occurrence of pollutions is somewhat physiologic. 574 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. They take place during sleep and are usually accompanied by lascivious dreams and a sense of erection. They are due to irritation produced by distention of the seminal vesicles with semen; this irritation is transmitted by sensory nerve fibers to the spinal cord, especially to the ejaculatory center, and when its maximum is attained it sets up a reflex contraction of the seminal vesicles and vasa deferentia. Accordingly pollutions are most common in the bloom of sexual life, when the semen is most abundantly produced. Physiological pol- lutions are not characterized so much by the frequency of their occur- rence as by the manner in which they take place. If a strong young man who lives on rich food has an emission about once a week without any bad reaction on his health, it is to be considered entirely physiological. The production of semen, and therefore its evacuation, varies in different persons ; it is greater in those who lead an active sexual lif e, whose mind is occupied with sexual matters, than in those who live moderately and engage in active mental pursuits. In the first class the increased production of semen {plethora seminalis), inconsequence of the reflex action produced by distention of the seminal vesicles, leads to frequent desire to empty these organs and to increased irri- tability of the ejaculatory apparatus. Nocturnal pollutions, then, become pathologic only when they exert a bad reaction upon the general health. They are pathologic when they occur with undue frequency, as for example, on several nights in succession or several times in one night, and when the characteristic accompaniments, erection and voluptuous feeling, are absent or considerably diminished. The patients feel weak and debilitated, are tired, disinclined to work, and morose or irritable. Pollutions having such after effects are naturally pathologic. Pollutions occurring during the day and resulting, as is usually the case, from slight mechanical or psychical irritation, are to be considered as a symptom of disease. It must be borne in mind that abnormal pollutions do not constitute a disease, but that they are only a symptom of some morbid condition. If a loss of semen occurs without volup- tuous feeling, without orgasm, without erection, the fluid escaping gradually instead of being forcibly ejected, the condition is then known as spermatorrhoea. This spontaneous and persistent loss of semen is very rare. It generally follows defecation and micturition. THE ABNORMAL LOSS OF SEMEN. 575 If morbid pollutions are considered as due to a motor neurosis of the sexual apparatus, a spasm of the musculature of the seminal vesicles, then spermatorrhoea represents a paresis of the ejaculatory ducts. It is conceivable that there may be various transitional forms between pollutions and spermatorrhoea; thus, for instance, pollutions may be associated with imperfect erections, and there are cases of spermatorrhoea in which slight rigidity of the penis supervenes, together with some pleasurable sensation. In order to understand the significance of pathologic pollutions and spermatorrhoea it is essential to know from what causes they arise and in what diseases they occur. Both occur in neurasthenia, a disease of most diverse manifesta- tions, but which will be considered here only in its relation to the sexual system. In this disease there is an hereditary or acquired debility of the entire nervous system, a nervous cachexia, so to speak. The nervous system's power of resistance, especially that of the affected centers, is so slight that the most trivial stimulation produces the maximum of irritability, as the result of which ejaculation ensues; or, conversely, the normal tonicity of the ejaculatory duct is raised to the highest point, so that the semen flows away spontaneously or escapes upon the slightest pressure. Thus, sexual excesses may cause this symptom, either directly or by inducing neurasthenia. Of the sexual excesses masturbation occupies the first rank; it is immaterial whether it be physical, that is, practised by frictioning the penis, or only psychical, an ejaculation being induced by conjuring up voluptuous fancies. At present we do -not believe in the dreadful results of masturbation described by Lallemand and Tissot, but yet it must be conceded that if the habit is persisted in for years it will impair the soundness of both body and mind, that it will result in enfeeblement and hyperesthesia of the nervous system. It is not so much the numerous losses of semen as it is the effect of the frequently repeated stimulation upon the nervous system which brings about this condition. The frequency with which masturbation is practised explains why abnormal pollutions result more frequently from this habit than from sexual excesses. That coitus interruptus, or coition terminated before its completion, for the purpose of preventing conception, may cause spermatorrhoea if it be persisted in for years, is no doubt correct, although such a result is exceptional. I have seen a general nervous condition follow this 576 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. practice much more frequently than the symptoms now under dis- cussion. The same is true of sexual abstinence. It is true that men who have been accustomed to regular sexual intercourse, but have been forced by circumstances to become continent, have frequent pollutions, although these emissions are not pathologic because they have no injurious reaction. They are rather an effort of nature to relieve seminal plethora. All the etiologic factors which have been mentioned do not cause pollutions and spermatorrhoea as often as they produce certain local affections of the urinary and sexual organs: chronic urethritis, which has extended to the ejaculatory ducts, and chronic inflammation of the seminal vesicles and prostate are conditions which I have frequently found in cases of abnormal loss of semen. If the former can be cured the latter will usually subside. It is in these cases that loss of semen during or immediately after defecation or micturition is the most common. Finally, frequent pollutions may occur in certain organic diseases of the spinal cord, in the early stages of tabes and myelitis, for instance. The diagnosis of pollutions and spermatorrhoea is usually readily made from the statements of the patient, although it must be remem- bered that there are discharges from the urethra which resemble semen and may be mistaken for such by the patient. These are the dis- charges occurring in prostatorrhcea and urethrorrhcea. As they are far less important than spermatorrhoea it is necessary to distinguish them from the latter disease, which is easily done by examining a drop of the discharge with the microscope. The characteristic picture of a drop of semen has already been des- cribed. Prostatorrhcea shows the characteristics of prostatic fluid, namely, lecithin corpuscles, small refractive specks, rings and flakes, epithelial cells, and a varying number of leucocytes if prostatitis is present. Rarely stratified corpuscles are found. In urethrorrhcea only a few leucocytes and pavement and cylindric epithelium from the urethral glands, together with long slender shreds of mucus are seen. Lecithin corpuscles and spermatozoa are absent. Urethrorrhcea has no pathologic significance. It occurs in highly sensitive persons when an afflux of blood to the penis causes a partial erection and forces the secretion of the urethral glands out into the urethra. SEXUAL NEURASTHENIA. 577 Prostatorrhoea is often a sequel of prostatitis. The excretory ducts of the prostate are rigid and have lost their tonicity, so that slight pressure exerted by scybalous masses suffices to press the prostatic secretion into the urethra, through which it passes to the external meatus. In regard to the significance of abnormal pollutions and spermator- rhoea, it has already been stated that they do not represent independent diseases, but that they are a single member of a complex group of symptoms which owe their existence to the conditions previously enumerated. They may be symptoms of general neurasthenia, which is called sexual neurasthenia when it chiefly affects the genital organs ; or in consequence of the reaction which they produce they lead to this disease of the nervous system. A knowledge of them is of the greatest importance and therefore we will consider them more in detail, following for the most part Krafft-Ebing's views. SEXUAL NEURASTHENIA. Sexual neurasthenia is one of those forms of nervous weakness which express themselves as functional disturbances of the genitalia. These may be the only symptoms of disease, although, as a rule, a multitude of others are present. Krafft-Ebing has analyzed the symp- tom-complex and given us a better understanding of it. He recognizes three stages of the disease: 1. A local neurosis of the genitalia, causing frequent pollutions and premature ejaculations. 2. A neurosis of the lumbar cord, char- acterized by neuralgia of the lumbo-sacral plexus, frequent nocturnal emissions, diurnal pollutions and impairment of sexual vigor. 3. Cerebro-spinal neurasthenia, in which the disease has advanced to general neurasthenia. Not all cases of sexual neurasthenia, however, pass through these typical stages. Thus, for example, there are cases of general neuras- thenia which have been preceded by sexual excesses or local sexual neurasthenia. Severe general neuroses may result from sexual excesses without involvement of the genital apparatus, or the most violent sexual debauchery may produce only local disturbances, no symptoms referable to the cord and brain being present. In this respect, too, there are many variations and combinations. In general it may be stated that masturbation is more prone to produce cerebral neuras* 39 578 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. thenia, while excessive sexual intercourse tends rather to cause the spinal form. The symptoms of sexual neurasthenia consist in cerebral manifes- tations, or sexual cerebrasthenia; in spinal manifestations, or sexual myelasthenia ; in lumbar and local genital manifestations; and, finally, in circulatory and digestive disturbances. As cerebral manifestations we recognize dizziness and a feeling of oppression which may amount to violent headache, conditions which are detrimental to the development of mental activity. The patients cannot work as they formerly could nor apply themselves continuously to labor; they begin to sleep poorly and become more or less ill-tempered and irritable. They are fully aware of their mental apathy and want of energy, and this knowledge increases their moodi- ness, so that they may become confirmed hypochondriacs. They cannot concentrate their mind upon one subject. Weakness of memory and sensory disturbances supervene; the latter consist of increased sensibility to light, weakness of vision (asthenopia neuras- thenica), tinnitus aurium, auditory hyperesthesia and disturbances of speech. Melancholia as well as hypochondria may ensue. The spinal manifestations of neurasthenia, or sexual myelas- thenia, usually occur in association "with cerebral neurasthenia, just as the latter is frequently accompanied by spinal symptoms. The spinal symptoms are weakness and fatigue upon walking, pain over the back, loins and extremities, paresthesia in these parts, a sensation of itching, coldness and numbness of the legs, together with a feeling of weight and heaviness. Lancinating pains like those of tabes also sometimes occur. The objective symptoms of spinal irritation are observed, namely, localized sensitive areas in the spinal column, fibrillary spasm of the fingers, tremor of the extremities and exaggerated patellar reflex. The local manifestations of sexual neurasthenia affect both the urinary and sexual organs. Pain over the bladder before and after micturition, urgency of urination and dribbling of urine are complained of, although the urine itself is found absolutely normal. These symptoms are due in part to increased irritability of the detrusor and in part to diminished tonicity of the sphincter. The disturbances of the sexual organs consist of pain in the testicles and epididymes, hyperesthesia of the glans penis, and occasionally involuntary contractions of the cremasters, causing a jumping or SEXUAL NEURASTHENIA. 579 dancing of the testicles, to which the Germans have given the name Hodentanz. Abnormal losses of semen also take place, and according to the frequency with which they occur may lead to weakness and exhaustion or result in spermatorrhoea. Finally the disturbances of the circulatory and digestive systems have to be considered. Among the well-recognized neuroses of the heart are stenocardia, palpitation, tachycardia, pseudo-angina, pain radiating from the cardiac region to the scapula and accompanied by a. feeling of oppression, and increased cardiac action after exertion, excitement and the use of strong drink. The objective signs of organic heart disease are absent. The digestive tract is in a condition of nervous dyspepsia. After each meal a feeling of pressure and pain develops in the region of the stomach, and retching or even vomiting may also be present. It is characteristic of this condition that the patients sometimes experience violent pain in the stomach after partaking of small quantities of easily digestible food, while at other times they can eat a good dinner of heavy food without feeling the worse for it. Less commonly nervous cardialgia, irregular attacks of vomiting and gastralgia, peristaltic agitation of the stomach and intestines, distention of the abdomen and constipation are present. Both palpation and examination of the stomach contents give negative results. It is well- known to what extent this nervous dyspepsia may produce disturbances of nutrition and thus simulate severe organic disease of the digestive tract. The prognosis of abnormal losses of semen and sexual neurasthenia is not so unfavorable as the patients themselves, and many physicians as well, are inclined to consider it. My experience leads me to believe that nocturnal pollutions and loss of semen during defecation usually subside under appropriate treatment, while losses occurring during micturition, and diurnal emissions occurring without any exciting cause are difficult to influence. If the condition is due entirely to natural sexual excesses the prognosis is good if a more moderate regimen of living is adopted. Pollutions due to local disease of the sexual organs can also frequently be improved or cured. Cases due to masturbation are difficult to help because the patients cannot relinquish their bad habit, or if they do give it up for a time, fall into it again. The most unfavorable cases of all are those in which there is an hereditary neurotic taint. The duration of the 580 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. disease is always considerable. It requires many months, or perhaps years, to put these patients in order. The treatment is to be directed partly to removal of the cause and partly to relief of symptoms, although the former is naturally the more important. As masturbation plays a role, even though it be not a great one, in the etiology of the disease, all possible means should be taken to guard against this evil. As far as children are concerned the task of preventing its acquirement devolves upon parents .and teachers rather than upon the physician, although the latter may be of assistance by vouchsafing proper advice. The appropriate means of prevention consists in careful observation of the child, the avoidance of obscene literature, care in the selection of his companions — as the habit is fre- quently taught by others — avoidance of arduous mental application, and encouragement in the practice of physical exercises such as gym- nastics, swimming, riding, fencing and gardening. For older persons, be they married or unmarried, who have continued to practise this vicious habit, it is first of all necessary to make them understand that the evil results are generally exaggerated. This may keep them from becoming neurasthenic or hypochondriacal. As much exercise and physical labor as possible, with a light, easily digestible diet are indicated. Patients who have acquired their disease by overindulgence in sexual intercourse do not require much counsel; they have generally become sensible, their condition forcing them to lead a different life. It is important, however, to make them understand that the evil results of their excesses, for example spermatorrhoea, are of no great signifi- cance and are of only temporary duration. If an organic disease such as tabes or myelitis is the cause, the mani- festations of the general disease are so much more pronounced than the local symptoms that treatment of the latter may not be indicated. The local disturbances, however, may annoy the patient very much and therefore they must be watched. The bromides, cold affusions to the back and genitals, and galvani- zation and faradization of the spinal cord are the appropriate remedies. The results are slight and seldom permanent. Relapses require treatment. The prospects of improvement and cure are best in those cases of frequent abnormal pollutions and spermatorrhoea dependent upon a SEXUAL NEURASTHENIA. 581 localized lesion in the sexual organs. Of such lesions by far the most common are those due to chronic gonorrhoea, which almost always extends to the posterior urethra and invades the prostate and seminal vesicles. The measures recommended for chronic gonorrhoea (quod vide) may be used with advantage in this condition, according to the indications of the individual case. One maxim though must always be observed : ne nimis ! As advan- tageous as is a definite and cautious local treatment, just so bad is it to carry this form of therapy too far. My experience has taught me that those who carry local treatment too far make just as great a mistake as those who completely discard it. If remnants of a gonorrhoea remain, the usual measures, particularly cauterization of the colliculus seminalis with a few drops of a 2% solution of silver nitrate, may be tried. It should be done at intervals, so as not to increase the already existing nervousness of the patients; if prostatitis is present, the gland should be massaged, the rectal thermophore used, and electrization of the prostate practised, one pole being placed in the rectum and the other over the symphysis. The metal sound, the psychrophore, and applications of cold water to the genitals may be used in conjunction with a few internal remedies and hygienic and dietetic measures. The bromides alone or in combination with ergot, or with iron and arsenic, according to the indications of the individual case, are useful drugs. Hygiene consists in regulating the diet and the general regimen of living and above all in securing a copious daily evacuation of the bow r els. Under this treatment the pollutions almost always become fewer and the spermatorrhoea entirely disappears. Some of these therapeutic measures are identical with those which I use in sexual neurasthenia, as abnormal losses of semen are often only a symptom of neurasthenia. It is evident that the employment of the local measures just mentioned will have to be more restricted in the case of patients of neuropathic taint. They are only permissible for the purpose of inspiring the patient with confidence that he will be cured. The disease being one in which the greatest desideratum is an alteration of the patient's mental condition, treatment naturally must be psychical. This gives results only when the physician possesses great authority and has the complete confidence of his patient. The first object of suggestive treatment should be to impress the 582 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. patient with the idea that his disease is not so severe as hebelieves,and that he will soon get better and be cured within a conceivable time. The best results are obtained by hygienic-dietetic treatment in a sanitarium. The same measures employed at home do not have the effect that they have when the patient is removed from his usual sur- roundings and vocation. Therefore it is best for well-to-do patients to go to a suitable sanitarium and take a systematic course of treat- ment. Regulation of the bowels; light, non-stimulating food eaten at regular intervals; the interdiction of alcoholic beverages and the restriction of tobacco; prescribed exercises together with physical labor in the intervals when possible; gymnastics, massage, galvanic or faradic electrization; hydrotherapeutic measures, such as full baths, half baths and sitz-baths, douches at first luke warm and then gradually reduced in temperature, together with friction; — these are the remedies with which the institution-physicians obtain such surprising results. Change of air, a sojourn in the country, sea baths and traveling also have a beneficial effect upon the mental and physical condition. Those who are not able to go to a health-resort or travel should be treated according to the same principles at home. As to medical treatment I recommend the various bromine salts, ergotin and strychnine, with or without the addition of iron and arsenic, according to indications. IMPOTENTIA VIRILIS. By impotentia virilis is understood a condition in which the power of having normal sexual intercourse is entirely lost or considerably dimin- ished. This disease is more accurately called impotentia cceundi in contra- distinction to impotentia generandi, which implies a defect in the semen, or in other words in its impregnating power. Both render the indi- vidual incapable of propagating his kind, unless artificial methods of fecundation are resorted to in the former condition. With few excep- tions, which will be referred to later, those who are unable to copulate are also unable to procreate; on the other hand inability to procreate does not imply incapacity to copulate. There are many men whose power of impregnation is lost, but yet who are able to have intercourse in a normal manner; and, vice versa, there are many others whose testicles produce an entirely normal secretion, and who therefore are not sterile in the strict sense of the word, although their inability to secure intromission of the penis ORGANIC IMPOTENCE. 583 renders them incompetent to procreate. Those exceptional cases in which emission takes place although the penis is only partly or not at all rigid are to be excluded from this class, as conception may occur if the seminal fluid gets into the vagina. Impotentia cceundi, the more important of the two affections, will be considered first. Apart from the existence of normal genital organs, the indispensable condition for the performance of the sexual act is a good erection, so it naturally follows that absence or insufficiency of erection constitutes the cause of impotence. This defect may relate to the time during which the penis remains rigid, to the degree of rigidity which it attains, or to faulty direction of the perfectly rigid penis. According to the cause upon which impotence depends we recognize : 1. Organic impotence. 2. Psychical impotence. 3. Nervous impotence. 4. Paralytic impotence. 1. ORGANIC IMPOTENCE. In this form the inability to copulate depends upon malformation or defect of the genital organs or neighboring structures. Among these are absence or rudimentary formation of the penis and exstrophy of the bladder with very short penis. Epispadias and hypospadias do not always cause impotence. I know a great many men afflicted with one or the other of these conditions who are able to perform the sexual act very satisfactorily, even though the semen is not ejected into the vagina, but escapes above or underneath. It is only in the extreme grades of this abnormality that coitus is impossible. When the penis is completely or mostly retracted into the scrotum in consequence of scrotal hernia, hydrocele, elephantiasis or tumors of the scrotum, it is useless as far as the sexual function is concerned. In reducible hernias a truss, and in the other abnormalities proper opera- tive procedures, will afford relief. Mutilation or abnormal size of the penis may also hinder cohabita- tion. Elephantiasis of the glans or body of the penis, tumors of the glans, urethral or preputial calculi may interfere with or completely prevent intromission. The prognosis of these cases is usually favorable. Sometimes the 584 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. abnormalities can be removed by operation without destroying the form of the penis. Even when it is necessary to cut off the anterior portion of the organ enough often remains for the patient to have connection. Impotence may be caused by congenital or acquired shortness of the fraenum, so that it bends the end of the penis downwards. In such cases even though cohabitation is possible it is usually so painful that the individual is compelled to abstain from it. Cure is readily obtained by dividing the fraenum. It has also been stated that varix of the dorsal vein of the penis may prevent connection. If the penis is deflected to one side or upwards or downwards when it becomes erect, this deformity may prevent or at least render inter- course difficult. The trouble depends upon the degree of deviation, which in turn is due to circumscribed infiltrations or indurations of the corpora cavernosa or their fibrous sheath. These infiltrations may be multiple or single, they may be limited to one corpus cavernosum, as is generally the case, or they may surround the whole penis. They may also extend into the corpus spongiosum. In consistency they may be soft or as hard as cartilage. When erection occurs deviation of the penis results, as the spaces within the corpora cavernosa are obliterated at the site of the infil- trations so that they cannot expand. The deviation occurs toward the side on which the indurations are situated. The etiology of this affection, which occurs most frequently in middle life, is not clear in all cases. The gouty diathesis, injuries during coitus, violent erections, and gonorrhoea have been specified as causes. Verneuil found diabetes mellitus in nine out of ten cases and therefore believes that there is a causal relation between the two affections. Tufher and Pousson also found them associated. In several of the cases which I have observed gonorrhoea and injury seemed to be the cause. I have not seen any cases in which the other supposed causes were operative. The tumors found in diabetes are usually in the corpora cavernosa, while the callosities resulting from long-standing gonorrhoea are usually first situated in the corpus spongiosum, from which they may occasionally extend to the corpora cavernosa. They are most common in the bulb and resemble urethral stricture; they are also often found in the pendulous portion of the urethra. Periurethral abscesses producing obliteration of the affected parts PSYCHICAL IMPOTENCE. 585 may have the same effect. Johnsohn saw distorsion of the penis follow an abscess in the right corpus cavernosum. When of considerable extent or rightly situated, ossification of the septum or fibrous sheath of the corpora cavernosa may have a similar effect. They are much less common than the previously mentioned affections (Velpeau, Malgaigne). Gummata of the corpora cavernosa may also cause deviation of the penis during erection (Ricord). Differential diagnosis between these growths and callosities and bony growths will seldom be difficult. Gummata offer the best prognosis of all these affections; regular antisyphilitic treatment or potassium iodide alone, together with local inunctions of mercurial ointment, will generally prove efficacious. Curvature of the penis due to laceration of the corpora cavernosa, commonly called fracture of the penis, offers no chance of cure. Ossifications in the septum, the so-called horns of the penis, may occasionally be removed by operation. The nodules occurring in diabetes offer a good prognosis. They are no doubt caused by this disease, as they become smaller when it responds to treatment. The most difficult to cure are those due to gonorrhoea. Boyer and Gross recommended the excision of such indurations. This procedure is good, although it is subject to restriction. Before resorting to opera- tion other measures should be tried, among which I recommend the use of sounds of increasing size. If there is a stricture it should be dilated with soft bougies. After the urethra will admit a 16 F., metal sounds may be employed and their size constantly increased. Local appli- cations of mercurial ointment, warm sitz-baths, and potassium iodide internally may be employed as auxiliary measures. Under this treat- ment I have seen many infiltrations become smaller and the curvature of the penis thus become less. It is only when this procedure is ineffectual and the infiltrations are multiple or large that excision should be undertaken. 2. PSYCHICAL IMPOTENCE. , Psychical impotence is the most important of all the forms of impo- tence and, moreover, is one of the most interesting subjects in medi- cine. Its clinical picture presents unusual diversities. The impair- ment of virility varies greatly, being less at certain times than it is at others. 586 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Although the conception of potency may be relative, it is neverthe- less constant insofar as it implies capability to have connection at certain intervals of time. It cannot be positively stated just how many times a man should be able to copulate within a given period of time. The age of the man, his disposition, his sympathy for the female, and many other things exert an influence. There is, however, a certain physiological measure. If this is diminished we speak of impotence, although we call it partial impotence in contradistinction to absolute, in which the individual is no longer able to perform the sexual act. As regards the age at which a man is able to copulate and the time of life at which this power ceases, it naturally varies, depending upon many different circumstances. The time at which it becomes extinct is even more variable than the period at which it begins. Many men retain their virility until an advanced age, while others lose it com- paratively early, or at least find that their power is becoming impaired. Sometimes this senile condition follows an exhausting disease, at others it supervenes as the result of physiologic processes. In the latter instance the transition from potency to impotency is gradual. A diminution of sexual power is noticed; while it was possible for him to have connection every day, such a person now finds that intervals of constantly increasing duration must elapse between the acts; or a longer time may be required for the consummation of coitus; or, whereas formerly any erotic excitation sufficed to produce an erection, unusual and complicated means are now required. It is also a reduction of potency when a man is able to cohabit only with certain women. This form of impotence, which comes under the heading of psychical, is called relative. It usually affects married men who cannot have intercourse with their wife, although they are potent with other women. Just as virility varies in different men, so likewise does it vary in the same individual according to external conditions and physical and mental disposition; it is to the latter that we will now particularly direct our attention. It has already been stated that the prerequisite of potency is an erection, which is under the control of the brain; therefore the mind exerts a notable influence upon the sexual functions. Impotence due to mental alterations is the most interesting as well as the most frequent and readily curable form. Only those cases in which mental impression is the exclusive cause can be placed in this category. PSYCHICAL IMPOTENCE. 587 I cannot agree with those authors who consider frequent attacks of gonorrhoea, prostatic disease and inflammation of the bladder or testicles to be causes. These troubles are responsible for psychical impotence only as far as they produce mental alterations. As long as they do not give rise to such changes they do not influence sexual power, a fact which is attested by thousands of cases of gonorrhoea. They do occasionally give rise to mental impressions which disturb the sexual capacity, but this is quite another matter. Upon investigation of the etiological factors of psychical impotence it is found that they are many and diverse. Persons who have led a most moderate sexual life or who may even have lived continently are sometimes affected, and, conversely, those who have given themselves over to the wildest excesses, who have indulged excessively in natural intercourse from their earliest youth and thus overtaxed their power, may also be subject to it. There are also cases in which the quality of coitus does, not correspond to physiological laws, in which unnatural situations and subtle means on the part of the female are required for the production of sexual excitement. Further- more persons who have been or still are addicted to masturbation are sometimes affected, and, indeed, they constitute the largest number of this class. Finally fear, superstition, hypochondria, or even a slight mental impression may render a person incapable of performing the sexual act. It is exceedingly rare for persons who have practised sexual inter- course very moderately or not at all to suffer from psychical impotence ; they constitute the largest contingent of those who are afflicted with nervous irritative impotence, which will presently be described. Such cases, however, do occur in the former class and depend upon absence of the sexual impulse. The sexual impulse leads to sensual excitation, which in turn leads to the performance of the sexual act. Therefore, if this impulse is absent, the desire and possibility of intercourse is wanting. Absence of the sexual impulse may be congenital or acquired. The former is certainly very rare, although there are perfectly healthy persons who have never experienced sexual desire. Such sexual anaesthesia is of cerebral origin. It is not dependent upon absence or defect of the external organs of generation or the spinal mechanism, for Ultzmann and myself have observed cases of congenital aspermatism in which virility was intact. Only those cases in which 588 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. sexual life is wanting, despite normally developed and functionally active organs of generation, come under this category. According to Krafft-Ebing this form generally occurs in persons who are affected with other functional cerebral disturbances, or who show, signs of mental and perhaps also physical degeneration. Closely related to these cases of defective sexual impulse are the so- called naturae frigidce, which are encountered more frequently in the female than in the male sex. Women thus constituted have only slight inclination for connection, derive no pleasure from it, and submit to it only from a sense of duty. In regard to acquired absence of the sexual impulse, mental overwork or diversion is most to blame. When the mind is absorbed in thought sensual excitation is not experienced. In most of these cases the im- potence is only temporary; as soon as the cause is removed the effect disappears. Cases have been reported, though, in which the mind was so engrossed in other subjects that the sexual impulse dwindled away and failed to develop again after the excessive activity had ceased. It is said that Sir Isaac Newton never had sexual intercourse, and it may well be believed that he, who was occupied with problems requir- ing the most assiduous and profound thought, never felt the sexual impulse. It is different in those cases in which the first cause of an unsuccessful coitus was a mental impression, the recollection of which occasioned still further failures upon subsequent attempts. An interesting explanation of the manner in which distrust or fear influences potency is afforded by Goltz's theory of inhibitor} 7 centers in the brain. It will be remembered that Goltz ascribes an inhibitory power to the brain by means of which the center of erection in the spinal cord is controlled. Although the latter may endeavor to send out impulses for the production of an erection, it is prevented from so doing by the irritated inhibitory center. The two centers are in con- flict; the inhibitory center in the brain is the stronger and conquers the center of erection in the cord. It is true that no proof of the correctness of this theory canbe adduced, but I place some value upon it as it explains how it is possible for anxiety to prevent the occurrence of erection; I believe that a large number of cases of psychical impotence are attributable to this cause, which not only lends weight to the theory, but also determines the method of treatment. As we shall see later, in the majority of cases PSYCHICAL IMPOTENCE. 589 it is not weakness of the genitalia or nervous system resulting from excesses or masturbation which leads to impotence, but rather lack of self-confidence and fear that these digressions may have inflicted harm. The stronger this fear the more remote the cure. The frequency with which cure is obtained, however, confirms this view. As soon as the patients' anxiety is removed, a thing which cannot always be easily accomplished, they regain their virility. In order for the patient to be freed from his fear it is necessary first of all for him to trust his physician and hope that he will be benefited by the treat- ment prescribed. For this reason I lay great stress upon prescribing a detailed plan of treatment for these patients. I either send them to a watering place and have them take a thorough course of treatment under the supervision of a physician, or treat them at home by means of general electrization, local faradization of the genitals, which produces erections, artificial carbonic acid baths, sounds of increasing size, cold rubs, cold baths, and the internal administration of placebos. It is very advantageous to employ several of these measures at the same time ; the less the patient's time is occu- pied the greater the number which should be used. The patient will then believe that a great deal is being done for him and gain hope that the treatment will be beneficial. It is most essential for the patient to abstain from coitus for a long time. He must not be allowed to attempt it every week for the purpose of testing his power, for a failure will greatly retard his recovery. I have my patients abstain for months at a time; they then get the idea that this long rest has so fortified their genital organs that they are again fully able to have connection. In like manner fear of failure is responsible for many cases of psychical impotence following excesses in natural coitus or mastur- bation. There is a general impression among the laity that excessive venery leads to early loss of sexual power, and it is certainly well that they think so, as otherwise excesses would be even more common than they are. As it is, many are restrained from the dissolute practices to which their nature impels them through fear of the consequences. Others, however, are reckless or their desires conquer their discretion. Then it comes to pass that coitus goes amiss, be it that erection does not occur when it is needed or subsides too soon, be it that an unusual 590 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. length of time and unusual effort are required for the consummation of the act; in short, it is noticed that coitus is not performed as it formerly was. This need not result from excesses, there being many other causes which explain its occurrence. The affected person may be physically or mentally exhausted or his thoughts diverted to other subjects. He may have been under the influence of drink or his feeling toward his female companion have been very slight; finally uncleanliness, disagreeable odor, or vulgar conduct may have produced a feeling of disgust or aversion. Any one of these suffices to explain why con- nection is not as satisfactory as it formerly was. The patients, however, naturally attribute it to their sexual excesses and look upon it as a form of punishment. When we come to consider atonic impotence we shall see that they are often right, although it is often only one of these accidental causes, together with transitory weak- ness, which produces the failure. If this once comes to pass, fear ensues that it may happen again, and it is this thought of failure more than anything else which prevents the occurrence of erection. Of minor importance are those temporary forms of impotence which sometimes immediately follow excesses. If a man has connection several times a night for several nights in succession, it is only natural that he should fail when he tries again after a short lapse of time, as sexual energy is in relation with the amount of seminal fluid and nervous energy which is stored up. If the former is spent and the latter ex- hausted, coitus naturally cannot take place. These conditions are so well understood by the laity that they do not give rise to the fear previously mentioned. It is known that proper rest will put things in order again. In many cases, too, marital conditions are the cause of relative im- potence. Thus a married man may have no trouble in having connec- tion with other women although he is not able to with his wife. Such cases have been observed in men, who in course of time have taken an aversion to their wife, in those whose wife aged early, and in those who found relations with other women so congenial that they no longer derived pleasure from intercourse with the woman to whom they are wedded. Under these circumstances it is naturally difficult for the physician to effect any change. We now come to a group of cases of psychical impotence which are caused by an aberration of mind relative to sexual matters, namely, PSYCHICAL IMPOTENCE. 591 perverse sexual feeling. These cases have received more attention from writers on medical jurisprudence, but they are nevertheless of particular interest and great importance from our point of view. The normal man feels the sexual impulse under circumstances which are too well-known to require detailed description here. The sight of nude or partly disrobed women, contact or lewd conversation with them, obscene pictures and the like awaken ideas which produce sexual excitement, as the expression of which an erection of the penis occurs. It is different with persons having perverse sexual impulses. That which arouses the physiological sexual feeling in normal men has no effect upon them; their sexual nature is excited by circumstances which have no influence whatever upon normal men. For example, the sight of women's hose or shoes makes no impression upon a normal man; I have a patient, however, who experiences sexual excitement only when he looks at the former article of apparel. It is easily explainable how such perverse feelings may result in impotence. Persons thus afflicted cannot get an erection when they try to have connection, because those things which excite them sexually are absent. The libido sexualis, however, is strong, indeed it is often too well developed. A large number of such persons are masturbators, that is, contem- plative masturbators [Gedanken-Onanisten] in contradistinction to those who produce orgasm and ejaculation by frictioning the penis without further voluptuous fancies; they picture unto themselves the most marvelous relations with women. This arouses their lust and erection and ejaculation follow. When they come in contact with women and try to have connection, they remain unmoved; they fail to find in reality that which their fantasy had depicted; no erection occurs, they are impotent. Perverse sexual impulse, then, may express itself as a mere imagina- tive proceeding, as in the case of the contemplative masturbators, or in the actual performance of an unnatural sexual act with other persons. These persons may be of either sex; it matters not so far as the result is concerned. The perversity of the conception often relates to secret things which are usually concealed from the eyes of men, although it may concern matters which bear absolutely no relation to anything ordinarily capable of arousing sexual excitement, or relate to objects which are seen every- where and have nothing whatsoever indecent about them. Thus 592 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Charcot and Magnan report a case in which the thought of a night-cap aroused sexual desire. It is interesting to note that in those cases in which an inadequate stimulus evokes sexual desire, although adequate physiological stimuli remain without effect, the inadequate stimulus may be used to render coitus possible. This supplies the basis upon which treatment must be founded. Thus there are persons who satisfy their sexual cravings by mere contemplation or conception of inanimate objects at onetime, and by perverse acts upon their own person at another. To this class also belong those who seek to appease their lust by perverse practices upon persons of their own or the opposite sex, or upon animals. The perverse acts which are practised with persons of the same sex merely represent an increase in the perverse ideas relating to persons of the opposite sex upon which the mind of the afflicted individual is concentrated. Just as in some cases sexual enjoyment is derived from the sight or conception of women's shoes or similar objects, in others it is obtained by acts of the most disgusting, horrible and criminal nature. Among these are the terrible deeds committed for the purpose of satisfying sexual passion, the acts of the sadists. As difficult as it is to understand this combination of sensuality and cruelty there are nevertheless certain weak analogies to it in physio- logical life. Thus there is some relation between these acts and the well-known fact that very sensuous women not uncommonly bite the man with whom they are having connection when the climax of coitus is reached. If the conception productive of sensual pleasure attain a higher degree and assume a murderous or criminal trend, deeds of violence result. The adequate sexual stimulus in the case of such perverts is the conception of the pain suffered by their victim. From this conception is generated the impulse to commit such deeds for the gratification of lustful desire. The principal form of sexual perversion, however, is love for those of the same sex. Here we encroach upon a domain to which the criminal judge lays claim; nevertheless the treatment of human weak- ness which devolves upon the physician comprises psychical as'well as physical conditions, and as paederasty is a form of mental aberration it should for this reason receive our attention. PSYCHICAL IMPOTENCE. 593 Love for one's own sex, or paederasty, may be congenital or acquired. In the first case the sexual disturbances depend upon a psychopathic or neuropathic constitution, that is, they occur in persons of bad heredity. These persons experience no sexual excitation through physiological stimuli, as for example, the sight of a naked woman, although the nude male figure is an adequate stimulus. If they try to have connection with a woman they fail, and unless they are morally degenerate, so that they cannot realize the abnormality of their condi- tion, the failure increases their despondency and mental suffering. Masturbation must have an especially unfavorable influence upon the sexual life of a person of such a bad heredity. It acts as a predisposing cause for the development of paederasty. When such an individual who was addicted to masturbation in his early years attains a mature age, he does not possess, writes Krafft-Ebing, " the aesthetic, ideal, pure and natural feeling which attracts him to the other sex. Thus the ardor of sensual feeling is extinguished and affection for the opposite sex very much reduced. This defect has an unfavorable influence upon the moral and mental condition, upon the character, disposition, impulses and emotions of young masturbators of either sex, and under certain circumstances causes the desire for the other sex to die out, so that masturbation is preferred to the natural method of appeasing sexual desire." In acquired paederasty it is generally misguidance on the part of others and the impossibility of satisfying the sexual impulse which makes otherwise normal men paederasts. Therefore it is no wonder that the vice is particularly common in closed and guarded institutions, such as boarding-schools, monasteries and prisons, and also on board ships. It more rarely happens that married persons practise it in order to avoid increase in the family. It most commonly originates in educational institutions where one boy with perverse sexual feelings seduces other pupils. Under the influence of example and the desire which is uppermost in the mind the children conquer their disgust, inflame their imagination with obscene pictures, and indulge in peder- asty. Homosexual propensities are also often observed in old people, mostly old rakes whose senses have become dulled to natural stimuli. They find no pleasure in normal sexual intercourse, sink morally lower and lower, and finally abandon themselves to the loathsome vice of paederasty. 40 594 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. In this category also belong the so-called Sodomites, persons who practise lustful acts with animals. Sodomy was an element of re- ligious cults among many ancient peoples, notably among the Egyp- tians. There are . different causes which lead men to rape animals. It is generally weak-minded cretins or insane persons who commit these acts during their periodical outbursts of sexual passion. It is only exceptionally that persons of apparently sound mind, who have not the opportunity of satisfying their lust in the natural manner, will abuse animals if they get the chance; it is an exceedingly rare occur- rence for a man or woman to conceive a passion for an animal. In such cases the persons are usually neuropaths whose sexual inclinations are toward animals and whose passion is aroused by the revolting deeds which they commit upon them. 3. NERVOUS IMPOTENCE. This form of impotence, which is also known as impotence due to irritable weakness, and is often associated with sexual neurasthenia, resembles the two principal forms already described, in that it is not caused by organic lesions of the central nervous system. The genital organs and the nervous mechanism controlling them are anatomically sound, but functionally deficient. All cases in which anatomical lesions are demonstrable or probably present do not belong to this group, but come under the last division, namely, paralytic impotence. In the present class of cases there is a functional defect the nature of which is not always easily determinable. To draw a comparison for the purpose of illustration let one imagine a lighting apparatus con- sisting of an electric battery connected by conducting coils to a platinum wire. The power of the battery, however, is so great that when the current is turned on the platinum wire soon glows through, so that a lasting light is not given off. Here all is sound, battery as well as wire, and yet the apparatus does not work as it should. If the dispropor- tion between the two parts is removed, and they are adjusted one to the other, the whole will then act properly. Similar conditions may be assumed in impotence due to irritable weakness. In this condition ejaculation takes place at the moment intromission of the penis occurs or even before it can be inserted into the vagina. At the moment when coitus should begin the penis becomes flaccid; men thus affected must naturally be considered impotent. NERVOUS IMPOTENCE. 595 Just as the battery in the lighting apparatus was too strong, so here are the nerves too strong; they occasion orgasm and ejaculation too soon, with the result that coitus cannot be continued. I have chosen this comparison because in irritative nervous impotence there is an excessive nervous activity. According to my experience those who suffer from this complaint are mostly young men who have indulged in sexual intercourse very rarely or not at all. The report of a case may serve as an illustration. A young man, twenty-three years of age and of a well-to-do family complained that it was impossible for him to have connection, as ejaculation always took place before he could secure intromission of the penis. He could obtain a good erection, but it would subside too soon. He considered his condition humiliating and unendurable, and feared that it would keep him from marrying. This young man was the only son of his parents, who had watched him with unremitting care, so that it had been impossible for him to indulge in sexual intercourse. When he became somewhat freer he made the attempt but failed, and the fiasco was repeated upon each subsequent trial. His statement that he had never masturbated was accepted, as he was upright and truthful. He had had an emission once or twice a month. The present trouble had existed for three years without changing much, although he had become able to secure intromission, whereupon ejaculation occurred at once. The case was cured by marriage. The condition here was evidently due to hypersensitiveness. In consequence of the long repression of his sensual desires the otherwise perfectly healthy man became so excited that the orgasm occurred sooner than in other men. The excessive irritability became tempered in wedlock, an occurrence which I have had the opportunity of observing in other cases. Two other cases may be cited as representing certain types. One is that of a young lawyer, and is worthy of notice on account of its termination. The patient, a strong, handsome man, was not watched so closely as the one previously mentioned, so that he early had the opportunity of entering into sexual relations. During his student days he developed, from what cause is unknown, a general nervous condition which expressed itself in the form Of great agitation, restlessness, inability to work and sleeplessness. In addition he experienced a tickling sensation in the urethra, which gave rise to 596 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. frequent erections and caused precipitate ejaculation whenever coitus was attempted. The patient was not of bad heredity and had masturbated very little during his youth; the genital organs were well developed and the urethra as revealed by the endoscope was entirely normal; its sensibility was diminished rather than increased. His illness, particularly the sexual disturbance, caused him to become hypochondriacal. I sent him to a hydrotherapeutic institute where he took a mild course of treatment. Upon his return he did not feel much better. He was afraid to marry because he thought he might not be able to fulfill his marital obligations. I endeavored to quiet his fears and convince him that such would not be the case ; indeed, I even recommended marriage as a cure. He did as I advised him. I had forewarned him that in the beginning of his married life matters would go even worse than with members of the demi-monde, but that he should not be disturbed by this. I tried to make him understand that his trouble was one which would diminish day by day. Three months after his wedding I saw him again. He stated that matters went exactly as I had predicted. At first ejaculation took place before intromission, then he gradually became able to secure intromission before the semen was discharged, and at length got so that he could have normal coitus. If we now consider a third case we shall have had an example of all the forms of impotence belonging to this class. It is that of a school- master who had masturbated considerably in his youth. Neurasthenic symptoms were not long in manifesting themselves. The patient was restless, unsettled in mind, and suffered from insomnia, a sense of pressure in the head, and irritation in the posterior urethra and at the external meatus. Emissions occurred three or four times a week, and were followed by great weakness, depression and ill-humor. Now and then a spontaneous discharge of prostatic fluid took place. Coitus was impossible because ejaculation occurred before the patient could secure intromission of the penis. Upon examination I found the patient highly nervous, the genitals well developed, the urethral orifice reddened, the urethra of normal caliber, but excessively sensitive in the posterior portion. In this case, therefore, there was sexual neurasthenia, prostatorrhcea, and irritative nervous impotence. I placed the patient upon treatment and made a favorable prognosis. NERVOUS IMPOTENCE. 597 I sent him to a hydrotherapeutic institute where he received tepid baths followed by cold douches, together with general faradization and a partial rest-cure. When he returned home I undertook to reduce the hyperesthesia of the urethra. For this purpose I applied a five per cent solution of silver nitrate to the entire posterior urethra once a week. On the last three days of the week large sounds of ascending sizes were passed. I used cocaine at first, but was soon able to dispense with it. The meatus was large enough readily to admit a number 30 French. Potassium bromide and ergotin were administered internally. Under this treatment the patient, who had not attempted to have intercourse for three months, improved considerably, the pollutions becoming less frequent and the annoying tickling in the urethra sub- siding. Thereupon I advised marriage. The patient, although some- what doubtful, followed my advice and married, with the result that he was completely cured of his nervousness and impotence. These three cases represent the forms of irritative nervous impotence commonly met with in practice. In the first case it was complete abstinence which led to a condition of excessive irritability, in the other two general neurasthenia existed, the cause being unknown in one instance and attributable to mastur- bation in the other. I would not venture to decide whether the urethral irritation present in the last case was a manifestation of the general neurasthenia or whether it was the cause of the latter. This is the question which invariably presents itself in these cases. Many incline to the opinion that the redness and swelling of the colliculus seminalis caused by mas- turbation produces nervousness in the form of priapism and precipitate ejaculation. This theory, which presupposes the existence of a peripheral neuritis affecting the sexual nerves and emanating from the colliculus seminalis, has something attractive about it, inasmuch as it affords a firm working- basis of treatment, but as a matter of fact it may not be correct ; anatom- ical proof has not been adduced in every case. It is, however, certain that local treatment of the inflamed parts generally relieves not only the local trouble, but also the general nervous condition. In every case of this form of urethral inflammation, whether it be the cause or concomitant of impotence, it is the duty of the surgeon to endeavor to reduce the hyperesthesia. Indeed, blunting of this urethral sensibility is indicated in those 598 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. cases in which the erection is perfect, intromission successful, and coitus therefore possible, but the time required for ejaculation too short. In certain men of vivacious temperament precipitate ejaculation is normal, and it also sometimes occurs in men of less brisk disposition who have not had intercourse for a long time. If this condition is transitory it is not important, but if it is of long duration it requires consideration by reason of its action upon the procreative power. According to the views now accepted the manner in which the semen reaches the generative passages is of some consequence. It is believed that certain reflex movements of the cervix and os uteri favoring recep- tion of the semen take place during coitus. If coitus be inopportunely terminated by early ejaculation, the female fails to reach that degree of excitement requisite for the production of these reflex movements. Therefore precipitate ejaculation bordering upon impotence demands treatment because of its influence upon conception. 4. PARALYTIC IMPOTENCE. This, the fourth form of impotence, differs materially from the others. The first three forms are alike in that the sexual apparatus so func- tionates that coitus would be possible were it not for certain hindering circumstances which are present. In the first form it is absence or malformation of the genital organs or disease of neighboring parts which renders the performance of the sexual act mechanically impos- sible. In psychical impotence it was seen that sexual power is often strong, but that it manifests itself at the wrong time or in the wrong way. In the third class also the sexual organs were functionally active, only their activity was too great. It was hypererethism which prevented the consummation of coitus. In paralytic impotence all is different. In consequence of struc- tural lesions in the muscular and particularly the nervous apparatus which are in relation with the genital organs, the patients are deprived of the first prerequisite for the performance of coitus, namely, erec- tion. This is not the case in any of the first three forms; erection occurred, but could not properly be made use of. The genitals of such patients sometimes show no greater changes than are observed in the other forms. Occasionally they have a with- ered, senile look. Sometimes the testicles show signs of atrophy, being small, soft and flabby and having lost their peculiar sensitive- PARALYTIC IMPOTENCE. 599 ness to pressure, as well as being more or less unresponsive to elec- tricity; at least it is often observed that the thigh is much more sensitive to the current than the testicles. Relaxation of the scrotum is another sign which is sometimes present. Sensitiveness of the penis to the electric current is also considerably diminished. In many instances, too, the sexual impulse is entirely destroyed or very much impaired. In these cases there is an organic change in the center of erection or in the paths of conduction. The exact nature of this change has not been determined, but it may be assumed that in well- advanced cases there is complete degeneration of the nerve-tissue. In others it is probable that there is only a partial degeneration or a temporary exhaustion of the nerve-cells, constituting the condition known as atony. Accordingly we distinguish two subdivisions in this fourth form; one with complete and permanent loss of sexual power, true paralytic impotence, the other with more or less serious disturbance of power, atonic impotence. In the latter condition erection occasionally though rarely takes place, but it is usually of short duration and is not adequate for the performance of satisfactory coition. Proper treat- ment and rest, however, may cure the atony. In contradistinction to those who suffer from true paralytic impotence, those affected with this form may recover and retain their virility for years. To this fourth main division also belong such cases as are not included in the other three groups, namely, those due to malforma- tions or defects of the genitals, mental abnormalities, and excessive nervous irritation. The etiological factors in the fourth group are excessive venery, masturbation, exhausting general diseases, affections of the spinal cord and brain, and, finally, the effect of certain drugs. In regard to excessive venery it has already been stated that the meaning of excess is difficult to define, varying with the individual. That which is excessive for one is only moderate for another. The state of the general health is valuable in deciding this question, for the reason that with few exceptions men who indulge immoderately in sexual intercourse become weakened and grow thin, although their appetite remains good. The final result of extravagance is impotence. There are a few men, however, who can give themselves over to such pleasure with impunity, but the number is very limited. With the means now at our disposal it is usually impossible for us 600 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. to determine just how continued excesses injure the organism, and what changes they produce. It is frequently impossible to detect any changes; the patients feel perfectly well, but nevertheless they are impotent. At the present time it is known that impotence has not the injurious results formerly attributed to it. All possible diseases were ascribed to excessive sexual indulgence, whereas it is very probable that the loss of sexual power in such cases was due to the general diseases themselves. It is true that extravagance in sexual intercourse generally results in emaciation, but in many cases the affected persons feel perfectly well. In this connection it is to be remembered that excess in natural coitus is not so common as is generally believed, for the simple reason that the very nature of the thing itself prevents great excess. After every sexual excess, it matters not how strong the man, there is a period of weakness which has to pass away before sufficient nerve- force is collected to enable the performance of the sexual act again; desire is also obtunded. As a rule, both man and woman become more moderate irrespective of any intervening external influence. In the case of the unmarried it is difficulty of opportunity and other circum- stances which raise a barrier before these over-ardent devotees of Venus. It is altogether different in masturbation. Conditions favoring success are much better, so that loss of bodily strength and the superven- tion of impotence are much more frequently observed. The most injurious of all is the straining of an organ still in the process of development. Sexual excesses cannot be practised before maturity, as both means and opportunity are absent; masturbation, on the con- trary, is often practised in earliest youth. The effect of excessive straining upon the undeveloped sexual organs, such as results from masturbation, is far more injurious than greater excesses indulged in after maturity. For coitus two persons are necessary, for masturbation one is enough. Therefore it is clear that a masturbator will exercise his sexual organ oftener than a person who has sexual intercourse; the latter requires a special time and opportunity, the former can always find both time and opportunity. There are persons who masturbate while lying in bed or upon a sofa, while sitting, riding in a carriage, attending the theatre, or when engaged in their work, and children who indulge in it during school hours. The greater the sexual propensities the oftener is the act committed. PARALYTIC IMPOTENCE. 6oi While roues are of gay and cheerful disposition, proud of their con- quests, and try to make up by good living the strength which they lose in debauchery, masturbators almost without exception become hypo- chondriacal as soon as they learn that masturbation is a vice, or at least injurious to the health. They know that the habit is wrong and injurious yet they do not abandon it. There is often a struggle between the sexual impulse, which they have gratified by masturbating, and their resolve not to defile themselves. For a time the latter may pre- vail, but eventually the former gains the mastery again. It is not surprising when this conflict is kept up for many years, as I know it is with many patients, that the nervous system suffers. It is not necessary to refer again to the evil results of masturbation which were mentioned in connection with psychical impotence; that which has been said explains how long- continued masturbation may produce atony and also degeneration of the centers of erection, and thus cause temporary or permanent impotence. As concerns further etiologic factors, certain exhaustive constitutional diseases have been named as causes of paralytic or organic impotence. Severe acute febrile diseases, during the course of which the spermatozoa become diminished or entirely disappear, will not be considered here, because this form of impotence is of no importance. Exhaustion and impotence persisting during convalescence are likewise of no conse- quence, sexual power almost invariably returning as strength is regained. Among the chronic diseases in which impotence occurs may be mentioned morphinism, phthisis, diabetes mellitus, obesity, anaemia, and cachexia of various forms. Diphtheria, when followed by paralysis and muscular atrophy, also occasionally produces impotence. I have never observed it in phthisis. According to many authors sexual desire and power is increased in phthisis. Others, however, contend that it is decreased. It is certain that diabetes reduces sexual strength; indeed, impotence often figures among the first symptoms, before loss of bodily strength occurs. It is almost universally believed that obesity diminishes potency. Although there is no rule without exceptions, it may be stated that very fat persons are usually more devoted to Bacchus than to Venus, their sexual desire being slight, their capacity usually deficient. In such cases it is not improbable that there is fatty disease of the testicles similar to that which affects the heart. 602 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Nothing specific is known concerning the influence of ansemia upon potency. If the relations existing between the genital organs and the brain and nerves are remembered, it is not surprising that impotence often results from diseases of the latter organs. Certain diseases of the brain and cord first cause increased sexual excitation, which is followed in the latter stages by weakness and finally absolute impotence. Thus, in tabes dorsalis sexual desire is usually first increased in consequence of irritation of the nerve tracts supplying the sexual apparatus, although it later becomes diminished and eventually entirely disappears. Cases have been known, however, in which advanced tabetics have retained a high degree of sexual power. Injury or disease of certain regions of the brain may also affect potency. The relations between the cerebellum and the genital system are best understood. By irritating the cerebellum Budge produced movement of the testicle. Concerning this he writes: " By a fortunate accident I made the surprising discovery that the testicles of an old cat, which were retained in the abdomen, moved immediately after death as soon as the cerebellum was irritated with the scalpel or caustic potash. When the right half of the cerebellum was irritated the left testicle moved, and vice versa. Even superficial irritation produces this effect. The movements were so plain that their reality could not be doubted. I hastened to open the entire skull and peritoneal cavity and found the testicles absolutely immobile ; not a sign of motion was present. As soon as one side of the cerebellum was irritated the testicle on the opposite side of the body became intumescent and moved from its position in such a manner as to form a right angle with the vas deferens. When I stopped the irritation it assumed its original position, and as soon as the irritation was renewed began to move again. The experiment was continued half an hour and always with the same result. After the first stim- ulus scarcely three seconds elapsed before the testicle began to move. Gradually the interval between stimulation and reaction became longer. The movement lasted only a short time and became weaker and weaker. I also irritated the cerebrum, the corpora quadrigemina, the thalami optici and the corpora striata, but no movements of the testicles were produced." A case bearing on this observation came under the notice of Dr. Wittemore and was reported by Dr. Fischer. It was that of an old PARALYTIC IMPOTENCE. 603 man, aged seventy-five, who in forty years of married life had begotten eleven children. Soon after his marriage he began to complain of dizziness and ringing in the head, from which he suffered more or less until his death. In addition to this he had ringing and severe pain in the left ear, together with difficulty of hearing, as well as several hasmiplegic attacks which were followed by morbidly increased sexual desire. This lasciviousness partly disappeared three months before his death, so that he had a desire to copulate not more than once or twice a night. He was unable to satisfy his desires, however, for the reason that erection was imperfect, and emission had not taken place for a year. On the day following his death the brain was examined. The dura was adherent to the skull, the arachnoid thickened and the pia very cedematous. The arteries were calcareous. In other respects the brain was healthy with the exception of the cerebellum. The right lobe was normal, the left about one-fifth smaller and having a cavity of considerable size within its substance. The walls of this cavity were in contact. The cavity contained serum which flowed out when it was opened. This case is remarkable in that strong desire was present which could not be satisfied on account of defective potency. Finally certain drugs which are reputed to lessen or even destroy potency must be considered. I shall not discuss the influence of riding because nothing definite is known in regard to it. It is also very difficult to judge the effects of medicines, for the reason that their action varies greatly in different individuals both in regard to the effect produced and the quantity required. Thus it happens that the most contradictory statements concerning this subject are found in literature. The least contention obtains in regard to the effects of strong drink, which is generally acknowledged to be unfavorable. It is a well- known fact that coitus is unsatisfactory or even impossible during intoxication. This condition not uncommonly occasions a form of psychical impotence depending upon a feeling of anxiety and uncer- tainty. Constant drinkers suffer from sexual weakness, and therefore are prone to indulge in masturbation. It is not certain whether this action is due to the alcohol or to other substances contained in the liquors. Beer has a decided retarding influence upon ejaculation (Curschmann, Gyurkovechky) ; the same 604 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. cannot be said of wine, for when taken in moderate quantities it is rather a stimulant and excitant. It was not without reason that the old Latins said: Sine Cerere et Baccho jriget Venus. Brandy also seems to have a temporary stimulant action upon the sexual power. Thus we must conclude that strong drink used in moderation does not have an unfavorable influence upon sexual power; it is excess which is injurious, and this corresponds to our knowledge of the effects of alcohol in other respects. It is known that alcoholic intoxication impairs the function of certain parts of the brain, so that it is quite possible for the center of erection or the conducting tracts to be paralyzed during acute or chronic alcoholism. Tobacco has a similar reputation. It was long since known as the "divine weed" because the priests often used it to dull their sexual passion. We have daily opportunities of witnessing the effect of chronic nicotine poisoning upon the nervous system. The tremor of the hands so common in excessive smokers is an indubitable nervous symptom. It is not permissible, however, to do more than consider the possibility of an injurious effect of nicotine upon the sexual power; convincing observations have not been made. The action of morphine is better understood. According to Levin- stein it first increases and then lessens sexual power. Sexual excitation and increased strength almost always follow an injection of morphine, particularly in those who are not accustomed to its use. Rosenthal states that moderate doses of morphine (0.03 to 0.06 a day) produce cheerfulness, loquacity, acuteness of the tactile sense and sexual excitement, the latter being an important symptom and one which is not generally known. Opium is said to be used in Persia as an aphrodisiac. This is in accord with the experiences of opium smokers, who at first are exceptionally strong sexually, but lose their power of copulation when continued action of the drug has produced marasmus. Gyurkovechy is of the opinion that the primary stimulating effect is due to paralysis of the cerebral centers which inhibit erection. Many other drugs are also supposed to diminish potency, among which may be mentioned lead, antimony, arsenic, carbon bisulphide, conium and camphor, but as nothing definite is known concerning their action I shall not discuss them in detail. Iodine, bromine, salicylic acid and potassium nitrate are certainly anaphrodisiacs, and therefore must be considered. PARALYTIC IMPOTENCE. 605 Four cases of impotence accompanied by more or less atrophy of the testicles are known to have developed during or immediately after a course of iodine-inhalations employed in the treatment of phthisis. In one of these cases desire was preserved and the testicles retained their normal size, although the power of erection was lost. In the other three cases sexual indifference and atrophy of the testicles were both well marked. The patients had neither desire nor power, and sought medical advice because they wished to perform their marital duties and desired children. Roland mentions two cases in which impotence and atrophy of the testicles developed after long- continued use of potassium iodide. Hammond also observed diminution of sexual desire after long use of large doses of the iodides, but never knew atrophy of the testicles to occur. Desire was restored after the drug had been stopped. Bromine is known to be a quickly acting anaphrodisiac. In many patients afflicted with frequent pollutions I have obtained good results by administering large doses of the bromine salts just before bedtime. I generally order two grammes (thirty grains) of potassium bromide at a dose. Persons who are forced by nervous disturbances to take these salts for long periods of time suffer a diminution of sexual desire and power. As a rule, however, both return after the drug is discontinued. Concerning salicylic acid Gyurkovechky states that it produces a temporary though certain impairment of virility. He relates that a Slavic society remained away from a certain Paris beer saloon because the members found that the consumption of a relatively small quantity of beer incapacitated them for coitus. Later it was learned that the beer contained salicylic acid. After this he investigated the matter and found that more or less temporary impairment of potency occurred during a course of salicylate of sodium, a drug now extensively used. The investigations of Kolbe and Lekmann in Munich, though proving the harmlessness of the protracted use of salicylic acid, have not contributed anything to our knowledge of its action upon the sexual power. No other works are known which confirm the theory that it exerts an unfavorable influence upon the sexual organs. [I have prescribed salicylic acid and the salicylates in a vast number of cases and have yet to hear a patient complain that it impairs his sexual vigor.] Potassium nitrate is considered by Hammond, Grimmaud de Caux 606 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. and Martin Saint Ange to be a powerful anaphrodisiac. The first named author saw a case of impotence after six months' use of the drug in the treatment of epilepsy. TREATMENT OF IMPOTENCE. From what has already been stated it is seen that the various forms of impotence differ greatly from one another. Apart from the four groups which we recognize there are differences in the forms of the same group. In psychical impotence it was first anxiety, then diversion of thought, and again deviation from normal physiological feeling which gave rise to virile weakness. In irritative nervous impotence both complete abstinence and general nervousness were blamed as causes. From these facts it is seen that the treatment of impotence cannot be routine, but that it must be directed to the cause. If it be due to deformity of the external genitals or neighboring parts, nothing short of an operation will afford relief. Not all malformations are remediable by operation, but there are certain deformities inter- fering with coitus, as for example, those due to hydrocele, hernia, infiltration of the urethra, and tumors of the scrotum, in which good functional results can be obtained by the proper operative procedures. If diabetes be the cause of the sexual weakness our therapeutic measures should be directed primarily against this disease. It is to be hoped that with improvement of the constitutional disease the special disturbances will disappear or become less. Although the cause of the disease must always supply the basis of our therapy, the treatment of impotence may nevertheless be divided into psychical, general hygienic and special medicinal. First, in regard to psychical treatment, it will be remembered that attention has already been directed to its extraordinary importance. Many persons suffering from impotence are timorous, dissatisfied with themselves and hypochondriacal. They often struggle with a feeling of shame and distrust; only rarely does a ray of hope pass through their mind. They have lost confidence in themselves and in others. They think that nothing can help them, that they are lost for this world. Their mind is constantly occupied with their disease, and consequently they are unable to concentrate their thoughts upon their occupation. This nervous depression has to be contended against above all things else, and it is the task of psychical treatment to do this; the patient TREATMENT OF QfPOT) Ml i , 607 must be made to take courage, to acquire confidence in himself and hope in the treatment employed. This cannot be attained in any better way than by causing the patient to acquire confidence in his physician. He must "swear to the statements of his physician," he must believe that which his physician says to be irrefutable How is the physician to attain this? This question is difficult to answer; however, material help will be afforded by an energetic manner, a careful examination of the patient, and the evincement of a kindly, active interest in his case. The unfortunate subjects of impotence generally have no one in the world whom they trust; they are ashamed to confide in their best friends. The physician becomes their father-confessor. Even the privilege of relating their trouble somewhat relieves their mind; if they find in the physician one who takes interest in their welfare and shows them sympathy, they usually begin to gain hope. The nervous depression yields to a more cheerful frame of mind begotten of hope, and thus much is won. We have seen how many cases of psychical impotence are caused by want of self-confidence, a certain feeling of anxiety. In such cases a cure will be obtained if the physician can restore his patient's self- confidence. This cannot be done, however, by merely telling him that he is well, that there is nothing the matter with him. Such state- ments produce the opposite effect. By diverting the patient's thoughts from himself, improving his general health, and forbidding him to have connection for a long time his confidence will be won and cure often obtained. Psychical treatment must be adapted to the patient's range of thought. I well remember a case of sexual perversion in which the patient expe- rienced orgasm only at the sight of a woman's shoe. By having him place a shoe above his bed and look at it during coitus he was able to complete the act, and later became able to do so without it. An important element of psychical treatment is to free the patient's mind from his morbid thoughts and get him to think of something else. For this purpose various amusements are of use. I direct those whom I do not send to a sanitarium to divide the day so that each part shall be given over to certain diversions or exercises. They must be con- stantly engaged in company, or employed in some physical work or exercise, as for example, gardening, gymnastics, bathing, swimming, walking, visiting in the country, or traveling. 608 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. This has the additional good effect of keeping them free from sexual excitement, which is beneficial in two ways: it exerts a favorable influence upon the mind, causing the patient to think that his long abstinence will strengthen his genitals, and also increasing sexual desire and really resulting in an accumulation of nervous energy. Hypnotism must also be incidentally mentioned. Although only little is known in regard to its effect upon this class of cases, it may be reasoned from analogy that its action might be favorable. I do not doubt that suggestive treatment may exert a salutary effect. Hygienic treatment is a valuable adjunct to psychical. The patient's habits of life must be so regulated that his body will be strengthened without the sexual organs being unduly stimulated. To this end diet, baths, sleep, regulation of the digestion, and physical exercise require special consideration. The diet must be nourishing but non- stimulating; spices and spiritous liquors in large quantities are particularly contraindicated. In regard to the latter a half bottle of red wine a day, and also a little cognac, may be allowed, but too much drink is decidedly injurious; for in that state of stimulation intervening between sobriety and intoxi- cation the sexual impulse is usually aroused, and patients are then prone to break our rule of abstinence, and, what is still worse, masturbators then relapse into their old habit. On the other hand, a little wine stimulates the appetite and enables the patient to take large quantities of food. For this reason wine may be allowed with the meals; beer, however, is permissible only in small quantities. I forbid any to be taken for at least two hours before bedtime. I have repeatedly observed that pollutions occur after beer-drinking late at night and that masturbators are wont to yield to their habit after similar indulgence. In regard to food, fat and substances which are bulky and yet contain but little nourishment are to be avoided. Meat, fish, eggs, and a mod- erate amount of farinaceous food should form the principal articles of diet; the patient should not eat heavily, however, nor at too late an hour. Repletion causes insomnia, which in turn is apt to give rise to erotic thoughts that may result in pollutions or lead masturbators to indulge in their habit. The same principles underlie the rules governing sleep. The patient ought not to lie upon a warm feather-bed, nor should he be too warmly covered. A quilt or blanket will suffice, although an extra coverlet may be placed over the feet. It is well-known that the softness and TREATMENT OF IMPOTENCE. 609 warmth of a feather-bed tend to cause pollutions and incite masturba- tors to indulge in their evil practice. The patient should not sleep upon his back, but lie on the side instead, because the former position tends to produce emissions. Furthermore, precautions should be taken to prevent the patient lying in bed too long with a distended bladder. Morning erections are reflex manifestations of irritation exerted upon the principal nerves by the distended bladder. Patients who have emissions toward morning should be awakened by an alarm-clock an hour before the time the emission usually occurs, in order that they may urinate. No rule can be given in regard to the amount of sleep required, as it varies in different persons. Sleep is a great restorer of vitality. Eight hours I consider the minimum. Many patients, especially men who have lived extravagantly, are accustomed to retire very late, and it is essential for them to go to bed early. Constipation is also an evil. I know cases of prostatorrhcea and spermatorrhoea which manifest themselves only when the bowels are constipated. The vascular congestion of the pelvic organs produced by sluggish bowels acts as a stimulus to the sexual organs and has to be combated. Therefore when regular bowel movements do not take place, laxatives in the most varied forms possible should be regularly used. Hygiene also includes a rational activity of all the organs and parts of the body. In many cases it will not be necessary to prescribe special physical work, as the daily occupation of the patient affords enough; in others, however, physical work is wanting or deficient, or is of such nature that it develops only certain parts. For such patients gymnastics, Swedish movements, massage and swimming are of material benefit. Apart from the favorable influence of these measures upon the mind they constitute one of the best means of promoting metabolism. This augmented activity of the vital proc- esses ought also to have a favorable effect upon the sexual vigor. The opposite effect, however, will be produced if exercise be carried too far, so that undue fatigue and lassitude ensue. The fact that athletes generally have, or at least are considered to have, but slight sexual power may be due to the fact that they overtrain. The amount of exercise must be regulated according to the indications in the individual case; too little is better than too much. The exercise must be of such a kind that all parts of the body will be equally strength- 41 6lO FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. ened. Walking is not enough; it must be combined with gymnastics, swimming, rowing, etc. The indications are best fulfilled by those forms of exercise employed in the mechano-therapeutic institutes, because here attention is directed in a systematic manner to the individual parts of the body. In cases in which for any reason active gymnastics are not permissible, massage forms a valuable substitute for the promotion of metabolism. In addition to those measures directed to the mind and general health of the patient, and which should always be considered in every case of impotence, there are special measures which are of service. Of these there are four: i. Baths. 2. Electricity. 3. Local applications. 4. Medicines for internal use. I consider baths to be one of the most important remedies which we have in the treatment of impotence. They may be employed in the most diverse forms, as simple washing, sponge baths, sitz-baths, half and full baths ; as rubs, douches and shower-baths ; as river, sea and brine-baths, and as light and Roman baths. Our knowledge of their effect is mostly empirical. We can, it is true, agree with Winternitz that the irritation produced by the action of heat or cold sets the muscles into activity, contracts the vessels and stimulates the peripheral nerves ; the influences of these actions upon the body, however, have not been followed in detail nor determined by experimentation. We do know from experience, which usually is by no means a bad teacher, that nearly all the various baths mentioned may be advantageously employed in the treatment of impotence. I consider the most effectual form to be the tepid or cold full bath followed by a cold douche to the spine. In large cities such baths may always be had. Natural sea baths are better, as the impact of the waves against the spine acts the same as the douche. The mildest form is simple washing. Similar to this is the sponge bath, a form which is often acceptable because it is cheap and requires little time. Not all patients have a bath-room nor means to visit a bathing establishment every day. The collapsible rubber tub, how- ever, can be obtained at a slight cost and can be closed and laid away after it has been used, thus taking up little room. In addition friction with a cold wet cloth may be employed, followed TRK\ I Ml \ I 0] IMI'ol I \CE. 6] I by a brisk rubbing with a course towel. This coi the best substitute for the cold bath in cases in which the latter cannot be endured or obtained. Frequent and protracted warm baths are contraindicated in impo- tence as they are weakening. Cold sitz-baths of short duration are to be used only under certain conditions, as their action upon the genitalia is too stimulating; during the first part of the treatment these organs should be given rest and not stimulation. Cold baths of long dur have rather a depressing effect. Exceptionally exciting and stimulating are carbonic acid baths, and full, half and sitz-baths. In all cases in which the sexual organs seem to have been strained these baths are counterindicated ; in those in which no weakness is present they afford a valuable means of favor- ably influencing the mind. I have seen patients get a strong erection in a carbonic acid bath, and thereby gain new courage and confidence. Natural or artificial brine-baths act as powerful promoters of metab- olism, although as is the case with many other thermal baths, par- ticularly those containing sulphur, their mode of action in impotence is not thoroughly understood. Electricity in the form of galvanism, faradism and Franklinization goes hand in hand with baths. Our knowledge of the action of this agent rests entirely upon experience. We know, however, that all three forms can be used with advantage. The constant current is the best. The parts to which it must be especially applied are the spinal column, the penis, testicles and per- ineum. There are many different methods of applying it, of which one alone or several in succession may be employed. The one which I usually use first consists in placing one electrode upon the left side of the vertebral column and then running the other upwards and down- wards just to the right of the spinous processes; the order is then reversed, the right being made stationary and the left passed up and down along the spine. The poles consist of a wet sponge or a metal disk covered with leather. The strength of the current is determined by the sensibility of the patient; it should be increased until a sharp tingling is produced. The application is followed by redness of the skin over the parts. As a rule, not so strong a current can be used upon the perineum as upon the other parts. One pole is placed over the sacral vertebrae and the other on the perineum and allowed to remain one or two minutes. Finally I pass the constant current through the 6l2 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. penis by placing one electrode upon the perineum and running the other along the anterior and posterior surface of the penis. I very rarely use the galvanic current within the urethra. It has often been recommended in cases of frequent seminal losses occurring either with or without erection. For this purpose a bougie having an electrode running through it and provided with a conical metal tip is used. This instrument is introduced into the urethra so that the tip lies in the prostatic portion ; it is then attached to the negative pole of a constant battery, the positive pole, covered with a sponge, being placed upon the perineum, and a current of not more than five milliamperes turned on. The negative pole is supposed to lessen the sensitiveness of the colliculus seminalis and ejaculatory ducts, to which the pollutions are due. If it is desired to galvanize the testicles a very weak current must be used as these organs are particularly sensitive to electricity. Strong currents impair rather than improve their nutrition. While the constant current is generally employed in cases where there is actual weakness of the genitals, especially in paralytic impotence, in the psychical forms of the disease the induction current is useful. It has an irritating, stimulating effect which is sometimes ocularly demonstrated to the patient during its application. If he sees an erec- tion follow an application of the induction brush he is greatly encouraged. By means of a metal brush the testicles and especially the penis can be considerably irritated. The sponge is placed upon the perineum or over the spinal column, while the brush, attached to an induction apparatus, is used upon the penis. The glans is especially sensitive. Therefore the current must be increased very slowly. Under its influence the skin becomes reddened, so doubtless stimulation of the circulation is produced as well as irritation of the peripheral nerves. I increase the current until slight smarting is produced and then con- tinue its application through the penis for two minutes. The procedure is repeated every three days. The results are very gratifying, particu- larly in psychical impotence. Many authors attribute great value to Franklinization. "The patient sits upon an insulated plate, being stripped down to the thighs, and by means of a copper sphere sparks are carried along the entire length of his spine, thus producing counterirritation and reflex excitation such as cannot be elicited by any other form of elec- TREATMENT OF IMPOTENCE. 01 3 tricity. Every spark leaves a slight elevation upon the skin, and the entire surface is reddened. The penis is also often affected by the current, and if sparks from the sacral region reach it ere< tions are often produced, even in cases in which no sexual excitement has occurred for months." We now come to the consideration of the so-called local application - which are commonly employed, and which consist principally in the use of metal sounds and caustic applications to the urethra. The sound-cure is conducted by passing a sound through the urethra every three or four days and allowing it to remain in situ for a few minutes. To begin with No. 18 F. is used and the size increased up to 26, or even 28 or 30. The object of such treatment is to dull the sensibility of the urethra. If the instrument is allowed to remain longer for a quarter or half an hour, an erection will often be produced. Winternitz's psychrophore may also be employed with advantage. It is really a double current catheter, the vesical end of which is closed. To the distal end of the double tubes long rubber pipes are fastened, one being connected to a vessel of cold water above and the other to a receiving vessel on the floor. If the water now be allowed to flow out of the jar above, an uninterrupted stream will pass through the catheter in the urethra. Cold and pressure of the instrument combine to exert a favorable influence upon the urethra and the different organs com- municating with it. If it be desired to produce erections, warm water up to 50 C. [122 F.] is more effectual. Cauterization of the prostatic urethra may be done in various ways. A very pleasant method is by means of Guyon's syringe. This instrument consists of a syringe to which a hollow, nodular- tipped rubber bougie is attached. The syringe is filled with nitrate of silver solution (1 to 10%) and the latter is injected through the hollow bougie by turning the piston around; each turn fore - a drop of fluid out of the knob. After the syringe has been filled and the bougie lubricated the latter is introduced into the urethra; at a distance of about 14 cm. [5I inches] the knob will be felt to enter the bulbous urethra; by slight pressure it is then carried 2 cm. [i of an inch] onward, whereupon the resistance experienced as the instrument goes through the bulb will be felt to subside. After the membranous urethra has been passed, which can be determined by rectal palpation, a drop of fluid is injected, the bougie pushed a half centimeter further onwards and another drop injected. In this manner the whole 614 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. prostatic urethra up as far as the internal sphincter of the bladder can be cauterized. It is even better to begin at the vesical sphincter and make the application from within outwards. This application is less painful than that made with Ultzmann's syringe; the latter instrument is used in the same way as Guyon's. Minute rods of cocoa butter containing nitrate of silver may be used for the same purpose. They are applied by means of a hollow tube and stylet. Thus it is seen that methods of cauterizing the urethra are not want- ing. I am of the opinion, however, that there is rarely occasion to resort to any of them. I consider that they are indicated and per- missible only when there is inflammation of the colliculus seminalis and neighboring parts or when the prostatic urethra is congested. The hyperesthesia of the urethra upon which so much stress is gen- erally placed is really a trivial matter. Nearly every urethra is sensitive when an instrument is introduced into it. It is at least very difficult to determine what degree of sensibility is normal, particularly as the manifestations of pain on the part of the patients when the same manip- ulations are practised vary upon different occasions. Simple hyperesthesia can be very much reduced by the use of sounds, and it is only in very severe cases of this kind that I would consider the application of a weak silver solution permissible. If we pass now to the consideration of internal remedies, there is a large number which have been reputed to cure impotence. As the reader will not be curious to know about all which have been recom- mended and used, only well-established facts will be stated. Of the many recognized aphrodisiacs I shall mention cantharides, atropine, phosphorus, johimbine, ergotin and strychnine. The sup- posed action of the two latter drugs has frequently been mentioned, but the observations are too few and not accurate enough to be accepted as positive. The first four in the list, moreover, exert an irritating action upon the genital organs. This is especially true of cantharides, which are given in the form of the tincture in the dose of 3 to 8 drops three times a day. An increased afflux of blood to the genitals is produced, which causes fre- quent erections and a pronounced desire to indulge in coitus or mastur- bation. It must always be remembered, however, that these phenom- ena may progress to severe inflammation; cases of strangury, cystitis and nephritis due to cantharides have been reported. TRKA I MEN I 01 [MPOT] N( I . 615 In like manner it has been endeavored to explain the undisputed stimulating action of phosphorus upon the sexual organs. It is more probable that this action is due to its general tonii and stimulating effect upon the nervous system. The preparations commonly empli are phosphorus itself in doses of 0.003 L>\> g r a day, zinc phosphide in doses of 0.02 [§ gr.] a day, and dilute hypophosphoric acid in the dose of twenty drops in water three times daily. The dilute phosphoric acid has less the action of phosphorus and therefore is not to be recommended. Hammond combined strychnine with phosphorus. He prescribed 100 pills made of Zinc phosphide, 0.6. [gr. i] Ext. of nux vomica, 2.0. [gr. xxx] of which one is taken three times a day ; or he ordered Strychnini sulph., 0.2. [gr. J] Acid hypophosphor. dil., 120.0. [fgjv] Of this mixture ten drops are taken in water three times a day and the dose gradually increased to twenty-five drops. Atropine has the same action as these drugs. It causes dilatation of the blood-vessels of the genital organs, and, according to Gross, relaxation of the musculature in the trabecular of the corpora cavernosa, as the result of which more blood flows into the penis. Gross also saw good results produced by this drug in cases complicated by pollutions and prostatorrhcea, the losses diminishing in frequency or entirely ceasing. I have never observed this action; on the contrary I must confess that I believe atropine exerts a stimulating action on the gen- itals, which expresses itself as erections of increased frequency and duration. I order pills of atropine sulphate containing J to I milli- gramme each [approximately v, 1 ,, to , \ „~ of a grain], of which two or three a day are taken. If troublesome disturbances of vision are pro- duced the drug must be stopped. More experience is necessary before judgment can be pronounced upon the recently introduced and highly recommended drug johimbine. What now are the indications for the employment of these several drugs? To prescribe them indiscriminately in any and every case of impotence would not be rational therapy. In certain stages of most cases they are even contraindicated. In organic impotence no one would think of using them; in irritative nervous impotence it is the task of the physician to reduce the irritability of the nervous system and especially that of the genital organ-: in 6l6 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. paralytic impotence the first requisite for improvement is a long period of rest, so that the organs can regain vigor; in psychical impotence, too, there is often a temporary weakness, so that it is well first to give the sexual organs rest and opportunity to recover force. During this time a course of general tonic treatment may be advantageously employed. This comprises the hygienic-dietetic regimen already described, to which may be added such internal roborants as iron and quinine. After the general health has been improved and the tone of the nervous system heightened, then phosphorus, atropine, and perhaps canthar- ides as well, may be used as auxiliary remedies. Inhalations of oxygen, which have been used by Gyurkovechky, may be considered to act in the same way. He has the patient inhale ten liters of oxygen at each sitting. Without presuming to explain the action of these inhalations, he recommends them most highly and attributes to them a distinct aphrodisiac effect; the latter is permanent, and as increase in bodily strength and general well-being also takes place almost without exception, it is probable that the favorable influ- ence exerted upon the sexual power depends upon the general improve- ment which is produced. As yet I have not used this treatment, but as it is recommended by such a careful observer I believe it to be worthy of mention. I must refrain from criticizing the treatment recently introduced by Zabludowsky, consisting of methodical massage of the genital organs, as I have not had any experience with it. The procedure would seem to be unpleasant for both patient and physician. I will confine myself to mentioning his method of producing vascular engorgement of the male genitals. A tube is put around the scrotum and root of the penis and drawn tight, and the tube is then flattened with a clamp. The scrotum and penis become engorged. The engorgement may be kept up for five to fifteen minutes. The effect of this procedure has yet to be determined. STERILITY IN THE MALE. Ultzmann has pointed out the difference between impotentia catundi and impotentia generandi. When the first exists the latter is also found to be present, but the reverse is not always the case. It is well-known, however, that the power of fecundation is not rarely absent when the power of copulation is preserved. Before passing to the consideration of sterility in the male I shall briefly describe the pathology of the semen. STERII.HA IN Mil. MM. I.. M" The composition and properties of normal semen have already been described. The semen may vary in quantity. In healthy men its quantity varies under normal conditions from five to twenty gramme-. This quantity may be diminished or increased. When the former i ondition obtains it is known as oligospermia, while the latter is called poly- spermia. The former is much more common than the latter. The quantity of semen is at times so small that only a few drops are ejaculated. This condition is physiological in old age and also occurs in young persons as the result of various diseases of the seminal passages. It is due to the absence of one or the other glandular secretions which are normally added to the testicular secretion. This absence may be caused by alterations in a certain organ, by failure of the organ to secrete, or by hindrance to the outflow of the secretion. By hydrospermia is understood an abnormal dilution of the semen. If fresh semen is put into a conical glass it separates into two layers, the lower of which is the thicker and the heavier of the two and usually constitutes from one-third to one-half the total quantity. If the semen is very thin, this layer, which is composed of cellular elements, is less than the upper layer, which is made up of the intercellular fluid. Hydro- spermia, then, occurs especially when few or no spermatozoa are present. It is often associated with oligospermia and azoospermia. In such cases the sperm-crystals form very quickly, often within half an hour, whereas in normal semen it takes two or three days for them to develop. The color of normal semen is grayish white, similar to that of boiled starch. It shows best on linen, making a grayish white stain having yellow borders and producing moderate stiffness of the fabric. If the stain is yellow there is an admixture of pus with the semen, a condition known as pyospermia. If the stain is of a homogeneous yellowish green color the pus is intimately mixed with the semen; this occurs only in spermatocystitis. Differing from this condition is pyospermia spuria, in which the seminal stain is grayish-white with here and there a streak or spot. This condition is due to a coexistent inflammation of the seminal or urinary passages. Pus becomes mixed with the semen as the latter is expelled. The condition occurs in gonorrhoea, cystitis colli and prostatitis. Under the microscope the semen oi pyospermia spuria shows pus cells, molecular debris, epithelium and living sperm- 6l8 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. atozoa; in true pyospermia the number of spermatozoa are small and they are lifeless or malformed. Red or brownish-yellow semen bespeaks the presence of blood (hemospermia). Like pyospermia this may also be true or spurious. In the first instance the seminal stain is of a red to a chocolate-brown color and is homogeneous, in the second isolated blood spots are dis- cernible upon the brownish-yellow base. Under the microscope bloody semen shows blood-corpuscles, which are more or less altered, epithelium, pigment, granules and flakes, molecular detritus, leucocytes, and spermatozoa. In true haemospermia, which is caused by severe inflammation of the seminal vesicles, spermatozoa are absent, dead, or malformed; in the spurious form, which is almost always due to a violent posterior urethritis, they are present, and are usually motile. Wine-colored, violet and blue semen, which is mentioned by Ultzmann, is probably due to the presence of indigo, and is of no path- ologic significance. Crystalline blue indigo is found upon micro- scopic examination. Three forms of male sterility are recognized: i. Those cases in which physiological semen is secreted, but owing to malformation of the genitals cannot be discharged into the vagina. 2. Those cases in which coitus, though possible, does not end with an ejaculation. 3. Those in which the semen, though ejaculated, has no power of fecundation. This may be due to death of the spermatozoa, or what is more frequent, to their absence. The first form is called sterilitas e dejectu seu dejormatione, the second sterilitas ex aspermatia, or for short aspermatism, the third azoospermia (absence of spermatozoa). 1. STERILITAS E DEFECTU SEU DEFORMATIONE. In this rather rare form, as a result of malformation of the penis, the semen is not ejaculated into the vagina, but escapes above or below. The most frequent causes of this condition are severe hypospadias and epispadias, and urethral fistulae. It is only when the opening through which the semen escapes is far back on the penis that the power of fecundation is lost; even under these conditions the semen may occasionally gain access to the vagina, the walls of the latter organ filling in the defect in the penis. Congenital or acquired shortness of the framum may produce such a deviation of the penis that the semen is ejaculated in a direction which prevents its ingress into the vagina. ASIM.KM \ I ISM. 6ig In such cases treatment is entirely operative. The prognosis is better when the trouble is due to shortening of the fraenum than when it is caused by hypospadias, epispadias, or urethral fistula. 2. ASPERMATISM. In this condition, as has already been stated, the semen is formed, but is not carried out of the body through the genital and urinary passages. We distinguish an absolute or permanent and a relative or temporary aspermatism. Absolute aspermatism may be congenital or acquired. In the former case ejaculation has never occurred, in the latter it has ceased to take place. The cause in these cases is always an organic lesion, which may be located anywhere from the seminal vesicles to the external urethral orifice. According as the lesion can or cannot be removed the aspermatism is permanent or temporary. Temporary or relative aspermatism is characterized by the fact that ejaculation occurs only occasionally or under certain conditions, failing to take place at other times or under other circumstances. This form of sterility may depend upon lesions of the urinary and seminal passages, non-irritability of the ejaculatory center, anaesthesia of the peripheral genital nerves, or inhibitor}' action of the brain upon the ejaculatory center. The forms of relative aspermatism accordingly are one due to insufficiency of the genital organs, an atonic, an anaes- thetic, and a psychical. That semen has never entered the urethra nor escaped therefrom during coitus, is a condition which may be due to various causes, the recognition of which is of diagnostic and particularly prognostic value. The cases in which there is congenital occlusion or absence of the ejaculatory ducts or deviation in their opening into the urethra are very rare. Cases of this kind have been reported by Munroe, Rindfleisch and Klebs. Acquired obstruction and deviation of the ejaculatory ducts are more common. Demeaux reports the case of a healthy man aged twenty-two years, who as the result of a fall upon his perineum developed an abs which necessitated incision. A few months afterwards the patient noticed that coitus no longer ended with a discharge of seminal fluid. 620 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Although there was no stricture of the urethra, urine voided after connection was heavily loaded with spermatozoa. Upon rectal palpation it was found that the perineum was contracted and the prostate drawn down, which led Demeaux to conclude that the ori- fices of the ejaculatory ducts had become displaced backwards as the result of the injury. Gonorrhoea may also cause aspermatism,not only by leading to the formation of urethral stricture, which will be discussed later, but also by advancing into the ejaculatory duct and producing thickening and contraction of its walls, and by producing alterations in the surrounding tissues which lead to obliteration of the ducts. Hypertrophy of the 'prostate, prostatic calculi, fibrous degeneration, tuberculous ulcerations, stones and concretions in the ejaculatory ducts, trauma, or injury inflicted during an operation, may likewise lead to occlusion or narrowing of the ducts. In regard to concretions they may develop as the result of inflam- mation, the pus becoming thick and cretaceous, or they may be formed out of dead spermatozoa, mucus and epithelium, with a de- posit of inorganic elements. Examples of injury to the ejaculatory duct inflicted in lateral or bilateral lithotomy which have resulted in aspermatism have been cited by Gross and Teevan. The formation of a fistula between the seminal vesicles and rectum which led to aspermatism has followed a recto-vesical lithotomy. In Sabatier's case ejaculation took place into the rectum. Covillard's case is even more remarkable; vesical calculi passed through fistulae in the perineum and down the inner side of the thigh, and the semen also followed this course. All the cases thus far mentioned which depended upon organic lesions were alike in that the semen did not enter the urethra, or at least did not reach that portion of it situated anteriorly to the prostatic part. '\We now come to that form of aspermatism in which the semen enters the urethra but does not flow out of it. Here there is a congenital or acquired narrowing of the urethra. A further point of differentiation between this class of cases and those previously described is afforded by the fact that the obstruction can be overcome, the aspermatism consequently being curable. Gonorrhoea is recognized as the most frequent cause of acquired urethral stricture. Doubtless the number of strictures causing reten- ASPERMATISM. 62 1 tion of the semen is few, although I have seen several myself and others have been reported. As strictures nearly always are permeable to the urine — cases of complete retention are not considered as they have no bearing upon aspermatism — it may be assumed that they will also permit the passage of the seminal fluid. This assumption, however, is not correct. The stricture may allow urine to pass through and yet be impermeable for the semen. The conditions for ejaculation are different than those for micturition. Semen is thicker than urine and the pressure which it exerts is less than that of the stream of urine; it is also conceivable that the stricture may be more yielding when the penis is flaccid than when it is erect. The scar-tissue may be deposited in such a manner that the shape of the stricture is changed when erection occurs, with the result that it becomes less permeable. By analogy the occurrence of spasm of the urethral musculature may be assumed in explanation of the condition. It is known that many strictures are permeable one day and impermeable the next. In such cases it is not that the lumen of the urethra has become so much smaller over night, but that muscular spasm, a spastic stricture so to speak, has been superimposed upon the organic lesion. This is an occurrence which every surgeon has often observed, and from which it follows that the stricture may be permeable again for days at a time. In like manner retention of semen may often be due to spasm superimposed upon stricture. Those cases in which the semen fails to be ejaculated, although the caliber of the urethra is comparatively large, are to be conceived as due to this cause. To these are added those cases of phimosis which lead to retention of semen. Concerning the treatment of these cases there is nothing to be said except about those depending upon stricture of the urethra and phi- mosis. The appropriate operative procedures arc self-evident. Cir- cumcision, dilatation of strictures, and reduction of urethral hyper- sensibility in cases where spasm superimposed upon stricture causes retention of semen will almost always effect a cure. The dulling of hyperaesthctic portions of the urethra may be secured by the repeated introduction of large metal sounds or by instillations of mild a>tringents or weak caustics. 62 2 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. ATONIC ASPERMATISM. In contradistinction to the forms of aspermatism previously described, the causes of which depend upon defects in, or impermeability of, the seminal passages, the form now to be discussed is due to non-irrita- bility of the ejaculatory center situated in the spinal cord. This non- irritability prevents coitus from being completed in the normal manner, although the patients are generally potent, erection being good and of sufficient duration, sexual impulse normal, and intercourse pleasurable. It is remarkable that men thus affected often have nocturnal pollutions which occur both with and without voluptuous sensation. This occurrence is due to the fact that when the seminal vesicles become distended with a certain amount of semen, they contract as the result of the mechanical irritation thus produced irrespective of any irritation in the central nervous system. This atonic aspermatism may be congenital or acquired; the latter is much more common. In the congenital cases the ejaculatory center in the cord is non-irritable ab origine; in the acquired cases its irritability has been lost in consequence of certain causative conditions, with the cessation of which the tonicity of the center is restored. Accordingly the acquired cases are often curable if the causative factors can be removed. Chief among these causes are excesses in venery . As in psychical impo- tence, so likewise here, masturbation has a more injurious effect than immoderate sexual intercourse. The reasons for this, as already stated, are that masturbation can be practised more frequently than even the most wanton excess and that the nervous excitement occurring in mas- turbation is greater than that incident to copulation. This is also shown by the fact that the general relaxation of the body is greater after masturbation than after coitus. It may also be assumed that the central nerve- cells, however well they may be regenerated, may in time become so weakened as the result of abuse that the usual stimuli no longer suffices to arouse them. The congenital cases are not amenable to treatment ; in the acquired cases we have seen that the cause is attributable to too great demands upon the ejaculatory center. The most effective remedy is rest; accordingly a long period of abstinence from sexual intercourse must be enjoined upon patients of this class, and a generous diet, together with a hygienic regimen, prescribed in order to build up the general health. Patients suffering from general neurasthenia require the usual ANAESTHETIC ASPERMATISM. 623 nervines and suggestive treatment described in the article on the treatment of impotence; if there is hyperesthesia of the urethra, local measures, such as the injection of slightly cauterant drugs and the introduction of metal sounds, are indicated. ANAESTHETIC ASPERMATISM. A few rare cases of aspermatism may be referred to sensory disturb- ances in the skin of the penis, as the result of which the reflex action of the peripheral nerves upon the ejaculatory center is rendered impossible. It has been attempted to demur to this theory by attribu- ting the nocturnal pollutions to purely psychical irritation of the nervous center occurring independently of peripheral irritation. Nocturnal emissions have been known to occur in anaesthesia of the penis, but they are doubtless due to purely mechanical irritation caused by distention of the seminal vesicles. Ulceration and scar-formation on the penis may lead to the same result. Absence of sensibility of the penis may also be congenital. When the condition is acquired an attempt may be made to restore the lost sensibility by means of the faradic current. PSYCHICAL ASPERMATISM. If psychical aspermatism is spoken of, it must be granted that the mind can influence ejaculation as well as erection. This influence is revealed by the fact that many men are able to retard ejaculation at will. It was this method which the adherents of Malthus practised in coitus interruptus, and one which is also made use of by sensualists for the purpose of prolonging the pleasure of intercourse. It is also known that ejaculation may occur only during intercourse with certain women, just as in psychical (relative) impotence coitus can be practised only with certain women; as in the latter so in the former, aversion, suspicion of infidelity, in short, psychical influences, are the causes which prevent the occurrence of emission. Reasoning still further by analogy it may be assumed that the inhibitory center in the brain is so stimulated by mental impressions that it sends forth an impulse suppressing the activity of the ejaculatory center. The removal of this condition lies without the realm of medical practice. 624 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. The diagnosis of aspermatism is self-evident. From what has already been said it is also evident that the differentiation between the various forms, which is important from the standpoint of prognosis and treatment, is not at all difficult. AZOOSPERMIA. In azoospermia, as in aspermatism, the power of copulation is usually not weakened, although in contradistinction to the latter coitus ends with an ejaculation. Notwithstanding this, however, the subjects of azoospermia are sterile for the reason that their semen has lost its power of fecundation. Generally speaking the criterion of fecundity consists in the pres- ence or absence of spermatozoa in the semen ; furthermore, it is to be observed whether they are inactive or dead or whether they soon die. The following conditions are recognized as the principal causes of azoospermia : the organs which produce the spermatozoa are absent or their function is destroyed; the semen may be rendered unfruitful by dis- ease of the seminal passages; the semen, though normally produced, may be prevented from passing out of the body by anomalies of the genital passages; finally severe constitutional disease may undermine the strength of the generative organs. Absence of both testicles, anorchism, of course precludes the possi- bility of fecundation. If the absence of the testicles is not congenital, being acquired during adult life, the individual may retain the power of copulation for a time, although the power of procreation is extinguished when the testicles are lost. Bilateral absence of the testicles affects the entire organism. The individuals are different in appearance, character and habit; they have no sexual desire and no voluptuous feeling, being similar to eunuchs who were mutilated in the early years of life. Unilateral anorchism does not destroy the power of fecundation, provided the second testicle is healthy and no other anomalies are present to alter the fertility of the semen. Cryptorchidism, a condition in which one or both testicles do not lie in the scrotum, but are abnormally situated, although more common than anorchism is nevertheless comparatively rare. It is not always easy to decide whether the testicles are absent or abnormally placed. As a rule, they can be felt in the inguinal canal, AZOOSPERMIA. 625 iliac fossa, or crural canal, but if they arc within the abdomen the appearance and habits of the patients must be taken into considera- tion in making a differential diagnosis. Unilateral cryptorchidism never causes sterility unless some other anomalies arc also present. Opinions differ in regard to the effect of bilateral exstrophy of the testicles. The literature on the subject shows that cryptorchidism does not always result in sterility. This, however, does not mean that crypt- orchids are not often sterile, a fact which evidently depends upon the pathic changes which have occurred in the testicles as the result of their malposition. They are usually small, undeveloped, atrophied and affected • with fatty or fibrous degeneration. The fecundating power of the semen depends upon the degree of degeneration present. Defin- itive information can be secured only by microscopic examination of the semen. Certain diseases of the testicles may also result in diminution or destruction of the fecundating power of the semen. If both testicles are destroyed by disease, permanent azoospermia is the result ; in cases in which the disease can be cured the azoospermia is only temporary; in others the function of the testicles is not entirely destroyed but is weakened. The result is that only a few spermatozoa are produced. This condition is called oligospermia (Ultzmann). The most common cause of lessened functional capacity of the testicle is atrophy. It may depend upon a variety of causes. In the first place there are testes which may be designated as undevel- oped. Here we have to do with malformations due to arrest of develop- ment, which are of rare occurrence, although they occasionally affect the testicles the same as other organs. The entire sexual apparatus usually shares in the non-development; the external organs are of the appearance and size of those of a child. Of greater importance are the atrophies which are due to demon- strable causes. As such are recognized lesions of the central nervous system and inflammation or continued compression of the testicles. Exceedingly rare arc degenerations due to disease of the nerve-tracts. Such disease may affect the spinal cord, particularly the lumbar region, where the centers of erection and ejaculation are situated, and also the brain. In addition to clinical observations, experiments prove that atrophy of the testicles may follow injury to certain portions of the brail) and cord. 42 626 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. Inflammation of the substance of the testicle, no matter what variety it be, may also be followed by atrophy. Although gonorrhoea usu- ally attacks the epididymis, it has been known to invade the testicle. Trauma is one of the most frequent causes. Simple catheterization may give rise to orchitis; metastatic orchitis accompanying parotitis is very frequent, and it is important to remember that there are cases of parotitis without orchitis, and vice versa. In the majority of cases the function of the testicle is restored after the inflammatory process subsides. Occasionally, however, the inflammation is followed by fibrous degeneration of the parenchyma of the gland, which, according to whether one or both testicles are involved, and also to the degree of inflammation, leads to oligospermia or azoospermia, and consequently to complete sterility. Finally, as concerns atrophy of the testicles due to compression, it is necessary for ,the pressure to be of considerable intensity and of long duration. Such pressure may be produced by large hydroceles, scrotal hernias and varicoceles. Among other diseases of the testicles which may result in sterility are syphilis, carcinoma and tuberculosis. The most favorable prognosis is afforded by syphilis. Both testicles are usually affected, but unless the gummatous degeneration be too far advanced antisyphilitic treatment will restore their function. Carcinoma more often results in oligospermia, for, as a rule, it is circumscribed and, moreover, generally affects only one testicle, so that sufficient healthy parenchyma remains. The same is true of tuberculosis. In the cases due to absence or occlusion of the epididymis and vas deferens the testicles are healthy, but owing to the former condition the semen cannot be carried to the seminal vesicles. If there is congenital absence of epididymis and vas deferens on both sides, the fluid ejaculated during coitus naturally cannot contain spermatozoa. The same effect is produced by acquired occlusion of the spermatic ducts. If the epididymes are attacked by inflammation complete obliteration of the ducts not uncommonly results. It is immaterial from what cause the inflammation develops; the result is the same. All depends upon the degree and the extent of the inflammation. As injury to the epididymis, syphilis, tuberculosis, carcinoma and sarcoma are rare, and their bilateral occurrence still rarer, they are not AZOOSPERMIA. 627 of great importance, particularly in comparison with the most frequent cause of sterility, namely, gonorrhceal epididymitis. Even though it be an exaggeration to state that "absolute impoten< e results when both epididymes are attacked by gonorrhoea" (Sanger), it is unfortunately true that this complication often leads to azoospermia. Out of eighty-three men affected with bilateral epididymitis Liegeois found spermatozoa in the semen of only eight. I have very fre- quently observed sterility in men who have had double epididymitis. Unilateral inflammation causes a decrease in the number of sperma- tozoa, an oligospermia. This well shows what a serious disease epididymitis is. It makes it necessary for us to treat every case of epididymitis most carefully, and above all things to endeavor to limit its extension as much as possible. If any portion of the seminal passage, by which term is meant the entire tract from the testicle to the external urethral orifice, becomes inflamed, the products of inflammation mingle with the semen. In epididymitis, inflammation of the vas deferens, spermatocystitis, pros- tatitis and gonorrhoea, the semen contains pus-cells and perhaps blood- corpuscles. As far as sterility is concerned it is only those processes in which the admixture diminishes or destroys the vitality of the sper- matozoa which are of importance. During the acute stage of the above named affections it is imma- terial whether the spermatozoa are destroyed at the seat of the disease or not, although after the disease has lasted longer it is of interest in respect to the general condition. A much discussed question now arises, namely, "what is the action of pus upon spermatozoa?" Many investigators state that the latter are killed by pus-cells or the microorganisms which are present with them. On the other hand, it has often been observed that patients who have had unilateral or even bilateral epididymitis, chronic prostatitis, or gonorrhoea not only produce semen containing active spermatozoa, but that they actually beget children. What is the meaning of this? How can these observations be har- monized ? The numerous cases of prostatitis and epididymitis in which admix- ture of pus and semen takes place and fecundation nevertheless occurs prove that pus is not always deleterious to the spermatozoa. At times, however, it may reduce or completely destroy their vitality. In many 628 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. cases this may be due to the thickness of the fluid produced by the admixture of pus. A case has been reported by Beigel in which the semen was extraordinarily thick and the spermatozoa motionless and close together; upon the addition of lukewarm water they became motile. Warm water was also injected into the vagina to dilute the semen, with the result that conception occurred. This case is an exception, for suppuration is rarely so profuse as to produce such a degree of thickening in the semen. For this reason I maintain with Fiirbringer that pus, although exerting an unfavorable influence upon the spermatozoa, does not destroy them nor render the semen unfertile. Conditions are exactly the same in hemospermia. Blood itself does not destroy the spermatozoa. Robin has shown that they may live in it four or five hours. One often has occasion to examine bloody semen which is ejaculated during the course of posterior urethritis, cystitis colli or prostatitis. The number of spermatozoa is generally diminished; a few are lifeless or inactive, the majority, however, are apparently normal. THE RELATION OF GENERAL DISEASES TO AZO- OSPERMIA. Physiological Azoospermia. That alterations in the general health may influence the secretory activity of the testicles is best shown by physiological or temporary azoospermia. By this term is meant the secretion of a' semen in which spermatozoa are absent at times and present at others. It has long been known that the frequency of ejaculation has a great influence upon the composition of the semen. The oftener it is dis- charged within a given time the less its quantity and thinner its con- sistency, whereby the number of spermatozoa become less and less. Finally it consists of the secretion of the accessory genital glands. Liegeois mentions the case of a medical student who had connection three or four times a day for ten days in succession, and whose semen upon repeated examination failed to show spermatozoa. After three weeks of abstinence from sexual intercourse they were found in abun- dance. A similar case reported by Casper (the medico-legal expert) is that of a naturalist aged sixty, who examined his semen microscopically THE RELATION OF GENERAL DISEASES TO AZOOSPERMIA. 629 with Casper for a long period of time. It was found that it became more fluid and poorer in spermatozoa the oftener coitus was indulged in. If he had connection on two successive days no spermatozoa were present; after abstaining for three days the ejaculate contained sperm- atozoa in abundance, although they were small; on the day after they were small and few in number. After five days of rest they appeared in abundance, and an interval of six days produced few though large spermatozoa. Thus it may happen that a man who is fully potent and in possession of his fecundating power may become temporarily sterile. This is a matter of practical importance. It explains why many men whose potentia cceundi et generandi are absolutely normal fail to beget children. The reason is that they have connection too often. This physiological azoospermia, therefore, is especially common among very sensual men. It is interesting to note that experiments upon animals confirm these observations. Plonnies proved that frequent ejaculations produced in dogs by electrical stimulation of the spinal cord brought about dim- inution in both quantity and quality of the semen; the spermatozoa are often entirely absent. Sexual Neurasthenia. These considerations lead us to that form of azoospermia which develops in certain forms of neurasthenia, and which is to be regarded as an augmentation of the transitory physio- logical form just described. Masturbators and men who have indulged excessively in coitus constitute the chief contingent of sexual neurasthenics. One of the most constant symptoms of this disease is nocturnal pollutions, or even spermatorrhoea. There are also various associated phenomena on the part of the nervous system and mind, as well as disturbances of nutrition. If the semen of a man thus affected be examined, it will not uncom- monly show signs of azoospermia, oligospermia, or changes in the spermatozoa— conditions which indicate that there is impairment of the power of fecundation. The principal alterations in the spermatozoa are impairment of motility and low vitality; they soon die. It has not been positively determined whether changes in their form, such as kinking and coiling of the tail, noticed by Ultzmann, and swelling of the head, observed by Neumann, are pathologic changes. It is certain, however, that impairment of nutrition and disturbances of the nervous system, and above all things undue demands upon the secreting organs, may 630 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. lead to grave disturbances in the nutrition and innervation of the testicles, and consequently to the production of a semen deficient as to quantity and quality. Syphilis. A constitutional disease in which azoospermia occasion- ally occurs is syphilis. It need scarcely be stated that syphilitic orchitis and gummata of the testicles are not referred to, because in these conditions the entire glandular substance is destroyed, so that no semen can be secreted, or else the lesion is circumscribed so that enough healthy tissue remains to secrete. It is only constitutional syphilis without localized lesions in the testicles which will be discussed. This form of the disease produces azoospermia in many cases, although in others living spermatozoa are found (Gross and Bryson). Demonstration of the latter fact is scarcely necessary, as the numerous children affected with hereditary syphilis who are born of healthy mothers prove that syphilitic men retain their power of procreation. Zeissl, however, states that he has known several men who had had syphilis, who although of strong constitution, were unable to beget children with perfectly sound women. As long ago as 1861, Lewin found that semen secreted by testicles presenting no abnormalities except signs of syphilis contained spermatozoa in only fifty per cent of cases. A few years ago I had the opportunity of observing a case which well illustrates the effect of syphilis upon the generative organs. It was that of a man who had lived in childless marriage two years, although his wife was perfectly healthy. This man had had syphilis. There were no signs of disease upon his genital organs except an old unilateral epididymitis. The semen contained no spermatozoa. After a course of energetic antisyphilitic treatment a few spermatozoa appeared. After further iodine-medication more were found, and finally his wife bore a syphilitic child. Thus it was demonstrated that azoospermia may be caused by constitutional syphilis without any signs of disease in the testicle being present, and that it may be cured by antisyphilitic treatment. Morphinism. The excessive use of morphine occasionally produces azoospermia. This is an occurrence to which Rosenthal has called attention. In the case which he described the patient had taken from 0.5 to 0.7 [ I to 1 gr.] of morphine subcutaneously every day for the relief of headache and insomnia. Paralysis of the bladder developed, and in the white fluid which escaped with the last drops of urine sper- THE RELATION OF GENERAL DISEASES TO AZOOSPERMIA. 63 1 matic crystals, but no spermatozoa, were found. After a protracted course of treatment, of which the most important part consisted in the withdrawal of the morphine, the semen was found to contain living spermatozoa, although they were not so numerous nor so active as they normally arc. Azoospermia resulting from morphinism, then, is merely transitory; as the system is freed from the poison the testicles produce a function- ally potent secretion. Many other cases in which men addicted to morphine have begotten Fig. 230. — Azoospermia, a. Dead spermatozoa, coiled and kinked. b. Molecular detritus, c. Spermatoblasts, d. Leucocytes, c. Epithe- lium. /. Flakes of pigment. children also prove that the above named action is not constant, and that it develops only when a certain grade of poisoning is reached. Tuberculosis. The widespread opinion that consumptives usually have numerous progeny is contradicted by observations which tend to show that tuberculosis exerts a deleterious effect upon the generative organs. The result of many observations shows that the truth lies midway between these opposing theories. Tuberculosis may rarely give rise 632 FUNCTIONAL DISTURBANCES OF THE SEXUAL ORGANS. to azoospermia and oligospermia. In many cases, however, the semen is entirely normal. The diagnosis of azoospermia presents no difficulties. A drop of fresh semen is placed under the microscope; absence of spermatozoa, or non-activity of a few which may be present, and also formation of spermatic crystals, proves the existence of azoospermia. When due to sexual excesses and general neurasthenia the chances of recovery are good. Treatment. The treatment of azoospermia has narrow limits. If due to syphilis then antisyphilitic treatment is in place; in syphilitic epididymitis local inunctions of mercury, with long- continued internal administration of potassium iodide, are advantageous. Neurasthenia and sexual excesses require above all things abstinence from sexual intercourse, together with the employment of the measures recommended for the treatment of impotence (quod vide). In morphinism the first requisite is the withdrawal of the drug. In cryptorchidism there is no treatment. If the patient is presented for treatment very early in life, the threatening arrest of development in the testicles may be prevented (see also under Cryptorchidism). In gonorrhceal epididymitis an attempt must be made to prevent extension of the inflammation. If thickening and hardness remain, a suspensory bandage should be worn, so that the testicle may be ele- vated and fixed. The testicle is first enveloped in cotton wet with a solution of aluminum acetate; this is covered with rubber tissue and the suspensory then put on. The dressing is changed every day. It should be continued for months. The patient should also take potas- sium iodide for a long time. In atrophy of the testicle little can be expected. Any treatment which may be employed in cases dependent upon a central lesion is naturally without result. In cases due to other causes electrization is worthy of trial. The current, which is passed from the positive pole placed on the spine to the negative laid upon the testicles, should be weak, and should be used for only a few minutes. [Azoospermia due to occlusion of the vas deferens resulting from gonorrhceal inflammation has been treated by anastomosing the vas with the head of the epididymis. This procedure was first practised by Edward Martin, of Phila- delphia. After experimenting upon dogs he performed the operation upon man with apparently successful results, inasmuch as the semen THE RELATION OF GENERAL DISEASES TO AZOOSPERMIA. 633 discharged nineteen days after operation contained motile spermatozoa. Posner and Cohen, of Berlin, have treated six cases by this method. They advise preliminary puncture of the testicle in order to determine whether spermatozoa are present. A portion of the head of the epididymis is excised, the vas opened longitudinally for the distance of a quarter of an inch, and then im- planted into the epididymis by means of four very small silver-wire sutures; the sutures are introduced from the outer surface of the vas into its lumen, thence into the incision in the epididymis and out through its fibrous tunic. Further experience with this operation is necessary to determine its exact value. I consider it worthy of trial. The possibility of the anastomosis becoming closed by the products of inflammation must be taken into consideration.] NDEX Abscess, of the kidney, 497 of the prostate, 311 peri urethral, 100 prevesical, 290 urinary, 140, 164 Acetic acid and ferrocyanide test, 58 Acetone, test for, 63 Acetonuria, 63 Achillodynia, 106 Albumen, quantitative estimation of, 59 tests for, 57, 58, 59, 60 Albuminometer, 59 Albumosuria, 60 Alexander's method of prostatectomy, 37* Ammonium urate, test for, 83 Amputation of the penis, 199 Aneurysm of the renal artery, 552 Angioma of the urethra, 173 Angioneurosis renis, 553 Animal parasites in the urine, 77 Anorchism, effect upon virility, 624 Arthritis, gonorrhceal, 103 Aspermatism, 619 anaesthetic, 623 atonic, 622 psychical, 623 Azoospermia, 624 etiology of, 624 in relation to general diseases, 628 physiological, 628 treatment of, 632 Bacteriorrhcea, 89 Bacteriuria, 74 Balanitis, 186 Balanoposthitis, 186 Beck's operation for hypospadias, 187 Belfield's method]of draining the seminal vesicles, 457 of prostatectomy, 365 Bevan's operation for retained testicle, 412 Bigclow's evacuator, 262 Bile-pigment, test for, 64 Bismuth test for sugar, 61 Biuret test, 60 Bladder, anatomy of, 206 Bladder, atony of, 298 capillary puncture of, 158, 342 357 carcinoma of, 269 chorio-epithelioma of, 268 curettage of, 212, 226, 247 digital examination of, 51 diverticulum of, 284 drainage of, in cystitis, 225 echinococcus disease of, 281 exstrophy of, 288 fibroma of, 268 foreign bodies in, 248 hernia of, 284 inflammation of, 208 See also under Cystitis injuries of, 278 irrigation of, 223 malformations of, 287 neuroses of, 290 papilloma of, 266 paralysis of, 297 parasites of, 281 rupture of, 279 sarcoma of, 268 stone in, 250 See also under Vesical calculus. tuberculosis of, 226 cystoscopy in, 238 diagnosis of, 235 etiology of, 227 pathological anatomy of, 229 symptoms of, 232 treatment of, 240 by hygienic measures, 241 by internal medication, 242 by local applications, 243 by operative procedures, 246 tumors of, 269 course, 274 diagnosis, 273 etiology, 270 symptoms, 271 treatment, 275 ulcer of, 283 varices of. 287 wounds of, 278 X-ray examination of, 52 Blood-casts, 73 635 6 3 6 INDEX. Blood in the urine, significance of, 5 test for, 65 See also under Hematuria. Bottcher's crystals, 572 Bottger's test for sugar, 61 Bottini's operation, 371 contraindications to, 373, 377 dangers of, 374, 377 indications for, 375 technic of, 372 Bougies a, boule, 7 bayonet, 144 filiform, 7 spiral, 144 Bright's disease, 482 See also under Nephritis Bubo, 96, 203 Bullous oedema, 44, 239 Bursitis, gonorrhceal, 105 Calcium carbonate, in the urine, 82 oxalate, in the urine, 80 phosphate, in the urine, 81 sulphate, in the urine, 80 Calculus, of the seminal vesicles, 460 prostatic, 386 renal, 524 ureteral, 524 urethral, 169 vesical, 250 Cancer, see under Carcinoma. Carcinoma, of the bladder, 269 of the kidney, 534 of the penis, 198 of the prostate gland, 389 of the seminal vesicle, 461 of the scrotum, 418 of the testicle, 420 of the ureter, 538 of the urethra, 173 Castration, technic of, 426 Casts, amyloid, 73 blood, 73 epithelial, 73 false, 74 fatty, 73 granular, 72 hyaline, 71 leucocyte, 73 origin of, 71 oxalate, 74 uric-acid, 74 waxy, 73 Catheter, Benique, 10 bicoudee", 7 Brodie's, 10 Catheter, Casper's, 350 Gouley's, 154 Malecot's, 353 Mercier's, 7 Nekton's, 6 olivary, 7 Pezzer's, 353 rat -tail, 148 silk -web, 7 Ultzmann's irrigating, 116 Catheterization, asepsis of, 46 of the ureters, 469 permanent, 355 technic of, 10 Chancroid, 194 diagnosis of, 196 etiology of, 194 prognosis of, 197 symptoms of, 194 treatment of, 197 urethral, 129 varieties of, 195 Chimney-sweepers' cancer, 418 Chordee, treatment of, no Chorio-epithelioma, of the bladder, 268 of the testicle, 421 Chromocystoscopy, 473 Chyluria, 64 Circumcision, 188 Clap, 90 See also under Gonorrhoea. Cock's operation for retention of urine 158 Colpocystotomy, 225 Condylomata, of the penis, 198 of the urethra, 130 Cowperitis, 101 Cryoscopy, of the blood, 473 of the urine, 470 Cryptorchidism, effect upon virility, 624 Cylindroids in the urine, 74 Cystic degeneration of the kidney, 539 of the testicle, 419 Cystin, 80 Cystitis, 208 cystoscopy in, 42 definition of, 208 diagnosis of, 218 due to stricture, 140, 216 due to tumors, 217 etiology of, 208 forms of, 210 gonorrhceal, 214 membranous, 218 pathological anatomy of, 211 prevention of, 219 [ N I ) I \ . Cystitis, symptoms of, 211 traumatic, 215 treatment of, 219 by hygienic measures, 220 by internal medication, 220 by local measures, 223 by operative procedures, 225 with retention of urine, 215 colli, 214 feminae, 215 Cystopexy, 359 Cystoscope, Albanian's, 32 Ay res', 35 Belfield's, t,^ Bierhoff's, 36 Bransford Lewis's operative, 34 Bransford Lewis's universal, 34 Brenner's, 30 Casper's, 32 F. Tilden Brown's, 35 Giiterbock's, 28 Hirschmann's, 28 Nitze's, 26, 28, 29, 32 Otis's, 34 operative, 32, 34, photographic, 28 ureteral, 30 Winter's, 28 Cystoscopic picture, in calculi, 43 in cystitis, 42 in foreign bodies, 43 in health, 39 in tumors, 43 Cystoscopy, 22 asepsis of, 46 diagnostic value of, 44 history of, 22 in renal examinations, 469 technic of, 38 therapeutic value of, 46 Cysts of the kidney, 539 of the prostate gland, 306 of the seminal vesicle, 459 of the sinus pocularis, 306 of the urethra, 173 Deferenitis, 438 Diacetic acid, test for, 63 Dilatation of the urethra, for chronic gonorrhoea, 124 contraindications to, 148 for stricture, 142, 146 limitations of, 148 Dilators, Horwitz's, 155 Kallmann's, 126 Oberlander's, 124 Distoma haematobium, 78 of the bladder, 2X1 of the kidney, 5 15 Diverticulum of the bladder, 285 Duplay's operation for hypospadias, 180 Dystopia renis, 477 Echinococcus disease of the bladder, 281 of the kidney, 544 of the prostate gland, 401 Einhorn's saccharomcter, 62 Ejaculation, mechanism of, 567 Electroscope, Casper's, 12 Elephantiasis of the female urethra, 174 of the penis, 201 of the scrotum, 417 Emissions, seminal, 573 pathological, prognosis of, 579 significance of, 573, 576 treatment of, 580 See also under Sexual neurasthenia. Enuresis, 300 Epididymis, anatomy of, 408 syphilis of, 428 tuberculosis of, 422 tumors of, 419 Epididymitis, 433 as a cause of sterility, 435, 627 complications of, 435 etiology of, 433 symptoms of, 433 terminations of, 435 treatment of, 436 Epinephritis, 549 Epinephroid, 533 Epispadias, 183 Epithelioma of the scrotum, 418 Epithelium, urinary, 70 Erection, mechanism of, 565 production of, 564 Esbach's albuminometer, 59 Essential haematuria, 553 Eustrongylus gigas, 545 Exanthemata, gonorrhceal, ic8 Exstrophy of the bladder, 288 Fermentation test for sugar, 62 Fibroma of the bladder, 268 Filaria sanguinis, 77 of the bladder, 281 of the kidney, 546 Filiform bougies, 7 Fistula of the urethra, [83 para urethral, ioo treatment of, 116 6 3 8 INDEX. Floating kidney, 541 See also under Movable kidney. Foetal kidney, 475 Folliculitis, urethral, 101 Forbes's lithotrite, 261 Foreign bodies in the bladder, 248 in the urethra, 166 Freyer's method of prostatectomy, 366 Fuller's method of prostatectomy, 366 Functional renal examination, general considerations, 469 in cystic degeneration of the kidney, in nephrolithiasis, 529 in neuralgia of the kidney, 555 in pyelitis, 504 in pyonephrosis, 515 in tuberculosis, 522 in tumors, 536 Funiculitis, 438 Galactocele, 446 Gonococcus, 9c methods of staining, 91 Gonorrhoea, 90 causes of, 90 complications of: extragenital, igi genital, 100 diet in, 109 infectiousness of, 99, 127 of the eye, 102 of the mouth, 102 of the rectum, 101 pathological anatomy of, 92 prognosis of, 108 symptoms of: acute, 94 chronic, 97 treatment of: acute anterior, 109 posterior, 114 chronic, 116 by abortive measures, no by dilatation, 124 by electrolysis, 126 by injections, 112 by instillations, 115, id 8 by irrigations, 112, 115, 116, 119 by internal remedies, 109 by internal urethrotomy, 126 by mechanical methods, 124 by ointments, 123 urethroscopy in, 19, 126 Gonorrhoea and marriage, 99, 127 Gonorrhceal achillodynia, 106 Gonorrhceal arthritis, 103 bursitis, 105 endocarditis, 107 exanthemata, 108 folliculitis, 100 lymphadenitis, 100 lymphangitis, 100 myelitis, 106 myositis, 105 ophthalmia, 102 osteomyelitis, 106 perifolliculitis, 100 periostitis, 105 phlebitis, 106 pleurisy, 106 prostatitis, 120 pulmonary infarct, 106 tendovaginitis, 105 Goodfellow's method of prostatectomy, 366 Gouley's tunnelled catheter, 154 Grawitz's tumor, 533 Guyon's lithotrite, 261 syringe, 118 Harris's segregator, 474 Haematocele, 446 Hsematuria, essential, 553 Hsematuria, general considerations, 5 in acute nephritis, 485 in chronic nephritis, 487 in gonorrhoea, 96 in hypertrophy of the prostate, 342 in nephrolithiasis, 528 in neuralgia of the kidney, 553 in renal tumors, 535 in vesical calculus, 255 in vesical tuberculosis 234 in vesical tumors, 271 Haemoglobin in the urine, test for, 65 Hemospermia, 618 Heat-tests for albumen, 58 Heller's test for albumen, 58 Hernia of the bladder, 284 Horseshoe kidney, 475 Horwitz's dilator, 155 Hydrocele, acute, 439 chronic, 440 diagnosis of, 443 etiology of, 441 symptoms of, 441 treatment of, 444 congenital, 413 cystic, 448 of the cord, 448 of the seminal vesicles, 459 INDIA'. 639 Hydronephrosis, 505 course of, 508 diagnosis of, 508 etiology of, 505 forms of, 505 pathological anatomy of, 506 prognosis of, 509 symptoms of, 507 treatment of, 509 Hydrospermia, 617 Hydrothionuria, 64 Hypertrophy of the prostate, 322 See also under Prostate gland, hyper- trophy of. Hypernephroma, 533 Hypospadias, 177 etiology of, 177 symptoms of, 179 treatment of, 180 Impotence, definition of, 582 forms of, 583 nervous, 594 organic, 583 paralytic, 598 psychical, 585 treatment of, 606 by electricity, 613 by hydrotherapeutic measures. 610, 613 by hygienic measures, 608 by internal medication, 614 by local applications, 613 by psychical methods, 606 Indican in the urine, 65 Infiltration of urine, 139, 164 Injuries of the bladder, 278 of the kidney, 550 of the penis, 185 of the prostate gland, 307 of the scrotum and testicle, 414 of the seminal vesicles, 454 of the urethra, 160 diagnosis, 162 treatment, 163 of the ureter, 561 Irrigation of the bladder, 223 Irritable bladder, 294 Janet's method of irrigation, no, 115, 119 Katheterpurin, 50 Keyes-Ultzmann syringe, 118 Kidneys, amyloid degeneration of, 495 anatomy of, 462 arteriosclerotic, 49 t, 493 Kidneys, circulatory disturbam ea of, 480 contracted, 492, 493 contusions of, 55 1 cyanotic induration of, .480 cystic degeneration of, 539 cysts of, 539 echinococcus, 544 diffuse hematogenous non-suppur- ative inflammation of, 482 dystopia of, 477 echinococcus disease of, 544 examination of, 467 fatty, 496 floating, 541 fcetal, 475 functional examination of, 469 haemorrhagic infarct of, 481 histology of, 466, horsesho.e, 475 hyperemia of, 480 inflammation of, 483, 497 See under Nephritis, Pyelitis, < tt . injuries of, 550 malformations of, 475. movable, 541 neuralgia of, 553 parasites of, 544 physiology of, 466 suppuration in, 497, 510 syphilis of, 546 tuberculosis of, 517 diagnosis of, 521 etiology of, 517 functional renal test in, 522 pathological anatomy of, 518 prognosis of, 522 symptoms of, 520 treatment of, 523 urine in, 520, 522 tumors of, 533 diagnosis of, 536 functional renal examination in, 536 pathological anatomy of, 533 prognosis, 537 symptoms, 534 treatment, 538 urine changes in, 535 Koch's urethroscope, 14 Kollmann's dilators, 126 LeFort's method of dilating strictures, 147, 148 Leucin, 80 Libido scxualis, nature and causes of, 567 Lipuria, 64 640 INDEX. Litholapaxy, 260 Lithotripsy, 260 Lithotomy, 264 Lohnstein's saccharometer, 62 Lubricants, 49 Luys' segregator, 473 Lymphadenitis, 203, 100 Lymphangitis, 100, no, 202 Maisonneuve's urethrotome, 151 Magnesium phosphate, in the urine, 82 Malformations of the bladder, 287 of the kidneys, 475 of the scrotum, 409 of the seminal vesicles, 454 of the urethra, 176 Massage of the prostate, 122, 319 Masturbation, as a cause of spermator- rhoea, 575 effects of, 575 prevention of, 580 McGilPs method of prostatectomy, 365 Megaloscope, 28 Micrococcus ureae, 76 Micturition, frequency of, 2 in health, 2 in disease, 3 mechanism of, 291 Moore's test, 62 Morphinism, as a cause of azoospermia, 630 Movable kidney, 541 diagnosis of, 542 etiology of, 541 prognosis of, 543 symptoms of, 542 treatment of, 543 Myelitis, gonorrhceal, 106 Myositis, gonorrhceal, 105 Nephralgia, 553 Nephrectomy, abdominal, 5^9 lumbar, 559 partial, 560 Nephritis: acute diffuse, 483 etiology of, 483 palhological anatomy of, 484 prognosis of, 485 symptoms of, 485 treatment of, 486 urine in, 485 chronic, 486 cardiac condition in, 488 dropsy in, 488 etiology of, 486 Nephritis, chronic, forms of, 490 pathological anatomy of, 489 prognosis of, 493 symptoms of, 487, 492 treatment of, 493 uraemia in, 488 urine in, 487, 491, 492 of pregnancy, 494 suppurative, 497 syphilitic, 546 Nephrolithiasis, 524 colic in, 527 diagnosis of, 528 etiology of, 524 functional renal test in, 529 pathological anatomy of, 524 prognosis of, 530 symptoms of, 527 treatment of, 531 urine in 528 Nephrotomy, technic of, 556 Neuralgia of the kidney, 553 Neurasthenia, sexual, 577 Neuroses of the bladder, 290 of the kidney, 553 of the prostate, 403 sexual, 577* Nicoll's method of prostatectomy, 371 Nitric acid test for albumen, 58 Nitze's cystoscopes, 26, 28, 29 Oberlander's dilators, 124 Ointments, urethral, 124 Oligospermia, 617 Orchitis, acute, 430 chronic, 432 Orgasm, definition of, 567 Osteomyelitis, gonorrhceal, 106 Otis-Kreisl urethrotome, 126 Otis urethrometer, 98 Papilloma of the bladder, 266 of the urethra, 172 Paranephritis, 549 Paraphimosis, 192 Parasites of the bladder, 281 of the kidney, 544 of the prostate gland, 401 Paraurethral fistula, 100 treatment of, 116 Penicillium glaucum, 75 Penis, amputation of, 199 carcinoma of, 198 cavernous induration of. 201 cavernous infiltration of, 201 condylomata of, 198 IM'I.X. 64I Penis, elephantiasis of, 201 injuries of, 185 luxation of, 185 tumors of, 198 Pericowperitis, 101 Perifolliculitis, 101 Perinephritis, 549 Periostitis, gonorrhceal, 105 Periprostatic phlegmon, 313 Periurethral abscess, 100 Phimosis, 187 Phlebitis, gonorrhceal, 106 periprostatic, 313 Phloridzin test, 469 Pollutions, seminal, 573 See also under Emissions, seminal. Polypi, urethral, 172 Polyspermia, 617 Post-gonorrhceal chorea, 107 Potassium urate, 78 Prevesical phlegmon, 290 space, 206 Propeptonuria, 60 Prostate gland, abscess of, 311 absence of, 305 anatomy of, 303 atrophy of, 305 carcinoma of, 389 calculus of, 386 concretions of, 386 cysts of, 306 echinococcus disease of, 401 hypertrophy of, 322 complications of, 341 cystoscopy in, 346 diagnosis of, 346 etiology of, 325 forms of, 322 pathological anatomy of, 327 prognosis of, 348 symptoms, 336 treatment, 348 by the Bottini operation, 371 by catheterization, 349 by cystopexy, 359 by double castration, 361 by ligation of the internal iliac arteries, 361 by perineal prostatectomy, 369 by suprapubic prostatectomy, 3 6 5 by vasectomy, 363 summary of, 379 inflammation of, 308 See also under Prostatitis. injuries of, 307 Prostate gland, massage of, 122 319 neuroses of, 403 parasites of, 401 physiology of, 303 sarcoma of, 392 syphilis of, 400 tuberculosis of, 379 diagnosis of, 384 etiology of, 379 pathological anatomy of. 381 prognosis of, 384 symptoms of, 382 treatment of, 384 tumors of, 389 diagnosis of, 393 pathological anatomy of, 390 symptoms of, 393 treatment of, 397 Prostatectomy, 365 combined method of, 371 concraindications to, 368 indications for, 366 mortality after, 367, 371 partial, 365 perineal, 369 suprapubic, 365 sequelae, 367, 371 Prostatic abscess, 311 Prostatic secretion, effect upon sperma- tozoa, 571 Prostatismus, 359 Prostatitis: acute, 309, 120 catarrhal, 309 follicular, 309 parenchymatous, 310 suppurative, 311 treatment of, 313 chronic, 314 etiology of, 314 diagnosis of, 315 pathological anatomy of, 314 symptoms of, 315 treatment of, 122, 319 Prostatorrhcea, 317 Prostatotomy, galvano-caustic, 371 Psoriasis mucosa, 21 Psychrophore, 613 Pubo-vesical ligaments, 206 Pulmonary infarct, gonorrhceal, 106 Pyelitis, 497 etiology of, 497 functional renal examination in, 5°4 pathological anatomy of, 498 prognosis of, 504 642 INDEX. Pyelitis, symptoms of, 500 treatment of, 504 urine in, 502 Pyelonephritis, 497 See also under Pyelitis. in hypertrophy of the prostate, 343 Pyonephrosis, 510 condition of ureters in, 513 diagnosis of, 515 etiology of, 511 forms of, 510 functional renal test in, 515 pathological anatomy of, 511 prognosis of, 516 symptoms of, 514 treatment of, 516 urine in, 514 Pyospermia, 617 Radioscopy, 52 in renal examinations, 468 in vesical calculus, 257 Rectum, gonorrhoea of, 101 Renal artery, aneurysm of, 552 thrombosis and embolism of, 481 Renal calculus, 524 Renal colic, 527 treatment of, 531 Renal pelvis, tumors of, 538 Resection of the urethra, 156 Retention of the testicle, 410 Retention of urine, due to cysts of the sinus pocularis, 306 due to prostatic hypertrophy, 338 due to stricture, 138 treatment of, 156 Retzius space of, 206 Robbins' ointment applicator, 123 Saccharometer, 62 Saccharomyces in the urine. 75 Sarcoma of the bladder, 268 of the kidney, 533 of .the prostate gland, 392 of the seminal vesicle, 461 of the testicle, 419 Scrotum, carcinoma of, 418 congenital diseases of, 409 eczema of, 416 elephantiasis of, 417 epithelioma of, 418 erysipelas of, 417 injuries of, 414 oedema of, 416 open wounds of, 416 Scrotum, phlegmon of, 417 tumors of, 417 Secretions, examination of, 55 Segregators, 473 Semen, abnormal loss of, 573 composition of, 569 pathology of, 617 properties of, 569 Seminal crystals, 572 Seminal emissions, 573 Seminal vesicles, acute inflammation of 455 anatomy of, 452 calculi of, 460 carcinoma of, 461 chronic inflammation of, 456 concretions of, 460 cysts of, 459 drainage of, 457 examination of, 453 hydrocele of, 459 injuries of, 454 irrigation of, 457 malformations of, 454 physiology of, 452 tuberculosis of, 457 Sexual neurasthenia, 577 in relation to azoospermia, 629 prognosis of, 579 symptoms of, 578 treatment of, 580 Sexual organs, physiology of, 564 See also under Aspermatism, Impo- tence, Neurasthenia, etc. Sinus pocularis, cysts of, 306 Sodium urate, 78 Sounds, varieties of, 6 Space of Retzius, 206 Spermatic cord, anatomy of, 409 hydrocele of, 448 inflammation of, 438 torsion of, 415 varix of, 449 Spermatic crystals, 572 Spermatocele, 447 Spermatocystitis, acute, 455 chronic, 456 Spermatorrhoea, definition of, 574 diagnosis of, 576 etiology of, 575 prognosis of, 579 treatment of, 580 See also under Sexual neurasthenia. Spermatozoa, characteristics of, 570 effect of chemicals upon, 570 INDEX. 643 Spermatozoa, effect of pus upon, 627 Sterility, 616 due to defect or deformity, 618 due to aspermatism, 619 due to azoospermia, 624 due to prostatic abscess, 312 forms of, 619 See also under Aspermatism, Azoospei'- mia, and Epididymitis. Stone-searcher, 10 Stone-sound, 10 Stone-crushing, 260 See also under Vesical Calculus. Stricture, of the female urethra, 159 of the male urethra, 131 conception of, 131 cystitis due to, 140 definition of, 131 diagnosis of, 138 etiology of, 132 hypersensibility of the urethra in, 149 location of, 136 pathological anatomy of, 133 prognosis of, 140 recurrence of, 159 resilient, 149 site of, 136 symptoms of, 137 treatment of, 141 by dilatation, continuous, 146 gradual, 142 by divulsion, 141 by electrolysis, 141 by external urethrotomy, 153 by internal urethrotomy, 150 by resection of the urethra, 156 valvular, 134 urinary stream in, 138 Struma suprarenalis, 533 Sugar, tests for, 61, 62 Sulpho-salicylic acid test, 59 Swinburne's urethroscope, 15 Syme's staff, 154 Syphilis, as a cause of azoospermia, 630 of the epididymis, 428 of the kidney, 546 of the prostate, 382 of the testicle, 428 of the urethra, 130 Teale's gorget, 155 Tendovaginitis, gonorrhoea! , 105 Teratoma of the testicle, 420 Testicles, anatomy of, 408 Testicles, atrophy of, as a cause of sterility 624 carcinoma of, 420 chorio epithelioma of, 421 congenital diseases of, 410 cystic disease of, 419 gangrene of, 415, 416 inflammation of, 430 injuries of, 414 open wounds of, 416 retention of, 410 sarcoma of 419 syphilis of, 428 teratoma of, 420 tuberculosis of, 422 tumors of, 419 wounds of, 416 Thompson's lithotrite, 260 urethrotome, 151 Torrey's antigonococcic serum, 104 Triangular ligament, 88 Trichomonas vaginalis, 77 Trigonum vesicale, 206 Trigonum of Lieutaud, 206 Trommer's test for sugar, 61 Tuberculin, value of, 233 Tuberculosis of the bladder, 226 of the epididymis, 422 of the kidney, 517 of the prostate gland, 379 of the seminal vesicles, 457 of the testicle, 422 of the ureter, 562 of the urethra, 175 See also under the various organs. Tuberculosis, as a cause of azoospermia, 631 Tumors of the bladder, 269 of the kidney, 534 of the penis, 198 of the prostate gland, 389 of the renal pelvis, 538 of the scrotum, 418 of the seminal vesicle, 461 of the testicle, 420 of the tunica vaginalis, 418 of the ureter, 538 of the urethra, 173 Tunica vaginalis, tumors of, 418 See also under Hydrocele. Tyrosin, 80 Ulcer of the bladder, 283 Ulcus molle, T94 Ultzmann's catheter, 116 Urachus, anomalies of, 289 644 INDEX. Uraemia, 488 treatment of, 494 Ureters, calculi of, 562 catheterization of, 469 examination of, 560 fistulas of, 561 inflammation of, 561 injuries of, 561 tuberculosis of, 562 tumors of, 538 Ureteral anastomosis, 561 calculus, 562 Urethra, anatomy of, 85 angioma of, 173 caliber of, 86 calculi of, 169 carcinoma of, 173 chancroid of, 129 condylomata of, 130 cysts of, 173 elephantiasis of, 174 fistula of, 183 foreign bodies in, 166 injuries of, 160 length of, 86 malformations of, 176 papilloma of, 172 polypus of, 172 prolapse of, 175 relations of, to true pelvis, resection of, 156 stricture of, 131 See also under Stricture. syphilis of, 130 tuberculosis of, 175 tumors of, 172 Urethral calculi, 169 fever, 149 forceps, 168 ointments, 124 Urethritis, bacterial, 89 causes of, 88 definition of, 88 gonorrhceal, 90 herpetic, 89 simple, 89 specific, 90 Urethrocele, 175 Urethrometer, Otis', 88, 98 Urethrorrhcea, 89 Urethroscopes, 12 Casper's, 13 Koch's, 14 Swinburne's, 15 Valentine's, 13 Urethroscopy, 12 Urethroscopy, asepsis of, 46 history of, 13 in chancre, 2r in psoriasis mucosa, 21 in tumors, 21 in ulcerations, 21 in chronic urethritis, 19 limitations of, 15 technic of, 16 Urethrotome, Maisonneuve's, 151 Otis-Kreisl, 126 Thompson's 151 Urethrotomy, external, 153 internal, 150 dangers of, 153 for chronic gonorrhoea, 126 for stricture, 150 Uric acid, tests for, 79 Urinary abscess, 140, 164 casts, 71 See also under Casts. haemorrhage, 5 microorganisms, 74 stream, changes in, 3 in stricture, 138 Urination, frequency of, 2 in health, 2 in disease, 3 mechanism of, 291 Urine, accidental contamination of, 83 acetone in, 63 admixture of blood with, 5 See also under Hematuria. albumen in, 57 albumose in, 60 animal parasites in, 77 bedside examination of, 67 bile pigment in, 64 blood in, test for, 65 blood corpuscles in, 68 casts in, 71 calcium carbonate in, 82 calcium oxalate in, 80 calcium phosphate in, 81 chemical examination of, 57 composition of, 55 diacetic acid in, 63 effect of certain drugs on, 65 epithelium in, 70 estimation of solids in, 56 fat in, 64 haemoglobin in, test for, 65 indican in, 65 infiltration of, 139, 164 magnesium phosphate in, 82 microorganisms in, 74 IMtKX. 645 Urine, microscopic examination of, 68 organized sediments of, 68 parasites in, 77 physical properties of, 55 propeptone in, 60 reaction of, 56 retention of, due to cysts of the sinus pocularis, 306 due to prostatic hypertrophy, 338 due to stricture, 138 saccharomyces in, 75 sugar in, 61 sulphuretted hydrogen in, 64 unorganized sediments of, 78 yeast-cells in, 75 Urine segregators, 473 Urates, tests for, 79, 83 Uro-genital diaphragm, 88 Valentine's urethroscope, 13 Varices of the bladder, 287 Varicocele. 449 treatment of, 451 Vas deferens, inflammation of, 438 Vaso-epididymostomy, 632 Vesical calculus, 250 Vesical calculus chemical examination of, 252 composition of, 250, 251 diagnosis of, 256 etiology of, 250 prognosis of, 259 symptoms of, 254 radioscopy in diagnosis of, 257 treatment of, 259 urine in, 255 Vesiculitis, acute, 455 chronic, 456 Watson's method of prostatectomy, 365 Winternitz's psychrophore, 613 Xanthin, 80 X-ray, diagnosis by, 52 in prostatic hypertrophy, 360 in renal examinations, 468 in vesical calculus, 257 Yeast-cells, in the urine, 75 Young's ointment applicator, 123 method- of prostatectomy, 369 operation for carcinoma of the pros- tate, 399 COLUMBIA UNIVERSITY LIBRARIES This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the library rules or by special arrangement with the Librarian in charge. 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